Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 - Lilburn during CMS and state inspections, most recent first.
A registered nurse failed to perform hand hygiene at key moments during a medication pass and did not properly clean shared medical equipment, such as a blood pressure machine and glucometer, between use with multiple residents. The nurse also used inadequate cleaning methods and expressed misunderstanding about required infection control practices. Facility leadership confirmed that these actions were not in line with established infection prevention policies.
A room in B Hall was found to have PTAC filters with visible grey, fuzzy debris, indicating a failure to follow the facility's policy for regular cleaning and inspection. The Maintenance Director confirmed the filters were not cleaned as scheduled due to other priorities, and both the Maintenance Director and Administrator acknowledged the absence of a formal Maintenance or Environmental policy.
Two residents prescribed psychotropic medications did not have required behavior monitoring documented every shift as ordered by their physicians. Despite clear orders and care plans, multiple dates were identified where staff failed to record behavioral observations, and interviews with nursing staff and the DHS confirmed that this documentation is a standard responsibility for each shift.
A resident with a documented chocolate allergy was served a meal tray containing chocolate cake, despite clear indications of the allergy on the care plan and tray slip. Multiple staff involved in meal preparation and delivery failed to recognize or remove the allergen, and the error was only avoided because the resident identified the issue and did not consume the cake.
A resident with multiple serious health conditions had a change in code status to DNR and was referred to hospice, as documented in physician orders and a POLST form. However, the care plan was not updated to reflect this change and continued to list the resident as full code. Staff interviews confirmed the care plan was inaccurate and not promptly updated as required by facility policy.
Staff failed to administer and document medications as ordered for two residents, including missed or delayed doses of antiviral and IV antibiotic therapies. In both cases, required documentation was incomplete, and facility policy for medication administration and follow-up was not followed, as confirmed by MAR review and staff interviews.
A resident with a documented chocolate allergy and a dislike for rice was served both a chocolate dessert and a rice-based meal, despite clear indications on her tray slip. Staff interviews confirmed awareness of the resident's dietary needs, but lapses in tray assembly and verification led to the errors. The facility lacked a policy on adhering to food preferences and allergy restrictions, contributing to the deficiency.
Failure to Perform Hand Hygiene and Sanitize Shared Equipment During Medication Pass
Penalty
Summary
During a medication pass, a registered nurse (RN) failed to perform hand hygiene at multiple critical points, including before preparing medications, after returning from the medication room, after entering and exiting resident rooms, and before donning and after removing gloves. The RN also neglected to sanitize hands between caring for different residents and after handling shared medical equipment. These actions were observed during the care of four residents, where the RN repeatedly moved between rooms and tasks without following hand hygiene protocols as outlined in the facility's policies. In addition to lapses in hand hygiene, the RN did not properly clean and disinfect shared medical equipment, such as a blood pressure (BP) machine and glucometer, between resident uses. The BP machine was used on multiple residents without being sanitized, and the glucometer was only wiped with small alcohol prep pads instead of the required EPA-approved disinfectant wipes. The RN expressed a misunderstanding about the necessity of cleaning the BP cuff, believing it was only required for equipment exposed to blood. Interviews with the Infection Control Nurse and the Director of Health Services confirmed that facility policy requires hand hygiene before and after resident contact, before donning gloves, and after glove removal, as well as cleaning and disinfecting shared equipment between each use. The observed failures to follow these protocols were acknowledged by the RN, who later admitted to the surveyor that he should have sanitized both his hands and the BP cuff between residents.
Failure to Maintain Clean PTAC Filters in Resident Room
Penalty
Summary
The facility failed to maintain clean Packaged Terminal Air Conditioner (PTAC) filters in one room out of 18 rooms in B Hall, as observed on two separate occasions. The PTAC filters in the identified room were found to have grey, fuzzy debris, indicating they had not been cleaned according to the facility's policy. The policy required staff to remove, inspect, and clean or replace air filters as needed. However, the Maintenance Director confirmed that the filters were not cleaned as scheduled due to other priorities, despite a monthly cleaning schedule and a log system in place. Interviews with the Maintenance Director and the Administrator revealed that maintenance staff are responsible for cleaning the filters and that issues are reported via a logbook and a new TELS system. The Maintenance Director was not aware of any formal Maintenance policy, and the Administrator confirmed the absence of a Maintenance or Environmental policy. The Administrator also stated that both the Maintenance Director and Housekeeping Director oversee the cleaning of PTAC filters and expected them to be clean.
Failure to Document Required Behavior Monitoring for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to document required behavior monitoring for two residents who were prescribed psychotropic medications. For one resident with diagnoses including depression, anxiety disorder, and insomnia, physician orders required monitoring for signs and symptoms of behaviors and mood related to depression, anxiety, and chronic pain every shift. However, multiple dates across several months were identified where behavior monitoring was not recorded as required. The resident was observed to be alert and reported pain and insomnia, but no changes were requested at the time of the survey. Another resident with diagnoses of schizophrenia, PTSD, bipolar disorder, and depression was also not consistently monitored as ordered. The care plan and physician orders specified behavior monitoring every shift, with instructions to document observed behaviors such as sad mood, anxiety, insomnia, aggression, and other specified behaviors. Review of the Medication Administration Record revealed numerous shifts across three months where behavior monitoring documentation was missing on both day and night shifts. Interviews with nursing staff and the Director of Health Services confirmed that it is the responsibility of the assigned nurse to complete behavior monitoring documentation each shift, as these are physician orders. Staff acknowledged that the orders are visible on the Medication Administration Record and that there was no reason for the documentation to be missed. The Director of Health Services emphasized that failure to complete the required documentation could result in communication breakdowns and lack of necessary follow-up.
