Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pruitthealth - Austell during CMS and state inspections, most recent first.
Two residents experienced deficiencies in care planning and implementation. One resident, with significant mobility impairments, was injured during a transfer when a CNA failed to provide hands-on assistance or use a gait belt as required by the care plan. Another resident, with multiple limb amputations and cognitive impairment, was unable to access the call light due to lack of appropriate care plan interventions and staff not ensuring the device was within reach. These failures resulted in actual harm and unmet needs.
Improper Transfer Assistance and Post-Fall Handling: A resident with a right tibial fracture, weakness, and non-weight-bearing status asked a CNA for help transferring from bed to wheelchair, but the CNA did not provide hands-on assistance or use a gait belt. The resident fell forward, injured her right knee, and struck her head. The CNA then rolled the resident over and placed a pillow under her head before notifying the nurse, which was inconsistent with facility policy requiring a licensed nurse to assess a fallen resident before movement.
Two residents requiring oxygen therapy did not receive care in accordance with physician orders and facility policy: one received oxygen at a lower flow rate than ordered, and another was administered oxygen without any physician order in place. Observations confirmed the discrepancies, and staff interviews revealed a lack of adherence to protocols for verifying and following oxygen orders.
Surveyors identified that two medication errors occurred when a nurse administered an incorrect dose of Omega-3 and failed to measure and apply Voltaren gel as ordered for a resident. The nurse did not use a measuring tool for the topical medication and omitted application to one area, resulting in a medication error rate above the acceptable threshold.
Surveyors found that two medication carts contained expired ophthalmic drops, a soiled nutritional supplement with an unreadable expiration date, and loose, unlabeled pills and capsules. Additionally, the controlled substance record book had unsecured, torn pages. Nursing staff were unable to identify the loose medications or their intended recipients, and facility policy requiring daily audits and proper medication storage was not followed.
Failure to Hold Quarterly Care Plan Conference: The facility did not complete a quarterly care plan conference for a resident with epilepsy, muscle weakness, and cognitive communication deficit. The resident did not recall any conference after admission, the family said the admission meeting was the only one held, and the SSD confirmed the quarterly meeting was due but not completed; the Administrator stated care plan conferences are expected on admission, with change of condition, quarterly, and annually.
A resident with intracerebral hemorrhage, cognitive impairment, and multiple limb amputations was unable to reliably use the call light provided. Observations showed the call light pad was often out of reach in bed or in a wheelchair, and the resident stated she could not activate it because she had no arms and sometimes had to scream for help. Staff interviews confirmed the resident had difficulty using the device, and the DON was unaware of the issue.
A resident with a chronic Foley catheter, UTI history, BPH, and bladder dysfunction had an open-ended urology referral, but the EMR lacked clear documentation that specialist appointments were scheduled, completed, or followed up on. Staff also failed to document outcomes from urology visits or act on prior NP recommendations, while the resident reported ongoing pain and urinary discomfort and was observed with blood in the catheter tubing. The urology office reported prior visits for catheter leakage, hematuria, and urinary retention, and said they had been trying to reach the resident for follow-up after a cystoscopy.
Failure to Notify Provider of Abnormal Urine Lab Results: The facility did not notify the physician/NP of abnormal urine lab results for a resident with a chronic Foley catheter, UTI history, dysuria, BPH, and DM2, and did not document notification to the resident or responsible party as required by policy. The resident had abnormal UA/culture findings with unsigned handwritten notes on the lab printouts, but the EMR lacked provider-notification documentation. Interviews showed the NP was unaware of the abnormal results, staff were unsure how to locate lab information, and the DON/ADON stated they were responsible for reviewing abnormal labs and ensuring provider notification.
A resident with dementia, Alzheimer’s disease, CKD, HTN, anemia, weakness, and impaired cognition was observed in a room without a privacy curtain. The curtain was missing on repeated observations, and a CNA said she noticed it but did not report it, while an RN confirmed no one had notified him. The DHS, Regional Consultant, and Administrator all stated that resident rooms are required to have privacy curtains and that staff should notify management when curtains are missing.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident’s family member paid for a private room with the understanding that other charges would be covered by Medicare and supplemental insurance, but was later billed for an excessive amount due to a billing error that charged for 484 days instead of 22. The bill was sent to collections before the error was identified, and a partial refund was eventually issued, but not in a timely manner.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as required by their care plan.
A resident with right-sided hemiplegia and dependence on staff for transfers was transported by a family member without receiving education or supervision from facility staff on safe transfer techniques, despite being at risk for falls. Facility staff confirmed there was no policy or training provided for such situations.
A resident who was cognitively intact was transported by facility staff to a medical appointment but was not picked up by the facility afterward. Due to a delay and a staff member's shift ending, the resident's son was asked to bring her back, resulting in the resident experiencing leg pain during the return trip. The facility did not have a transportation policy in place.
A resident's clinical records were found to be incomplete, with multiple instances of missing documentation for the administration of prescribed medications such as Hiprex, gabapentin, and carvedilol. Facility policy and the DON confirmed that nurses are expected to document all medication administration, but records showed several undocumented doses, raising concerns about the accuracy of care provided.
