Below 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 - West Atlanta during CMS and state inspections, most recent first.
A resident with cognitive impairment and extensive care needs experienced an unwitnessed fall and was later found to have a femur fracture after being hospitalized. The facility's investigation into the injury of unknown source was incomplete, as it did not include interviews with direct care staff, the resident, the resident's representative, or other relevant individuals, and only two statements from department heads were collected. This did not meet the facility's own policy requirements for investigating such incidents.
A resident with a documented NPO status and gastrostomy tube order was given a food tray, resulting in the resident being found with food in their mouth. This failure to follow the care plan was followed by a significant decline in the resident's respiratory status, requiring hospital transfer and intensive care interventions.
A resident with a history of dysphagia, pneumonia, and a G-tube was repeatedly provided food despite NPO orders, due to failures in staff assessment, communication, and the meal ticket system. The resident was given sandwiches and later a food tray, resulting in aspiration events and hospitalizations. Staff interviews confirmed that dietary orders were not properly clarified or communicated, and the facility's policies for reviewing and implementing specialized diets were not followed.
Improper Handling of Clean Laundry and Linen: Staff failed to follow infection control protocols when transporting clean linen from the dryers to the folding area. A bin designated for clean laundry was found with garbage, dirt particles, used tissue, and soiled linen inside, and its cover had liquid and dirt on it. Folded sheets and blankets were also observed uncovered and unbagged on a shelf in the clean laundry room. Laundry staff confirmed the linen should have been covered and stated they had received IP training, but could not say when.
Failure to protect a resident from resident-to-resident abuse. A resident with diagnoses including depression, agitation, and cognitive deficits was involved in repeated altercations with his roommate. One incident involved the resident unplugging the TV, cursing at the roommate, and then being struck with a cane, causing a laceration and bleeding to the eye area. A later incident involved the resident reporting that the roommate again hit him with a cane, causing another cut and bleeding; the facility substantiated the abuse based on resident and witness statements.
A resident with diagnoses including schizophrenia, substance-induced psychotic disorder, depression, and PTSD was not referred for PASRR Level II evaluation despite behavioral concerns and psych consult orders. Records showed frequent disruptive and verbally abusive behavior, refusal of psych meds, and an observed hallway outburst, while the SSD and AD both confirmed the resident should have been classified as Level II.
A resident’s room contained a bottle of hydrogen peroxide, scissors, and an uncapped safety razor stored within easy reach. The resident had diagnoses including ADHD and dementia, and her care plan noted hoarding behaviors. The resident said wandering residents enter her room at times, and staff confirmed these items should not be stored in resident rooms.
Failure to provide an ordered vegetarian diet with equivalent nutrition. A resident with dementia, CHF, malnutrition, and a vegetarian preference received meals that did not match the meal ticket or menu on multiple occasions, including meat items on the ticket and different foods on the plate. The RD confirmed the meals did not match the ticket or menu, the Administrator admitted she was not aware of the separate vegetarian menu and had been removing meat from the regular menu, and the resident had recent weight loss with poor intake reported by her son.
The facility failed to prevent two garbage dumpsters from overflowing, which prohibited the lids and side doors from closing, creating a potential for pests, rodents, and insects. One dumpster was also missing a plug, leading to potential leakage of garbage contaminants. The Dietary Manager and Maintenance Director confirmed the issues, with the latter unaware of the overflow and missing plug.
The facility failed to ensure a dignified dining experience for three residents. One resident received breakfast 10 minutes after others, another was the last to receive lunch, and a resident was pulled backwards in a geriatric chair. Staff were also heard referring to residents as 'feeders'. The DHS confirmed these actions were inappropriate and indicated a lack of staff training on resident dignity.
The facility failed to provide bed hold information in writing at the time of transfer or within 24 hours for three residents transferred to the hospital in the last 120 days. Staff interviews revealed a lack of awareness and clarity about who was responsible for providing the bed hold notices, and the required documentation was not provided.
The facility failed to ensure that residents were seen by a physician at the required intervals, with four residents not receiving the mandated visits. Staff interviews confirmed the requirement for regular visits, but the protocol was not followed, leading to the deficiency.
The facility failed to ensure all food items on the steam table were held above 135°F, affecting nine residents on a puree diet. The puree beef patty was found at 132°F, and the Dietary Manager confirmed the deficiency.
