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 - Lithonia, Llc during CMS and state inspections, most recent first.
Food safety practices were not followed in the kitchen when expired sour cream and milk were found in the walk-in cooler, expired milk was placed on meal trays and carts, and pork chops were observed submerged in water in the sink used for produce washing and meat thawing. A cook also reported manually adding sanitizer solution when the sanitizer machine was not working, without testing the concentration or measuring the volume, while dietary staff stated they had not received training on storage, labeling, and dating.
Dumpster Area Not Kept Clean and Closed: The facility failed to keep the outdoor dumpster and surrounding refuse area free of litter and in a sanitary condition. Surveyors observed two dumpsters, with one dumpster door left open and trash bags overflowing, along with debris including a box, gloves, straw remnants, and surgical masks around the area. The DM acknowledged the open dumpster and debris, the RD was unsure who was responsible for upkeep, and the Maintenance Director stated his department was responsible for dumpster maintenance.
Oxygen concentrator filter not maintained clean. A resident with chronic respiratory failure with hypoxia, dementia, shortness of breath, and dependence on supplemental oxygen had an oxygen concentrator filter observed with grey, fuzzy debris on multiple occasions. Facility policy required the external filter to be washed weekly and as needed, but staff interviews showed unclear responsibility for cleaning the filter, and the LPN, Maintenance Director, DON, and Administrator all observed visible dust or debris on the equipment.
An unlocked medication cart on the G Hall Corridor was observed unattended and out of direct sight of an RN for three to five minutes. RN DD confirmed the cart should have been locked, and CMA EE stated she stepped away briefly to get ice. The facility policy states medication supplies are to be stored securely and accessible only to authorized personnel.
Surveyors found that staff failed to maintain required cold holding temperatures for orange juice during breakfast meal service. Facility policy required the Dietary Manager or designee to ensure all potentially hazardous cold foods were held at or below 41°F, including keeping items on ice during tray line and limiting time on trays before service. During an observation, a cook measured three four-ounce containers of orange juice at temperatures above 51°F instead of 41°F or below. The cook acknowledged the correct standard, and the RD later confirmed that cold items should be kept on ice during tray line. This failure had the potential to affect most residents receiving an oral diet.
The facility failed to ensure proper food storage and sanitation, with expired and unlabeled food items found in storage areas. The ice machine showed signs of inadequate cleaning, and wet nesting of clean kitchenware was observed. The Dietary Manager and Registered Dietitian acknowledged these issues, indicating ongoing staff training and audits.
A facility failed to assess a resident with dementia for self-administration of medication, leaving pain-relieving ointments unsecured at the bedside. Another resident with intact cognition had medications left unattended in her room, contrary to facility policy. Staff interviews revealed a lack of awareness and adherence to procedures, posing risks of unauthorized access and medication interactions.
A resident with paranoid schizophrenia was not screened for PASRR level two, despite facility policy requiring such assessments for significant mental illnesses. The resident, taking anti-psychotropic and anti-depressant medications, was not referred for further evaluation as she exhibited no triggering behaviors. Staff interviews confirmed the oversight, potentially impacting the resident's access to appropriate care.
A CNA failed to clean a shared blood pressure cuff between uses on two residents, contrary to the facility's infection control policy. The CNA initially claimed to have cleaned the cuff but later admitted she had not, citing nervousness. The ADON confirmed the requirement for cleaning before and after each use.
The facility failed to resolve grievances related to lost personal items for three residents, as required by its grievance policy. Multiple clothing items went missing, and grievances were not documented or followed up in a timely manner. Interviews revealed a lack of clear procedures and accountability in handling grievances and lost items, leading to unresolved issues and dissatisfaction among residents and their families.
A resident with end-stage renal disease and bilateral amputations was not offered showers as per her care plan, despite being cognitively intact and expressing a preference for showers. The facility's records showed she was scheduled for showers twice a week, but she often received bed baths instead. Staff interviews revealed a lack of awareness of her preferences, and the DON confirmed she was not on the daily showers list, leading to inadequate hygiene care.
