Average — CMS composite of the measures below.
The next survey window likely opens around December 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 - Fort Oglethorpe during CMS and state inspections, most recent first.
A resident whose preferred language was Spanish, with documented ability to communicate and little cognitive decline, was not provided effective communication in his preferred language despite facility policies and a care plan calling for interpreter services and other supports. Staff, including a RN, CNA, and LPN, attempted to communicate primarily in English or through nonverbal cues, did not routinely use interpreter services, and had not previously used the language line. During an interview facilitated by an interpreter, the resident reported never having used the language line with staff and being unable to have meaningful conversations, only trying to understand what was occurring.
Surveyors found that PTAC units in two resident rooms were not maintained in a clean, intact condition as required by facility policy, with one unit having a broken front grill, visible residue, and a broken air filter, and another unit containing debris, rust, and a rusty, clogged main screen. The Maintenance Supervisor acknowledged the poor condition of these units despite stating that PTAC units were serviced monthly, and the Administrator confirmed that maintenance staff were responsible for routine cleaning and upkeep of PTAC units and that failure to maintain them could negatively impact cleanliness.
The facility failed to provide and document scheduled bathing and related ADLs for three dependent residents, despite a policy requiring point-of-care ADL charting and daily nursing review. One cognitively intact resident with significant mobility and medical issues was care planned for showers three times weekly but received far fewer showers or bed baths, with no refusals documented; the resident reported rarely receiving showers and never refusing them, while CNAs and an LPN acknowledged showers were not consistently provided or verified. A second cognitively intact amputee with visual impairment and need for personal care assistance was scheduled for regular showers but received only a fraction of them, with the resident observed disheveled and stating she wanted baths and that staff were lazy, and the LPN Unit Manager confirming missed and undocumented bathing. A third resident with dementia and impaired mobility, care planned for scheduled showers and ADL setup, received significantly fewer baths than scheduled, had greasy hair despite repeated family requests for hair washing, and was observed in bed with a CNA confirming that hair care is part of ADLs; the Administrator stated all residents should be receiving showers without excuses.
A facility failed to follow its own smoke-free policy and care plan for a grandfathered supervised smoker. A resident with hemiplegia, vascular dementia, lack of coordination, and moderate cognitive impairment was care planned as a supervised smoker requiring staff oversight at designated smoking times. However, review of assignment sheets on multiple days showed no staff assigned to smoke breaks, and observations found the resident waiting in the lobby at scheduled smoking times without staff arriving, then returning to his room. Staff, including an RN, an LPN, a CNA, and the staffing coordinator, confirmed that no specific person was designated to supervise smoking and that it was generally assumed the CNA on the resident’s hall would handle it, leading the resident to report that he frequently missed his smoke breaks.
A cognitively intact resident with hemiplegia, gait impairment, and right-hand contracture had a documented preference for going outside and using his motorized wheelchair independently. After an incident involving driving the power chair while impaired on THC, the Medical Director removed the wheelchair, limiting the resident’s mobility; staff noted the resident felt his freedom had been taken away, and the resident signed AMA related to the incident.
The facility failed to properly label and store food, with expired items and undated frozen pizzas found in storage. Additionally, a staff member did not follow hand hygiene protocols after touching a trash can lid, continuing food preparation without washing hands. These deficiencies could increase the risk of foodborne illness for residents.
The facility failed to provide written transfer notices to residents and their responsible parties for hospitalizations. A resident with dementia, another with chronic kidney disease, and a third with cognitive impairment were transferred without written notification. The Director of Health Services acknowledged the lack of awareness and policy regarding this requirement.
The facility failed to assist residents with hand hygiene before meals, as observed in five residents who required varying levels of assistance. Staff interviews revealed inconsistencies in practice, with some staff not assisting unless hands were visibly soiled, citing lack of resources and time. The Infection Control Preventionist and Director of Health Services acknowledged the absence of a specific policy for hand hygiene before meals.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident with a history of inappropriate behavior. Despite witnessing incidents, staff failed to follow the facility's abuse prevention policy and care plan interventions, allowing the abuse to occur in front of the nursing station. The facility's investigation was inadequate, as no additional staff or residents were interviewed, and there was a delay in providing psych services to the offending resident.
The facility failed to thoroughly investigate two incidents of resident-to-resident sexual abuse. Despite policy requirements, the facility did not interview additional staff, residents, or family members present in surveillance footage during incidents involving a resident groping another. The Administrator confirmed that no further interviews were conducted to ensure a comprehensive investigation.