A resident with multiple diagnoses was found with over-the-counter medications at her bedside without being assessed for the ability to self-administer. An LPN confirmed the oversight and removed the items, and the Director of Health Services was unaware of the situation prior to it being reported.
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to a resident who was discharged from Medicare Part A coverage and remained in the facility. The Financial Controller was unaware of the requirement, and the resident and/or the responsible party did not receive the necessary notice.
A facility failed to provide specialized psychiatric services for a resident with schizophrenia as recommended by the PASRR Level II summary. Despite having a care plan and being on antipsychotic medication, there was no documented evidence that the resident received the necessary psychiatric and psychotherapy services.
The facility failed to develop care plans for antipsychotic and anti-anxiety medications for a resident with dementia and anxiety, and did not adhere to dietary restrictions for another resident with a lactose allergy, leading to potential gaps in treatment and care.
A resident with a documented lactose allergy was repeatedly served food items containing lactose, despite clear indications on the meal tray ticket and physician orders. The Dietary Manager confirmed the oversight and revealed the absence of a facility policy regarding therapeutic diets and food allergies.
A resident with dementia and anxiety was receiving multiple psychotropic medications, including haloperidol. The facility failed to conduct an annual Gradual Dose Reduction (GDR) assessment for the resident's antipsychotic medication, as required by their policy. The last documented GDR was over a year ago, and this deficiency was confirmed by the Director of Health Services.
The facility failed to ensure medications were dated when opened, discarded on the discard dates, and stored according to manufacturer recommendations on one of three medication carts. Observations revealed several medications were either not labeled with open and discard dates or were stored improperly. Interviews confirmed that all nurses and Unit Managers were responsible for ensuring proper storage, labeling, and discarding of medications.
The facility failed to ensure the ice scoop bin and beverage dispenser were free from green and black buildup on one unit. Observations revealed that the ice scoop was stored in a container with black buildup and used by CNAs to deliver ice to residents. The water dispenser also had green and black buildup. Staff confirmed the buildup and the lack of a cleaning schedule for the ice scoop.
Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate a serious bodily injury of unknown source for one of ten sampled residents. The resident in question had multiple diagnoses, including cognitive communication deficit, vascular dementia, and required extensive assistance with activities of daily living. The resident experienced a fall that was unwitnessed, and later was found to have a right femur intertrochanteric fracture, which was discovered only after the resident was sent to the hospital for unrelated symptoms. The facility's policies required that, in the event of an injury of unknown source, interviews should be conducted with the resident, staff who provided care, other residents, and any pertinent outside sources, as well as gathering signed statements and observing the resident for behavioral clues to the injury's cause. Upon review, the investigation conducted by the facility was found to be incomplete. Only two witness statements were collected, both from department heads, and there was no evidence that direct care staff, the resident, the resident's representative, other residents, or outside sources were interviewed. There was also no documentation of observations of the resident or an evaluation of whether the resident felt safe. The investigation did not address the potential connection between the unwitnessed fall and the subsequent discovery of the fracture. Interviews with facility staff, including a Certified Medication Aide, the Unit Manager, the Director of Health Services, and the Administrator, confirmed that the standard practice was to collect statements for injuries of unknown source but not for unwitnessed falls. The Administrator, who served as the abuse coordinator, stated that the investigation was inconclusive and acknowledged that not completing a thorough investigation could result in not finding the true root cause. The documentation provided by the facility was confirmed to be the complete investigation, which lacked the required thoroughness as outlined in facility policy.
Failure to Follow NPO Care Plan Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to follow the care plan for a resident who was designated as nothing by mouth (NPO) due to multiple diagnoses, including pneumonia, dysphagia, respiratory failure with hypoxia, and cognitive communication deficit. The resident's care plan, initiated on 10/16/2025, specified the use of a gastrostomy tube for nutrition and water flushes as ordered, with a physician's order confirming NPO status. Despite these documented interventions, the resident was observed with a food tray and food in his mouth, specifically three shrimps, on 11/15/2025. The incident was documented in the electronic medical record, and the kitchen staff was subsequently educated about the resident's NPO status. Following this event, the resident experienced a significant change in condition, including decreased oxygen saturation and respiratory distress, which required escalation of oxygen therapy and eventual transfer to the hospital. Hospital records indicated the resident was admitted with acute respiratory distress, hypoxic respiratory failure, and required intensive care interventions, including thoracentesis and ventilatory support. The Director of Health Services confirmed that the resident's NPO restriction was documented in the care plan and acknowledged that the care plan was not followed when the resident was given a food tray.
