Average — CMS composite of the measures below.
A standard survey is most likely before 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 - Ocilla during CMS and state inspections, most recent first.
Soiled Wheelchairs in Resident Rooms: Wheelchairs in two resident rooms were observed with dirt and dust buildup, including a brown substance on one wheelchair seat. The Administrator confirmed the equipment was soiled, stated wheelchairs are cleaned monthly, and was unsure whether maintenance kept a log. The MDS Director said she maintained a monthly cleaning log but could not access the records due to a computer glitch, and the facility had no environmental/equipment policy.
A facility failed to implement person-centered care plans for several residents’ ADL-related nail care and for one resident’s ordered oxygen. Observations showed multiple residents with long, dirty, or untrimmed fingernails or toenails despite care plans that included nail care or ADL support, and one resident’s oxygen concentrator was set above the ordered 2 LPM. Staff and the MDS Coordinator confirmed that nail care was part of grooming/ADL care and that staff were expected to follow the care plans.
A resident with Alzheimer’s disease and COPD was observed wearing O2 via NC while the concentrator was set at 2.5 LPM instead of the ordered 2 LPM. An LPN confirmed the incorrect setting, and the ADHS and DHS stated nurses should verify the concentrator matches the physician’s order.
An LPN left a medication cart unlocked and out of eyesight during med pass while entering resident rooms, and later confirmed the cart was left unsecured during all observed instances. Surveyors also found dirt and a sticky substance in a medication cart drawer and a wet substance with wet sterile dressings in a treatment cart drawer; the WCN and ADHS confirmed the carts should be clean, dry, and secured.
Failure to provide nail care as part of ADL assistance affected five residents with cognitive impairment and dependence for personal hygiene. Observations showed long, dirty fingernails or toenails with brown or yellow substance underneath, and residents or staff confirmed the nails needed trimming and cleaning. The DHS stated nail care should occur during baths or be provided by CNAs or nurses depending on the resident, but records and observations showed the care plans and routine nail care were not being followed.
An LPN failed to follow physician orders and facility policy for a resident with a G-tube, moderate cognitive impairment, dysphagia, and chronic nausea/vomiting. The nurse did not check tube placement or residuals before bolus feeding and did not provide the ordered 200 mL water flush, using unmeasured water from a cup instead; the resident vomited immediately after the feeding.
A CNA passed out food trays to 10 residents without sanitizing her hands, then assisted a resident with positioning and touched the resident’s arms, shoulders, and seat before continuing to pass more trays without hand hygiene. The CNA confirmed she did not sanitize her hands before, between, or after these actions, despite the facility policy and leadership expectations for hand sanitation during tray service.
Surveyors found that the facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, resulting in a deficiency.
Soiled Wheelchairs in Resident Rooms
Penalty
Summary
The facility failed to ensure residents’ living areas were safe, clean, comfortable, and homelike in two of 51 rooms, involving wheelchairs and a personal fan with dirt and debris buildup. Observations on 9/16/2025, 9/17/2025, and 9/18/2025 showed wheelchairs in room [ROOM NUMBER]A and room [ROOM NUMBER] with dirt and dust accumulation on various parts of the equipment, including a brown substance on the seat of the wheelchair in room [ROOM NUMBER]. During a concurrent interview on 9/18/2025, the Administrator confirmed both wheelchairs were soiled with dirt and dust and that the wheelchair seat in room [ROOM NUMBER] had a brown substance. The Administrator stated wheelchairs are cleaned monthly and was unsure whether maintenance kept a log. The Maintenance Director stated she keeps a maintenance log for monthly wheelchair cleaning but did not have access to the records because of a computer glitch. The Surveyor reviewed photographs with the Maintenance Director, who confirmed the equipment was soiled and stated her expectation was that residents have clean, safe, working wheelchairs. When asked for a policy related to environment/equipment, the Administrator stated there was no environmental/equipment policy.
