Pruitthealth - Covington

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect a significant weight loss for one of five residents (R) (R46) reviewed for nutrition. This had the potential to result in unmet care needs due to the facility not recognizing weight loss and the need for interventions.Findings include:Record review revealed that resident (R)46 was admitted to the facility with the diagnosis included, but limited to encephalopathy, pneumonia, severe sepsis with septic shock, malignant neoplasm of oropharynx.Record review revealed that Resident R46 experienced a significant, unplanned downward weight trend. R46's weight decreased from 151.4 pounds on 10/01/2025 to 141.0 pounds on 01/02/2026, representing a 10.4-pound (6.9%) weight loss over approximately three months. This weight loss meets the criteria for significant weight change.Review of dietary progress notes from 01/12/2026 revealed: Resident's weight is trending down. varied intake 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of the policy titled Care Plan, revision date 10/21/2025, the facility failed to develop and to implement a care plan to address significant weight loss for one of five residents reviewed for nutrition. This had the potential to result in unmet care needs due to the facility not recognizing weight loss and the need for interventions.Findings include:Review of the facility policy titled Care Plan revealed: Care Plan Review and Update:4. Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment.Record review revealed that Resident R46 was admitted to the facility with diagnoses including, but not limited to, encephalopathy, pneumonia, severe sepsis with septic shock, and malignant neoplasm of the oropharynx.Record review revealed that R46 experienced a significant downward weight trend. R26 weight decreased from 151.4 pounds on…

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, policy review and interviews, the facility failed to ensure safe smoking for one of one resident (R) reviewed for smoking. The sample size was 47. Findings include:Review of the facility policy titled Smoke Free Policy with a revised date of 02/10/2026, revealed the policy statement to be as of January 1, 2015, smoking is not allowed on the Healthcare center premises by visitors, partners or patients/residents. Smoking will only be allowed in outdoor designated areas for those residents grandfathered in prior to January 1, 2015. Assessment and Care Planning section, 2. Each patient/resident will be assessed, utilizing the Smoking Observation Form, by a licensed nurse upon admission, re-admission, and/or with a Significant Change. An admission Smoking Care Plan shall be developed by the Licensed Nurse on the admission Interim Care Plan Form. 3. An assessment is completed at least quarterly thereafter only if the answer to either of the first two (2) questions indicate 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 observations, staff and resident interviews, record review, and review of the facility policies titled Oxygen Administration, the facility failed to obtain an oxygen order for one resident (R) out of 14 sampled residents that were on continuous oxygen. This deficient practice had the potential to cause hospitalization related to the resident potentially not being on a therapeutic oxygen setting.Findings include:Review of the policy titled Oxygen Administration revised 8/2/2023 and reviewed on 11/17/2025 policy statement revealed it is the policy of Pruitthealth Hospice and Healthcare Centers/Veteran Homes to provide oxygen safely and accurately to appropriate patients/residents. The scope states this policy is for nurses and respiratory therapists. The procedure section revealed oxygen will be administered by licensed personnel only when ordered by the physician, PA or NP. The physician order may be written PRN for comfort/dyspnea or may specify the number of liters, method of administration and length…

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, record review, and review of the facility policy titled, Medication Administration; General Guidelines, the facility failed to ensure that one of 30 sampled residents (R) (R36) did not have unauthorized and unsecured medications at the bedside. This failure created the potential for medication errors and unauthorized access to medications by other residents. Findings include: A review of the policy titled, Medication Administration: Guidelines review date 7/22/2024 under the section titled Procedure revealed, 3. Patients/residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 5. All current medications and dosage schedules, except topicals used for treatments, are listed on the patient/resident's Medication Administration Record (MAR)or within the e-MAR System for facilities using electronic charting of medications. 10. Medications…

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 and resident interviews, the facility failed to provide a safe, clean, comfortable, homelike environment for two out of 35 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]). Specifically, room [ROOM NUMBER] bathroom contained missing tiles on the left side of the toilet, the floor was sticky and malodorous with multiple large spiders and spider webs noted in the corners of the ceiling. In addition, a roach was observed crawling on the wall in room [ROOM NUMBER]. The sample size was 30 residents. Findings include: 1. Observation and interview on 2/25/2025 at 3:36 pm in room [ROOM NUMBER] revealed, multiple spiders and spider webs in the bathroom ceiling and broken tiles around the toilet bowl. The bathroom floor was sticky and malodorous. R52 who resided in room [ROOM NUMBER] revealed, he did not have a problem with rodents or pests, but the spiders had been there for a while. Observation on 2/26/2025 at 1:51 pm and at 4:30 pm in room [ROOM NUMBER] revealed, the spiders and spider…

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, record review, and review of the facility's policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to report an allegation of abuse to the State Survey Agency within two hours for one of four Residents (R) (R2) reviewed for abuse. Findings include: Review of the facility's policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, dated 7/29/2019, indicated, 1. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. 2. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending physician, and the patient's designated representative of any allegation or incident described above and of the pending…

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 review of the facility's policy titled, Care Plans, the facility failed to develop a person-centered care plan for one of 17 residents (R) (R#59). Specifically, the facility failed to develop a care plan that addressed R#59 indwelling urinary catheter care needs. Findings include: Review of the facility policy titled Care Plans, revised July 27, 2023, subtitled, Care Plan Review and Update revealed: 1. Care plan updates/reviews will be performed within seven days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. 2. Updates to the care plans should be made with any changes in condition at the time the change in condition occurred. Record review for R#59 revealed diagnoses of but not limited to hydronephrosis with renal and ureteral calculous obstruction, chronic kidney disease, stage 4 (severe), and end stage renal disease. Review of Minimum Data Set (MDS) dated [DATE], revealed for Section C…

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 and staff interviews, the facility failed to properly store and maintain personal care use equipment in a sanitary manner for two shared bathrooms on the 100 Hall for four residents' rooms (Rooms 104, 105, 106, 107); Specifically, the facility failed to properly label and store contoured fracture bedpans, urinals, and specimen collector pan. The facility census was 69. Findings include: Observation on 9/5/2023 at 11:50 a.m. revealed in the shared bathroom located between rooms [ROOM NUMBERS], one urinal stored on the top of commode tank was unlabeled and unbagged. Two contoured bedpans and a fracture bedpan nested together on the floor were unlabeled and not secured in a bag. Observation on 9/5/2023 at 12:03 p.m. revealed in the shared bathroom located between rooms [ROOM NUMBERS], one urinal stored on the top of commode tank was unlabeled and unbagged. One contoured bedpan and one fracture bedpan nested together on the floor were unlabeled and not secured in a bag. Observation on 9/6/2023…

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.