Failure to Follow NPO Orders and Ensure Nutritional Safety
Penalty
Summary
The facility failed to provide appropriate nutritional treatment and services for a resident with dietary orders for nothing by mouth (NPO). Upon admission, the resident had a history of pneumonia, dysphagia, respiratory failure, and required a gastrostomy tube (G-tube) for nutrition. Despite clear orders and documentation indicating the resident was NPO and at high risk for aspiration, staff did not properly assess or clarify dietary needs at admission. On the day of admission, an LPN provided the resident with two ham and cheese sandwiches and ice water, without confirming the hospital discharge orders or recognizing the presence of a G-tube. This resulted in the resident aspirating and subsequently being hospitalized for aspiration pneumonia. The deficiency was further compounded when, after the resident's return to the facility, a food tray was again provided to the resident despite ongoing NPO orders and clear recommendations from speech therapy. The meal ticket system failed to reflect the correct NPO status, and a CNA unfamiliar with the resident gave the food tray, which led to the resident having food in his mouth. The error was identified and corrected by a supervisor, but not before the resident was exposed to further risk. Interviews with staff confirmed that communication breakdowns occurred between nursing, dietary, and therapy departments, and that the meal ticket system did not always accurately display specialized diets. Throughout the resident's stay, there were multiple documented instances of aspiration, pneumonia, and hospitalizations directly related to the failure to follow NPO orders. Staff interviews revealed that the admitting nurse did not verify discharge orders upon admission, and that subsequent communication lapses and system errors led to repeated provision of food to the resident. The facility's own policies required timely review and clarification of dietary orders, but these were not consistently followed, resulting in the resident not receiving the necessary care and services to meet nutritional needs.
Improper Handling of Clean Laundry and Linen
Penalty
Summary
The facility failed to ensure staff followed proper infection control protocols when transporting clean linen from the dryers to the folding area. During a tour of the laundry services, a covered bin designated for clean laundry was observed with garbage, dirt particles, and soiled linen inside it. The cover of the bin had a liquid substance and dirt particles on it, and the inside of the bin contained used tissue, garbage, and a soiled blanket at the bottom. A shelf in the clean laundry room was also observed with folded sheets and blankets left uncovered and unbagged. Laundry attendants confirmed that the linen on the shelf should have been covered. One laundry attendant stated there were two bins available for transporting clean linen from the dryers to the folding area and that the bin in the room was one of them; she also stated she placed linen on the cover instead of in the bin when transporting it without being covered. Both laundry attendants stated they had received infection control in-service training but could not state when. The Housekeeping Supervisor confirmed the bin was for clean laundry and stated staff were aware it should be cleaned daily and that all trash should be removed from it. The Infection Preventionist stated all laundry attendants had been in-serviced on infection prevention regarding laundry services this year and provided documentation.
Failure to Protect Resident from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Review of the facility policy showed it was intended to preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of property. The resident involved had diagnoses including major depressive disorder, restlessness and agitation, cognitive communication deficit, dysphagia following cerebral infarction, altered mental status, and other cognitive symptoms following cerebral infarction. His MDS showed a BIMS score of 14 out of 15, indicating he was cognitively intact, and his care plan noted behavioral symptoms, frequent refusal of medications and skin observations, and that he poured water on his roommate. The record documented two resident-to-resident assault events involving the same resident and his roommate. In one incident, the resident unplugged the TV while his roommate was watching it, cursed at the roommate, and the roommate then struck him with a cane, causing bleeding to the left eyelid, a laceration, broken glasses, and bleeding to the left lower chin; the resident was sent to the hospital for evaluation. In a later incident, the resident reported that his roommate hit him with a cane and caused a cut to his lower left eye with bleeding; wound care was provided and he was again sent to the ER for evaluation. The facility investigation substantiated resident-to-resident abuse based on resident and witness statements, and Social Services later confirmed the resident's behavior was discussed with his family but he never received behavioral services.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer one resident for PASRR evaluation by the appropriate State-designated authority. Review of the facility’s Behavior Management policy showed that residents with risk behaviors or the potential for risk behaviors are to be evaluated for the Behavior Management Program, and that assessments are to be completed upon admission, readmission, or when behavior changes. The resident’s EMR showed diagnoses including disorganized schizophrenia, psychoactive substance use with psychotic disorder and hallucinations, depression, and PTSD. The admission MDS dated 7/5/2025 indicated no Level II PASRR conditions, and no psychological therapy was documented in Section O. Physician orders included a psych consult for aggressive and argumentative behavior and refusal of psych meds, and nursing notes documented frequent disruptive behavior, verbal abuse toward staff and other residents, non-compliance with redirection, and refusal of psych medications. An observation showed the resident yelling and screaming in the hallway after not being invited to the resident council meeting. The Social Services Director stated the resident had been listed as Level I but should have been classified as Level II based on diagnosis, and the Admissions Director confirmed the resident should have had a PASRR Level II.
