PruittHealth-Elkin

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to refer residents with serious mental disorders to the state's mental health authority for Preadmission Screening and Resident Review (PASRR) assessments, upon admission for 2 of 2 residents reviewed with serious mental disorders (Residents #21 and #42). Findings included: 1. Resident #21 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder. , The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #21 was cognitively intact with the diagnosis of bipolar disorder and received antipsychotic medication. Review of the facility's records indicated Resident #21 was not referred to the state-designated authority for PASRR screening. On 6/4/25 at 11:14 a.m., the facility's Financial Counselor revealed she was responsible for requesting PASSR screenings of residents by the state-designated authority when notified by the MDS nurse of newly admitted residents who had diagnoses requiring…

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 and resident, staff and physician interviews, the facility failed to secure smoking materials, specifically, a lighter and failed to assess a resident's ability to smoke independently for 1 of 1 resident (Resident #2) reviewed for smoking. Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to embolism of left middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, idiopathic epilepsy, and epileptic syndromes with seizures of localized onset, intractable, without status epilepticus (also called refractory, uncontrolled, or drug-resistant epilepsy), repeated falls, and vascular dementia, moderate, with other behavioral disturbance. A review of the observation for smoking assessment dated [DATE] revealed the facility had marked no on the smoking assessment form, indicating Resident #2 did not smoke. A review of the most recent quarterly minimum data set…

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 maintain the tile of the kitchen floor in good condition and failed to dispose of expired nutritional supplements in 1 of 3 residents' nourishment room refrigerators. Findings included: 1. During the initial tour of the kitchen on [DATE] at 10:00 a.m. and during the follow-up visit on [DATE] at 12:00 p.m., there were missing floor tiles observed beneath the meal tray serving steamtable, the dishwashing machine, and beneath the 3-compartment wash sink. An interview with the Dietary Manager revealed the kitchen floor had the missing tiles for approximately 8-9 years due to a problem with drainage pipes which were repaired, and the areas were covered with concrete, but the floor tiles were never replaced. During an interview on [DATE] at 9:32 a.m., the Administrator stated the kitchen's floor had been in that condition for approximately 8-9 years. She indicated she had been in discussion with corporate office's area vice president for about six…

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 interviews, the facility failed to ensure the side doors and top lids of 2 of 2 trash dumpsters remained closed when not in use. Findings included: During the initial tour of the facility accompanied by the Dietary Manager on 1/08/23 at 10:50 a.m., two trash dumpsters were observed enclosed within a fenced in area with the side doors of the dumpsters open. Half of the top lid of 1 of 2 of the dumpsters was open with two filled trash bags lying on top of the closed half of the lid. Throughout the observation, it was raining and both dumpsters were filled with trash bags. A second observation with the Dietary Manager on 1/10/23 at 12:25 p.m. revealed the side door of 1 of the 2 trash dumpsters was open. There were plastic bags of trash in the dumpster.

Based on observations, record review, resident and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint surveys conducted 4/1/2021 and 1/9/2020, and a complaint survey conducted 5/28/2021. This was for three deficiencies that were cited in the areas of Activities meet the interest and need of each resident (F679), Increase or prevent a decrease in range of motion and mobility (F688), and food procurement, store/prepare/serve-sanitary (F812). The three areas were recited on the current recertification survey of 1/11/2023. The duplicate citations during two federal surveys of record demonstrates a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: 1. F679 - Based on observations, interview with the Resident Council, resident and staff interviews and record reviews, the facility failed to provide activities as scheduled when the Activities…

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, interview with the Resident Council, resident and staff interviews and record reviews, the facility failed to provide activities as scheduled when the Activities Director (AD) was placed in the Nurse Aide (NA) role. Additionally, the facility failed to provide any scheduled activities on the weekends. This was for 4 of 4 residents (Residents #52, #38, #20 and #26) reviewed for facility activities. Findings included: 1. Resident #52 was admitted to the facility 12/19/2022 with a diagnosis that included, in part, diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was cognitively intact. The assessment indicated the resident stated it was very important to her to do things with groups of people, to have books, magazines and newspapers to read, to participate in religious services and to do her favorite activities. The care plan, updated 12/23/22, included a focus area of activities/recreation. A care plan intervention revealed Resident #52 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, record review, and staff interviews, the facility failed to review and revise the care plan in the areas of range of motion for 1 of 2 residents (Resident #33) reviewed for range of motion. The findings included: Resident #33 was admitted to the facility on [DATE]. His cumulative diagnoses included nontraumatic intracerebral hemorrhage, Parkinson's disease, hemiplegia, and contractures of the bilateral hips, bilateral ankles, right knee, and left hand. A review of Resident #33 ' s most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS indicated the Resident had severe cognitive impairment, was dependent on one staff member for all activities of daily living (ADL) care needs and had limited range of motion in bilateral upper and lower extremities. A review of Resident #33's care plan dated 9/5/2022 identified the following problem areas: 1) The Resident had impaired ADL functioning related to a history of a cerebral vascular accident (CVA) with left side…

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 record review, the facility failed to provide treatment and services to a resident (Resident #33) who demonstrated a reduction in range of motion of the bilateral lower extremities in the hips, ankles, and knee, and in the left upper extremity. This occurred in 1 of 2 residents reviewed for limited range of motion. The findings included: Resident #33 was admitted to the facility on [DATE]. His cumulative diagnoses included nontraumatic intracerebral hemorrhage, Parkinson's disease, hemiplegia, and contractures of the bilateral hips, bilateral ankles, right knee and left hand. A review of Resident #33 ' s most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS indicated the Resident had severe cognitive impairment, was dependent on one staff member for all activities of daily living (ADL) care needs, and had limited range of motion in bilateral upper and lower extremities. A review of Resident #33 ' s care plan dated 9/5/2022 identified 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 observations, staff interviews, and record review, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection or injury for 1 of 2 residents (Resident #33) reviewed with indwelling urinary catheters. The findings included: Resident #33 was admitted to the facility on [DATE]. His cumulative diagnoses included nontraumatic intracerebral hemorrhage, reflux uropathy, Parkinson's disease, and hemiplegia. A review of Resident #33 ' s most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS indicated the Resident had severely impaired cognitive skills and had an indwelling urinary catheter. A review of Resident #33 ' s care plan dated 9/5/2022 identified a problem area that read: The Resident has a urinary catheter related to hydronephrosis and a ureteral stone with stent placement. The interventions included to keep the drainage bag below the level of the bladder with a privacy bag in place, prevent tension on the urinary meatus (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.