The facility failed to maintain the required operating temperature for the dishwashing machine, potentially affecting 114 residents. Observations and interviews revealed that the machine did not consistently reach the necessary temperatures for washing and rinsing, and staff were unaware of the required temperature levels. Temperature logs showed inconsistencies, with several instances of recorded temperatures below the required 120 degrees Fahrenheit.
A resident with intact cognition and significant physical impairments was left unclothed and uncovered by a CNA during care, following a disagreement about scheduling assistance. The resident reported feeling neglected and isolated, with delays in call light responses and inconsistent care. Staff interviews confirmed the incident and highlighted the resident's specific care needs.
The facility failed to provide a safe, clean, and homelike environment, with deficiencies observed in six rooms across two halls. Issues included dirty and damaged bathroom exhaust fan vent covers, PTAC units, low water pressure in a bathroom sink, damaged hallway handrails, and a strong odor in the west wing. The Environmental Services Director noted maintenance staff clean filters monthly, but there was uncertainty about recent cleaning due to construction. The facility lacked a formal Maintenance or Environmental policy, and the maintenance logbook showed no recorded issues, indicating a lack of documentation and communication.
A resident expressed concerns about persistent odors from a roommate's area, affecting his quality of life and ability to enjoy meals. Despite reporting the issue to several staff members, no grievance was filed. Staff attempted to offer alternatives, but the resident declined. Interviews revealed a lack of adherence to the facility's grievance policy, with the Unit Manager not considering the issue serious enough and the Wound Care Nurse unaware due to being on vacation. The grievance log showed no documentation of the complaint.
The facility failed to provide adequate assistance with ADLs for two residents. One resident, with multiple sclerosis, was observed unkempt and with a strong urine smell, indicating a lack of grooming and personal hygiene care. Despite needing substantial assistance, her fear of the mechanical lift was misinterpreted as a refusal of care, leading to missed showers. Another resident, severely cognitively impaired, was observed with long facial hair, suggesting a lack of grooming. The facility lacked specific policies for ADLs and grooming, contributing to these deficiencies.
The facility failed to document and administer pain medication for two residents, leading to potential risks for medical complications and diminished quality of life. One resident experienced an unwitnessed fall and was given Tylenol without proper documentation, while another resident missed several doses of prescribed pain medication due to unavailability.
A resident with a history of fractures fell during a transfer using a mechanical lift due to the use of an incorrect size sling, which resulted in a strap breaking. Staff involved were aware of the incorrect sling size but proceeded with the transfer, leading to the resident's fall. The resident expressed fear of using the lift again, and the resident's daughter raised concerns about the care provided.
A facility failed to disinfect reusable equipment and perform hand hygiene during medication administration, affecting five residents. An RN and an LPN used an electronic blood pressure cuff on multiple residents without disinfecting it between uses. The RN also did not consistently perform hand hygiene when moving between residents' rooms. The Director of Health Services confirmed the expectation for equipment disinfection to ensure resident safety.
The facility failed to administer medications per physician orders and within the required time frame for three residents, resulting in an 80.7% medication error rate. Medications were often given late, and one resident did not receive a prescribed nasal spray.
The facility failed to promptly and thoroughly resolve resident grievances regarding missing laundry, despite multiple complaints and policies in place. Observations revealed multiple bags of unclaimed clothing, and interviews confirmed ongoing issues with missing items. The Environmental Services Director acknowledged problems with labeling, and the Administrator confirmed that the issue was still being addressed.
A resident with multiple medical conditions reported that money was missing from her debit card. The facility's investigation revealed that a CNA had used the resident's debit card without proper consent, leading to the CNA's termination and the return of the misappropriated funds. Interviews confirmed that the CNA violated facility policy by accepting and using the resident's debit card.
A resident with multiple diagnoses, including multiple sclerosis and functional quadriplegia, fell during a shower due to the facility's failure to provide the required two-person assistance. Despite the resident's total dependence on two or more persons for physical assistance, only one CNA was present, leading to the fall. Interviews and records confirmed the incident and the facility's non-compliance with its fall occurrence reduction policy.
The facility failed to lock medication and treatment carts when unattended, as observed in two medication carts and one treatment cart. Staff interviews confirmed that carts should be locked, but multiple instances of unlocked carts were noted, placing residents, staff, and visitors at risk.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to transfer assistance and call light accessibility. One resident, with a history of right tibial shaft fracture, morbid obesity, generalized muscle weakness, and lack of coordination, experienced a fall and injury during a transfer from bed to wheelchair. The resident, who was cognitively intact and non-weight-bearing on the right leg, requested assistance from a CNA. The CNA did not provide hands-on assistance or use a gait belt, instead attempting to grab the resident's loose pants, which failed to prevent the fall. The resident sustained a laceration to the right knee and a head injury, requiring hospital transfer. The care plan for this resident included interventions for fall risk and assistance with transfers, but these were not adequately implemented by staff during the incident. Another resident, with multiple limb amputations and moderate to severe cognitive impairment, required total assistance for all activities of daily living. The care plan for this resident did not address the inability to use upper extremities to activate the call light, despite documentation that the call light should be kept within reach at all times. Observations revealed that the call light was frequently placed out of reach, and the resident was unable to summon assistance independently. The resident reported having to call out loudly for help, and staff confirmed the call light was not reliably accessible. The care plan failed to include specific interventions or adaptive equipment to address the resident's unique needs for call light access. These deficiencies were identified through observations, staff and resident interviews, and record reviews, which demonstrated that the facility did not ensure care plans were comprehensive, measurable, and tailored to the residents' individual needs. The lack of proper implementation and documentation of care plan interventions led to actual harm in one case and placed another resident at risk of unmet needs.