Hazardous Items Left Within Reach in Resident Room
Penalty
Summary
The facility failed to ensure hazardous chemicals and sharp items were safely secured in one resident’s room. R49’s record showed diagnoses including attention deficit hyperactivity disorder and dementia, and the quarterly MDS documented a BIMS score of 14, indicating little to no cognitive impairment. R49’s care plan noted that she hoarded different items in her room, including silverware, plates, other residents’ personal items, condiments, and straws, and included an approach to remove excess items with resident involvement. During observations, a 30-ounce bottle of 3% hydrogen peroxide was found stored on top of R49’s personal refrigerator within easy reach of R49 and potentially others, and R49 stated the bottle belonged to her daughter and had been left there. R49 also stated wandering residents enter her room at times. Later, one pair of scissors and one uncapped safety razor were observed stored within reach in the room. R49 acknowledged the scissors and uncapped razor were a safety concern for other residents and stated she did not have a lock box to store them. Staff interviews confirmed that hydrogen peroxide, scissors, and uncapped safety razors should not be stored in resident rooms.
Failure to Provide Ordered Vegetarian Diet
Penalty
Summary
The facility failed to provide a therapeutic vegetarian diet that took into account one resident’s clinical condition and preferences with an equally nutritious meal. The resident had diagnoses including coronary artery disease with angina, atrial fibrillation, chronic systolic heart failure, protein-calorie malnutrition, vascular dementia, generalized weakness, and other symptoms and signs concerning food and fluid intake. Her quarterly MDS showed a BIMS score of 7, indicating severe cognitive decline. Her care plan identified her vegetarian preference and nutritional risk, with interventions to honor preferences, monitor intake and weight, and provide diet per orders. Observations showed repeated mismatches between the resident’s meal ticket and the food actually served. On one occasion, the meal ticket listed Italian marinated pork loin, brussels sprouts, stuffing, and a dinner roll, while the resident’s plate contained a grilled cheese sandwich, green beans, and brussels sprouts. On another occasion, the meal ticket listed beef tips and mushrooms in sauce, green peas, parslied rice, and a dinner roll, while the plate contained pasta salad, parslied rice, and a dinner roll. On a third occasion, the meal ticket listed chicken alfredo fettuccine, buttered broccoli, and garlic bread, while the plate contained a black bean quesadilla, tomato soup, and broccoli. The menu for the week showed daily vegetarian meals with an entree, starch, and vegetables, but the resident’s actual meals did not match the ticket or the menu. The resident’s weight record showed losses of 3 pounds in May 2025, another 3 pounds in June 2025, a 0.7-pound gain in July 2025, and a 1-pound loss in August 2025. The RD stated the vegetarian diet was intended to be nutritionally equivalent if the menu was followed, but confirmed the resident’s actual meal did not match the meal ticket or the menu. The Administrator stated she had been assuming dietary manager duties, was ordering supplies and meals, and admitted she was not aware there was a separate vegetarian menu, explaining that she had been removing meat from the regular menu instead. The resident’s son stated the meals were not equivalent to a supplemental or nutritious meal and that the resident often barely ate and complained of nausea after eating.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to prevent two garbage dumpsters from overflowing with excess garbage, which prohibited the top lids and side doors from closing. This situation created a potential for pests, rodents, and insects. Observations revealed that one dumpster had trash bags overflowing from the top and sides, while the other had a large cardboard box and a garbage bag with a tan-colored liquid hanging out of the side door. Additionally, one of the dumpsters was missing a plug, which could lead to potential leakage of garbage contaminants. The Dietary Manager confirmed the overflow and the missing plug, stating that the dumpsters are emptied daily by a waste management company, and he makes rounds two to three times a day to ensure the area is clean. The Maintenance Director revealed that the dumpsters are emptied twice a week, typically in the afternoon, and that early pick-up can be arranged if needed. However, he was not aware that the dumpsters were full and overflowing and did not realize that one of the dumpsters was missing a plug. The Maintenance Director mentioned that he would likely need to purchase a plug to address the issue. The facility census was 101 residents at the time of the observation.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for three residents on the [NAME] Unit. Specifically, one resident did not receive her breakfast until 10 minutes after others had already been served and some had finished eating. Another resident was the last to receive her lunch tray, which led her to question staff about the delay. Additionally, a resident was pulled backwards in his geriatric chair by an LPN when leaving the dining area, and staff were heard referring to residents as 'feeders' during lunch. These actions were observed during meal times and were corroborated by staff interviews. The Director of Health Services (DHS) was unaware of these incidents and confirmed that residents should be treated with respect, receive meals at the same time, and not be referred to as 'feeders'. The DHS also stated that residents in geriatric chairs should not be pulled backwards. The facility's document titled 'Your Rights as a Patient' emphasizes the right to be treated with respect and dignity, which was not upheld in these instances. Interviews with staff revealed a lack of training related to the dignity of residents, contributing to the observed deficiencies.
