Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 - Decatur during CMS and state inspections, most recent first.
A Laundry Aide delivered clothes on a partially covered cart instead of the enclosed transport cart, and a cell phone was found in a clean linen cart. Staff confirmed both practices were not acceptable and identified cross contamination and infection control concerns.
Hazardous Chemical Left Accessible in Hallway: A can of cleanser deodorizing powder was observed on a hallway handrail outside a resident's room with no staff or housekeeping cart nearby. An LPN confirmed the chemical should not have been there, and the DHS and Administrator stated chemicals should be kept in a locked area because leaving them in the hallway is unsafe.
A resident reported that after requesting evening medications, a nurse left the room and was overheard saying, “I’m not going back in there. I may have to slap someone.” The resident called a family member, who came to the facility, questioned why police had not been notified, and later filed a police report. The resident also filed a formal grievance documenting the nurse’s statement. Despite a written policy requiring that all real or perceived abuse allegations, including verbal threats, be reported to the SSA within two hours and investigated, the facility treated the incident as a customer service issue, reassigned the nurse, and did not report the allegation to the SSA or conduct an abuse investigation, as confirmed by staff interviews.
A resident with an indwelling suprapubic catheter related to neurogenic bladder, BPH, and urinary retention had a care plan that included multiple catheter-related interventions but did not include a physician’s order to irrigate the catheter with normal saline every shift. Facility policy required the comprehensive care plan to describe all services to be furnished, and the omission occurred despite established processes for the MDS Coordinator and IDT to communicate order changes and for nursing leadership to ensure timely care plan updates.
A resident with a suprapubic catheter had the urinary bag visible from the hallway without a privacy cover, and an attempted cover was hanging on the bed frame instead of covering the bag. The resident had multiple diagnoses including hemiplegia, DM2, epilepsy, receptive-expressive language disorder, and dysphagia. Staff, including a CNA and the DON, confirmed the bag was not properly covered, and the facility’s resident rights and catheter policies did not address covering the bag.
A resident with bipolar disorder, MDD, anxiety disorder, PTSD, and schizophrenia was admitted with a Level I PASARR, but the record showed no Level II PASARR evaluation. The MDS indicated the resident had not been evaluated, and a PASRR Level II referral was cancelled because the facility did not provide the medication list needed to complete the assessment. The SSD, DON, and Administrator stated they assumed the screening had been completed or was handled by others.
A resident with dementia and total incontinence and another resident with MS and bowel/bladder incontinence did not receive timely incontinent care, with staff confirming wet briefs, urine odor, and delayed changes despite care plan directions for prompt care after each episode. A separate resident with a suprapubic catheter had catheter irrigation supplies that were not sterile and were not set up per the ordered procedure; an LPN confirmed the items used for irrigation and showed a syringe that would not fit the catheter, while the DON stated catheter irrigation was expected to be sterile.
Unlocked and Unattended Medication Cart: Surveyors observed one first-floor medication cart left unlocked and unattended, with several rolls of resident medication on top. The LPN confirmed she left the cart while going to the bathroom and said her support staff was on break; the DON and Administrator confirmed the observation. Facility policy required medication carts to be locked or attended by authorized personnel.
The facility failed to dispose of expired food items in accordance with its policies, as observed during an inspection. Expired items were found in the dry storage pantry, walk-in freezer, and on kitchen shelves, including water bottles, donuts, and various seasonings. Interviews with the DM and DON confirmed the presence of expired items, which should have been removed to prevent potential illness among residents.
A long-term care facility failed to implement proper infection control measures, including Enhanced Barrier Precautions (EBP) for a resident with a stage 2 pressure ulcer and adequate hand hygiene by staff. An LPN did not sanitize hands between assisting residents, and the resident with the wound was not placed on EBP, contrary to facility policy. Staff confirmed these practices could lead to cross-contamination and infections.
The facility failed to ensure that the POLST and medical records accurately reflected residents' code status choices. One resident's POLST indicated full code, while physician orders stated DNR, and the face sheet had conflicting information. Another resident's POLST showed AND and DNR, but physician orders listed full code. The SSD and DON confirmed these inconsistencies, and an audit was underway to correct the records.
