Pruitthealth - Rome

Based on observation, staff interviews, and review of facility policies titled Labeling, Dating, and Storage, the facility failed to ensure food items, stored in two of the two kitchen refrigerators and one of one freezer were properly dated and labeled; that one of three male kitchen staff wore facial hair restraints during food preparation; two of two fans were dirty and blowing on clear dishes and food preparation area. These failures have the potential to compromise food safety, impair sanitation practices, and increase the risk of foodborne illness for 87 of 89 residents who receive meals prepared in the facility's kitchen.Findings included:During the initial tour of the kitchen on 2/17/2026 at 9:30 am, observation revealed dirty fans in the dishwashing area over the dirty area, but was blowing toward the clean area. One fan was observed in the corner near the three-compartment sink, blowing towards the food preparation area.During an observation of the walk-in refrigerator on 2/18/2026 at 9:36 am, two pitchers of a yellowish liquid were observed with no label or date; one box…

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 Specialty Services: Dental Services, Vision Services, Podiatry, the facility failed to ensure Activities of Daily Living (ADL) care was provided for two of two sampled residents (R) (R53 and R85) related to toenail care.Findings included:1. During an observation on 2/17/2026 at 10:33 am, R53's fingernails were observed to be long and jagged. R53 stated he had asked for them to be cut a while ago, and added his toenails were really long. R53 removed his shoes and socks, which revealed that his toenails were overgrown on both feet, curling into the skin. The toenails were cloudy/tan colored and were curled up on the side of the nails, pulling away from the nailbed.A review of the electronic medical record (EMR) revealed that R53 was admitted to the facility on [DATE], with diagnoses including, but not limited to, vascular dementia, emphysema, and chronic obstructive pulmonary disease.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 observations, staff interviews, record review, and review of the facility policy titled Restorative Nursing Policy and Procedure, the facility failed to ensure that one of three sampled residents (R) (R85) received restorative services to prevent contractures and/or to prevent a decrease in range of motion (ROM) mobility.Findings included: During an observation on 2/17/2026 at 10:24 am, 3:59 pm, and on 2/19/2026 at 9:31 am, R85 was observed lying on his back with both hands tightly closed in a fist. He had no splints or hand rolls in his hands, and none were visible in the room. During an observation on 2/19/2026 at 9:37 am, Certified Nursing Assistant (CNA) II was observed providing morning Activities of Daily Living (ADL) care for R85. During this observation, the CNA did not open or wash the resident's hands, and no range of motion or lotion was provided to the resident's hands. During an interview with CNA II at this time, she stated they don't do anything for R85's hands.A review of the electronic…

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 policy review, observation, interview, and record review, the facility failed to ensure the dish machine operated at the correct temperature and that equipment and surfaces were kept clean and in good repair. This had the potential to affect 82 of 82 residents who received meals prepared in the facility's kitchen. Findings included: A review of the facility policy titled Cleaning Procedures: Kitchen Area, revised 8/3/2017, provided by the facility, revealed Monthly: l. Take out removable drawers and wash them with a detergent and warm water. 2. Rinse shelves and drawers with a clean sponge or cloth. 3. Sanitize using appropriate strength solution. Check walls, ceilings, floors, and vents for chipped and/or peeling paint, and keep in good repair. Control lighting, ventilation, and humidity to prevent moisture condensation and the growth of molds and mildew. Monthly: wash the walls, ceilings, doors, and vents with hot water and detergent. Heavily soiled surfaces need to be cleaned more often. The type of surface determines the type of detergent needed and the cleaning method…

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 policy review, interview, and record review, the facility failed to ensure residents and/or their representatives participated in care planning conferences for four of five residents (R) (R26, R7, R51, and R29) reviewed for care conferences. The deficient practice of not inviting residents and/or family members to care planning conferences potentially could decrease resident/family satisfaction with care. Findings included: A review of the facility policy titled Care Plans, revised 7/27/2023, provided by the facility, revealed Document IDT [interdisciplinary team] attendance using Care Conference notes . Complete Care Conference Acknowledgement form with signature from patient/resident and/or resident representative, Care plan meetings should be documented in [electronic charting system]/LTC [long term care] using the Multidisciplinary Care Conference User Defined Assessment (UDA) as evidence that the care conference has taken place and occurred with the multidisciplinary team, the patient/resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, interview, and record review, the facility failed to ensure residents and/or their representatives were informed of the risks of psychotropic medications for five of five residents (R) (R83, R29, R37, R33, and F58) reviewed for psychotropic medications. The deficient practice could potentially cause residents and/or their representatives to make uninformed decisions about their treatment, increasing the risk of adverse reactions. Findings included: A review of the facility policy titled Unnecessary Medications Use and Monitoring, reviewed 12/5/2024, provided by the facility, revealed no mention of the discussion of the risks versus the benefits. 1. A review of R83's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) date of 11/21/2024, in the electronic medical record (EMR), revealed an admission date of 11/15/2024. R83 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating R83's cognition was moderately impaired, was taking…