Failure to Implement Person-Centered Care Plans for Nail Care and Oxygen
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for five sampled residents related to nail care, and for one resident related to oxygen administration. The facility policy titled admission Comprehensive Plan of Care stated that the comprehensive person-centered care plan is to include measurable goals and timeframes to meet the resident’s medical, nursing, and psychosocial needs and the services to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial needs identified in the comprehensive assessment. For one resident with paraplegia, traumatic brain injury, and severe cognitive impairment, observations showed long jagged broken nails coated with a dark substance under the nails and around the cuticles on two separate occasions. The resident’s care plan included nail care as needed, and the resident had a physician order for podiatry/dental/ophthalmic care as needed. For another resident with moderate cognitive impairment and dependence for toileting and personal hygiene, the care plan included checking nails and ensuring they were clean, yet observations showed long brown fingernails on two occasions, and the resident stated the nails were too long and did not want them that way. A third resident with Alzheimer’s disease, COPD, dysphagia, and muscle weakness had a care plan that included setting up the resident for ADLs and oxygen as ordered. Observations showed long fingernails that the resident wanted cut, and the resident reported that toenails were addressed by podiatry but fingernails were not. The same resident’s oxygen order was for 2 LPM via nasal cannula continuously, but observations showed the concentrator set at 2.5 LPM and later between 2 and 2.5 LPM, and an LPN confirmed the oxygen setting was 2.5 LPM. Two additional residents had care plans that included setting up for ADLs, but observations showed their nails were long, thick, yellow, and dirty with debris underneath. One resident with diabetes, generalized weakness, and cognitive communication deficit had long, thick toenails with yellowish-brown substance underneath, and the other resident with severe cognitive impairment and dementia had long fingernails with brown and yellow substance underneath. In each case, the DHS and MDS Coordinator confirmed that nail care was part of ADL care and that staff were expected to follow the care plans, but the observed nail care and oxygen care were not being implemented as ordered or as reflected in the care plans.
Oxygen Setting Not Kept at Ordered Level
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when R28’s oxygen was not administered at the ordered setting. R28 had a Quarterly MDS dated 8/14/2025 showing a BIMS score of 11, indicating moderate cognitive impairment, and diagnoses including Alzheimer’s disease, COPD, dysphagia, and muscle weakness. Her care plan stated she used oxygen related to COPD, with the goal of maximizing oxygen saturation levels by administering oxygen as ordered by the physician. The physician order dated 7/26/2024 directed oxygen at 2 liters per minute via nasal cannula continuously every shift. Observations on 9/16/2025 at 9:50 a.m. and 9/17/2025 at 9:19 a.m. showed R28 wearing oxygen via nasal cannula while the oxygen concentrator was set at 2.5 LPM instead of the ordered 2 LPM. An LPN confirmed the concentrator was set at 2.5 LPM and should have been set at 2 LPM, and stated she was to check the concentrator settings and make sure residents were on the physician-ordered setting. The ADHS and DHS both confirmed that nurses should check the oxygen concentrator settings and verify they match the physician’s order.
Unlocked Medication Cart and Unsanitary Carts on Unit One
Penalty
Summary
The facility failed to ensure that a medication cart on Unit One was locked or under direct supervision of authorized staff while it was in an area where residents could access medications. During observation, an LPN left the medication cart unlocked and out of eyesight while entering resident rooms to administer medications, including standing behind a curtain and away from the cart during the med pass. The LPN later confirmed she left the cart unlocked and out of eyesight during all three observed instances and acknowledged that a resident could enter the medication cart. The facility policy stated that medication supply is accessible only to licensed nursing personnel, Certified Medications, and pharmacy personnel, and that medication carts should remain locked when out of eyesight of the nurse. The facility also failed to maintain one medication cart and one treatment cart on Unit One in a sanitary manner. During observation, the bottom of the last drawer of the medication cart had dirt and a sticky substance, and the LPN confirmed the cart was not clean. In a separate observation, a wet substance was seen in the bottom of the third drawer of the treatment cart, and sterile dressings were wet. The WCN stated that wound cleanser had spilled, that the cart should be clean and dry, and that contaminated items would be disposed of. The ADHS stated that nurses are responsible for keeping medication carts clean, and the pharmacy consultant stated she trains nurses to keep medication carts locked and within eyesight if the cart is unlocked.