Failure to Follow Care Plan for Resident with Chocolate Allergy
Penalty
Summary
A deficiency occurred when a resident with a documented chocolate allergy was served a meal tray containing chocolate cake. The resident's care plan, which clearly indicated a chocolate allergy and specified that no food containing chocolate should be provided, was not followed. The allergy was documented in both the electronic health record and on the meal tray slip, which was supposed to be checked by staff responsible for meal distribution. Multiple staff members, including registered nurses, certified nursing assistants, and dietary aides, were involved in the meal tray preparation and delivery process. Despite the allergy being noted on the tray slip, a dietary aide placed the chocolate cake on the tray, and another aide, unfamiliar with the term "Black Forest Cake," did not recognize it as containing chocolate. The final verification step failed to catch the error, and the tray was delivered to the resident's room with the chocolate cake still present. The resident, who was cognitively intact, identified the error and did not consume the cake, confirming her allergy to staff. Interviews with staff revealed that while they were generally aware of the resident's allergy, lapses in communication and verification led to the failure to remove the chocolate cake from the tray. The facility's policy required staff to check tray tickets for allergies, but this protocol was not effectively followed, resulting in the deficiency.
Failure to Update Care Plan to Reflect Resident's Code Status Change
Penalty
Summary
The facility failed to update the care plan for a resident to accurately reflect her current code status following changes documented in physician orders and the POLST form. The resident, who had multiple complex medical diagnoses including cerebrovascular accident, hemiplegia, COPD, heart failure, diabetes, and chronic kidney disease, was initially admitted as a full code. Subsequent physician orders and a signed POLST form indicated a change to Do Not Resuscitate (DNR) status and a decision not to hospitalize or send the resident out for appointments, as well as a referral to hospice care. Despite these documented changes, the resident's care plan continued to list her as a full code, and this discrepancy was not corrected in a timely manner. Record reviews and staff interviews revealed that the facility's policy required care plan updates within seven days of any change in condition or code status. The LPN interviewed confirmed that code status information is available in multiple locations, including the care plan, but acknowledged the care plan was not accurate. The Social Work Director also confirmed the care plan did not reflect the resident's current DNR and hospice status and was unable to explain how the update was missed. This failure to update the care plan was identified through review of records and staff interviews.
Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
Staff failed to administer medications as ordered by physicians for two residents, as observed through record reviews, staff and resident interviews, and policy review. Facility policy requires medications to be administered and documented according to physician orders, with any missed or withheld doses to be explained and documented. In the first case, a resident with multiple diagnoses, including COPD, prostate cancer, and herpes zoster, had physician orders for both oral and topical Acyclovir to treat shingles. The first oral dose was not administered due to unavailability, and three additional doses were not signed as administered on the MAR. The resident filed a complaint, and comparison of his personal records with the MAR confirmed these discrepancies. Facility staff could not confirm whether the medication was given or simply not documented, and acknowledged that all doses must be documented, with reasons provided for any missed doses. In the second case, another resident was admitted for post-amputation care and required IV antibiotics (Ceftazidime) every eight hours via a PICC line. The hospital discharge summary specified the timing for the next dose, but the first dose was not administered until approximately 28 hours after admission, resulting in a significant gap in treatment. The MAR confirmed the delay, and staff interviews revealed that emergency medication storage was available, and procedures were in place to obtain or substitute medications if unavailable. However, these procedures were not followed, and the required documentation and physician notification were not completed. Both cases demonstrate a failure to follow physician orders and facility policy regarding medication administration and documentation. Staff interviews confirmed the expectation for complete and accurate documentation, including reasons for any missed doses, but this was not consistently practiced. The deficiencies were identified through direct observation, record review, and interviews with residents and staff.
Failure to Adhere to Resident Food Allergies and Preferences
Penalty
Summary
The facility failed to adhere to documented food preferences and allergy-related restrictions for one resident, resulting in the resident being served food items that were either disliked or posed an allergy risk. The resident, who was cognitively intact and had a documented chocolate allergy and a dislike for rice, was observed receiving a broccoli chicken rice casserole instead of the listed spaghetti with meat sauce, despite rice being noted as a dislike on her food slip. Additionally, the resident was served a piece of chocolate cake, even though her tray slip clearly indicated a chocolate allergy. Multiple staff interviews revealed that dietary and nursing staff were aware of the resident's chocolate allergy and food preferences, and that tray slips included this information. However, there was a breakdown in the process of verifying and assembling meal trays. Some staff members did not recognize that "Black Forest Cake" contained chocolate, and others admitted to possibly placing incorrect items on trays. The final verification process failed to prevent the chocolate cake from being served to the resident. The facility did not provide a policy related to adhering to food preferences and allergy-related restrictions. Staff, including dietary aides, CNAs, and the Dietary Kitchen Manager, acknowledged the errors and confirmed that the resident should not have received rice or chocolate. The administrator confirmed that staff are expected to follow tray slips carefully, especially regarding allergies and preferences, but this expectation was not met in this instance.
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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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How nearby facilities compare on the same public inspection record.
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| Life Care Center Of Gwinnett | 3.4 mi | ★★★★★ | 0 | 0 |
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| Stone Mountain Run Of Journey Llc | 6.2 mi | ★★★★★ | 9 | 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.