A facility failed to develop a person-centered care plan for a resident, a bilateral amputee with end-stage renal disease, regarding her bathing preferences. Despite being cognitively intact and expressing a preference for showers, the resident was not offered showers as per her care plan. Instead, she received bed or sponge baths, and staff were unaware of her preferences. The DON confirmed the resident was not on the Daily Showers list, leading to her receiving only one shower since admission.
A facility failed to maintain mechanical lifts in a state of readiness, affecting a resident with mobility and cognitive impairments. The resident, dependent on mechanical lifts for daily activities, was left waiting in discomfort due to an uncharged lift. Observations revealed multiple lifts not plugged in, and the DON acknowledged the issue, despite new lifts being purchased.
Expired Food and Improper Sanitizing Practices in Kitchen
Penalty
Summary
Food safety practices were not adequately upheld in the kitchen, as opened food products in the walk-in refrigerator were found unlabeled, undated, and not discarded when expired. During the initial tour, surveyors observed 19 one-ounce single packs of sour cream with an expiration date of 01/12/2026 and 10 half-pint cartons of milk with an expiration date of 03/15/2026 in the walk-in cooler/refrigerator. The facility’s policy required foods to be used before expiration, use-by, best-by, or sell-by dates and to be discarded if not used by those dates, and required food and beverage items to have identifying labels and received/opened dates as applicable. Surveyors also observed a large silver bowl containing meat, identified by the cook as pork chops, submerged in water in the sink designated for washing produce and thawing meat. During breakfast tray pass, expired milk was found on meal trays and carts, including on trays for two residents. One resident had a BIMS score of 14 with no cognitive impairment and a care plan noting risk for altered nutritional status with instructions to observe intake and provide the ordered diet. Another resident had a BIMS score of 12 with no cognitive impairment and a care plan noting a therapeutic diet with diet as ordered. In addition, the sanitizer machine for the three-compartment sink was not working, and a cook stated he manually poured sanitizer solution into the water without testing the sanitizer concentration or measuring the volume.
Dumpster Area Not Kept Clean and Closed
Penalty
Summary
The facility failed to ensure the outdoor garbage and refuse area was kept free of litter and maintained in a sanitary manner. The facility policy titled, Waste Disposal: Dietary Services, dated 10/20/2025, stated that dumpster lids, doors, and plugs should be kept closed at all times and that dumpster and surrounding areas should be kept clean and free of debris. During observation on 03/18/2026 at 11:58 AM, the Dietary Manager confirmed the presence of two dumpsters. The dumpster adjacent to the brick wall had its left door completely open and was overflowing with clear trash bags protruding from the opening. Surveyors also observed one compressed empty box, purple gloves, remnants of straws, and several white surgical face masks surrounding the dumpsters. The Dietary Manager acknowledged the trash and debris around the dumpster and confirmed the dumpster was open. A later observation on 03/18/2026 at 3:00 PM again showed the same dumpster mid-open with overflowing clear trash bags and purple gloves protruding onto the ground, along with the same debris around the dumpsters. The Registered Dietitian stated she was uncertain who was responsible for maintaining the dumpster, while the Maintenance Director stated his department was responsible for dumpster upkeep and noted that the night shift had been notified of their responsibilities.