Failure to Provide Nail Care as Part of ADL Assistance
Penalty
Summary
The facility failed to ensure Activities of Daily Living care was provided for five sampled residents related to nail care. The deficiency involved residents with varying levels of cognitive impairment and dependence for personal hygiene, including residents with paraplegia, traumatic brain injury, cerebral infarction, Alzheimer’s disease, diabetes, dementia, and generalized weakness. Facility policy stated that specialty services included dental, vision, podiatry, hearing, and mental health services, and the record review showed orders and care plans that included nail care or podiatry-related services for the affected residents. For one resident with paraplegia and traumatic brain injury, observations showed fingernails and toenails that were extremely long, jagged, untrimmed, and dirty with brown substance under and around the nails. Staff confirmed the nails were long, dirty, and needed trimming, and the podiatrist had been onsite on two dates without evidence that the resident received nail care during those visits. The DHS confirmed the resident was not seen by the podiatrist by error and stated the nails should have been addressed during bathing, with CNAs expected to report nail care needs. For another resident with moderate cognitive impairment and dependence for toileting and personal hygiene, observations showed long, brown fingernails, and the resident stated she did not want them that long. A CNA later trimmed the nails and stated she had just been given nail clippers and a list of residents whose fingernails needed cutting, that CNAs do not usually cut nails, and that it had been months since the residents’ nails were cut. A third resident with Alzheimer’s disease and weakness had long fingernails and said she wanted them cut, while also reporting an ingrown toenail that had not been addressed. The DHS stated the fingernails were long and dirty and that residents should receive routine nail care on bath days. Two additional residents had long, thick, yellow toenails or long fingernails with brown and yellow substance underneath them. One resident with diabetes and cognitive impairment was dependent on staff for personal hygiene, and observations on multiple days showed toenails that remained long, thick, yellow, and dirty. The DHS confirmed the nails were long and dirty and stated that nails should be trimmed by CNAs if the resident was not diabetic, otherwise by a nurse, and that nail care should be documented. Another resident with severe cognitive impairment and dependence for personal hygiene had long fingernails with brown and yellow substance underneath them, stated the nails needed to be trimmed and cleaned, and the DHS confirmed the care plan was not being implemented because personal hygiene, including nail care, was not addressed.
Failure to Follow G-Tube Feeding Orders
Penalty
Summary
The facility failed to follow physician orders and professional standards of care for a resident with a gastrostomy tube who had a BIMS score of 12, indicating moderate cognitive impairment. The resident’s diagnoses included type 2 diabetes, cerebral infarction, congenital stenosis and stricture of the esophagus, gastrostomy tube, chronic nausea and vomiting, and dysphagia. The care plan identified the need for tube feedings to maintain nutritional stability, with interventions to flush as ordered and provide tube feedings as ordered. Physician orders directed staff to check G-tube residuals before feeding, hold the feeding and call the medical doctor if residuals were greater than 100 mL, check placement prior to medication administration and flushes every shift, and administer formula via G-tube bolus 237 mL after meals and at bedtime with 200 mL water flushes after each feeding, after every meal, and at bedtime. During observation, an LPN did not check placement or residual before connecting the syringe for bolus feeding and did not measure the water flush as ordered; instead, she poured cold water from a drinking cup into the syringe and flushed with amounts that did not total the ordered 200 mL. The resident vomited immediately after the feeding, and the LPN later confirmed she had not checked residuals or placement and had not flushed with 200 mL of water as ordered.
Hand Hygiene Not Performed During Meal Tray Service
Penalty
Summary
Infection Control-Dining Services was not followed when a CNA passed out food trays to 10 residents in the dining hall without sanitizing her hands. During the meal observation, the CNA also assisted one resident by adjusting the resident’s positioning and touched the resident’s arms, shoulders, and seat, then continued passing additional food trays without sanitizing her hands between residents or after touching the resident. The facility policy titled Infection Control-Dining Services states that partners will wash their hands just before starting work in the kitchen and when they have used their hands in an unsanitary way, including handling dirty dishes or patients/residents. The CNA confirmed she did not sanitize her hands before passing trays, between passing trays, or after touching the resident. The Administrator stated staff should sanitize their hands between passing food trays, and the Infection Preventionist stated staff are expected to sanitize their hands before food trays are passed and between each tray.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential incidents. Specific actions or inactions leading to this deficiency were observed by surveyors, but no further details about the individuals involved or the exact nature of the hazards are provided.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 71 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ocilla
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palemon Gaskins Mem Nsg Home | 0.3 mi | ★★★★★ | 16 | 0 |
| Harmony Health And Rehabilitation | 7.8 mi | ★★★★★ | 12 | 0 |
| Pruitthealth - Fitzgerald | 9 mi | ★★★★★ | 4 | 0 |
| Harborview Tifton | 17 mi | ★★★★★ | 22 | 0 |
| Rehabilitation Center Of South Georgia | 17.2 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pruitthealth - Ocilla.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.