Failure to Provide Bed Hold Information at Time of Transfer
Penalty
Summary
The facility failed to provide bed hold information in writing at the time of transfer or within 24 hours for three residents who were transferred to the hospital in the last 120 days. The facility policy requires that a bed hold notice be given during admission and another at the time of transfer. However, for Resident 106, there was no documented evidence of a bed hold notification being provided when the resident was transferred to the hospital. Interviews with staff, including LPNs and the Admissions Coordinator, revealed a lack of awareness and clarity about who was responsible for providing the bed hold notices. The Director of Health Services confirmed that the required documentation was not provided for Resident 106's transfer on 3/31/2024. Similarly, Resident 68 was transferred to the hospital on 4/8/2024, and there was no evidence in the EMR that a bed hold policy was provided. Interviews with the Financial Counselor and LPN Unit Manager indicated that nursing staff had not been sending out the bed hold notice forms but would start doing so in the future. For Resident 19, who was transferred to the hospital on 4/20/2024, there was also no documented evidence of a bed hold notification being provided. The DHS confirmed that nursing staff are supposed to send the bed hold policy with a resident when going to the hospital, but this was not done in these cases.
Failure to Ensure Regular Physician Visits
Penalty
Summary
The facility failed to ensure that residents were seen by a physician at the required intervals. Specifically, four residents were not seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. For instance, Resident 52, who had multiple diagnoses including paranoid schizophrenia and type 2 diabetes mellitus, had no documented physician visits for the past year. Similarly, Resident 74, who was admitted under commercial insurance and later transitioned to Medicaid, was only seen by a physician twice, with no further visits documented. The Director of Health Services and the physician both acknowledged the requirement for regular visits but failed to ensure compliance. Additionally, Resident 1, who was readmitted with acute respiratory failure and COPD, had no documented physician visits from January 2023 through May 2024. Resident 50, who had diagnoses including lack of coordination and unspecified dementia with behavior disturbances, also had no documented physician visits for the last 12 months. Interviews with staff, including the Corporate Nurse Consultant, confirmed that each resident should have an in-person physician or nurse practitioner visit every 30 days, with the physician alternating visits with the nurse practitioner every 60 days. However, this protocol was not followed, leading to the deficiency.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to ensure all food items on the steam table were held above 135 degrees Fahrenheit to prevent bacteria growth. This deficiency affected nine residents ordered a puree consistency diet out of a total of 99 residents receiving an oral diet. During an observation, the puree beef patty was found to have a temperature of 132 degrees Fahrenheit. The Dietary Manager confirmed the temperature and acknowledged that all food items on the steam table need to be held at or above 135 degrees Fahrenheit. The Dietary Manager also noted that there had not been any previous issues with the steam table maintaining food temperatures until that meal.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident (R71) for the ability to self-administer medications before allowing medications to be left at the bedside. The resident, who had diagnoses including schizophrenia, major depressive disorder, anemia, and chronic kidney disease, was observed with over-the-counter products (vapor rub and cough drops) on the nightstand. The resident reported that her family had brought the items for her, and she kept them in her room. However, there was no documentation in the electronic medical record indicating that R71 had been assessed for the ability to self-administer medications. During an interview, an LPN confirmed that residents could have medications at their bedside if assessed to do so, but verified that R71 had not been assessed. The LPN then removed the items from the bedside. The Director of Health Services later reported that she was unaware of the resident having over-the-counter medications in the room prior to the nurse bringing the items to her attention. This oversight had the potential to allow access to medications not prescribed by a physician to other residents, staff, or visitors.