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 a review of facility policy, record review, observations, and interviews, the facility failed to ensure one of 22 sampled residents (R) (R52) reviewed for self-administration of medication was capable of storing and administering her own medication. This failure created the potential for the resident to experience a medication error related to her inability to properly self-administer the medication. Findings included: The facility's Self-Administration of Medications by Patients/Residents Policy dated most recently reviewed 1/6/2025 read, in pertinent part, Each patient 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; and The opportunity to self-administer medications is reviewed during the routine assessment by the healthcare centers interdisciplinary team utilizing the Electronic Health Record Observation…

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 a review of facility policy, record review, and interviews, the facility failed to ensure one of five residents (R) (R58) reviewed for abuse was free from misappropriation of his personal funds when Certified Nursing Assistant (CNA4) wrote checks and cashed checks for herself from R58's personal checking account. This failure created the potential for this and other residents to experience further staff-to-resident misappropriation and created the potential for R58 to suffer negative financial consequences related to the misappropriation. Findings included: The facility's Abuse Prevention and Reporting Policy dated most recently revised on 8/18/2023 read, in pertinent part, Exploitation: Unjust or improper use of another person's or his/her property through undue influence, coercion, harassment, duress, deception, false representation, false pretense, or other similar means for one's own profit or advantage; and This (facility) will not tolerate abuse, neglect or exploitation of its residents by anyone.…

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 policy review, observations, record review, and staff interviews, the facility failed to ensure one of three residents (R) (R3) reviewed for accidents was appropriate for the use of side rails on her bed. This failure created the potential for the resident to be injured related to potentially unnecessary side rails installed and in use on her bed. Findings included: The facility's Bed Rails Policy dated most recently revised on 8/8/2024, read, in pertinent part, It is the policy of Pruitthealth and its affiliated healthcare centers (collectively, the Organization) that healthcare center patients (including those referred for rails, except when the use of bed rails has been appropriately determined to be medically necessary in accordance with this policy or in instances where the use of bed rails has been specifically requested by the patient or the patient's representative. A review of R3's Face Sheet dated 1/9/2025 indicated the resident was admitted to the facility on [DATE]. The document indicated…

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, interview, and document review, the facility failed to ensure a Certified Nursing Assistant (CNA3) provided care as educated through training and in-services for residents in isolation positive for 2019-nCoV, by not applying the appropriate Personal Protective Equipment (PPE) while providing care for two of nine residents (R) (R35 and R58) on special droplet isolation on the long 100 hallway. As a result of this deficient practice, the residents had the potential for harm by spreading the 2019-nCoV to residents who previously tested negative. Findings included: A review of the employee record for CNA3 revealed a hire date of 9/3/2024. Documentation in the record revealed an orientation checklist. A review of the Position Description Acknowledgement in the employee file for CNA3 documented I understand that as a result of my employment, I may be exposed to blood, body fluids, infectious diseases, air contaminants, and hazardous chemicals and that the healthcare center should provide to me…

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, interview, record review, and facility policy review, the facility failed to provide resident-specific activities as interventions for wandering into other resident rooms for one of 22 sampled residents (R) (R77). Findings included: A review of the facility policy titled Procedure: Care of the Wandering Resident, dated 2019, provided by the facility revealed 2. Continuously reorient the resident to his or her room and belongings 3. Encourage group activities and attempt to keep the resident occupied 8. Ask the resident to fold towels and washcloths, or sort other harmless items . 13. Tag team with other staff so someone is responsible and available to visually monitor the resident at all times. A review of R77's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 10/6/2024 revealed an admission date of 9/30/2024. R77 had a Brief Interview for Mental Status (BIMS) score of 99 out of 15 indicating R77's cognition was severely impaired, had behaviors of wandering,…

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.