Pruitthealth - Monroe

Based on observations, staff interviews, and review of the facility policy titled, Pot/Pan Washing and Sanitation and review of the Sanitizing Solution Product Specification document, the facility failed to ensure dishware was air dried before usage to prevent the potential for cross contamination and bacteria contamination. The deficient practice had the potential to affect 62 of 63 residents receiving an oral diet. Findings include: Review of the facility policy titled Pot/Pan Washing and Sanitation revealed Air dry pots and pans on the drain board. Never use a dish towel. Review of the [name of company/product] Sanitizer Product Specification Document revealed Allow equipment to drain thoroughly and air dry. Observation on 5/4/2024 at 10:45 am of Dietary [NAME] CC taking the food processor bowl, lid, and blade out of the sanitizing solution from the three-compartment sink revealed she placed them on the drying rack for 10 seconds. Dietary cook CC was observed drying the food processor lid and the food processor bowl with a white paper towel. Dietary [NAME] CC did not allow 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.

Based on observations and staff interview, the facility failed to properly maintain the walk-in freezer to prevent ice build-up on food storage shelves and food products. The deficient practice had the potential to affect 62 of 63 residents receiving an oral diet. Findings include: Observation on 5/3/2024 at 8:30am of the walk-in freezer revealed ice build-up on the food storage shelf under the air condenser. The food storage shelf had six mounds of ice, the mounds were two inches in height and two inches in diameter. Continued observation revealed ice build-up on the top of food item inside a clear, plastic, resealable bag. The ice build-up on the plastic bag had a mound of ice on the left side that was about three inches in height and two inches in diameter. Further observation revealed ice build-up on top of a food item that was inside a box. The food item had a small ice mound on top that was about one inch in height and half inch in diameter. Observation on 5/5/2024 at 9:00 am of the walk-in freezer revealed that the previous ice build-up on the food storage shelf and on 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, staff interview, and review of facility policy titled, MDS Assessment Accuracy, the facility failed to accurately code an annual Minimum Data Set (MDS) assessment for Pre-admission Screening and Resident Review (PASRR) Level II for one of 26 sampled residents (R) (R2) from a sample of 26 residents. The deficient practice had the potential to affect the accurate assessment of R2's care needs. Findings include: Review of the facility policy titled MDS Assessment Accuracy revealed it is the policy of this healthcare center that each Minimum Data Set (MDS) reflect the acuity and the medical status of each patient/resident in accordance with acceptable professional standards and practices. The assessment will be scheduled to accurately account for the acuity and complexity of the patient/resident. Each Assessment Reference Date (AFD) will be chosen to capture services rendered and reflect an accurate clinical profile of each patient/resident. Review of the electronic medical record (EMR)…

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 follow the care plan for three of 26 sampled Residents (R) (R14, R24, and R30). Specifically, the facility failed to create a care plan for nutrition services for R14; failed to follow a physician's order for oxygen (O2) that was care planned for R24; and failed to add refusal of hand splint in the care plan for R30. The deficient practice had the potential for R14, R24, and R30 not to receive needed care services. Findings include: 1.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for R14 documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Review of R14's Physician Orders revealed an order for a regular, no added salt (NAS) diet. Review of R14's care plans revealed no care plan created for nutrition. Review of a Registered Dietician Note/Nutrition assessment dated [DATE] documented etiology: poor appetite intake, with intervention large…

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, resident and staff interviews, and review of the facility's policies titled, Restorative Nursing Program and Restorative Nursing Process, the facility failed to follow an Occupational Therapy (OT) Restorative Nursing Program (RNP) recommendation for orthotic application for two of 26 sampled residents (R) (R1 and R30) reviewed for ROM and mobility. This deficient practice had the potential of resulting in progression of contractures. Findings include: Review of the facility's policy titled Restorative Nursing Program revised 11/4/2021 revealed it is the policy of the healthcare center to provide restorative nursing which actively focuses on achieving and maintaining optimal physical, mental, and psychological functioning and wellbeing of the patient/resident. Documentation: 1. Restorative nursing care will be documented in the electronic health record (EHR) or paper form. 2. The nurse will evaluate patient's progress. Document in patient's care plan. Review of facility's…

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 policy titled, Oxygen Administration, the facility failed to ensure oxygen (O2) was administered in accordance with the physician order for one of 20 residents (R) (R24) receiving oxygen therapy. The deficient practice had the potential for respiratory difficulty for R24. Findings include: Review of facility policy titled Policy titled Oxygen Administration revealed under category Policy Statement It is the policy of [NAME] Health Hospice and Healthcare Centers/Veteran Homes to provide oxygen safely and accurately to appropriate patients /residents. Oxygen will be administered by licensed personnel only when ordered by the physician, PA, or NP. The physician order may be written PRN [as needed] for comfort /dyspnea [shortness of breath] or may specify the number or liters, method of administration and length of time the oxygen is to be administered. Review of R24 's electronic medical record (EMR) revealed 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.

