PruittHealth-Town Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and Physician and staff interviews, the facility staff failed to notify the physician when 70/30 Insulin (type of insulin used to control blood sugar by providing both immediate and extended insulin action) was not administered or administered late for 1 of 1 resident reviewed for notification (Resident #82). The findings included:Resident #82 was admitted to the facility on [DATE] with diagnoses that included diabetes.Resident #82's physician orders included an order dated 8/20/25 for Humulin 70/30 insulin 90 units to be given at 8:00AM and 5:00PM with blood sugar checks taken before. The August 2025 Medication Administration Record (MAR) for Resident #82 revealed Humulin 70/30 was administered late and not administered on the following dates and times with associated blood sugar values (normal blood sugar levels are between 70 and 99):-On 8/22/25 the ordered 8:00AM Humulin 70/30 90-unit dose was administered at 12:19PM with a recorded blood sugar of 405. The MAR comment specified…

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 reviews, and resident and staff interviews, the facility failed to protect the resident's right to be free from misappropriation of controlled opioid pain medication by staff. This affected 1 of 3 residents reviewed for misappropriation of property (Resident #75).The findings included:Resident #75 was admitted to the facility on [DATE] with diagnoses including lumbar stenosis with lumbar fusion (a procedures for severe lumbar spinal stenosis, a condition where the spinal canal in the lower back narrows, compressing nerves). Resident #75 discharged home on 9/25/2024. Resident #75 physician orders dated for 9/10/2024 revealed an order for Oxycodone 5 milligrams (mg) one (1) tablet every 4 hours as needed for moderate pain on a pain scale of 4-6. Resident #75 Minimal Data Set (MDS) dated [DATE] revealed resident was cognitively intact. Resident #75 was coded as receiving opioids and also on a scheduled pain regimen. A review of the Initial Allegation Report completed by the previous…

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 and staff interviews, the facility failed to report an allegation of physical abuse to law enforcement and adult protective services (APS) for Resident #10 and report an allegation of misappropriation of medication to the State Survey Agency and local law enforcement within the required time frame and did not report the allegation to adult protective services and for Resident #75. The deficient practice occurred for 2 of 4 residents reviewed for reporting of abuse allegations (Resident #10 and Resident #75). The findings included: 1.Resident #10 was re-admitted to the facility on [DATE]. Review of the Initial Allegation report dated 10/17/2024 and completed by the previous Director of Nursing (DON), and containing the name of the current Administrator, revealed Resident #10 reported “that a man had come to his room the other night and beat him.” The allegation was reported to the DON on 10/17/2024 at 2:00 PM. The State Agency was notified via fax on 10/17/2024 at 2:19 PM. The section 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 observation, record review, and physician, resident and staff interviews, the facility failed to administer 70/30 Insulin (type of insulin used to control blood sugar by providing both immediate and extended insulin action) and failed to adhere to administration times as ordered by the physician for 1 of 1 resident reviewed for significant medication errors (Resident #82).The findings included:Resident # 82 was admitted to the facility on [DATE] with diagnoses that included diabetes and hypertension.Resident #82 physician orders included an order dated 8/20/25 for Humulin 70/30 insulin 90 units to be given at 8:00AM and 5:00PM with blood sugars taken before. Resident #82's admission Minimum Data Set (MDS) was in progress. Resident #82's care plan dated 8/22/25 revealed Resident #82 had a goal to maintain appropriate blood glucose levels and Resident #82 would not have diabetic distress that will require hospital stay through next review period. Resident #82 interventions included: - Monitor blood…

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 3. Resident #26 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute on chronic respiratory failure with hypoxia, and solitary pulmonary nodule. A review of Resident #26's physician orders dated 06/04/24 revealed an order for continuous oxygen at 5 liters per minute (LPM) via nasal cannula. Resident #26's Oxygen Use care plan dated 06/04/24 revealed that his oxygen use was related to COPD with acute exacerbation, and acute on chronic respiratory failure. Interventions included saturated oxygen monitoring, ample time to perform activities of daily living (ADL), and notifying his physician of any changes. A review of Resident #26's Scheduled 5-day Minimum Data Set (MDS) assessment dated [DATE] rated Resident #26 as cognitively intact. He received oxygen therapy during the MDS assessment period. An observation of Resident #26 on 06/16/24 at 11:22 AM found him sitting in his wheelchair, with his eyes closed and the tv 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.