Improper Transfer Assistance and Post-Fall Handling
Penalty
Summary
The facility failed to follow its established transfer procedures when assisting a resident with a known right tibial fracture, morbid obesity, generalized muscle weakness, and lack of coordination. The resident’s care plan identified a risk for falls related to generalized weakness and impaired physical mobility, and the resident was non-weight-bearing on the right leg with wheelchair use ordered. Facility policies stated that a gait belt will be used with residents who require assistance with transfers and that staff should provide appropriate assistance during transfers. On the day of the event, the resident asked the CNA for help transferring from the bed to the wheelchair. The resident reported that she attempted to scoot into the wheelchair using her left leg because she was non-weight-bearing on the right leg, but her left leg gave out and she fell forward onto her right knee, causing a laceration, and then struck her head. The resident stated the CNA did not provide hands-on assistance and only tried to grab her loose pants, which did not prevent the fall. A gait belt was visible and accessible in the room. The CNA’s written statement and interview indicated that she grabbed the resident’s pants as the resident began to stand and transfer, but the pants came up and the resident landed on the floor. The CNA confirmed she did not make contact or provide physical assistance before the resident began to fall, and she stated the resident did not refuse help. The CNA also rolled the resident over and placed a pillow under her head before notifying the nurse, despite the facility policy stating a fallen resident should not be moved until examined by a licensed nurse. The resident’s progress note documented a swollen area on the head and a wound on the right knee, and the resident was later transported to the hospital.
Failure to Administer Oxygen as Ordered and Without Physician Order
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For one resident with diagnoses including COPD, chronic respiratory failure with hypoxia, and heart failure, the physician's order specified oxygen at 2 liters per minute (LPM) via nasal cannula continuously. However, observations on multiple occasions revealed that the oxygen concentrator was set below the ordered rate, at 1.5 LPM and under 2 LPM. The LPN confirmed the setting was incorrect and adjusted it only after being prompted during the survey. For another resident with chronic respiratory failure, COPD, and heart disease, there were no physician orders for oxygen therapy in the electronic medical record prior to the survey, despite the resident being observed wearing oxygen at 2 LPM via nasal cannula on two separate occasions. The LPN was unable to locate any oxygen orders after searching the record and could not explain the basis for administering oxygen. The care plan for this resident did not address respiratory conditions until the deficiency was identified during the survey, at which point a problem of COPD was added and an order for oxygen was obtained. Facility policy required that oxygen be administered only with a physician's order and at the prescribed flow rate, and both the Administrator and DON confirmed that staff are expected to follow these orders. The failure to administer oxygen at the correct setting for one resident and to ensure a physician's order was in place for another constituted a deficiency in respiratory care, as staff did not adhere to established protocols and physician instructions.
Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
Surveyors observed that the facility failed to ensure accurate administration of medications, resulting in a medication error rate of 7.14% during the review period. Specifically, two medication errors were identified out of 28 opportunities observed. One error involved a nurse administering only one capsule of Omega-3 (fish oil) to a resident, despite the physician's order for two capsules to be given orally twice daily. In the same observation, the nurse dispensed Voltaren Arthritis Pain (diclofenac sodium) gel by squeezing an unmeasured amount into a medication cup and applied it only to the resident's shoulders, omitting the lower back as specified in the physician's order. The nurse did not use a measuring tool to ensure the correct 2-gram dosage and was unaware of the specified amount in the electronic record. Interviews with facility staff confirmed that the expectation is for medications to be administered exactly as ordered by the physician. The nurse involved acknowledged not referencing a specific dosage for the topical medication, and both the Administrator and Director of Nursing reiterated the facility's policy of zero tolerance for medication errors and the requirement for staff to follow all physician orders precisely.
