Pruitthealth - Ocilla

Federal health inspectors cited PRUITTHEALTH - OCILLA in OCILLA, GA for a deficiency under regulatory tag F-F0584 during a standard health inspection conducted on 2025-09-18.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 7 deficiencies cited during this inspection of PRUITTHEALTH - OCILLA.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-02.

Federal health inspectors cited PRUITTHEALTH - OCILLA in OCILLA, GA for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-09-18.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 7 deficiencies cited during this inspection of PRUITTHEALTH - OCILLA.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-02.

F 0677 Level of Harm - Minimal harm or potential for actual harm

on the nursing staff orientation, so staff was aware that nail care is a required care area for each resident.

The DHS provided a copy of the CNA's complete orientation check list and Partner Orientation Checklist which listed nail care. The DHS revealed, it is her expectation that nail care, cleaning of the nails and trimming if residents were not receiving podiatry care needs to be done on bath days or upon request from residents.

Residents Affected - Few

1. 5. A review of the EMR revealed that Resident R36 was admitted to the facility with diagnoses that included but not

limited to major depressive disorder, recurrent, severe with psychotic symptoms and unspecified dementia, unspecified severity, with other behavioral disturbance, and generalized weakness.

A review of the quarterly MDS assessment dated [DATE REDACTED] for Section C (Cognitive Patterns) revealed a Brief

Interview for Mental Status (BIMS) score of seven, which indicated severe cognitive impairment and Section GG (Functional Abilities and Goals) revealed the resident was dependent on staff for personal hygiene care.

A review of the care plan dated 9/4/2025 revealed an intervention that included but not limited to staff to set up resident for ADLs.

Observation and interview on 9/16/2025 at 9:40 am with Resident R36 revealed his fingernails were long with a brown and yellow substance underneath them. Resident R36 revealed his fingernails needed to be trimmed and cleaned.

Observation and interview on 9/17/2025 at 1:00 pm with Resident R36 revealed his fingernails were long with a brown and yellow substance underneath them. Resident R36 revealed he would like his fingernails to be trimmed and cleaned.

Observation and interview on 9/17/2025 at 2:10 pm with the DHS confirmed the resident's nails were long and dirty with a yellow-brown substance. The DHS confirmed that all residents have an activity of daily living (ADL) care plan, as that was how staff know what interventions need to be implemented. She confirmed that the care plan for Resident R36 was not being implemented by failure to address personal hygiene including nail care.

Interview on 9/17/2025 at 2:15 pm with CNA BB revealed that he cleans nails when giving a resident a bath. CNA BB revealed, he would only trim a resident's nails if they were not diabetic and if resident allowed him to do so. He stated he doesn't normally care for Resident R36 but that he was going to give the resident

a bath and provide nail care since the resident's nails were soiled and long.

Cross Reference F-F656

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pruitthealth - Ocilla

209 West Hudson Street Ocilla, GA 31774

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, interviews, record review, and review of facility's policy titled Enteral Nutrition (Tube Feedings), the facility failed to follow physician orders and professional standards of care for one of four residents (R) Resident R31 that received enteral feedings. This deficient practice had the potential to place Resident R31 at increased risk of complications and adverse clinical outcomes. Findings include:Review of the facility policy titled Enteral Nutrition (Tube Feedings), with a review date of 9/12/2024 revealed: 2. The Physician will write orders prescribing formula, rate, route of administration, and flush orders for individual patient/residents.

