Cycle 1
Health 2024-09-05 · Fire 2024-09-05
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Lithonia, GA
PruittHealth - Lithonia, LLC
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2816 Evans Mill Road, Lithonia, GA
(770) 482-2961
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
146
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ethica Health
Operator or chain grouping
Approved since
1989-11-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
48 facilities
Chain averages 4 overall / 4 health / 3 staffing / 3 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
0.37
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.45
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.24
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
0.82
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
2.73
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
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
3.15
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,285
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.47
Composite VBP score used to determine payment impact.
Payment multiplier
1.0046
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
8.29
Baseline 38.75% · Performance 29.79% · Measure score 8.29 · Achievement 8.29 · Improvement 5.95
Adjusted total nurse staffing
1.80
Baseline 2.81 hours · Performance 3.49 hours · Measure score 1.80 · Achievement 1.46 · Improvement 1.80
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.88% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 11.43% · Lower 95% interval 7.62% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.77% |
95.27%
1.5 pts better
|
Numerator 30 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 1 · Denominator 31 · Adjusted rate 2.05% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 174 |
| Staff flu vaccination coverage | 47.34% |
42%
5.3 pts better
|
Numerator 80 · Denominator 169 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.2
0.5 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.0 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.0
0.7 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.2% |
91.2%
10 pts worse
|
93.4%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 78.7% · Q2 75.5% · Q3 83.6% · Q4 87.1% · 4Q avg 81.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.9% |
95.0%
0.9 pts better
|
95.5%
0.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.2%
1.4 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.9% · Q3 1.5% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
9.6%
9.6 pts better
|
11.4%
11.4 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 who lose too much weight | 7.3% |
5.9%
1.4 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 9.9% · Q3 9.6% · Q4 3.9% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.9% |
20.7%
14.8 pts better
|
19.6%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 6.0% · Q3 5.6% · Q4 6.9% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.0% |
21.4%
0.6 pts worse
|
16.7%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 21.1% · Q3 24.3% · Q4 23.9% · 4Q avg 22.0% · 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 | 22.1% |
17.9%
4.2 pts worse
|
16.3%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 23.6% · Q3 16.6% · Q4 21.6% · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.7% |
16.2%
7.5 pts worse
|
14.9%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 30.5% · Q3 25.0% · Q4 17.6% · 4Q avg 23.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.1%
0.7 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.6% · Q4 1.1% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.7% |
2.5%
2.2 pts worse
|
1.7%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 8.8% · Q3 6.0% · Q4 2.9% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.2% |
16.1%
2.9 pts better
|
19.8%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 11.5% · Q3 15.3% · Q4 10.4% · 4Q avg 13.2% |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
6.2%
1.6 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 9.7% · Q3 8.7% · Q4 5.3% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.0% |
80.4%
20.4 pts worse
|
81.7%
21.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 57.6% · Q3 69.6% · Q4 84.2% · 4Q avg 60.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
12.2%
3.1 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 10.3% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.7% |
78.2%
4.5 pts worse
|
79.7%
6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.2% |
24.2%
7 pts better
|
23.9%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 23.1% · Expected 32.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-10 · Fire 2022-06-10
5 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-08-15 · Fire 2019-08-15
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-05
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-18
D · Potential for more than minimal harm
2024-09-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-18
D · Potential for more than minimal harm
2019-08-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-09-29
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-09-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-05
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-05
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-09-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-20
E · Potential for more than minimal harm
2024-04-03
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-05-18
D · Potential for more than minimal harm
2024-04-03
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-05-18
D · Potential for more than minimal harm
2024-04-03
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 2024-05-18
D · Potential for more than minimal harm
2024-04-03
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-05-18
D · Potential for more than minimal harm
2022-06-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-07-25
D · Potential for more than minimal harm
2019-08-15
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 2019-09-29
D · Potential for more than minimal harm
2019-08-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-09-29
Penalties and ownership
What sits behind the stars
Ownership
Community Health Systems Inc
5% Or Greater Indirect Ownership Interest · Organization
Clinical Services Inc
Operational/Managerial Control · Organization
Health Scholarships Inc
5% Or Greater Direct Ownership Interest · Organization
Health Systems Real Estate, Inc
5% Or Greater Direct Ownership Interest · Organization
Lambert, Reno
Operational/Managerial Control · Individual
Mahorn, Shanathania
Operational/Managerial Control · Individual
Ogoo, Agnes
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Rockdale Healthcare Center
Conyers, GA
1-star overall rating with 1-star inspections with $15,971 in total fines with 18 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Westbury Center Of Conyers For Nursing And Healing
Conyers, GA
3-star overall rating with 4-star inspections with $10,527 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Pebblebrook Health Center At Park Springs
Stone Mountain, GA
4-star overall rating with 3-star inspections with $19,408 in total fines with 6 recent health deficiencies
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