Deficient Medication Storage and Labeling Practices
Penalty
Summary
Surveyors observed that the facility failed to ensure medications and biologicals were stored in a safe and secure manner on two of five medication carts. On one cart, two expired ophthalmic drops were found, along with a nutritional supplement bottle that was soiled, stored in a bag with a crystallized substance, and had an expiration date that was no longer visible. Additionally, a loose, unlabeled pill and capsule were discovered in the medication drawer. The controlled substance record book on this cart had multiple pages that were torn, loose, and no longer secured within the binder, creating a risk for inaccurate or incomplete controlled substance accountability. On a second medication cart, another loose, unlabeled capsule was found in the medication drawer. Nurses interviewed during the survey were unable to identify the loose medications or determine which residents they were prescribed to. The facility's policy requires nurses to check all medications for expiration and deterioration before administration, maintain clean and organized medication carts, and complete daily audits to remove outdated, contaminated, or deteriorated medications. However, these procedures were not followed, as evidenced by the presence of expired medications, soiled supplements with unreadable expiration dates, and loose, unidentified pills. Interviews with nursing staff and facility leadership confirmed the findings, acknowledging that expired medications and supplements should not be administered and that loose, unidentified medications could result in residents not receiving their prescribed medications. The presence of unsecured pages in the controlled substance record book was also confirmed, with staff noting that this could result in medications not being administered properly or according to orders. The facility's expectations were reiterated by the administrator, who stated that nursing staff are responsible for ensuring expired medications are not present and that medication carts remain clean and free of loose pills.
Failure to Hold Quarterly Care Plan Conference
Penalty
Summary
The facility failed to coordinate a quarterly care plan conference for one sampled resident, R21, and the record contained no documentation of a care plan conference after admission. The facility policy titled Care Plans stated that care plan meetings, other than the admission Comprehensive Care Plan completed during a Post admission Care Conference, should document IDT, resident, and/or resident representative attendance in the Care Conference Notes, and that comprehensive care plans should be reviewed at least quarterly according to the OBRA MDS schedule. R21’s EMR showed admission to the facility with diagnoses including epilepsy, muscle weakness, and cognitive communication deficit, and the quarterly MDS assessment showed a BIMS score of 13, indicating cognitive intactness. R21 told surveyors that she did not remember having a care plan conference since moving into the facility, though she thought her family may have been involved. R21’s family stated that a care plan meeting was held at admission and that it was the only one, and they reported difficulty communicating with the facility and not receiving an invitation for a formal care plan conference. The SSD stated that long-term residents have quarterly care plan conferences, that families and residents are informed a month in advance, and that R21 should have had a quarterly conference in October 2025, but she did not see that it was completed. The SSD confirmed that the only care plan conference completed for R21 was the initial admission conference, and the Administrator stated that care plan conferences are expected to be done timely on admission, upon change of condition, quarterly, and annually.
Call Light Not Accessible for Resident With Multiple Amputations
Penalty
Summary
The facility failed to ensure that the call light provided was appropriate for the physical condition of a resident who had diagnoses including nontraumatic intracerebral hemorrhage and multiple limb amputations. The resident’s quarterly MDS indicated a BIMS score of 9 and total assistance for all care, including eating, oral hygiene, toileting, bathing, and dressing. The care plan directed staff to keep the call light within reach and to reinforce teaching on its use, but it did not include a problem statement or indication that the resident could not use the call light because of her upper extremity limitations. Observations and interviews showed the resident was unable to activate the call light pad that was being used. The call light was seen placed out of reach while she was in bed and in her wheelchair, and she stated that because she had no arms it was a challenge to push the call light and that she sometimes screamed out loud to get help. A CNA was observed leaving the call light out of reach before returning it, and the Therapy Outcome Coordinator and Nurse Unit Manager confirmed the resident had difficulty using the current device and could benefit from a more reliable call light system. The DON stated he was not aware the resident could not activate the call pad.
Failure to Track and Follow Up on Urology Referrals
Penalty
Summary
The facility failed to ensure timely coordination and follow-up of physician and NP recommendations for one resident with a chronic Foley catheter and multiple urinary diagnoses, including UTI, BPH with lower urinary tract symptoms, neuromuscular bladder dysfunction, bladder disorder, and dysuria. The resident also had type 2 diabetes mellitus and was cognitively intact with a BIMS score of 14, but required extensive assistance to total dependence for ADLs. His care plan identified risks related to the chronic indwelling catheter, urinary comfort, and infection prevention, and included coordination of follow-up with specialists such as urology. A urology consult was ordered for neurogenic bladder/BPH with chronic Foley, and the EMR showed an open-ended urology referral from June 2025. However, documentation of follow-up was inconsistent and incomplete. A printout of abnormal UA results contained a handwritten note indicating the need for a urology appointment, but the note was unsigned and staff could not identify who wrote it. No subsequent orders or documentation were found confirming that the urology follow-up had been scheduled or completed, and there were no uploaded records or visit notes verifying that the resident attended any urology appointments. During observations and interviews, the resident reported ongoing pain for about a month and was seen waiting to go to the ER for a UTI, with a Foley catheter in place and dark blood visible in the tubing. He continued to report discomfort on later interviews and recalled seeing the urologist the previous month but could not recall the date. The resident’s wife reported frustration with communication and stated the facility was responsible for arranging transportation to appointments. The urology office later reported that the resident had been seen for catheter leakage, then for blood in urine and urinary retention, with a cystoscopy performed, and that they had been trying unsuccessfully to get him back for follow-up to discuss the results. Facility leadership and nursing staff acknowledged that nurses were responsible for following up on specialist recommendations, tracking outcomes, obtaining documentation when residents returned without records, and ensuring referrals and appointments were completed.