Failure to Provide Preferred Language Communication Services
Penalty
Summary
The facility failed to honor a resident’s right to communicate in his preferred language, Spanish, despite documentation and policies indicating that language services were available. The resident’s EMR listed Spanish (Castilian) as his preferred language, and his annual MDS showed a BIMS score of 13, indicating little or no cognitive decline. His care plan identified that he did not speak the dominant language of the facility, noted that he understood some English, and outlined approaches such as using simple English phrases, encouraging gestures or assistive devices, involving family or friends who spoke his language, and providing a language interpreter line or foreign language translation device. The facility’s Notice of Nondiscrimination also stated that free language services, including qualified interpreters and information in other languages, were available for people whose primary language was not English. In practice, staff did not implement these communication supports for this resident. A RN reported attempting to understand the resident using nonverbal cues and English, noting her own primary language was Filipino and that the resident spoke Spanish. A CNA stated that although the resident’s preferred language was Spanish, she asked him to communicate in English and did not use other communication methods. An LPN reported difficulty understanding the resident due to the language barrier and acknowledged he did not speak Spanish; he stated that CNAs were only able to obtain a few phrases from the resident. During an interview with the resident and the LPN, an interpreter from a language line was brought in using a postcard with the language line information, and the LPN indicated he had never used the language line before. The resident stated he had never used the language line to communicate with staff and that he could not have a meaningful conversation, only trying to understand what was happening.
Failure to Maintain Clean and Intact PTAC Units in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain PTAC (Packaged Terminal Air Conditioner) units in a safe, clean, and intact condition as required by facility policy and resident rights to a safe, clean, comfortable, and homelike environment. The facility’s HVAC policy required staff to remove or open the PTAC access cover, inspect and clean or replace dirty air filters, reinstall the filter and access cover, clean the grill, and ensure filters were replaced or thoroughly cleaned at least every three months. Despite this policy, observations in two rooms on the 200 Hall showed PTAC units that were not properly maintained, including broken components, visible residue, debris, and rust. In one room, observations on two separate days revealed a PTAC unit with a broken front grill, visible residue inside the unit, and a broken air filter. In another room, observations on two separate days showed a PTAC unit containing debris and visible rust. During an observation and interview, the Maintenance Supervisor confirmed that the PTAC unit in the first room had a broken front grill with an approximately six-inch by four-inch piece of plastic missing, and that the PTAC unit in the second room had a main screen that was rusty and clogged. The Maintenance Supervisor stated that PTAC units were serviced monthly and acknowledged the observed units were not in good condition. In a separate interview, the Administrator stated that maintenance staff were responsible for the cleanliness and upkeep of PTAC units, that the expectation was for the units to be routinely cleaned and maintained, and that failure to maintain PTAC units could negatively impact cleanliness.
Failure to Provide and Document Scheduled Bathing and ADL Care for Three Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document scheduled bathing and related ADLs for three dependent residents, despite a policy requiring CNAs and nurses to document ADL care at the point of care and for nurses to review ADL documentation daily. The facility’s policy states that ADLs must be tracked daily in the EHR or CNA ADL flow sheet and that nurses should not accept illegible documentation. For one resident with hemiplegia, morbid obesity, CHF, diabetes, muscle weakness, difficulty walking, and abnormal posture, the MDS showed the resident was cognitively intact and required substantial to maximal assistance with bathing and other ADLs, and the care plan called for showers or baths on scheduled days and as needed, with daily hygiene care. However, review of bathing sheets over several weeks showed only eight documented showers or bed baths, fewer than the three scheduled showers per week, with no documentation of refusals in either the bathing records or progress notes. Interviews with this resident revealed she understood she was supposed to receive showers three times per week and reported she had not received a shower that week and generally only received one shower per week. She stated she had never refused showers and wanted showers or bed baths three times per week as scheduled. CNAs interviewed stated residents typically receive showers three times per week, that refusals should be documented after multiple attempts, and that this resident did not refuse showers. An LPN confirmed the resident’s shower schedule, acknowledged that she did not consistently receive showers or bed baths, and, after reviewing the shower sheets, stated it appeared the resident had not been consistently asked to shower. The LPN and the LPN Unit Manager both stated that if care or refusals were not documented, it meant it was not done, and the Unit Manager acknowledged she had not been verifying showers daily, citing being busy. For a second resident with peripheral vascular disease, gait abnormalities, a left below-knee amputation, phantom limb pain, legal blindness, and a need for assistance with personal care, the MDS showed the resident was cognitively intact, and the care plan included providing showers or baths on scheduled days and as needed. Review of bathing sheets over about a month showed bathing documented on 14 dates, but only six baths were actually received, fewer than the three scheduled showers per week, with only one documented refusal due to cold water. The LPN Unit Manager confirmed, based on the point-of-care history, that the resident did not receive scheduled bathing and reiterated that if it was not charted, it was not done. During observation and interview, this resident, found lying in bed disheveled, stated she was not refusing to bathe and that staff were simply lazy, and confirmed she wanted the baths. For a third resident with unspecified dementia, white matter disease, gait abnormalities, need for assistance with personal care, and bilateral artificial hip joints, the MDS indicated severe cognitive impairment. The care plan identified risk for ADL decline related to impaired mobility and dementia, with goals that ADL needs be met and interventions including providing showers per schedule and setting up the resident for ADLs. Review of bathing sheets over a similar period showed bathing documented on 14 dates, but only five baths were received, again fewer than the three scheduled showers per week, with only one documented refusal. A family representative reported having requested staff three or four times over two weeks to wash the resident’s hair during bathing. A CNA described ADLs as including washing hair, shaving, bathing the body, and cutting nails, and, on observation, confirmed the resident’s hair appeared greasy while the resident was lying in bed. The Administrator confirmed that everyone should be receiving showers and that there were no excuses for not doing so.