Failure to Provide SNF ABN to Resident Discharged from Medicare Part A
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to a resident who was discharged from Medicare Part A coverage. Specifically, the resident was discharged from Medicare Part A skilled services and remained in the facility with benefit days remaining. There was no documented evidence that the SNF ABN was provided to the resident or the responsible party. During an interview, the Administrator revealed that the Financial Controller was new and only familiar with Medicare Part B, and was unaware that the SNF ABN was a required notice for residents discharged from Medicare Part A skilled services who remained in the facility. The Administrator confirmed that the resident and/or the responsible party did not receive an SNF ABN.
Failure to Provide Specialized Psychiatric Services
Penalty
Summary
The facility failed to provide specialized psychiatric services for a resident with a serious mental illness (SMI) as recommended by the Preadmission Screening and Resident Review (PASRR) Level II summary. The resident, who was admitted with a diagnosis of schizophrenia and was receiving antipsychotic medication, had a care plan that included behavioral health assessment/service plan and diagnostic/ongoing psychiatric care. However, a review of the electronic medical record (EMR) revealed no documented evidence that the resident received the recommended specialized services. Observations over several days showed the resident was pleasant and exhibited no behaviors. Interviews with staff, including a registered nurse and a social worker, confirmed that the resident should have been receiving psychiatric and psychotherapy services. The social worker believed the services were already in place but was unable to locate any documentation to support this. An email communication indicated that the consent and paperwork for treatment were resent, but there was no evidence that the services had been provided up to that point.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to potential gaps in their treatment and care. For one resident, who had diagnoses of dementia and anxiety, the facility did not create care plan areas for the use of antipsychotic and anti-anxiety medications, despite these medications being prescribed and administered regularly. Interviews with staff revealed that the comprehensive care plans should have included these medications, and the oversight was acknowledged by the Case Management Director and the Director of Health Services. This failure persisted despite multiple quarterly assessments and updates to the care plan, indicating a systemic issue in the care planning process. Another resident, who was on a controlled carbohydrate diet and had a lactose allergy, was not provided with meals that adhered to these dietary restrictions. Despite the care plan and meal tray ticket indicating the lactose allergy, the resident was served foods containing lactose, such as cream sauce and sherbet. The Dietary Manager confirmed this discrepancy during an observation. This failure to implement the care plan as ordered highlights a lapse in the facility's dietary management and adherence to prescribed dietary needs.
Failure to Provide Lactose-Free Diet as Ordered
Penalty
Summary
The facility failed to ensure that a resident (R77) was served a lactose-free diet as ordered by the physician. Despite the resident's meal tray ticket indicating an allergy to lactose, R77 was repeatedly served food items containing lactose. This included a cheese omelet and regular milk for breakfast, as well as country fried steak with cream sauce and sherbet for lunch. The Dietary Manager confirmed that these items contained lactose and acknowledged that the resident should not have been served these foods. Additionally, the Dietary Manager revealed that there was no facility policy regarding therapeutic diets, food allergies, or lactose intolerance. R77 had a medical history that included type 2 diabetes, hemiplegia/hemiparesis, chronic kidney disease, and moderate protein calorie malnutrition. The resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Despite the clear documentation of the lactose allergy in the electronic medical record and on the meal tray ticket, the facility's failure to adhere to the prescribed diet resulted in the resident being served inappropriate food items. This deficiency was identified through observations, resident and staff interviews, and record reviews conducted by the surveyors.