Failure to Notify Provider of Abnormal Urine Lab Results
Penalty
Summary
The facility failed to notify the physician/NP of abnormal laboratory results for one of 47 sampled residents, R9, and failed to document notification of the resident or responsible party as required by policy. The facility policy titled Diagnostic and Laboratory Services: Procedure for Processing stated that when laboratory results are outside normal limits, the licensed nurse is responsible for notifying the provider and documenting the notification in the clinical record, and also for communicating results to the resident and/or responsible party when a new provider order is received related to the test results. R9 was admitted with diagnoses including UTI, BPH with lower urinary tract symptoms, neuromuscular dysfunction of the bladder, other bladder disorders, dysuria, and type 2 diabetes mellitus. The resident’s MDS showed a BIMS score of 14, indicating cognitive intactness, and he required extensive assistance to total dependence for ADLs. He had an indwelling urinary catheter, was not on a bladder toileting program, and was always incontinent of bowel. His care plan addressed risk for UTI related to the chronic catheter, bladder dysfunction, stool incontinence, and dehydration, and included performing lab tests as ordered. The record showed abnormal urine testing results on two occasions. The 11/13/2025 UA/culture finalized on 11/18/2025 showed greater than 2 organisms recovered with none predominant, and a handwritten note on the printout stated that the specimen was contaminated and that urology would need to determine treatment, but the note was unsigned and unidentifiable. The 12/2/2025 UA also had abnormal results with an unsigned handwritten note stating, "NP Notified, No New Orders, Sensitivity Pending." The EMR did not contain documentation that the physician or NP was notified of either abnormal result, and there was no documentation that the resident or responsible party was notified. During interviews, the NP stated he had not been notified of the abnormal results and would have ordered a repeat UA if he had been informed. Staff interviews showed uncertainty about locating lab results, and the DON and ADON stated they were responsible for reviewing abnormal labs and ensuring provider notification. During observations, R9 was in pain, waiting to go to the ER for a UTI, and had dark blood visible in Foley tubing; his wife reported blood in the catheter tubing, ongoing pain, and poor communication from the facility.
Missing Privacy Curtain in Resident Room
Penalty
Summary
The facility failed to ensure a privacy curtain was in place in one resident’s room. The resident had diagnoses including vascular dementia, moderate Alzheimer’s disease, chronic kidney disease, hypertension, lack of coordination, anemia, and generalized weakness, and the quarterly MDS showed a BIMS score of 8, indicating moderately impaired cognition. The resident was also care-planned for ADL decline related to COVID-19, Alzheimer’s disease, dementia, hypertension, PVD, and anemia, and for risk of skin breakdown related to weakness, bowel and bladder incontinence, and dementia, with interventions including incontinence care. Observations on multiple dates showed the resident’s privacy curtain was missing from the room. During an interview and observation, the resident was seated in a wheelchair and stated he was confused about what he was supposed to be doing that day and did not recall what he had eaten. A CNA stated she had noticed the curtain was missing but did not notify anyone, assuming it had been removed for cleaning. An RN confirmed the curtain was missing and stated no CNA had notified him. The DHS, Regional Consultant, and Administrator each stated that all resident rooms were required to have privacy curtains and that staff were expected to notify management when curtains were missing.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Ensure Accurate Billing and Timely Refunds for Private Room Charges
Penalty
Summary
The facility failed to ensure accurate billing and timely refunds for a resident who was admitted and later discharged after a short stay. The resident’s family member requested a private room and paid $3,720 as requested by the facility, with the understanding that all other charges would be covered by Medicare and supplemental insurance. Despite this, the family member later received a bill for over $56,000, reflecting an erroneous charge for 484 days of private room care, when the actual stay was only 22 days. The family member contacted the facility multiple times regarding the excessive bill. Upon review, the Business Office Manager confirmed that a billing entry error had occurred, resulting in the resident being billed for far more days than were actually provided. Documentation showed that the bill was sent to collections for the unjustified amount. Eventually, a partial refund of $992 was issued to the resident. The facility’s admission agreement stated that overpayments would be refunded as soon as possible after insurance claims were verified and paid, but the refund was not provided in a timely manner.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as intended, based on their documented preferences and medical directives.
Failure to Provide Supervision and Family Training for Safe Resident Transfer
Penalty
Summary
A deficiency was identified when a resident, who was dependent on staff for transfers due to right-sided hemiplegia and had documented impairments in both upper and lower extremities, was not provided with adequate supervision or training for safe transfer from a wheelchair to a personal vehicle. The resident's care plan and physical therapy notes indicated she was at risk for falls and required staff assistance for all transfers. Despite this, after a medical appointment, the resident's son was responsible for transferring her into a car and transporting her back to the facility without any education or guidance from facility staff on how to perform the transfer safely. Interviews with facility staff confirmed that there was no policy in place regarding the transportation of residents by family members, and the Director of Rehabilitation stated that no education was provided to the family on safe transfer techniques due to the resident's condition. The lack of supervision and absence of family training for safe transfers created a situation where the resident was at risk for falls and injury during the transfer process.
