Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 - Swainsboro during CMS and state inspections, most recent first.
A resident with anxiety, bipolar disorder, and major depressive disorder, who was cognitively aware, non‑ambulatory, and dependent for ADLs, was removed from his room by a CNA while yelling out, pushed in a geriatric chair into a shower room, and left there alone with the door locked for approximately 30 minutes to an hour without receiving a shower and without his consent. The resident reported telling the CNA he did not want to go into or be left in the shower room and later expressed anger about being confined there against his will. An LPN and another CNA found the resident locked in the shower room, observed him in a reclined geriatric chair asking to be let out, and noted he had a pink face and difficulty breathing. The CNA admitted he placed the resident in the shower room and left him unattended so the resident would quiet down and not disturb others, and the Administrator acknowledged that this confinement met the facility’s definition of seclusion and abuse.
Incomplete Care Plan and Tube Feeding Not Followed as Ordered: A resident with dysphagia, gastrostomy status, and a feeding tube had a care plan that addressed aspiration risk and nutritional stability, but staff did not follow the physician’s tube feeding order. Observations showed Jevity 1.5 infusing during the day even though it was ordered only overnight, and an LPN confirmed the pump should have been off by 6:00 AM. The CMI Director stated the care plan should always be followed.
A resident with a feeding tube had Jevity 1.5 ordered to run overnight, but observations showed the pump infusing during the day at 60 ml/hr. An LPN and an LPN/Unit Manager confirmed the infusion should have been stopped at 6:00 AM, and the DHS stated staff were responsible for following the physician’s enteral feeding order.
The facility failed to remove expired medications from a storage room, as observed with two expired vials of naloxone HCL injection. Staff interviews confirmed that expired medications should not be present due to potential decreased effectiveness. Facility policies require removal of expired medications, but these were not adhered to, leading to the deficiency.
A resident with severe cognitive impairment was found self-administering albuterol nebulizer treatments without an assessment or physician order, contrary to facility policy. The resident had nine albuterol ampules on her nightstand, and a nurse confirmed she was not permitted to self-administer or keep the medication in her room.
A resident with impaired mobility and cognitive communication deficit was found without a call light within reach, despite care plan interventions requiring it to be accessible. Observations confirmed the call light was often left out of reach, and both the resident and a CNA acknowledged the issue.
Involuntary Seclusion of Resident in Locked Shower Room by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from involuntary seclusion when a CNA placed the resident in a locked shower room, unattended, for an extended period without the ability to exit. The facility’s own abuse and seclusion policy states that every patient has the right to be free from abuse and involuntary seclusion, defining abuse as unreasonable confinement with resulting mental anguish and involuntary seclusion as separation from others or confinement against the resident’s will. Despite this policy, the CNA removed the resident from his room while he was yelling out, pushed him in a geriatric chair into the shower room, and left him there with the door locked, without providing a shower and without the resident’s consent. The resident involved had diagnoses including generalized anxiety disorder, bipolar disorder, and major depressive disorder, and was documented on the quarterly MDS as cognitively aware (BIMS score of 12), non‑ambulatory, and dependent for ADLs. The resident later reported that he told the CNA he did not want to go into the shower room, did not want to be left there, and that he was left there against his will for a long time. Staff interviews and documentation indicated that the resident remained in the locked shower room for approximately 30 minutes to one hour. When an LPN checked on him, she found him alone in the locked shower room, seated in a reclined geriatric chair, with his face pink in color and having difficulty breathing, and another CNA heard the resident pleading to be let out and thanking staff when they entered. The CNA admitted in a subsequent interview that he placed the resident in the shower room and left him unattended because the resident was yelling out and he wanted the resident to quiet down and not disturb his roommate and other residents. He acknowledged that he did not provide a shower and stated he “just put him in there so that he would hush.” The resident expressed anger about the incident to both the LPN and Social Services, and the Administrator confirmed that staff reported the resident was locked in the shower room for 30 minutes to an hour and that such confinement constituted seclusion and abuse under facility policy. The incident was reported as staff‑to‑resident abuse to the State Survey Agency and law enforcement, and the facility documented that the resident experienced psychosocial harm as evidenced by his anger about being locked in the shower room against his will.
