Pruitthealth - West Atlanta

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility policy titled, Bed Hold Acknowledgment Form: Georgia, the facility failed to provide bed hold information, in writing, at the time of transfer or within 24 hours, for three of 45 residents (R) (R106, R68, and R19) who were transferred to the hospital in the last 120 days. Findings include: A review of the facility policy titled Bed Hold Acknowledgment Form: Georgia, reviewed 1/11/2024, revealed the Policy included Two notices related to the healthcare center's bed hold policy will be issued. The first notice of bed hold policies is given during this admission, which is well in advance of any transfer. The second notice, which specifies the duration of the bed hold policy, will be issued at the time of any transfer. 1. A review of R106's Electronic Medical Record (EMR) revealed he was discharged from the facility to a hospital on 3/31/2024, and there was no documented evidence of a bed hold notification being provided to the resident or the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure residents were seen by a physician in the facility at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter, for four of 10 residents (R) (R1, R50, R52, and R72) reviewed for frequency of Physician visits. Findings include: 1. Review of the electronic medical record (EMR) revealed R52 had diagnoses to include but not limited to paranoid schizophrenia, type 2 diabetes mellitus with diabetic chronic kidney disease, anxiety disorder, unspecified, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, and mood disturbance. Further review of the EMR for the past year did not indicate any physician visits for R52. Review of the EMR for R74 admitted to the facility on [DATE]. R74 admitted under Commercial Insurance and became Medicaid effective 7/17/2024 per the Resident Census. Further review revealed that R74 was seen by the physician on 7/7/2023 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interview, and review of the facility policy titled, Food Temperatures, the facility failed to ensure all food items on the steam table were held above 135 degrees Fahrenheit (F) to prevent bacteria growth. The deficient practice affected nine residents ordered a puree consistency diet from a total of 99 residents receiving an oral diet. Findings include: Review of the facility policy titled Food Temperatures revealed: 1. All hot foods served from the steam table must be held at or above 135 degrees F. Steam table temperatures were obtained on 5/18/2024 at 12:45 pm. The Dietary Manager (DM) assisted with taking the food temperatures using the facility's calibrated thermometer. Continued observation revealed the puree beef patty had a temperature of 132 degrees F. During an interview on 5/18/2024 at 12:45 pm, the DM confirmed that the puree beef patty had a temperature of 132 degrees. The DM confirmed that all food items on the steam table need to be held at or above 135 degrees. A continued interview with the DM revealed that there had not been any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Self-Medication, the facility failed to assess one of 40 sampled residents (R) (R71) for the ability to self-administer medications prior to leaving medications at the bedside. The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents, staff, or visitors. Findings include: Review of the facility policy titled Self-Administration of Medication by Patient/Residents, last reviewed 1/12/2024, under Policy Statement revealed Each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients/residents of the healthcare center. Medication self-administration also applies to family members who wish to administer medication. Review of the electronic medical record (EMR) for R71 revealed diagnoses that included but not limited to schizophrenia,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to one of three residents (R) (103) reviewed that were discharged from Medicare Part A coverage. Findings include: Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, revealed that R103 was discharged off Medicare Part A skilled services on 5/18/2024 and remained in the facility afterwards with benefit days remaining. There was no documented evidence that the SNF ABN was provided to either R103 or the responsible party. During an interview on 5/19/2024 at 2:26 pm, the Administrator revealed that the Financial Controller was new and was familiar with Medicare Part B. They were unaware that the SNF ABN was a required notice for residents discharged from Medicare Part A skilled services who remained in the facility. She confirmed that R103 and/or the responsible party did not receive an SNF ABN.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to provide specialized psychiatric services for one resident (R) (R19) with a serious mental illness (SMI) as recommended by the Preadmission Screening and Resident Review (PASRR) Level II summary. The sample size was 40 residents. Findings include: Review of the electronic medical record (EMR) revealed R19 was admitted to the facility on [DATE] and had a diagnosis of schizophrenia. R19 was receiving Zyprexa (antipsychotic medication) 5 milligrams (mg) at bedtime. Review of the admission Minimum Data Set (MDS) revealed R19 was assessed on the 1/11/2024 admission as receiving antipsychotic medication. Review of the Georgia PASRR Level II Summary dated 1/24/2024 revealed specialized services for SMI were recommended for R19. The specialized services included behavioral health assessment/ service plan and diagnostic/ongoing psychiatric care. The resident had a corresponding care plan. Review of the EMR revealed no documented evidence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, and review of the facility policy titled, Care Plans, the facility failed to develop a care plan for one resident (R) (R50) of five reviewed for unnecessary medications and failed to implement care plan interventions for one of four residents (R77) reviewed for food/nutrition. Specifically, the facility failed to develop a care plan for the use of antipsychotic and anti-anxiety medication for R50 and failed to implement a care plan for diet as ordered for R77. These failures created the potential for R50 and R77 to not receive treatment and/or care according to their needs. Findings include: A review of the facility policy titled Care Plans, revised 7/27/2023, revealed the admission Comprehensive Plan of Care section included 3. The comprehensive-person centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing, and psychological needs, the services that are to be furnished to attain or maintain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and record review, the facility failed to ensure one of 40 sampled residents (R) (R77) was served a lactose free diet as ordered by the physician. The deficient practice caused R77 to be served food items that contained lactose, which R77 was allergic to. Findings include: Review of the electronic medical record (EMR) revealed that R77 had diagnoses that included but not limited to type 2 diabetes, hemiplegia/hemiparesis, chronic kidney disease, and moderate protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R77 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Review of the Physician Orders revealed R77 was ordered to receive a Controlled Carbohydrate (CCHO) liberalized diabetic and lactose allergy diet. During an interview on 5/17/2024 at 11:50 am, R77 revealed that he was lactose intolerant, and it was indicated on his meal tray ticket allergy to lactose but…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility policy titled, Monitoring of Antipsychotics, the facility failed to ensure that a Gradual Dose Reduction (GDR) assessment was completed at least annually for one of five sampled residents (R) (R50) reviewed for unnecessary psychotropic medication use. This failure had the potential to affect R50's highest practicable mental, physical, and psychosocial well-being. Findings include: A review of the facility policy titled Monitoring of Antipsychotics, reviewed 7/5/2023, revealed the Procedure section stated, 6. Gradual dose reduction is attempted with all patients/residents who receive antipsychotic medications. For patients/residents who have a true psychiatric diagnosis of schizophrenia, a gradual dose reduction assessment will be conducted twice in two separate quarters with at least one month between attempts the first year that the patient/resident is admitted or after the facility has initiated an antipsychotic medication. After the first…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, review of the facility policy titled, Medication Storage in the Healthcare Centers, review of the facility-provided documents titled 2024 Insulin Expiration Calendar-28 Day and 2024 Latanaprost and Levemir Expiration Calendar - 6 Weeks (42 Days), and review of manufacturer packet inserts, 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). These deficient practices created the potential for residents to receive medications with altered effectiveness. Findings include: A review of the facility policy titled Medication Storage in the Healthcare Centers, revised [DATE], revealed the Policy Statement included, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The Procedure section stated, 3. Nurses are required to check all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility policy titled, Cleaning Procedures: Serving Equipment, the facility failed to ensure the ice scoop bin and beverage dispenser was free from green and black buildup on one of two units (West). The deficient practice had the potential to cause an adverse outcome to those served from the affected ice scoop bin and beverage dispenser. Findings include: Review of the facility policy titled Cleaning Procedures: Serving Equipment, last revised 9/29/2022, policy statement revealed: It is the policy of (said facility) to maintain a clean and sanitary environment to prepare patient/resident meals. Ice Scoop: Daily 1. Remove ice scoop and holding bin from the ice machine. 2. Wash and Sanitize. 3. Allow to air dry. 4. Return ice scoop and holding bin to the ice machine. Observation on 5/17/2024 at 8:49 am revealed an ice chest on cart near the [NAME] nurse station. The scoop for the ice was in a clear container that had water and black buildup along the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, staff interviews, and the review of the facility policy Resident Trust Policy, the facility failed to provide resident trust fund account quarterly statements for two of three resident (R) A and R B, reviewed. Eighty-seven (87) resident trust fund accounts are managed by the facility. Findings included: A review of the policy titled Resident Trust Policy dated September 2009 indicated: Policy- Upon written authorization of a resident, the healthcare center must safeguard, manage, and account for the personal funds of the resident deposited with the healthcare center. For the purposes of this policy, the center business office staff shall be referred to as the Financial Counselor. 6. The resident shall have reasonable access, upon request, to a record of all transactions made to his/her account. Quarterly statements will be provided in writing to the resident or the resident's responsible representative within 30 days after the end of the quarter. 1. A review of R B annual Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and record review of the Maintenance Director Position Description the facility failed to ensure that it was maintained in a safe, clean, and comfortable, homelike environment on two of two wings (East Wing and [NAME] Wing) related to resident rooms with missing floor tile; peeling paint; peeling base board; missing dry wall; stained privacy curtains; dirty air filters; dirty vents on the Packaged Terminal Air Conditioner (PTAC) units; one resident's bathroom had a broken grab bar and rust around the toilet; and stain and missing ceiling tiles in resident common areas; shower rooms with dirty floors and walls; and the smoke porch aluminum ceiling was rusted with several holes. Findings included: A review of the Maintenance Director Position Description with a modified date of December 2016 indicated Job Purpose: The Maintenance Director assumes administrative authority, responsibility and accountability to maintain the facility physical plant and essential mechanical,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and record review, the facility failed to ensure that the menu was followed to ensure the appropriate nutrition to residents and failed to notify the Registered Dietician for substituted food. This deficient practice affected 88 of the 93 residents in the facility receiving an oral diet. Findings included: Record review of grievances filed by residents revealed grievances about the food were filed monthly by residents to include but not limited to residents not receiving food listed on meal ticket not served on meal tray, turkey served two -three times weekly, requests for boiled eggs but receives powdered eggs. Observations of meals throughout survey period revealed observed meals served that were not on the menu and meals were not served per resident's meal tray ticket. During meal observation on the east and west wing on 8/24/2023 it was revealed that none of the residents had grapefruit sections, glazed cinnamon raisin biscuit, or bacon that was listed on their tray…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews and record review, the facility failed to provide meals that were prepared by methods that conserve nutritive value, flavor, and appearance and provide meals that were palatable, attractive, and at a safe and appetizing temperature for affected 88 of 93 residents in the facility receiving an oral diet. Findings included: An observation of the breakfast meal, served on 8/16/2023, revealed all food items were served on undivided plates with food items touching. There was no separation of food items. A review of the grievances filed by residents revealed grievances about the food were filed monthly by residents to include but not limited to residents not receiving food listed on meal ticket not served on meal tray, turkey served two -three times weekly, requests for boiled eggs but receives powdered eggs, inconsistency with meal portions, food not looking like what is on meal ticket. A test tray (lunch) was requested on 8/23/2023. Senior Nurse Consultant observed wearing a hair net. Senior Nurse Consultant stated that she and the Administrator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, and review of the Dietary Manager Position Description, the facility failed to maintain the kitchen in a clean and sanitary condition. This deficient practice had the potential to affect 88 of the 93 residents receiving an oral diet. Findings included: A review of the Dietary Manager Position Description with a modified date of January 2016 indicated Job Purpose: Plans, organizes, develops, and directs the overall operation of the Dietary Department in accordance with current federal, state, and local regulations governing the center and as directed by the Administrator. Responsible for maintaining the Dietary Department in a clean, safe, and sanitary manner and provide nutritionally adequate meals in accordance with regulatory guidelines. Key Responsibilities: 8. Maintains the proper storage, preparation, distribution and serving of food under sanitary conditions in accordance with regulatory guidelines. 11. Supervises the operation of all major equipment to include but not limited to the dish machine, garbage disposal, blender, mixer,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interviews, and review of the policy Sanitation Checklist Form, the facility failed to properly maintain the area around the dumpster grounds. This practice created the potential for transmission of disease by pests/rodents, and insects. Findings included: A review of the policy titled Sanitation Checklist Form review date 8/16/2017 indicated: Garbage, Trash Disposal, Housekeeping: 6. Dumpster area is clean and free of excess garbage. All garbage is placed in dumpster. Dumpster doors and lids are closed and free of pests infestation. An observation on 7/26/2023 at 12:00 p.m. of the two dumpsters located on the left side of the facility. Observation of seven mattresses, a large wood pallet, four pieces of wood located behind the first dumpster. Behind the second dumpster was a pile of trash with plastic trash bags, empty bottles, cans, and trash inside of a plastic bag. Observation of large black bugs crawling behind the dumpster. Six steps away from the two dumpsters was a medication cart. Beyond the medication cart was the grease receptable, the lid was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and the facility documents, the facility failed to promptly fix water leak problems throughout the facility that resulted in mold in the resident rooms and resident common areas. This had a potential to effect 93 out of 93 immune compromised residents. Findings included: A review of the policy titled Infection Prevention and Control Program Surveillance Reporting reviewed dated 1/24/2023 indicated Policy Statement: It is the policy of this facility to establish and maintain an Infection Control Program that includes detection, prevention, and control of the transmission of disease and infection among patients/residents and pai1ners. The Administrator of the Healthcare Center is responsible for the Infection Control Program. All infection prevention and control practices reflect current Centers for Disease Control (CDC) guidelines Infection Control Committee: The infection Control Committee, which consists of the (Infection Preventionist) IP, key administrative personnel,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews and review of the facility policy titled Partner Background Screening to Prevent Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to have onsite two out of twelve employee files selected for review. The file for License Practical Nurse (LPN) AA and Certified Nursing Assistant (CNA) FF were not in the facility for thirty-six days of the survey. The facility had a census of ninety-three residents. Findings included: A review of the policy titled Partner Background Screening to Prevent Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property dated 12/7/2022 indicated: Policy Statement- It is the policy of PruittHealth and its affiliated providers (collectively, the Organization) to conduct a background check of individuals being considered for employment prior to their employment. Such background checks should meet the requirements of applicable law and regulations, including any applicable licensure requirements. Procedure: 1. All entities within the Organization should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and record review, the facility failed to assess one of 31 sampled residents (R) (R#17) for the ability to self-administer medications prior to leaving medications at the bedside. Findings included: An observation and interview were conducted on 8/15/2023 at 1:43 p.m. R#17 was observed in his room sitting on his bed. His lunch tray was observed on the bedside table along with a medicine cup with a yellowish colored capsule in the cup. R#17 stated that the nurse left the pill on his table for him to take his pill. R#17 stated that he was going to take the pill after he ate his lunch and that the nurse always leaves his pill for him to take. He stated that he always takes it after he eats his lunch. A review of the Electronic Medical Record (EMR) for R#17 revealed he presented with diagnosis including but not limited to Diabetes Mellitus Type 2 with diabetic polyneuropathy, major depressive disorder, hypertension, and unspecified convulsions. A review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and the facility Policy titled Resident Trust Fund, the facility failed to honor two out of three residents (R A and R B) requests for access to their funds within the same day. Findings included: A review of the policy titled Resident Trust Policy dated September 2009 indicated Policy: Upon written authorization of a resident, the healthcare center must safeguard, manage, and account for the personal funds of the resident deposited with the healthcare center. For the purposes of this policy, the center business office staff shall be referred to as the Financial Counselor. 3. Residents have access to petty cash on an ongoing basis and are able to arrange for access of larger funds. 16. Each healthcare center will have a predetermined petty cash amount on hand for resident use. This amount is to be determined and approved by the Assistant [NAME] President. The Petty Cash should be reconciled to this amount on a weekly basis. 1. A review of R B annual Minimum Data Set (MDS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and the facility Policies titled Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Mission Statement and Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to safely protect two of 31 sampled residents (R) (R#4 and R#29) from Misappropriation of funds. Specifically, the facility permanently used R#4 money without the resident's consent and R#29 had unauthorized purchases on her personal credit card. Findings included: Review of the policy titled Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Mission Statement dated 12/7/2022 indicated: Policy- It is the mission of (the facility) and its affiliated providers (collectively, the Organization) actively to preserve each patient's right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of patient property. Whenever a patient, family…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, the facility failed to notify the State Agency (SA) within the required two hours of an incident involving an elopement of one resident (R) (R#17) of 31 sampled residents. Findings included: A review of the facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property revised on 10/9/2020 revealed: It is the policy of PruittHealth and its affiliated provider entities (collectively, the Organization) to investigate allegations and occurrences of patient abuse, neglect, exploitation, mistreatment, and misappropriation of patient property. A record review of the Electronic Medical Record (EMR) for R#17 revealed diagnosis including but not limited to Diabetes Mellitus Type 2 with diabetic polyneuropathy, major depressive disorder, single episode, hypertension, and unspecified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, interviews and the facility policy titled Documentation: Charting Activities of Daily Living (ADLs) and the Certified Nursing Assistant Position Description the facility failed to provide oral care for one of three sampled residents (R) (R#8) dependent on staff for activities of daily living (ADL) care. Findings included: A review of the policy titled Documentation: Charting Activities of Daily Living (ADLs) review date 11/22/22 indicated Policy Statement: It is required for Activities of Daily Living (ADL) care given by Certified Nursing Assistants and Nurses to be documented under Care Assist in patient's/resident's Electronic Healthcare Record (EHR). For the healthcare centers not utilizing EHR, all documentation will be completed using the CNA ADL Flow Sheet Form. Procedure: 2. The responsibility of the person completing the documentation on the CNA/ ADL Flowsheet is to code the maximum amount of support the patient/resident received over the entire shift irrespective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and the facility policy titled Hydration: Dietary Services the facility failed to ensure that water was within reach for one of three residents (R) (R#8) reviewed for hydration. Findings included: Review of the policy titled Hydration: Dietary Services revised date of 1/6/2021indicated: Policy Statement- It is the policy . that patients/residents will be adequately hydrated. Procedure: 1. The Registered Dietitian will consider risk factors for patients/residents becoming dehydrated. Functional impairments making it difficult to drink or reach for fluids or communicate fluid needs (i.e., aphasia) Dementia in which patient/resident forgets to drink. 3. The Registered Dietitian may calculate daily fluid requirements for all patients/residents fluid requirements. 6. Each patient/resident will be provided a drinking glass and water pitcher in their room unless they are on a fluid restriction. 7. Water pitchers are filled with ice/water at least, but not limited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and the facility policy titled Specialty Services: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health and the Social Services Position Description, the facility failed to ensure two of 31 sampled residents (R) (R#5 and R#11) received adequate assistance and support from social services department. Specifically, R#11 missed two scheduled oral surgeries and three outside ophthalmologist appointments and R#5 missed three scheduled psychiatry appointments. Findings included: A review of the policy titled Specialty Services: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health. Review date [DATE] indicated: It shall be the responsibility of this healthcare center to obtain regular and emergency specialty services for each patient/resident to ensure the highest well-being of the residents. Procedure: 1. It shall be the responsibility of this healthcare center to provide safe and convenient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff, and resident interviews the facility policy titled Nutritional Screening and Assessments/Food Preferences, Hydration: Dietary Services and the Dietary Manager Position Description the facility failed to honor preferences for two of fourteen residents (R) (R#4 and R#5) with likes, dislikes, and preferences. Findings included: A review of the policy titled Nutritional Screening and Assessments/Food Preferences review date 1/8/2021 indicated Policy Statement: It is the policy . for patient/resident to receive an initial nutritional screening and comprehensive nutritional assessment upon admission. The Food Preference Form is completed for each patient/resident upon admission and annually to assure food choices and preferences are granted. Procedure: 3. The Dietary Manager, Dietitian, or designee will visit the patient/resident to discuss patient/resident's preferences, choices, and/or religious, ethic, and cultural preferences within five days. The preferences will be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to protect the rights one of ten sampled residents (Resident [R] #66) reviewed for choices. Specifically, R#66 chose to have a shower once per week and the facility failed to provide a shower for the resident and only assisted the resident with bed baths. Findings include: A policy related to choices was requested from the facility, but the facility did not have a policy for resident choices. Review of R#66's Face Sheet revealed the facility admitted the resident on 04/07/2021. The resident had diagnoses including chronic pain, idiopathic peripheral autonomic neuropathy, chronic obstructive pulmonary disease, psoriatic arthritis, spinal stenosis of lumbar region without neurogenic claudication (compression of spinal nerves), shortness of breath, other abnormalities of gait and mobility, and muscle weakness. Review of R#66's annual Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a resident with a newly diagnosed serious mental illness was referred for a level II Preadmission Screening and Resident Review (PASRR). This effected one (Resident [R] #72) of six residents reviewed for PASRR. Findings include: A policy was requested from the facility related to PASRR, but the facility provided no policy for its PASRR referral process. A review of a Face Sheet revealed the facility admitted R#72 on 10/05/2016 and had diagnoses which included schizophrenia, paraplegia, and major depressive disorder. Further review of the Face Sheet revealed the diagnoses of schizophrenia and major depressive disorder were added on 10/23/2016, following admission to the facility. A review of R#72's annual Minimum Data Set (MDS) assessment, dated 04/14/2022, revealed R#72 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated R#72 had active diagnoses of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to include serious mental illness diagnoses on the level I Pre-admission Screening and Resident Review (PASRR) screening completed prior to admission for two of six sampled residents (Resident [R] #68 and R#43) reviewed for PASRR. Findings include: A policy was requested from the facility related to PASRR, but the facility lacked a policy for their PASRR referral process. 1. A review of a Face Sheet revealed the facility admitted R#68 on 06/06/2013 and had diagnoses that included hemiplegia, peripheral vascular disease, and schizophrenia. Further review of the Face Sheet revealed the diagnosis of schizophrenia was present upon admission to the facility. A review of R#68's annual Minimum Data Set (MDS) assessment, dated 04/07/2022, revealed the resident was unable to complete the interview for the Brief Interview for Mental Status (BIMS). According to the Staff Assessment for Mental Status, R#68's cognitive skills for daily decision making were severely impaired. The MDS noted R#68 had active diagnoses of depression and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.