Failure to Provide Assigned Supervision for Grandfathered Supervised Smoker
Penalty
Summary
The deficiency involves the facility’s failure to follow its Smoke Free Policy and care plan requirements for a grandfathered supervised smoker, resulting in a lack of assigned staff supervision during designated smoking times. The facility’s policy states that when a grandfathered resident is identified as needing supervision, a partner must be physically present in the designated smoking area for all supervised smokers. The resident’s EHR documented diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, unspecified lack of coordination, hypertension, vascular dementia, and bilateral age-related nuclear cataracts. The resident was identified as a current every day smoker, with a quarterly MDS showing a BIMS score of 12 (moderate cognitive impairment), and the care plan documented that he was a supervised smoker at risk for smoking-related injury, requiring staff supervision during smoking at designated times. Despite these documented needs and the facility’s policy, review of CNA assignment sheets for multiple dates showed no medical staff assigned to supervise smoke breaks. Interviews with nursing staff and the staffing coordinator confirmed that no specific individual was designated for the resident’s smoke breaks and that it was generally assumed the CNA on the 100 hall would manage this responsibility. Observations on two separate days showed the resident waiting in the lobby at scheduled smoking times without staff arriving to supervise, leading him to return to his room and report that he frequently missed his smoke breaks. Staff interviews further revealed confusion and inconsistency about who was responsible for supervising smoking, including reference to a prior assignment book that may no longer be in use, demonstrating that the facility did not implement its own procedures for supervised smoking for this resident.
Resident’s motorized wheelchair removed after THC-related incident
Penalty
Summary
The facility failed to promote care in a manner that maintained or enhanced a resident’s dignity, respect, and rights for one resident who was cognitively intact with a BIMS score of 15 and who had diagnoses including hemiplegia and hemiparesis following cerebral infarction, right hand contracture, gait and mobility abnormalities, unsteadiness on feet, weakness, and generalized muscle weakness. The resident was his own responsible party, used a motorized wheelchair independently, and had a documented preference for going outside for fresh air and self-directed activities, including signing himself out and going off campus when the weather was good. The resident’s motorized wheelchair was removed by the Medical Director after an incident in which he was reported to have driven the chair while impaired on THC. Documentation showed the interdisciplinary team discussed the incident and stated that if he chose to go off grounds he needed an adult to accompany him for safety, but the resident reported that his freedom had been taken away and that he might go to another facility. A note indicated he signed AMA for operating the electric wheelchair while impaired, and the Medical Director confirmed the wheelchair was removed and that it limited the resident’s mobility. Staff also stated that rapid drug screening could have been presented, but the resident was not drug screened on the day of the incident and was tested several days later.