Failure to Ensure Resident Return Transportation from Medical Appointment
Penalty
Summary
A cognitively intact resident, as indicated by a BIMS score of 14 out of 15, was admitted to the facility and required transportation to and from a medical appointment. The facility arranged for transportation to the appointment, but failed to ensure the resident was picked up afterward. Certified Nurse Aide (CNA) 2 confirmed leaving the resident at the appointment, expecting CNA1 to pick her up. CNA1 reported that due to a delay at the appointment and her scheduled end of shift, she informed the resident's son that she could not wait to return the resident to the facility. As a result, the resident's son transported her back, during which the resident reported being placed in the back of the car, causing leg pain. The facility administrator acknowledged there was no policy on transportation, but stated the expectation was for the facility to provide return transportation if it had provided the initial transport.
Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate documentation for one resident. Review of the resident's electronic medical records and Medication Administration History (MAH) revealed multiple instances where administration of prescribed medications, including Hiprex, gabapentin, and carvedilol, was not documented on several dates across January, February, May, and June. The facility's policy requires medications to be administered as prescribed and documented accordingly, but the records showed missing documentation for both morning and evening doses on specific dates. Interviews and policy reviews confirmed that the expectation was for nurses to document medication administration as part of standard care. The Director of Nursing stated that documentation of administered medications is required. The lack of documentation in the resident's records had the potential to result in the resident not receiving accurate care, as there was no evidence to confirm whether the medications were given as ordered.
Dishwashing Machine Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the dishwashing machine consistently reached the required operating temperature, which had the potential to affect 114 out of 117 residents receiving an oral diet from the kitchen. Observations revealed that the dishwashing machine did not consistently achieve the necessary temperatures for washing and rinsing, with recorded temperatures during three consecutive cycles being below the required levels. Kitchen staff were observed operating the dishwashing machine without knowledge of the required temperatures and chemical levels, as their primary responsibility had been food scrap removal, not machine operation. Interviews with the Dietary Manager and a Regional corporate representative acknowledged the temperature discrepancies. The facility's policy required the use of temperature indicator sticks or a waterproof thermometer to verify the internal temperature of the dishwashing machine, but the observations and temperature logs indicated inconsistencies. The temperature logs showed that the machine did not consistently reach the required temperature of 120 degrees Fahrenheit, with several instances of recorded temperatures at 118 degrees Fahrenheit or lower. The deficiency was identified through a combination of observations, interviews, and record reviews, highlighting a failure in maintaining proper dishwashing machine temperatures.
Resident Left Unclothed and Uncovered During Care
Penalty
Summary
The facility failed to ensure a resident's right to dignity, as evidenced by an incident involving a resident, R41, who was left unclothed and uncovered during care. R41, a quadruple amputee with intact cognition, reported that a CNA became upset when she requested assistance at a specific time for a Valentine's Day party. The CNA allegedly threw one of R41's prosthetic legs at the wall and left her naked and uncovered. This incident was reported to the facility, and interviews confirmed that the resident was left in this state. Further interviews revealed that R41 felt neglected and isolated following the incident, with delays in response to her call light and inconsistent care from staff. The resident expressed feeling targeted after filing a complaint about the CNA's neglect. Staff interviews indicated that R41 was not difficult but required specific care due to her condition, including dedicated time for getting up and bathroom breaks. The Director of Healthcare Services and the Administrator both stated that it was the responsibility of all staff to answer call lights and ensure residents' privacy and dignity.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by several deficiencies observed in six of 64 rooms across two of four halls. Observations revealed dirty and damaged bathroom ceiling exhaust fan vent covers, dirty and damaged PTAC units, a bathroom sink with low water pressure, damaged hallway handrails, and a strong pungent odor in the west wing hallways. These issues were confirmed during interviews and walking rounds with the Administrator, Environmental Services Director (ESD), and Maintenance Director (MD). The ESD noted that maintenance staff were responsible for cleaning filters monthly, but there was uncertainty about whether this had been done recently due to ongoing construction work. Additionally, the ESD mentioned that certain rooms required more frequent cleaning due to persistent odors. The facility lacked a formal Maintenance or Environmental policy, as confirmed by the Administrator, ESD, and MD. The maintenance logbook for the [NAME] Wing showed no recorded issues in the past month, indicating a lack of documentation and possibly communication regarding maintenance needs. The ESD stated that environmental issues were expected to be addressed promptly, but the absence of a structured policy and documentation system may have contributed to the oversight of these deficiencies. The Administrator acknowledged the need for immediate correction of the identified issues.