Based on observations and staff interviews, the facility failed to remove a dented canned good item stored for use, seal open-to-air frozen food, ensure pans were dry before being stacked, and cover facial hair for 2 of 2 kitchen observations. These practices had the potential to affect food served to residents in the facility. The findings included: a. The kitchen was toured on 6/16/2024 at 10:55 with the Assistant Dietary Manager. The rack of canned goods was observed, and a can of spaghetti sauce was noted to have a large dent on the side of the can. The dent was approximately 3 inches long and dented approximately ½ inch into the can, and the paper label on the can was torn in the dent. The Assistant Dietary Manager explained dented cans should be removed from the rack and placed on the shelf labeled dented cans. The Assistant Dietary Manager did not know why the can had not been removed. b. The freezer was observed with [NAME] #1 at 11:15 AM on 6/16/2024. The freezer was observed to have an open box of beef patties, an open box of cube steak, and an open box of fish nuggets.…

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, Ombudsman, and Social Work interviews, the facility failed to provide a letter of transfer or discharge to residents (Resident #39) for 1 of 3 residents reviewed for transfer and discharge and failed to send a summary of discharge and transfer residents to the Ombudsman (Resident #47) for 1 of 2 residents reviewed for hospitalization. The findings included: 1. Resident #39 was admitted to the facility 10/8/2021. Review of the medical record for Resident #39 revealed on 6/7/2024 she was transferred to the hospital for evaluation after experiencing shortness of breath. The medical record documented Resident #39 returned to the facility on 6/17/2024. Review of the medical record for Resident #39 revealed no letter of transfer or discharge was in the medical record. The Social Worker (SW) was interviewed on 6/19/2024 at 11:42 AM. The SW explained the facility had not been sending letters of transfer or discharge to residents who were sent to the hospital for treatment or discharged from the facility. The SW explained she was not aware the letters should be sent.…

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 interview the facility failed to accurately code the significant change in status Minimum Data Set (MDS) assessments for 1 of 5 residents reviewed for MDS accuracy (Resident #47). Findings included: Resident # 47 was readmitted to the facility on [DATE] with diagnoses that included cognitive communication deficit and cerebral vascular accident (CVA). Review of a form titled Observation Detail List Report dated 05/14/24 at 10:40 PM revealed Resident #47 had moderate difficulty hearing and the speaker had to increase volume and speak distinctly. Resident #47 was recorded to use bilateral hearing aids. A review of the most recent Minimum Data Set (MDS) significant change assessment dated [DATE] revealed Resident # 47 was cognitively intact. The MDS assessment was not coded to reflect Resident #47 had a moderate ability to hear at section B0200 and he utilized hearing Aid or other hearing appliance used to hear at section B0300 as required by the RAI manual (Resident…

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 dry 6 of 6 steamer pans before stacking for storage. This had the potential to affect food served to all residents. Findings included: The kitchen was observed on 1/23/2023 at 9:12 AM. A metal shelving unit was noted with stacked steamer pans ready for use. Two medium pans were separated and noted to be wet in between the pans. Two large pans were separated and noted to be wet in between the pans, and two small pans were separated and noted to be wet between the pans. The dietary manager (DM) was interviewed at the time of the observation. The DM reported the pans should have been air dried completely before being stacked for storage and use. The DM reported he thought kitchen staff may have been in a hurry to put the pans up for storage. The DM was interviewed again on 1/25/2023 at 1:02 PM. The DM reported he had talked to the kitchen staff and found that the pans were stacked wet because the staff were rushing to tidy the kitchen. The Administrator was interviewed on 1/26/2023 at 1:27 PM. The Administrator reported…

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 review of Resident Council Meeting Minutes, resident and staff interviews, the facility failed to resolve repeated concerns voiced at Resident Council meetings regarding call lights not being answered timely and cold coffee being served for 3 of 6 months (10/27/22, 11/30/22 and 1/4/23) reviewed for Resident Council. Findings Included: A record review of the 10/27/22 Resident Council minutes revealed the following concerns: a. Call lights were being turned off and staff stating they would come back, and they would not come back. The response from nursing was that a nursing staff huddle had been completed to address call lights. A record review of the 11/30/22 Resident Council minutes revealed the following concerns: a. Breakfast and Coffee was cold when received by residents. The response from dietary was the dietary department transfers the food cart immediately to the hall once it is full. Insulated serve ware was being used to retrain heat. The temperatures are checked on the line and the food is hot when it leaves the kitchen. Dietary will discuss the distribution 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.