Oxygen concentrator filter not maintained clean
Penalty
Summary
The facility failed to maintain respiratory equipment in a clean and sanitary manner for one resident receiving oxygen therapy. The resident was admitted with diagnoses including chronic respiratory failure with hypoxia, dementia, shortness of breath, and dependence on supplemental oxygen. The resident’s annual MDS documented that the resident was dependent on staff for all activities of daily living and received oxygen therapy and hospice services. Physician orders included oxygen at 3 liters per minute via nasal cannula continuously, with orders to change respiratory circuit/supplies weekly and monitor pulse oximetry as needed, and the care plan addressed oxygen use with interventions to administer oxygen as ordered and monitor for signs of hypoxia. Observations of the resident’s oxygen concentrator on three separate occasions showed the concentrator filter had grey, fuzzy debris present. Facility policy stated the large external black filter should be washed with soap and water once each week and as needed, and the exterior of concentrators should be cleaned weekly and between resident use. During interviews, the LPN, Maintenance Director, DON, and Administrator each observed the filter and noted visible dust or debris. The LPN stated the Maintenance Director was responsible for cleaning the filter, the Maintenance Director stated CNAs were expected to notify Maintenance when filters were dirty, the DON stated she was not aware of who was responsible for cleaning the filters or the process, and the Administrator stated she was unsure how often the filters were cleaned.
Unlocked Medication Cart Left Unattended
Penalty
Summary
Medications and biologicals were not stored securely on one of eight hallways when a medication cart on the G Hall Corridor was observed unlocked, unattended, and out of direct sight of a nurse. The cart remained unlocked and unattended for three to five minutes during the observation. The facility policy titled Medication Storage in Health Care Centers states that medications and biologicals are to be stored safely, securely, and properly, and that the medication supply is accessible only to licensed nursing personnel, certified medication aides, and pharmacy personnel. During interviews, RN DD confirmed the cart was unlocked and unattended and stated it should have been locked, and CMA EE stated she stepped away from the cart briefly to get ice.
Improper Cold Holding Temperatures for Orange Juice During Meal Service
Penalty
Summary
The facility failed to ensure that cold food, specifically orange juice, was maintained at or below 41°F in accordance with its policy titled “Food Temperatures.” The policy, revised on 10/21/2025, states that the Dietary Manager or designee is responsible for ensuring all food reaches and maintains proper temperatures prior to tray assembly, and that all potentially hazardous cold foods must be held at 41°F or less, including being held on the line in an ice bath and not set up on trays more than 15 minutes before meal service unless kept chilled. During a breakfast observation on 03/05/2026 at 7:29 a.m., a cook used the facility’s thermometer to check three four-ounce plastic containers of orange juice, which each registered above 51°F instead of the required 41°F or below. The cook acknowledged that the orange juice should have been at or below 41°F. A subsequent interview with the Registered Dietician on 03/06/2026 confirmed that cold items should be kept on ice during tray line service and that she had spoken with dietary staff about this practice. This deficiency had the potential to affect 134 of 141 residents receiving an oral diet by promoting the growth of pathogens that cause foodborne illness. No specific individual resident medical histories or conditions at the time of the deficiency were described in the report.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food storage and sanitation practices in the dietary department, as observed during a survey. Opened food items in the dry storage and walk-in refrigerator were not securely wrapped, labeled, or dated, and some were past their expiration dates. Specific items included expired thickened orange juice, nutritional drinks, stuffing mix, sour cream packets, cottage cheese, cream cheese icing, and a cabbage and carrot mix. Additionally, a head of lettuce was found without a label or date. The Dietary Manager (DM) acknowledged the responsibility of all staff to check expiration dates and admitted to ongoing in-services for new staff regarding storage, labeling, and dating. The DM also confirmed that the ice machine, which had not been deep cleaned since a previous date, showed signs of a reddish-black substance, indicating a lack of routine maintenance. Furthermore, the facility did not maintain sanitary cleanliness in the kitchen, as evidenced by wet nesting of clean pots, pans, and baking trays. The sanitizing process involved rewashing dishes through a low-temperature dishwasher, but wet nesting was still observed. The Registered Dietitian (RD) confirmed that kitchen audits were conducted monthly, focusing on equipment base, labeling, dating, and cleanliness. However, the RD did not physically label or date food items, relying on staff to do so when deliveries arrived. The RD also noted that she had reported the need for ice machine cleaning in the previous month's report. Both the DM and RD acknowledged the issue of wet nesting and discussed plans to address it, but these actions were not part of the deficiency findings.