Incomplete Care Plan and Tube Feeding Not Followed as Ordered
Penalty
Summary
The facility failed to develop or implement a comprehensive person-centered care plan for one sampled resident, R84. The facility policy on Care Plans stated that the comprehensive person-centered care plan is to include measurable goals and time frames to meet the resident’s medical, nursing, and psychosocial needs and the services needed to attain or maintain the resident’s highest practicable physical, mental, and psychosocial needs identified in the comprehensive assessment. R84 was admitted with diagnoses including pneumonitis due to inhalation of food and vomit, dysphagia following cerebral infarction, and gastrostomy status. The annual MDS showed the resident had a feeding tube and received 51 percent or more of total calories and 501 cc through the tube. The care plan dated 04/8/2026 identified that R84 had a feeding tube and was at risk of aspiration, with a goal to maintain nutritional stability through the next 90 days and interventions including tube feeding as ordered, flushing as ordered, notifying the MD of any problems, and elevating the head of the bed per protocol. The physician order dated 01/28/2026 directed Jevity 1.5 at 60 ml per hour from 10:00 PM through 6:00 AM with water flushes at 50 ml per hour during the same time period. However, observations on 04/21/2026 showed Jevity 1.5 infusing via feeding pump at 60 ml per hour at 10:56 AM and again at 3:03 PM. An LPN confirmed the pump should have been turned off at 6:00 AM and not infused during the day, and the Case Mix Director confirmed the care plan interventions included administering the tube feeding as ordered and that the care plan should always be followed.
Feeding tube infusion continued outside ordered time
Penalty
Summary
The facility failed to follow the prescribed enteral feeding order for one resident with a feeding tube, R84. R84 was admitted with diagnoses including pneumonitis due to inhalation of food and vomit, dysphagia following cerebral infarction, and gastrostomy status. The annual MDS dated 01/28/2026 documented that the resident had a feeding tube and received 51 percent or more of total calories and 501 cc through the tube. The physician order dated 01/28/2026 directed Jevity 1.5 to infuse at 60 ml per hour from 10:00 PM through 6:00 AM, with a water flush at 50 ml per hour during the same time period. Observations on 04/21/2026 at 10:56 AM and again at 3:03 PM showed Jevity 1.5 infusing through a feeding pump at 60 ml per hour during the day, outside the ordered time frame. During interviews, an LPN confirmed that the feeding pump should have been turned off at 6:00 AM and not infused during the day, and another LPN/Unit Manager confirmed that the formula was infusing despite the order to stop at 6:00 AM. The DHS stated that nurses were responsible for following the physician's order for administering the feeding tube formula and that the night-shift nurse was responsible for turning off the feeding at the ordered end time, with the day-shift nurse responsible if it had not been stopped.
Expired Medications Found in Storage Room
Penalty
Summary
The facility failed to ensure that expired medications were not stored in one of its medication storage rooms, which could potentially place residents at risk of receiving medications with altered effectiveness. During an observation of the medication room at the Back Nurses' Station, two vials of naloxone HCL injection with an expiration date of March 1, 2024, were found. The Unit Manager confirmed the presence of these expired medications and acknowledged that they should have been removed before expiration. Interviews with staff, including a Registered Nurse and the Director of Health Services, revealed a consensus that expired medications should not be present in the medication room due to the risk of decreased potency and effectiveness. The facility's policies on expired medication and medication storage require that expired medications be removed and disposed of according to policy, and that nurses check for expiration before administration. However, these procedures were not followed, leading to the deficiency.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident, identified as R35, for the ability to safely self-administer medications before leaving medications at the bedside. The facility's policy requires that a licensed nurse and physician determine if a resident can safely self-administer medication. However, R35, who has severe cognitive impairment as indicated by a BIMS score of 6, was found with nine albuterol solution ampules on her nightstand. There was no documented assessment or physician order allowing R35 to self-administer medication. Observations revealed that R35 self-administered albuterol nebulizer treatments three times daily and took additional doses as needed, despite not being permitted to do so. A registered nurse confirmed that R35 was not allowed to self-administer breathing treatments or keep albuterol medication in her room. The lack of assessment and unauthorized self-administration of medication by R35 represents a failure to adhere to the facility's policy, potentially placing the resident at risk of unsafe medication use.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of the resident. The resident, identified as R72, had diagnoses including cognitive communication deficit and impaired mobility, and required partial to moderate assistance with mobility. The resident's care plan, dated February 10, 2025, included an intervention to place the call light within reach due to the resident's risk for falls and impaired mobility. However, observations on March 4 and 5, 2025, revealed that the resident was seated in a wheelchair behind a privacy curtain with no call light within reach. In an interview, the resident confirmed that the call light was often left out of reach, preventing her from calling for help when needed. A Certified Nursing Assistant also confirmed that the call light was not within reach and acknowledged that it should be accessible at all times.
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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 Swainsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Emanuel County Nursing Home | 7.7 mi | ★★★★★ | 0 | 0 |
| Twin City Trails Of Journey Llc | 10.5 mi | ★★★★★ | 9 | 0 |
| Azalea Health And Rehabilitation | 14.9 mi | ★★★★★ | 8 | 0 |
| Pleasant View Nursing Center | 15.6 mi | ★★★★★ | 6 | 0 |
| Scott Health & Rehabilitation | 16.9 mi | ★★★★★ | 5 | 0 |
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