Failure to File Grievance for Resident's Roommate Odor Complaint
Penalty
Summary
The facility failed to file a grievance on behalf of a resident who expressed concerns about persistent odors coming from his roommate's area, particularly during activities of daily living care and wound treatment. The resident, identified as R47, reported that the smell was affecting his ability to enjoy meals and impacting his quality of life within the facility. Despite expressing these concerns to multiple staff members, including a Certified Medication Aide, a Certified Nursing Assistant, and a Unit Manager, no grievance was filed on his behalf. The staff members attempted to accommodate the resident by offering alternatives such as eating in the dining room, but the resident declined these offers. Interviews with staff revealed a lack of understanding or adherence to the facility's grievance policy. The Unit Manager did not consider the issue serious enough to warrant filing a grievance, and the Wound Care Nurse was unaware of the complaint due to being on vacation. The Director of Health Services and the Administrator were also unaware of the resident's concerns, indicating a breakdown in communication and protocol adherence. The facility's grievance log showed no documentation of a grievance being filed for this issue, highlighting a failure to follow the established grievance procedures.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, R42 and R106. Resident R42, who has multiple sclerosis and other health issues, was observed to have unkempt hair, facial hair, and a strong urine smell, indicating a lack of grooming and personal hygiene care. Despite her care plan requiring substantial assistance with ADLs, including showers and grooming, R42 reported that she was afraid of the mechanical lift used for transfers, which staff misinterpreted as a refusal of care. Documentation showed inconsistencies in her bathing schedule, with several missed shower days. Resident R106, who is severely cognitively impaired, was also observed with long facial hair, suggesting a lack of grooming. Despite needing substantial assistance with personal hygiene, there was no evidence of grooming being provided. Interviews with staff revealed that if a resident refused a shower, a bed bath was offered, and refusals were documented. However, the facility lacked specific policies for ADLs and grooming, contributing to the deficiencies observed.
Failure to Document and Administer Pain Medication
Penalty
Summary
The facility failed to document the administration of pain medication on the electronic Medication Administration Record (eMAR) and follow up on the assessment related to a fall for one resident, and to reorder or follow up on the delivery of pain medications for another resident. This deficiency had the potential to place the residents at risk for medical complications, unmet needs, and a diminished quality of life. Resident R97, who was admitted with diagnoses including muscle weakness and type 2 diabetes mellitus, experienced an unwitnessed fall in the bathroom. The resident was on a scheduled pain medication regimen and had a history of falls. After the fall, the resident was found with bruises and was given Tylenol for pain, but the administration was not documented on the eMAR. The nurse involved did not document the dressings applied to the resident's wounds and was unaware of how to access wound care assessment notes in the EMR. The nurse also failed to communicate the bleeding and dressing application to the nurse practitioner. Resident R23, admitted with fractures and functional limitations, was prescribed hydrocodone/acetaminophen for pain management. However, the resident did not receive the medication on several occasions due to it being unavailable. The facility's policy required medications to be reordered when the supply was low, but this was not adhered to, resulting in missed doses. The unit manager confirmed that no resident should go without pain medication, highlighting a lapse in medication management and ordering procedures.
Resident Fall Due to Incorrect Sling Size During Transfer
Penalty
Summary
The facility failed to ensure the safety of a resident during a transfer using a mechanical lift, resulting in an accident. The resident, who had a history of fractures and required assistance with activities of daily living, was being transferred from a wheelchair to a bed when the incident occurred. The staff used an incorrect size sling, which led to the breakage of a strap and caused the resident to fall to the floor. Interviews with the staff involved revealed that they were aware the sling was not the correct size but proceeded with the transfer due to a lack of alternatives. The resident, who had intact cognition, expressed fear and reluctance to use the mechanical lift following the fall. The resident's daughter, who is also the responsible party, voiced concerns about the care her mother was receiving and questioned how such an accident could occur. The Director of Health Services expected staff to use proper equipment and have two people assist with mechanical lifts, but this expectation was not met in this instance.
Infection Control Deficiency in Medication Administration
Penalty
Summary
The facility failed to properly disinfect reusable equipment and perform hand hygiene during medication administration, affecting five residents. During observations, a registered nurse (RN) used an electronic blood pressure cuff on multiple residents without disinfecting it between uses. The RN also failed to perform hand hygiene consistently when moving between residents' rooms. This practice was observed during medication administration for two residents, where the RN did not disinfect the blood pressure cuff after checking each resident's blood pressure and did not perform hand hygiene after administering medications. Similarly, a licensed practical nurse (LPN) was observed using the same electronic blood pressure cuff on two residents without disinfecting it between uses. The LPN acknowledged the failure to disinfect the equipment during an interview. The Director of Health Services confirmed that the expectation was for the blood pressure cuff to be disinfected between uses to ensure resident safety. The failure to adhere to proper infection control practices had the potential to spread microorganisms among residents.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to administer medications per physician orders and within the required time frame for three residents. Resident 21, who had diagnoses including sepsis, protein-calorie malnutrition, and acute kidney failure, did not receive their medications on time. The medications were administered at 10:43 am instead of the scheduled 9:00 am. Interviews with the resident and staff confirmed that medications were often given late, and the Director of Nursing acknowledged that medications should be administered within a one-hour window before or after the scheduled time. Similarly, Resident 18, with diagnoses including hypertension, morbid obesity, major depressive disorder, and liver disease, also received their medications late at 10:54 am instead of 9:00 am. An interview with the resident confirmed that medications were frequently late, and an observation during a medication pass revealed that an additional medication, guaifenesin, was administered without an order. Resident 27, who had acute respiratory failure and nasal congestion, did not receive their prescribed nasal spray during a medication pass. The Certified Medication Aide stated that the resident would request the saline mist when needed, but it was not offered to the resident as per the physician's order. The facility's medication error rate was found to be 80.7 percent, significantly higher than the acceptable rate of less than 5 percent. The facility's policy requires medications to be administered within 60 minutes before or after the scheduled time, but this was not adhered to, leading to the deficiencies observed during the survey.