Review of the Annual Minimal Data Set (MDS) for Resident R31, dated 8/8/2025 revealed that Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Section I (Active Diagnoses) diagnoses included, but not limited to: type 2 diabetes, cerebral infarction, congenital stenosis and stricture of esophagus, gastrostomy tube, chronic nausea and vomiting, and dysphagia.Review of the care plan for Resident R31, dated 8/8/2025 revealed, Resident R31 needed tube feedings related to her diagnosis of congenital stenosis and stricture of esophagus. The goal was to maintain nutritional stability via enteral tube feeding. Interventions included: flush as ordered, follow enhanced barrier precautions, treatment as ordered by medical doctor, and tube feedings as ordered.Review of the Physician Orders for Resident R31 dated 8/6/2024 revealed, gastrostomy tube (G-tube) residuals are checked before feeding and if residual is greater than 100 milliliters (ML) then hold the feeding and call the medical doctor for further orders every shift; check placement prior to med administration/flushes every shift; and formula [name] via G-tube bolus 237ML after meals and bedtime (four times a day.) Special instruction orders included: flush with 200ML water after each feeding, after every meal and at bedtime. Observation of Resident R31 enteral feeding process on 9/17/2025 at 8:06 am revealed, Licensed Practical Nurse (LPN) CC dressed out

in gown and gloves. LPN CC did not check placement or residual prior to connecting the large syringe used for bolus administration of formula. LPN CC flushed with cold water poured into a drinking cup from her medication cart water pitcher. She poured the water into the large syringe up to the 60ML measurement line on the side of the syringe and then poured the remaining water from the cup up to 50ML measurement line. LPN CC disconnected the syringe. Resident R31 immediately vomited but declined nausea medication offered by the nurse.Interview with LPN CC on 9/18/2025 at 8:30 am confirmed, LPN CC did not check residuals or placement and did not measure the water. She also confirmed that she did not flush with 200ML of water as ordered by the physician. She states she has received an in-service on tube feedings. Interview with Assisted Director of Health Services (ADHS) on 9/18/2025 at 10:09 am revealed, the enteral tube feeding process includes the nurse gathering supplies, follows enhanced barrier precautions and sets up their supplies in a clean manner. The nurse checks residuals, administers the formula and flush per the physician orders.Interview with the Director of Health Services (DHS) on 9/18/2025 at 10:39 am revealed,

the expectation is that nurses' follow policy. They are expected to complete the task as ordered by the physician. Nurses receive education and annual competency for enteral tube feedings.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pruitthealth - Ocilla

209 West Hudson Street Ocilla, GA 31774

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited PRUITTHEALTH - OCILLA in OCILLA, GA for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-09-18.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 7 deficiencies cited during this inspection of PRUITTHEALTH - OCILLA.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-02.

Federal health inspectors cited PRUITTHEALTH - OCILLA in OCILLA, GA for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-09-18.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 7 deficiencies cited during this inspection of PRUITTHEALTH - OCILLA.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-02.

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on observations, staff interviews, and the facility's policy, Infection Control-Dining Services, the facility failed to ensure that staff used proper hand sanitation methods during one of two meal observations.

This deficient practice had the potential to affect the 10 residents dining and contribute to the potential spread of infectious disease.Findings include:Review of the facility policy titled Infection Control-Dining Services with a review date of 11/30/2023 revealed, 2. All partners will wash their hands just before they start to work in the kitchen and when they have used their hand in an unsanitary way such as smoking, sneezing, using the restroom, handling poisonous compounds, dirty dishes or handling patients/residents.Observation on 9/17/2025 at 12:31 pm revealed, Certified Nursing Assistant (CNA) EE passing out food trays to 10 residents in the dining hall area. She passed out food trays without sanitizing her hands. She then assisted one resident by adjusting her positioning. CNA EE touched the resident's arms, shoulders, and her seat. CNA EE did not sanitize her hands before passing more additional food trays. Interview on 9/17/2025 at 12:35 with CNA EE confirmed, she did not sanitize her hands before passing food trays, between passing food trays, or after touching the resident with positioning assistance.

CNA EE stated she is supposed to sanitize her hands before and between passing food trays and anytime

she touches a resident.Interview on 9/18/2025 at 9:13 am with the Administrator revealed, all staff should be sanitizing their hands between passing food trays. They receive training on infection control at least monthly.Interview on 9/18/2025 at 2:05 pm with the Infection Preventionist revealed, it is her expectation that staff sanitize the hands of residents and their own hands before food trays are passed and between passing each food tray. She stated staff receive training monthly on infection control practices.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet