PruittHealth - Carrollton

Based on observations, staff and resident interviews, record reviews, and review of the facility's policy titled Self-Administration of Medications by Patients/Residents, the facility failed to assess two of 27 sampled residents (R) (R44 and R21) to determine whether it was clinically appropriate for them to safely self-administer medications. This deficient practice had the potential to place R44 and R21 at risk for unsafe medication administration. Findings include: Review of the facility's policy titled Self-Administration Protocol, revised 1/28/2020, revealed the Policy Statement stated, 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 patient/resident of the healthcare center. Medication self-administration also applies to family members who wish to administer medication. The Procedure section included . 4. If the patient/resident or family member demonstrates the ability to safely self-administer…

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 facility policy titled, Food Ordering, Receiving, and Storage, the facility failed to ensure opened food items were dated. This deficient practice had the potential to affect residents receiving an oral diet. The census was 34. Findings include: Review of the facility policy titled, Food Ordering, Receiving, and Storage, reviewed 8/3/2017, revealed the Storage and Rotation Guideline section stated the facility must date and store all food items received on delivery day. During the initial Kitchen tour on 11/12/2024 at 9:50 am with the Dietary Manager (DM), observation of the walk-in freezer revealed an unlabeled and undated opened bag of frozen sweet potatoes. Observation of the walk-in refrigerator revealed an unlabeled and undated open block of Swiss cheese and one unlabeled and undated carton of heavy cream. During an interview on 11/13/2024 at 1:35 pm, the DM confirmed the unlabeled and undated food items and stated the Dietary [NAME] and Dietary Aides were responsible for labeling, dating, and proper storage of food. She…

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 interviews, and review of the facility's policy titled, Medication Administration: Hand Hygiene, the facility failed to maintain infection control practices by not ensuring hand hygiene during two of three medication administration observations. This deficient practice had the potential to increase the potential for cross-contamination and spread of infection. The facility census was 34. Findings include: Review of the facility's policy titled, Medication Administration: Hand Hygiene, review date 10/14/2024, documented Policy Statement: It is the policy of (name of facility) Pharmacy Services that partners will use appropriate hand hygiene during medication administration. Appropriate hand hygiene reduces the spread of germs and decreases the spread of infections. The Procedure section included 1. During medication administration, use hand hygiene before and after touching a patient . after touching a patient's immediate surroundings, and before and after glove removal. Observation on 11/13/2024 at 9:06 am revealed Licensed Practical Nurse (LPN) AA did…

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 reviews, staff interviews, and review of the facility's policy titled, Care Plans, the facility failed to develop a Baseline Care Plan (BCP) for one of 29 sampled residents (R) (R190). Specifically, the facility failed to develop a baseline care plan that included narcotic administration. The facility census was 34. Findings include: Review of the facility's policy titled Care Plan revised 7/27/2023 documented under Procedure: New admission Baseline Plan of Care: 1. Upon a new admission, a baseline care plan will be developed by admitting nurse/nurses in conjunction with other IDT, the patient/resident and /or patient/resident representative. The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission. Review of Electronic Medical Records (EMR) revealed R190 was admitted on [DATE] with diagnoses including but not limited to chronic pain. Review of R190's Minimum Data Set (MDS) assessment dated [DATE] documented in Section C (Cognition)…

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 reviews, staff interviews, and review of the facility's policy titled, Care Plans, the facility failed to review and revise a comprehensive care plan for one of 29 sampled residents (R) (R5) related to oxygen (O2) therapy. The deficient practice had the potential to cause R5 to not receive the necessary treatment required to provide and meet her needs. Findings include: Review of facility's policy titled Care Plans revised 7/27/2023 documented under Care Plan Review and Update: 1. Care Plan updated/ reviews will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. Review of electronic medical records (EMR) revealed R5 was re-admitted to the facility on [DATE] with diagnoses including but not limited to pneumonia. Review of Minimum Data Set (MDS) dated [DATE] documented no information. Review of R5's care plan dated 10/7/2024 revealed no documentation for O2 administration since admission on [DATE] to survey date…

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's policy titled, Controlled Substances for HealthCare Centers, the facility failed to maintain the correct narcotic count for one of 29 sampled residents (R) (R190). The deficient practice had the potential to cause drug-control issues and potentially cause negative effects for residents. The facility census was 34. Review of the facility's policy titled Policy Controlled Substances for HealthCare Centers revised 4/30/2024 documented under Policy Statement: . Reconciliation of controlled substances will be performed at the end of each shift by licensed professional nurses . Under Accounting: 1. A physical inventory of all controlled substances is conducted at each shift change by the incoming and outgoing licensed professional nurses. 2. The inventory is documented on the Controlled Drug Shift Audit Sheet. Review of Electronic Medical Records (EMR) revealed R190 was admitted on [DATE] for diagnosis including but not limited to chronic pain.…

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, the facility failed to maintain a homelike environment related to disrepair of a ceiling on one hall and peeling/dirty wallpaper on three of three hallways (100, 200, and 300 halls). Findings include: Observation on 6/2/2023 at 11:00 a.m. revealed wallpaper peeling from the walls of the 100 hall. Specifically in the following areas: 1. Wallpaper peeling outside room [ROOM NUMBER] and between the therapy office. 2. Wallpaper peeling over the door of the oxygen storage room, janitor closet, and between the health clinic doors. Additionally, wallpaper was seen peeling in front of the nurses' station by the soiled linen room. .Observations on 6/2/2023 at 10:19 a.m. revealed peeling wallpaper from the walls on the 200 hall in the followings places: 1. Above the exit door at the end of the 200 hall. 2. Above room [ROOM NUMBER] door and above room [ROOM NUMBER] door, vertically down the wall between room [ROOM NUMBER] and 212. 3. Above room [ROOM NUMBER] door. 4.…

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 interview, record review, review of the facility's policy titled, Care Plan, the facility failed to implement the care plan interventions for weekly weights and to consult with the registered dietician for one of eight Residents (R) (R#21) with a significant weight loss. Specifically, the facility failed to ensure that R#21 was assessed by the Registered Dietician for noted significant weight loss, and to ensure that the plan of care for R#21 addressed current weight status. Findings include: Review of the facility's policy titled, Care Plan dated 12/31/1996 indicated: Policy Statement-It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. 3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a…

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, resident and staff interviews, record review, and review of the facility's policy titled, Smoke Free Policy, the facility failed to have a process in place to evaluate and monitor the use of a vaping device for one of one Resident (R) (#15). Findings include: Review of the facility's policy titled, Smoke Free Policy revised 10/12/2022 revealed the new smokeless cigarettes', including vapor devices, are not to be used in (inside) the healthcare center. These are to be used . as outlined in this policy for patients/ residents who are . permitted to smoke. Patients/ residents who are grandfathered in will be assessed for risks/hazards prior to smoking .During the assessment for the smoker, the assessor will ensure the grandfathered resident is able to demonstrate use of the smoking device (e-cigarettes' or vaping device) per manufacturers recommendations. An assessment . will be completed quarterly .After completion of the assessment, the care planning team shall review and utilize 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 observation, staff interviews, record review, and review of the facility's policy titled, Weight Monitoring Program, the facility failed to provide evidence that a nutrition assessment was completed by the Registered Dietitian for one of eight Residents (R) (R#21) with a significant weight loss. Specifically, the facility failed to ensure that R#21 was assessed by the Registered Dietician for current weight loss status. Findings include: Review of the facility's policy titled, Weight Monitoring Program dated 6/13/2018 indicated: Policy Statement- It is the policy of the facility for each patient/resident to be weighed once a month unless otherwise ordered by the physician or contraindicated by patient/resident's medical condition. The Weight Team will review patient/resident weights monthly to determine risk of weight loss or weight gain. 3. Hospital Returns: A hospital return weight will be obtained and documented on the Yearly Weight Record Form within 24 hours and then the patient/resident 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.