Failure to Resolve Resident Grievances Regarding Missing Laundry
Penalty
Summary
The facility failed to ensure prompt and thorough efforts to resolve continued resident grievances regarding missing laundry. Despite having policies in place for handling grievances and missing items, the facility did not effectively address multiple complaints from residents about missing clothing. The grievance logs for 2023 and 2024 documented several instances where residents complained about missing clothing, and interviews with residents confirmed ongoing issues. One resident reported missing several pants and long sleeve shirts and stated that the Environmental Services Director had not been in contact about replacing those items. Another resident, the Resident Council President, confirmed that there were still issues with missing clothing and that the Environmental Services Director had been notified but had not resolved the issue. Observations of the laundry room revealed multiple bags of unclaimed resident clothing, indicating a systemic issue with the management of residents' laundry. The Environmental Services Director acknowledged problems with labeling residents' clothing and stated that unclaimed clothing was kept for 90 days before being donated to residents. The Administrator confirmed that the facility was still working on resolving the missing items issue. These findings indicate a failure to adhere to the facility's grievance policy and to take prompt and effective action to resolve residents' complaints about missing laundry.
Misappropriation of Resident's Funds by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property by facility staff. The resident, who had multiple medical conditions including multiple sclerosis and functional quadriplegia, reported that money was missing from her debit card. The facility's investigation revealed that a Certified Nursing Assistant (CNA) had used the resident's debit card without proper consent. The resident had initially given the CNA her debit card to help with pregnancy-related expenses, but the CNA used more money than agreed upon. The CNA was subsequently terminated and returned the misappropriated funds to the resident. Interviews with the former administrator, the resident, the resident's responsible party, and other staff members confirmed that the CNA had violated facility policy by accepting and using the resident's debit card. The financial counselor also corroborated the resident's claim by reviewing the credit card statements and reporting the issue to the former administrator. The facility's policy clearly states that staff are not allowed to take money from residents, and this policy was breached in this instance.
Failure to Provide Required Two-Person Assistance Results in Resident Fall
Penalty
Summary
The facility failed to provide the required two-person assistance to a resident (R5) who needed such assistance, resulting in the resident falling during a shower. R5's medical record indicated multiple diagnoses, including multiple sclerosis, functional quadriplegia, and muscle weakness, and the resident was assessed as totally dependent on two or more persons for physical assistance. Despite this, during a shower, only one CNA was present, and R5 fell while being dressed after the shower. The facility's policy on fall occurrence reduction was not followed, as the resident was not provided with the necessary two-person assistance, leading to the fall. Interviews with the resident and staff confirmed the incident. R5 reported falling twice, once due to a Hoyer lift malfunction and the second time during the shower when only one CNA was present. The CNA involved admitted to asking the assisting CNA to leave and attempted to dress R5 alone, resulting in the fall. The post-fall observation noted that the lack of two-person assistance was a contributing factor to the fall. The facility's failure to adhere to its policy and provide adequate supervision and assistance directly led to the incident.
Failure to Lock Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that medication and treatment storage carts were locked when unattended and out of the view of a nurse. This deficiency was observed in two of six medication carts and one treatment cart. On multiple occasions, medication carts were found unlocked and unattended in the hallways. Specifically, an LPN was observed approaching an unlocked medication cart without the keys, and another nurse admitted to leaving her cart unlocked while attending to a resident in a closed room. Additionally, during a wound care procedure, a treatment cart was left open with the keys in the lock, and another staff member accessed the cart without locking it afterward. Interviews with the Director of Health Nursing and the Administrator confirmed that medication carts should be locked when unattended. The facility's policies on medication storage and administration were reviewed, revealing that only authorized personnel should have access to medications and that carts should be locked or attended at all times. Despite these policies, the observed practices placed residents, staff, and visitors at risk of unauthorized access to medications and potentially hazardous treatment supplies.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 368 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Austell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Anderson Mill Center For Nursing And Healing Llc | 1 mi | ★★★★★ | 1 | 0 |
| Presbyterian Village | 2.2 mi | ★★★★★ | 6 | 0 |
| Powder Springs Center For Nursing & Healing | 2.9 mi | ★★★★★ | 3 | 0 |
| Pruitthealth - Marietta | 4.9 mi | ★★★★★ | 6 | 0 |
| Autumn Breeze Health And Rehab | 4.9 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pruitthealth - Austell.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.