Failure to Secure Medications and Assess Self-Administration
Penalty
Summary
The facility failed to assess a resident, identified as R88, for self-administration of medication and did not secure medications properly. R88, who has a diagnosis of Alzheimer's disease with early onset and dementia, was observed with pain-relieving ointments on his bedside table. Despite the facility's policy requiring a prescriber's order and an assessment for self-administration, there was no documentation or care plan indicating that R88 was authorized to self-administer these medications. Interviews with staff, including a CNA and an LPN, revealed a lack of awareness regarding R88's self-administration of medication, highlighting a gap in communication and adherence to the facility's procedures. Another resident, R43, was found with medications left unattended at her bedside, despite having intact cognition as indicated by a BIMS score of 15. The medications, which included ointments for various conditions, were reportedly left by nurses for CNAs to apply after the resident's bath. This practice was contrary to the facility's expectations, as stated by the Registered Nurse Supervisor and the Director of Nursing, who both emphasized that medications should not be left unattended in residents' rooms. Interviews with CNAs confirmed that this was a recurring issue, with medications being left at the bedside at least twice a week. The deficient practices observed in both cases had the potential to allow unauthorized access to medications by residents and visitors, posing a risk of medication interactions or overmedication. The facility's failure to adhere to its own policies regarding medication security and self-administration assessments contributed to these deficiencies, as evidenced by the lack of proper documentation and communication among staff members.
Failure to Conduct PASRR Level Two Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to conduct a Pre-Admission Screening and Resident Review (PASRR) level two for a resident diagnosed with paranoid schizophrenia, which is a significant mental illness. The facility's policy requires that residents with significant mental illness or intellectual/developmental disabilities undergo a PASRR level two assessment to ensure they receive care in the most integrated setting appropriate to their needs. However, the resident, who was admitted with a diagnosis of paranoid schizophrenia and was taking anti-psychotropic and anti-depressant medications, was not screened for PASRR level two. The care plan for the resident included interventions for paranoid schizophrenia and bipolar disorder, but there was no focus area for PASRR level two screening. Interviews with facility staff, including the RN Supervisor, Director of Nursing, and Social Services Director, revealed that the resident was not referred for a PASRR level two assessment because she did not exhibit any behaviors that would trigger such a referral. The Social Services Director confirmed that the resident was not referred for PASRR level two, as the facility's practice was to refer residents only if they exhibited behaviors indicative of a major mental disorder. This oversight had the potential to prevent the resident from receiving necessary specialized services.
Failure to Clean Shared Blood Pressure Cuff
Penalty
Summary
The facility failed to adhere to its policy on cleaning and disinfecting shared medical equipment, specifically a blood pressure cuff, before and after use between residents. The policy, reviewed on 12/29/2023, mandates that shared equipment such as blood pressure cuffs and pulse oximeters be cleaned with soap and water or an appropriate cleaner and then disinfected prior to and after use on different patients. However, an observation on 9/4/2024 revealed that a Certified Nurses Aid (CNA) did not clean the blood pressure cuff between taking vital signs of two residents in the same room. The CNA was observed removing the electronic blood pressure cuff from one room and using it on two residents without cleaning it in between. When questioned, the CNA initially claimed to have cleaned the cuff but later admitted she had not done so, citing nervousness. The Assistant Director of Nurses confirmed that the protocol requires cleaning before and after each use. The CNA was seen searching for disinfecting wipes at the nurse's station after completing her rounds, indicating a lapse in following the established infection control procedures.
