Cycle 1
Health 2025-05-15 · Fire 2025-05-15
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Lilburn, GA
Pruitthealth - Lilburn
1-star overall rating with 1-star inspections with $59,423 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
788 Indian Trail Road, Lilburn, GA
(770) 923-2020
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
152
Certified beds
Average residents
118
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pruitthealth
Operator or chain grouping
Approved since
1991-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
95 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.59
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.25
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.48
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
2.79
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,862
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.96
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.48
Baseline 51.52% · Performance 53.53% · Measure score 2.48 · Achievement 2.48 · Improvement 0
Adjusted total nurse staffing
0.51
Baseline 2.61 hours · Performance 2.93 hours · Measure score 0.51 · Achievement 0 · Improvement 0.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.67% |
10.72%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 18.92% · Lower 95% interval 8.4% |
| Discharge to community | 45.92% |
50.57%
4.6 pts worse
|
No Different than the National Rate · Eligible stays 63 · Observed rate 33.33% · Lower 95% interval 35.98% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 85% |
95.27%
10.3 pts worse
|
Numerator 17 · Denominator 20 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 20 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 15% |
2.29%
12.7 pts worse
|
Numerator 3 · Denominator 20 · Adjusted rate 13.15% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.52% |
8.2%
6.7 pts worse
|
Numerator 2 · Denominator 132 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
91.2%
8.1 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 99.1% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
95.0%
4.1 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.2%
1.1 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.8% · Q3 1.8% · Q4 1.8% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 26.3% |
9.6%
16.7 pts worse
|
11.4%
14.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 17.9% · Q3 17.5% · Q4 42.1% · 4Q avg 26.3% |
| Percentage of long-stay residents who lose too much weight | 0.5% |
5.9%
5.4 pts better
|
5.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.5% |
20.7%
10.2 pts better
|
19.6%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 10.2% · Q3 11.7% · Q4 11.3% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.4% |
21.4%
9 pts better
|
16.7%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 14.7% · Q3 13.0% · Q4 8.8% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.5% |
17.9%
6.4 pts better
|
16.3%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 12.2% · Q3 5.6% · Q4 5.1% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.7% |
16.2%
10.5 pts better
|
14.9%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 6.2% · Q3 1.2% · Q4 0.0% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.1%
0.6 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.6% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
2.5%
1.1 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.2% |
16.1%
4.9 pts better
|
19.8%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 30.1% · Q2 7.1% · Q3 3.7% · Q4 5.3% · 4Q avg 11.2% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
6.2%
1.8 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 5.0% · Q3 2.7% · Q4 2.5% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
80.4%
15.1 pts better
|
81.7%
13.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.6% · Q2 98.5% · Q3 98.6% · Q4 98.4% · 4Q avg 95.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.3% |
12.2%
0.1 pts worse
|
12.0%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 14.3% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
2.2%
0.2 pts better
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.4% · Q4 2.6% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
78.2%
17.3 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 37.9% |
24.2%
13.7 pts worse
|
23.9%
14 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 37.9% · Observed 47.6% · Expected 30.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-18 · Fire 2024-01-18
4 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-04-01 · Fire 2022-04-01
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-05-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-05-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-25
D · Potential for more than minimal harm
2024-01-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-05-15
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-05-15
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-05-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-05-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-05-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-05-15
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-06-25
E · Potential for more than minimal harm
2024-01-18
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-18
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-18
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-26
K · Immediate jeopardy
2023-09-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-17
K · Immediate jeopardy
2023-09-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-17
K · Immediate jeopardy
2023-09-18
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-09-18
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-09-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-09-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-09-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-09-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-11-17
E · Potential for more than minimal harm
2022-04-01
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-05-16
D · Potential for more than minimal harm
2022-04-01
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-05-16
D · Potential for more than minimal harm
2022-04-01
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-05-16
C · Minimal harm
2022-04-01
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-05-16
Penalties and ownership
What sits behind the stars
$59,423
2023-09-18
Fine
Fine · fine $59,423
Fine
$0
2023-09-18
Payment Denial
Payment Denial · denial start 2023-09-22 · 56 days
56 day denial
Ownership
United Health Services Of Georgia, Inc.
5% Or Greater Direct Ownership Interest · Organization
J Paige Pruitt Trust
5% Or Greater Indirect Ownership Interest · Organization
Lisa P Hamby Trust
5% Or Greater Indirect Ownership Interest · Organization
Neil L Pruitt Jr Trust
5% Or Greater Indirect Ownership Interest · Organization
Pruitt, Neil
Operational/Managerial Control · Individual
Pruitt, Neil
Corporate Director · Individual
Pruitt, Neil
Corporate Officer · Individual
Smith, Toni
W-2 Managing Employee · Individual
Uhs-Pruitt Holdings, Inc.
5% Or Greater Indirect Ownership Interest · Organization
United Health Services Inc
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Life Care Center Of Gwinnett
Lawrenceville, GA
5-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Meadowbrook Health And Rehab
Tucker, GA
1-star overall rating with 1-star inspections with $47,466 in total fines with 15 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Delmar Gardens Of Gwinnett
Lawrenceville, GA
3-star overall rating with 3-star inspections with 4 recent health deficiencies
Jump out