The facility failed to maintain cleanliness in two resident rooms, compromising resident safety. In one room, the PTAC unit had visible debris, including a dead bug, due to inconsistent cleaning schedules. In another room, a dark brown substance was found on bathroom surfaces, indicating inadequate cleaning and disinfection procedures. Staff interviews revealed a lack of clarity in cleaning responsibilities, increasing infection risk.
A facility failed to submit a PASARR Level II for a resident after a new mental illness diagnosis was added. The resident had diagnoses including bipolar disorder, major depressive disorder, anxiety disorder, and PTSD. The Social Service Director confirmed the oversight, acknowledging the responsibility to refer for PASARR Level II evaluation when a new mental disorder is identified.
Clean Linen and Laundry Cart Cross-Contamination
Penalty
Summary
The facility failed to protect clean linen from cross-contamination when a Laundry Aide delivered clothes on a partially covered laundry cart to the first floor. During observation, the Laundry Aide confirmed she was using the laundry sorting cart instead of the enclosed transportation cart because the enclosed cart was difficult for her to push due to back concerns, and she acknowledged that the cart should have been covered. The Environment Manager later stated that laundry was expected to be delivered in a timely manner, properly covered, and without additional items on the cart, and confirmed that uncovered transport was not his expectation because it created an infection control issue and items were not isolated. The facility also had a cell phone placed in a clean linen cart. A CNA confirmed the phone was hers and stated it should not have been in the linen cart, identifying cross contamination as the consequence of personal items being placed there. The Director of Health Services and the Administrator stated that personal items left on clean linen carts were not acceptable and that nothing personal should be in the clean linen cart because of the potential negative impact on infection control.
Hazardous Chemical Left Accessible in Hallway
Penalty
Summary
The facility failed to store potentially hazardous chemicals so they were not accessible to cognitively impaired residents. During an observation on 03/04/2026 at 5:28 AM, a 21-ounce can of name brand cleanser deodorizing powder was found placed on a handrail in the second-floor hallway by a resident's room, with no staff or housekeeping cart in sight. An LPN confirmed at 5:31 AM that the can was in the hallway and stated it should not have been there, adding that she was not sure why it was left there. Later, the Director of Health Services and the Administrator stated that chemicals should not be left in the hallway and should be kept in a locked area for the health and safety of staff and residents.
Failure to Report and Investigate Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of verbal abuse to the State Survey Agency (SSA) and to conduct an abuse investigation in accordance with its own policy and regulatory requirements. The facility’s policy on reporting patient abuse, neglect, exploitation, mistreatment, and misappropriation of property required the Administrator or designee to notify the appropriate state agencies, the attending physician, and the patient’s representative of any allegation of abuse, including verbal threats, within two hours of the allegation. The policy also required that an investigation be initiated into the allegation. A resident reported that, after requesting evening medications, she overheard a nurse leaving her room and stating, “I’m not going back in there. I may have to slap someone.” The resident subsequently telephoned her family member to report this statement. The resident’s family member went to the facility, questioned why police had not been notified, and reported that the nurse who initially received his concern did not act and stated he was getting ready to go home. The family member filed a police report that same evening. The resident later filed a formal grievance documenting the nurse’s statement, and the facility categorized the occurrence as a customer service matter, removed the nurse from the resident’s assignment, and planned staff inservices on good customer service. The facility did not report the allegation to the SSA and did not complete an abuse investigation related to the verbal threat. Staff interviews, including with a CNA, the Social Services Director, and the Administrator, confirmed that real or perceived allegations of abuse, including verbal threats, were understood to be reportable and to require immediate reporting and investigation, but this did not occur for this resident’s allegation.
Failure to Add Ordered Catheter Irrigation to Resident Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to include physician-ordered suprapubic catheter irrigation in a resident’s comprehensive care plan. The facility’s care plan policy, revised 10/21/2025, requires that the comprehensive care plan describe the services to be furnished to attain or maintain the resident’s highest practicable well-being. Review of the resident’s care plan dated 12/10/2025 showed a problem of an indwelling catheter related to neurogenic bladder, BPH, and urinary retention, with interventions such as changing the catheter at the urologist’s office per spouse preference, administering cranberry supplement for UTI prophylaxis as ordered, keeping catheter tubing free of kinks, maintaining the drainage bag below bladder level, preventing tension on the urinary meatus, and providing catheter care per policy. However, there was no mention of irrigating the urinary catheter. Record review showed a physician’s order for the resident to have the suprapubic catheter irrigated with 50 cc of normal saline every shift, which was not reflected in the care plan. In interviews, the MDS Coordinator stated she communicated with the IDT in morning meetings about changes to orders or residents’ status and indicated she should have been informed of the urinary catheter irrigation order so she or a unit nurse could add it to the care plan. The DON stated that expectations were for the Charge Nurse, Unit Manager, or MDS Coordinator to make care plan changes as soon as they were ordered. The Administrator reported that the MDS department had stated in a morning meeting that they were caught up with MDSs and care plans, but that this was not accurate.
Visible Urinary Catheter Bag Without Privacy Cover
Penalty
Summary
The facility failed to provide dignity to one resident with an indwelling urinary catheter because the catheter bag was visible from the hallway and was not covered with a privacy cover. The facility’s resident rights policy and indwelling catheter policy did not mention covering the urinary bag. The resident, R88, was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, type 2 diabetes mellitus, epilepsy, hyperlipidemia, contracture of the left hand, receptive-expressive language disorder, and dysphagia. The resident’s CAA identified problems with communication, ADLs, an indwelling catheter, dental care, and a pressure ulcer, and the care plan included an indwelling catheter problem and prophylactic ABT. R88 had a suprapubic catheter insertion and physician orders for catheter care every shift and a 16Fr catheter with a 10cc bulb. During observations, the urinary catheter bag was seen visible from the hall without a privacy cover, and later an attempt to cover it was observed, but the cover was hanging on the bed frame and did not cover the bag. A CNA confirmed the bag was not properly covered. The DON stated the foley bag came from the hospital without a cover and that a cover had to be put on it, and the Administrator stated resident rights always came first.
Failure to Complete Level II PASARR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Level II PASARR was completed for a resident with multiple mental health diagnoses, including bipolar disorder, major depressive disorder, anxiety disorder, PTSD, and schizophrenia. Record review showed the resident was admitted with a Level I PASARR, and the MDS indicated he had not been evaluated for a Level II PASARR. The care plan addressed psychosocial wellbeing and difficulty expressing self related to a history of CVA, but the record also included a Georgia PASRR Level II referral cancellation notice stating the referral was cancelled because the facility failed to provide the medication list needed to complete the assessment. During interviews, the Social Services Director stated that, based on the resident’s diagnoses, a Level II PASARR should have been performed within 30 days of admission. She also stated the resident had been admitted before she was onboarded and that the resident was not included in a PASARR audit she had completed. The DON and Administrator stated they assumed the resident’s PASARR II had been performed by the SSD, and the DON confirmed the resident qualified for screening but was unsure why he was screened. The DON also stated the assessment was carried out at admission, consent was obtained from the family, and a mental health provider was contacted.