Failure to Conduct Annual GDR Assessment for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a Gradual Dose Reduction (GDR) assessment was completed at least annually for a resident (R50) who was receiving antipsychotic medication. According to the facility's policy titled Monitoring of Antipsychotics, a GDR assessment should be conducted annually after the first year of antipsychotic medication use. However, the last documented GDR for R50's haloperidol was dated 4/27/2023, and no other GDRs were completed in the last 12 months. This failure was confirmed by the Director of Health Services (DHS) during an interview, who acknowledged that the pharmacist normally conducted a GDR for antipsychotic medications at least annually and that one should have been completed for R50. R50's medical records revealed that the resident had active diagnoses of dementia and anxiety and was receiving multiple psychotropic medications, including haloperidol, Xanax, mirtazapine, and PRN lorazepam. Despite regular psychiatric evaluations and medication management, no changes were recommended by the psychiatric clinician in progress notes dated 10/23, 1/24, and 4/24. The DHS verified that the pharmacist's email dated 5/18/2024 confirmed the resident's medication regimen but did not include a recent GDR assessment for haloperidol, highlighting the facility's failure to adhere to its own policy and regulatory requirements.
Failure to Properly Store, Label, and Discard Medications
Penalty
Summary
The facility failed to ensure medications and biologicals were dated when opened, discarded on the discard dates, and stored according to manufacturer recommendations on one of three medication carts (East Unit Cart 2). Observations revealed that several medications, including insulin vials, insulin pens, ophthalmic solutions, and inhalers, were either not labeled with open and discard dates or were stored improperly. Specifically, medications such as Novolog insulin, Levemir insulin, Humalog Kwik Pen, Incruse Ellipta inhaler, Trelegy Ellipta inhaler, and Anoro Ellipta inhaler were found to be opened with expired discard dates. Additionally, unopened medications with pharmacy labels instructing refrigeration until opened were not stored in the refrigerator as required. Interviews with the LPN and the Director of Health Services (DHS) confirmed that the medications should have been labeled with open and discard dates and stored according to manufacturer and pharmacy instructions. The LPN acknowledged that medications administered past the discard date could be less effective, potentially causing altered effects for the residents. The DHS stated that all nurses working on the medication carts were responsible for ensuring proper storage, labeling, and discarding of medications, and that Unit Managers were expected to check the medication carts weekly for compliance. The failure to adhere to these protocols created the potential for residents to receive medications with altered effectiveness.
Failure to Maintain Clean Ice Scoop Bin and Beverage Dispenser
Penalty
Summary
The facility failed to ensure the ice scoop bin and beverage dispenser were free from green and black buildup on one of two units (West). Observations revealed that the ice scoop was stored in a clear container with black buildup and water along the edges. This ice scoop was used by CNAs to deliver ice to residents' rooms. Additionally, the water dispenser on the same unit had green and black buildup on the rubber parts inside the dispenser. The Dietary Manager confirmed the buildup and reported that the container was cleaned daily, but more attention to cleaning might be needed. There was no documentation of the last cleaning for the ice scoop container. Interviews with staff, including an LPN and the Director of Health Services (DHS), confirmed the presence of the buildup and the lack of a cleaning schedule for the ice scoop on the units. The DHS acknowledged the need to develop a system for regular cleaning moving forward. The facility policy titled Cleaning Procedures: Serving Equipment, last revised on 9/29/2022, was reviewed and indicated that the ice scoop and holding bin should be washed, sanitized, and air-dried daily, but this procedure was not followed as observed during the survey.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Atlanta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sadie G. Mays Health & Rehabilitation Center | 1.7 mi | ★★★★★ | 6 | 0 |
| Buckhead Center For Nursing And Healing | 3.3 mi | ★★★★★ | 13 | 0 |
| Terraces At Peachtree Hills Place, The | 4.2 mi | ★★★★★ | 5 | 0 |
| Westminster Commons | 4.4 mi | ★★★★★ | 0 | 0 |
| Nurse Care Of Buckhead | 4.7 mi | ★★★★★ | 6 | 0 |
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