Based on observations, staff interviews, record review, review of the facility's policies titled, Medication Administration: Oral Medications and Medication Administration: Insulin Injections and review of the facility document titled, Oral Dosage Forms That Should Not Be Crushed 2016, the facility failed to ensure the medication error rate was less than 5%. There were two errors with 27 opportunities for two of five residents (R) (R38 and R56) for a medication error rate of 7.41%. These failures had the potential to result in medication not being given in accordance with the physician's orders or manufacturer's recommendations and the potential to adversely affect R38 and R56's clinical conditions. Findings include: 1. A review of the facility's policy titled Medication Administration: Oral Medications, revised 12/10/2021, revealed the Policy Statement of It is the policy of [facility name] Pharmacy that oral medications are administered in an organized and safe manner. The Special Considerations section included 1. Refer to Crush List prior to crushing any medication for assurance…

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, staff interviews, and review of the facility's policy Documentation of Skin and Wound Care, the facility failed to ensure wound assessments were completed weekly for one of three sampled residents (R2) and failed to accurately document skin assessments for one of three sampled residents (R2). Findings include: Review of facility policy Documentation of Skin and Wound Care revealed 'Policy Statement: It is the policy of the Healthcare center to complete documentation that reflects the current resident status as related to skin/wound care. Documentation will provide current and timely documentation on resident's condition related to skin/wound care, accurate information on resident's status as it pertains to skin/wound care, record care rendered and interventions in place and provide a detailed history of the wound assessments that have occurred in the healthcare center. Weekly Documentation: Weekly Documentation of Treatments will be completed on Wound Manager in the EHR (electronic health record) and Focus Observation to include Skin observation.' Record…

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, staff interview, and review of the facility policy Weight Monitoring Program, the facility failed to ensure resident with significant weight loss was addressed in a timely manner for one of three sample residents (R2) with a significant weight loss. Findings include: Review of facility policy 'Weight Monitoring Program' last revised 6/2/2023 revealed 'Weight Team: 3. Weight Team Responsibilities: The Weight Team's responsibilities include evaluating weights for significant changes; recommending appropriate interventions; reviewing patient/resident meal, supplement, and snack intakes; revision of interventions, if necessary; attending weekly meetings; completing the Weight Loss/Gain Checklist and completing weekly documentation in the patient/resident's chart.' Record review of the most recent Quarterly Minimum Data Set (MDS) for R2 dated 8/2/2023 revealed under section K-Swallowing/Nutritional Status revealed resident had a 5% weight loss in one month or a 10% weight loss in six months and was not on physician prescribed weight loss regimen. Record review 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 observations, interviews, and policy review the facility failed to ensure opened food items in the walk-in refrigerator were dated; failed to discard food items after Best If Use By date; and failed to properly thaw food items to prevent food borne illness. This deficient practice had the potential to effect 49 of 51 residents receiving an oral diet. Findings include: Review of the facility policy titled Labeling, Dating, and Storage with a reviewed date of 1/8/21 revealed: Foods will be stored in their original containers or in an approved container or wrapped tightly with film, foil, etc and clearly labeled with the name of the item and the use by date. The policy also stated those items that require refrigeration and/or require refrigeration once they have been opened will be labeled with the use by date. Review of the facility policy titled Foodborne Illnesses with a reviewed date of 1/8/21 revealed: Foods will be used before the expiration date, use by date, best by date, and sell by date indicated on the food item. Food not used prior to the expiration date, use by…

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) (Form CMS-10055) to two residents (R) (R#18 and #43) who remained in the facility from a sample of five residents who were discharged from Medicare Part A services in the last six months. Findings include: 1. R#18 was discharged from Medicare Part A services on 8/19/22 and remained in the facility. However, the only notice that was provided to the resident was the Notice of Medicare Non-Coverage (NOMNC) (Form CMS-10123). There was no evidence that the facility had issued an SNFABN (Form CMS-10055) to R#18 or her responsible party, providing the opportunity to continue with skilled services, at her cost, if Medicare did not reimburse. 2. R#43 was discharged from Medicare Part A services on 6/3/22 and remained in the facility. However, the only notice provided to the resident was the NOMNC (Form CMS-10123). There was no evidence that the facility had issued the SNFABN (Form CMS-10055) to R#43 or his responsible party, providing the opportunity to…

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, interviews, and review of facility policy titled ''Medication Storage in the Healthcare Centers, the facility failed to ensure all medications carts were locked when out of view of the nurse for one of two medication carts and failed to ensure medications were properly secured inside of the medication cart when out of view of the nurse. Eight of 51 residents were wanderers. Findings include: Review of facility policy Medication Storage in the Healthcare Centers last revised 9/15/17 revealed: Procedure: 2. Only licensed nurses and the pharmacy personnel are allowed access to medications. Respiratory Therapists may access medications used in the provision of respiratory services. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. During observation of medication cart on 10/22/22 at 8:01 a.m. the medication cart was unlocked and unattended. The Administrator locked the cart and stated the nurse must have forgot to lock it. During observation of medication administration on 10/22/22 with RN AA revealed 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.

Based on observation, interview, and recipe review the facility failed to properly prepare puree Salisbury steak to ensure adequate nutrient content. This deficient practice had the potential to effect 10 residents receiving a pureed diet from 49 residents that receive an oral diet. Findings include: Review of the cycle menu for lunch meal revealed residents ordered puree diet were to receive Baked Beef Steak. Review of the recipe for Puree Salisbury Steak revealed ingredients consist of prepared Salisbury steak, broth from base, and thickener. Observation on 10/22/22 at 10:30 a.m. of dietary cook BB puree Baked Beef Steak revealed dietary cook BB placed 12 cooked beef steaks in the food processor and purred, opened the lid and added 4 more beef steak to the food processor bowl and pureed. Dietary cook BB then poured about two cups of hot water into the food processor bowl using a gallon measuring pitcher and pureed. The cook opened the lid and added about another two cups of hot water and pureed. Dietary cook BB finished puree and placed in steam table pan. During an interview 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.