Federal inspectors documented multiple safety violations at PruittHealth-Macon during a May 15 inspection, finding staff routinely ignored physician orders and care plans designed to protect vulnerable residents.
The oxygen failures involved two residents with serious respiratory conditions. One resident with sarcoidosis and eosinophilic asthma was prescribed three liters of oxygen per minute as needed. When inspectors observed her on May 13, the flow rate was set between 1.5 and 2 liters per minute. The resident told staff she couldn't feel oxygen flowing through her nasal cannula.
A second resident with acute respiratory failure and low oxygen levels was ordered to receive three liters of oxygen continuously. Inspectors found him on May 12 with his nasal cannula not in place and the flow meter set at 2.5 liters. The next day, his oxygen wasn't in place at all. On May 14, while the cannula was positioned correctly, the flow meter was set at just one liter per minute.
Licensed Practical Nurse EE confirmed both residents were supposed to receive three liters continuously and acknowledged nursing staff should check oxygen settings each shift.
Fall prevention measures were similarly ignored for a resident who had already suffered a major injury. The resident, identified as R52, broke her right femur in a fall on February 5. Her care plan required fall mats beside her bed, non-skid socks, and assistance when agitated.
Inspectors observed the resident on three separate occasions without any of these safety measures in place. On May 12, no fall mats were on the floor next to her bed. Two days later, she was eating breakfast without non-skid socks and no fall mats in position. That afternoon, Licensed Practical Nurse EE entered her room and confirmed she was at high risk for falls but acknowledged she had neither fall mats nor non-skid socks.
The nurse told inspectors that high fall-risk residents should have beds in low position and items within reach, and should be encouraged to use call lights for assistance.
A certified nursing assistant said she would know about fall precautions from electronic records but wasn't sure if specific interventions were listed. She revealed no shift reports were conducted, with nurses only communicating changes verbally when they occurred.
Infection control violations put residents at risk during wound care. A resident with multiple stage-four pressure ulcers received treatment that violated basic safety protocols. During a May 14 wound care session, Licensed Practical Nurse AA repeatedly changed gloves without washing her hands between procedures.
The nurse cleaned one wound, removed her gloves, then put on new gloves without hand hygiene before applying a dressing. During treatment of a second wound, she assisted with removing fecal matter from the bed with a gloved hand, removed only that glove, failed to wash her hands, then put on a new glove to continue wound care.
The facility's infection control policy requires all staff to implement prevention procedures. The Director of Health Services confirmed all nursing staff should follow infection control practices.
Inspectors also found unlabeled personal care items stored improperly. A wash basin and urinal in one resident bathroom remained uncovered and exposed to the environment during multiple observations over three days.
Mental health screening failures affected two residents with serious psychiatric conditions. Both residents had diagnoses requiring specialized evaluation under federal law, but neither received the required Preadmission Screening and Resident Review assessment.
One resident with bipolar disorder, major depression, and anxiety was admitted in 2023 but never received the Level II screening. Her care plan addressed mood distress related to bipolar disorder, and quarterly assessments documented psychiatric and mood disorders. The Director of Health Services confirmed no screening had been completed and couldn't explain why.
A second resident with schizoaffective disorder and bipolar disorder also lacked the required screening. This resident received antipsychotic, antianxiety, and antidepressant medications and had care plan problems for behavioral symptoms, psychotropic drug use, elopement risk, and cognitive issues. The Social Worker confirmed the resident should have been submitted for screening based on her diagnoses.
Hearing services were denied to a resident who repeatedly asked staff to speak louder and remove their masks so he could read lips. The resident, admitted with multiple medical conditions including paraplegia, had moderate hearing difficulty documented in his assessment and care plan.
Despite his obvious hearing impairment, no referral to audiology was made from admission through the inspection date. His physician's orders contained no hearing evaluations or assessments. The resident told inspectors he had not been evaluated for a hearing device and no facility staff had discussed his hearing loss with him.
The Social Services Director confirmed the resident wasn't on her referral list for audiology consultation and had never been seen by an audiologist. She acknowledged a January note referring him to audiology but confirmed no follow-up or visit occurred.
Restorative care ordered by physicians was ignored for a resident with stroke-related complications. The resident had a contracted left hand and was supposed to wear a hand orthotic three to four hours daily. Inspectors observed her on three consecutive days without the brace.
The resident told inspectors she rarely wore the brace and hadn't worn it in weeks. A certified nursing assistant said the resident received restorative care for her lower body but not her upper body. A licensed practical nurse confirmed the physician's order for a splint but was unsure if the resident ever wore it.
Smoking safety assessments were incomplete or missing for three residents who used tobacco. Facility policy required quarterly assessments using a smoking observation form, with care plans developed based on results.
One resident with dementia and cognitive impairment was observed smoking but had no smoking assessment in his clinical record and no smoking-related care plan. His assessment incorrectly documented no tobacco use despite appearing on the facility's smoking list.
A second resident with severe cognitive impairment had an incomplete smoking assessment marked "in process" from April 2024. A third resident's quarterly assessment incorrectly stated he had a past history of smoking but was currently not smoking, despite inspectors observing him smoking on two consecutive days.
The Director of Health Services confirmed the assessment failures and stated that without accurate assessments and care plan interventions, staff wouldn't know what to monitor.
The maintenance director acknowledged that air vents throughout the facility hadn't been cleaned in years and filters in the ductwork hadn't been changed. He described the building as old and needing extensive work.
All violations were classified as having minimal harm or potential for actual harm, affecting few residents. The facility must submit a plan of correction addressing each deficiency.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pruitthealth - Macon from 2025-05-15 including all violations, facility responses, and corrective action plans.