Deficiencies in Food Storage and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices in the kitchen, as well as adequate hand hygiene by staff, which could potentially lead to the spread of foodborne illness and infection among residents. During an inspection, it was observed that six unopened containers of poultry seasoning were stored past their expiration date, and frozen pizzas were found without any received, open, or expiration dates in the walk-in freezer. Additionally, opened cases of sliced ham and beef roast in the walk-in cooler were not labeled with open dates, only received dates. The Dietary Manager (DM) and Cook1 acknowledged these oversights, with Cook1 admitting that the expired poultry seasoning should have been discarded earlier. Furthermore, the facility's staff failed to adhere to hand hygiene protocols. Cook1 was observed preparing food without washing hands after touching the trash can lid, which is against the facility's hand washing policy. The DM confirmed that dietary staff are required to wash their hands after handling unclean items, such as trash, to prevent the spread of bacteria. These lapses in food safety and hygiene practices were identified as deficiencies during the survey, posing a risk to the health of 108 out of 109 residents receiving meals from the kitchen.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification of hospital transfers to residents and their responsible parties (RPs) for three residents, which is a requirement. Resident 80, who was admitted with a diagnosis of dementia, was transferred to the hospital due to an elevated temperature and a painful, swollen elbow. Although the family was notified by phone, there was no written notice provided. The Director of Health Services (DHS) admitted to not being aware of the requirement for written notices and confirmed that the facility lacked a policy addressing this requirement. Resident 32, with chronic kidney disease and a femur fracture, was transferred to the hospital following a fall and head laceration. The resident was sent with a packet of papers, but no written notice of transfer was provided to the resident or RP. Similarly, Resident 73, who was cognitively impaired, was transferred to the hospital due to seizure-like activities without a written notice being provided. The facility was unable to produce any documentation of written notices for these transfers, indicating a systemic issue in their notification process.
Failure to Provide Hand Hygiene Before Meals
Penalty
Summary
The facility failed to offer hand hygiene to residents prior to meals, as observed in five residents out of a sample of 32. These residents, who had varying degrees of cognitive impairment and required assistance with hygiene, were not assisted with hand washing before meals. For instance, one resident with moderately impaired cognition and dependent on staff for hygiene was not helped with hand washing before meals, despite expressing a desire to do so. Another resident, who was bed-bound and required moderate assistance with hygiene, also reported not being offered help with hand washing before meals. Interviews with staff revealed inconsistencies in the practice of assisting residents with hand hygiene. A Licensed Practical Nurse admitted to not assisting a resident with hand washing before setting up their meal tray. Certified Nurse Aides also reported not assisting residents with hand sanitation unless their hands were visibly soiled, citing a lack of hand wipes and time constraints. The Infection Control Preventionist acknowledged that while hand wipes were used in the dining room, they were not used for residents on the units, and the Director of Health Services confirmed that there was no specific policy for hand hygiene before meals, although it was expected to be done to prevent infections.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R62, from sexual abuse by another resident, R50. R62, who was admitted with dementia and Alzheimer's, was not cognitively intact, as indicated by a BIMS score of 5 out of 15. R50, who had a history of dementia, psychotic disturbance, and high-risk heterosexual behavior, was involved in inappropriate sexual behavior towards female residents, including R62. The facility's policy on preventing abuse was not followed, as evidenced by incidents on 06/10/24 and 07/01/24 where R50 was seen groping R62 in front of the nursing station. Staff members witnessed these incidents but failed to separate the residents or follow the care plan interventions. The facility's investigation revealed that no additional staff or residents were interviewed after the incidents, and there was a lack of documentation regarding R50's receipt of psych services until several weeks later. Surveillance footage confirmed the inappropriate contact between R50 and R62, and staff did not adequately intervene to ensure the safety of the residents. The Administrator acknowledged that staff did not adhere to the abuse policy or the care plan, which required separating the residents to prevent further incidents. Despite these failures, there have been no further incidents reported between R50 and R62 or with other residents.
Inadequate Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into two incidents of resident-to-resident sexual abuse involving Resident 62 and Resident 50. The facility's policy on the prevention of patient abuse, neglect, exploitation, mistreatment, and misappropriation of property requires a comprehensive investigation, including obtaining signed statements from pertinent parties and assessing the cognitive status of victims and witnesses. However, during the incidents on June 10 and July 1, the facility did not interview additional staff, residents, or family members present in the surveillance footage to gather further witness statements or ensure that no other individuals were affected. The first incident was reported by an LPN on June 10, when Resident 50 was observed groping Resident 62. The facility's investigation did not include interviews with other residents or staff members following a review of surveillance cameras. In the second incident, reported on July 1 by a CNA who witnessed Resident 50 grabbing Resident 62's breast, additional staff members were interviewed, but there was no evidence that residents or Resident 50's family were interviewed. The Administrator confirmed that no further interviews were conducted to ensure a comprehensive investigation.
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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 Fort Oglethorpe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare Ft Oglethorpe | 1.1 mi | ★★★★★ | 2 | 0 |
| Center For Advanced Rehab At Parkside, The | 1.4 mi | ★★★★★ | 10 | 0 |
| Nhc Healthcare Rossville | 3.1 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of East Ridge | 3.3 mi | ★★★★★ | 6 | 0 |
| Nhc Healthcare, Chattanooga | 6.1 mi | ★★★★★ | 0 | 0 |
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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.