Delayed Incontinence Care and Improper Catheter Irrigation
Penalty
Summary
Timely incontinence care was not provided for two residents who were documented as always incontinent of bowel and bladder. One resident had diagnoses including Alzheimer’s disease, dementia, chronic kidney disease, and palliative care, and was dependent for ADLs. The resident’s care plan directed staff to provide incontinent care after each episode and keep the resident clean and dry. During observations, the resident’s room smelled of urine on multiple occasions, and staff confirmed the resident smelled of urine and had a wet brief. One CNA stated the resident had last been changed at 7:00 AM while also reporting responsibility for 14 residents. Another CNA stated the resident had last been changed between 7:30 AM and 8:00 AM and did not change the resident after the interview. A third CNA stated she changed residents every two hours but confirmed the resident smelled of urine and had a wet brief, stating the resident had last been changed around 3:00 AM. A second resident with multiple sclerosis, urinary retention, and bowel and bladder incontinence was cognitively intact and required substantial to maximal assistance for toileting and hygiene. The resident’s care plan directed staff to offer peri care before leaving the room and provide incontinent care after each episode. The resident filed grievances stating that on two occasions the resident was not changed from 11:00 PM to 7:00 AM and was not changed until 9:00 AM. A CNA statement confirmed the resident pressed the call light at 11:20 PM requesting to be changed, but staff told the resident they were waiting for other CNAs to arrive before assisting. The statement also documented that rounds began at 1:00 AM on the other end of the hall and did not start with the resident’s need. During an interview and observation, the resident stated the resident had not been changed since 3:00 AM and would probably not be changed until 9:00 AM or 9:30 AM. Appropriate catheter irrigation and sterile catheter care were not provided for a resident with a suprapubic urinary catheter, neurogenic bladder, diabetes, multiple sclerosis, chronic pain, and bowel incontinence. The resident’s physician ordered irrigation of the suprapubic catheter with 50 cc normal saline every shift, and the care plan directed catheter care per policy. In the resident’s room, surveyors observed two catheter-tip syringes stored in bags labeled as tube feeding syringes, along with opened bottles of normal saline on the nightstand; the syringes were not sterile and there was no date showing when the saline or syringes had been opened. The resident stated these items were used to irrigate the catheter every shift. An LPN confirmed the items were used for catheter irrigation and stated that was all the facility had available. The LPN then showed a 10 mL prefilled sterile syringe of sterile normal saline used to flush IV catheters, stating it was what she used to flush the resident’s catheter, although the syringe had a Luer-Lok tip and would not fit a catheter. The DON stated catheter irrigation was expected to be done in a sterile fashion.
Unlocked and Unattended Medication Cart
Penalty
Summary
The facility failed to ensure that one of two medication carts on the first floor was locked and attended. During a tour on 03/04/2026 at 5:05 am, surveyors observed the door to a medication cart on the first floor left unlocked and not being directly monitored by authorized personnel. Several rolls of unidentifiable resident medication were found on top of the cart. The report states the cart was unattended at a time when wandering residents were on the floor. Review of the facility policy titled Medication Storage in Healthcare Centers stated that medications and biologicals are to be stored safely and securely, and that medication rooms, carts, and medication supplies are to be locked or attended by persons with authorized access. In interview, the LPN confirmed the cart was hers and said she had rushed to the bathroom due to an urgent need while her support staff was on break. She also stated she could have completed the task of putting away the medication or placed it in the cart until her return. The DON and Administrator confirmed the observation of the unlocked and unattended medication cart, and the DON identified the medication on top of the cart as pizza roll, which was used for blood pressure, cholesterol, and other resident-specific purposes.
Expired Food Items Found in Facility Kitchen
Penalty
Summary
The facility failed to adhere to its policies on food safety, specifically regarding the disposal of expired food items. During an inspection, surveyors observed expired items in the dry storage pantry, including four one-gallon bottles of water and 24 bottles of distilled water. Additionally, the walk-in freezer contained four packs of expired variety pack donuts. Further inspection revealed several expired seasoning bottles on a shelved area in the kitchen, including ground thyme, sesame seed, sriracha seasoning, poultry seasoning, paprika seasoning, crushed red pepper seasoning, and whole celery seed. Interviews with the Dietary Manager (DM) and the Director of Nursing (DON) confirmed the presence of expired food items in the kitchen. The DM acknowledged that expired food items should not be present in the kitchen and emphasized the importance of removing them before they expire to prevent potential illness among residents. The DON stated that audits should be conducted to ensure expired food items are removed and disposed of, as their presence could lead to residents becoming sick from consuming expired products. The deficiency had the potential to affect 124 residents receiving food from the kitchen, with the facility's census being 130.
Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for a resident with a wound and inadequate hand hygiene practices by staff. Specifically, a Licensed Practical Nurse (LPN) did not sanitize her hands after pushing a resident's wheelchair and before assisting another resident with their meal. This was confirmed through observations and staff interviews, where it was acknowledged that such practices could lead to cross-contamination and the spread of infections among residents. Additionally, the facility did not place a resident with a stage 2 pressure ulcer on EBP, despite the facility's policy requiring such precautions for residents with wounds. The resident, who had severely impaired cognition, was receiving treatment for the pressure ulcer but was not on EBP, as confirmed by multiple staff members, including the Wound Care Nurse and the Assistant Director of Nursing. The staff indicated that the decision to place residents on EBP was at the discretion of the facility, which led to the omission of necessary precautions for the resident. The failure to adhere to the facility's infection control policies, both in terms of hand hygiene and EBP, was acknowledged by various staff members, including the Director of Nursing and the Clinical Competency Coordinator. These deficiencies had the potential to cause infections for the resident with the wound and other residents in the facility, as the lack of proper precautions could facilitate the transmission of germs.
Discrepancies in POLST and Code Status Documentation
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life Sustaining Treatment (POLST) and other medical records accurately reflected the residents' choices regarding their code status. For one resident, there was a discrepancy between the POLST, which indicated a full code status, and the physician's orders, which stated Do Not Resuscitate (DNR). Additionally, the resident's face sheet contained conflicting information, listing both full code and Do Not Intubate (DNI) statuses. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) confirmed these inconsistencies and acknowledged that the advance directive was not reconciled with the physician orders. Another resident's records also showed inconsistencies, with the POLST indicating Allow Natural Death (AND) and Do Not Attempt Resuscitation, while the physician's orders listed a full code status. The face sheet for this resident showed a DNR status. The SSD revealed that nurses were responsible for entering orders upon admission and suggested that the discrepancy might have occurred during a readmission from the hospital. The SSD was conducting an audit to ensure that the system accurately reflected the residents' wishes.
Facility Fails to Maintain Cleanliness in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in two resident rooms, compromising the health and safety of the residents. In one room, the Packaged Terminal Air Conditioner (PTAC) unit was found with visible debris, including a dead bug, indicating a lack of regular maintenance and cleaning. The facility's policy required air filters to be cleaned or replaced every three months, and the manufacturer's guidelines recommended a thorough cleaning of the unit annually. However, interviews with the Maintenance Director and other staff revealed inconsistencies in the cleaning schedule, with PTAC units generally cleaned once a year and filters cleaned monthly. The Administrator acknowledged the expectation to follow the manufacturer's specifications, but the PTAC units had not been cleaned recently, posing a risk of airborne illness if debris were to be blown into the room. In another room, the bathroom was observed with a dark brown substance smeared on the inside door handle, handrails, and door jams. Despite some cleaning efforts, the inner sides and door jams remained soiled. Interviews with housekeeping and nursing staff indicated a lack of clarity and coordination in responsibilities for cleaning bodily fluids. The Housekeeping Aide and Certified Nursing Assistants (CNAs) were expected to clean up body fluids, with housekeeping following up to disinfect the areas. However, the presence of the brown substance suggested that these procedures were not effectively implemented, increasing the risk of infection for the residents.
Failure to Complete PASARR Level II for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to submit a Preadmission Screening and Resident Review (PASARR) Level II for a resident after a new mental illness diagnosis was added. The resident, identified as R10, was admitted with diagnoses including bipolar disorder, major depressive disorder, anxiety disorder, and PTSD. Despite these qualifying diagnoses, the facility did not complete a PASARR Level II, which is necessary to ensure the resident receives the appropriate level of care and services. The deficiency was identified through a review of R10's electronic medical records and an interview with the Social Service Director (SSD). The SSD confirmed that it was her responsibility to refer residents for a PASARR Level II evaluation when a new mental disorder, intellectual disability, or related condition was identified. However, she acknowledged that this referral was not made for R10, despite the resident's current diagnoses requiring it. This oversight had the potential to affect the care and services provided to the resident.
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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.
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Nursing homes near Decatur
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Georgia Regional Atlanta Ltc | 1.5 mi | ★★★★★ | 3 | 0 |
| Glenwood Health Center By Harborview | 3.2 mi | ★★★★★ | 10 | 0 |
| Crossings At East Lake Of Journey Llc, The | 4.5 mi | ★★★★★ | 8 | 0 |
| Decatur Center For Nursing And Healing Llc | 6.7 mi | ★★★★★ | 7 | 0 |
| Harborview Decatur | 6.8 mi | ★★★★★ | 0 | 0 |
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