Failure to Resolve Grievances Related to Lost Personal Items
Penalty
Summary
The facility failed to appropriately resolve grievances related to lost personal items for three residents. The facility's grievance policy requires that grievances be resolved within a reasonable time frame and that the complainant be kept informed of the progress. However, the facility did not adhere to this policy. For one resident, multiple clothing items went missing in April 2023, but only one unrelated grievance was documented in December 2023. The family expressed distrust in the facility's ability to keep items safe. Another resident filed a grievance for missing clothing in February 2024, but no follow-up was completed until the survey investigation in March 2024. A third resident filed a grievance in September 2022 for missing a large amount of clothing, but no resolution was documented. Interviews with facility staff revealed a lack of clear procedures and accountability in handling grievances and lost items. The Administrator acknowledged the need for improvement in the lost and found process and the absence of a policy for laundry services. The Social Service Specialist indicated that grievances should be investigated and followed up within 14 days, but this was not consistently done. The Laundry Staff reported issues with labeling and returning laundry, and unclaimed items were kept in a container for an unknown period. The facility's failure to follow its grievance policy and effectively manage lost items led to unresolved grievances and dissatisfaction among residents and their families.
Failure to Offer Resident Scheduled Showers
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not offering her the choice of showers, which was part of her care plan. The resident, identified as R2, was a bilateral amputee with end-stage renal disease on hemodialysis. Despite being cognitively intact and expressing a preference for showers, she was not offered this option. The facility's records showed that R2 was scheduled for showers on Mondays and Thursdays, but she often received bed baths instead. Interviews with staff revealed a lack of awareness and understanding of R2's preferences and care plan, leading to her not being offered showers. The Dialysis Social Worker reported that R2 arrived for treatment in the same clothes over several days and had poor hygiene, indicating a lack of proper bathing. The Director of Nursing confirmed that R2 was care planned for showers twice a week but was not on the daily showers list, and her shower days coincided with her dialysis days, which did not accommodate her needs. This oversight resulted in R2 not receiving showers as per her care plan, affecting her comfort and hygiene.
Failure to Implement Resident's Bathing Preferences
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident, identified as R2, regarding her bathing preferences. R2, a bilateral amputee with end-stage renal disease on hemodialysis, was cognitively intact and expressed that it was somewhat important for her to choose between different bathing options. Despite this, the facility's ADL care plans did not include her preferences for showers or baths. The care plans dated March 13, 2024, lacked any goals or interventions related to her bathing preferences. Observations and interviews revealed that R2 was not offered showers as per her care plan, which stated she should receive showers on Wednesday and Saturday evenings. Instead, she was given bed or sponge baths, and staff were unaware of her preference for showers. The Director of Nursing confirmed that R2 was not on the Daily Showers list, despite being care planned for showers twice a week. This oversight led to R2 receiving only one shower since her admission in November 2023.
Mechanical Lift Readiness Deficiency
Penalty
Summary
The facility failed to maintain mechanical lifts in a state of readiness, impacting the care of a resident with significant mobility and cognitive impairments. The resident, who has a history of arthritis, Alzheimer's Disease, cerebrovascular accident, dementia, and hemiplegia or hemiparesis, was observed to be dependent on mechanical lifts for all activities of daily living. During an observation, multiple mechanical lifts were found in the hallways, not in use, and most were not plugged into power sockets, rendering them unavailable for immediate use. On a subsequent observation, a resident was found in discomfort, requesting assistance to be moved from a wheelchair to a bed. A CNA indicated that the mechanical lift near the resident's room was not charged, necessitating a wait for assistance. The Director of Nursing acknowledged issues with the mechanical lifts, noting that new lifts had been purchased and additional ones were approved for purchase. Despite an in-service training, the deficiency persisted, as staff were expected to ensure all lifts were charged and ready for use.
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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 Lithonia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rockdale Healthcare Center | 6.4 mi | ★★★★★ | 1 | 0 |
| Westbury Center Of Conyers For Nursing And Healing | 6.9 mi | ★★★★★ | 8 | 0 |
| Pebblebrook Health Center At Park Springs | 6.9 mi | ★★★★★ | 0 | 0 |
| Georgia Regional Atlanta Ltc | 7.6 mi | ★★★★★ | 3 | 0 |
| Glenwood Health Center By Harborview | 8.1 mi | ★★★★★ | 10 | 0 |
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