PruittHealth-Trent

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident and staff interviews, the facility failed to provide restorative services as outlined in the plan of care for 1 of 3 residents reviewed for rehabilitation and restorative services (Resident #47).Findings included:Resident #47 was admitted to the facility on [DATE] with active diagnoses that included lumbar spinal stenosis with neurogenic claudication (intermittent leg pain from impingement of the nerves emanating from the spinal cord), hypertension, and diabetes mellitus.Resident #47's Minimum Data Set assessment dated [DATE] revealed he was assessed as cognitively intact. He had no functional impairment of range of motion to his upper and lower extremities and no contractures.Review of a restorative communication sheet from therapy dated 4/28/26 indicated Resident #47 required Active Range of Motion and Active Assisted Range of Motion to both lower extremities six days per week. The documented goal was to reduce the likelihood of functional loss and prevent skin integrity…

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 interview with staff and Nurse Practitioner, the facility failed to ensure that the medical provider documented a plan to address Resident # 1's diabetes during a required regulatory visit. This was for 1 of 3 residents whose medical records were reviewed related to medical needs (Resident #1).The findings included:Record review revealed Resident # 1 was admitted to the facility on [DATE] with a diagnosis of diabetes.Record review revealed Nurse Practitioner (NP) # 1 documented she was seeing the resident for a regulatory visit on 9/26/25, and Resident # 1's diabetes was diet controlled.Review of labs revealed Resident # 1 had a HgbA1C (Hemoglobin A1C), which was ordered on 10/14/25, by Nurse Practitioner # 1. The lab report included that the lab was drawn on 10/14/25 at 7:18 AM and the results on 10/15/25 showed a result of 8.1 % with a normal range noted on the lab report to be less than or equal to 5.7. (A Hemoglobin A1C measures average blood sugar levels over the past 2-3 months…

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 food was sealed when stored, the floor was clean, and food storage shelves were free of grainy food particles for 1 of 1 main facility kitchen. The findings included:During kitchen observations made on 1/30/26 beginning at 7:50 AM the following were observed. In the dry storage room there was a container of multiple large bags of cereal. The top bag was open. The lid to the container was found on the floor underneath another shelving unit in the dry storage room. Grits were on a shelf and not sealed up and closed, rather the top of the grits bag was rolled up. The metal shelf, where the grits were located, had a liner. The liner on this shelf and another kitchen shelf in the dry storage room had very fine grainy particles visible on the liner. Underneath the shelving units in the dry storage room were multiple items and food crumbs which included but were not limited to loose, dry cereal, a dried up orange peeling, two closed packets of cookies, two water bottles, two condiment packets, a carbonated drink, 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.

Based on observations, and interviews with staff, contracted pest control technicians, and a local health department employee, the facility failed to ensure 1) cleaning practices and food storage practices were carried out in the main kitchen to deter attraction of pests and 2) communicate effectively with pest control technicians to ensure contributing factors to pests could be identified and efforts made to resolve any issues for 1 of 1 main kitchen area in the facility.The findings included:Review of pest control records provided by the facility's corporate office and Health Department records revealed the following information:On 5/19/25 Contracted Pest Control Technician # 1 noted the following in an invoice. A few roaches were found in the kitchen area. The area was inspected and serviced. There were sanitation issues identified in the kitchen which could lead to pest problems. The floor under the cook/steam line was in need of cleaning and there was food or grease build-up observed in the kitchen. The inspection report invoice noted, Please clean regularly.On 7/30/25 Pest…

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 and Responsible Party (RP) interviews, the facility failed to ensure a copy of the resident's advanced directive was included in the resident's record and failed to honor the resident's wishes with regards to code status as expressed by the resident's RP on admission. This was for 1 of 11 residents (Resident #94) reviewed for advanced directives. Findings included: A review of Resident #94's hospital Discharge summary dated [DATE] revealed his code status in the hospital was full code (a medical term that indicates a patient wants to receive all available measures to save their life in an emergency). It was initialed by Unit Manager #1 indicating she reviewed the document. Resident #94 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of the facility's admission document titled NC Advanced Directive for Healthcare dated [DATE] and signed by Resident #94's RP and the facility's Admissions Director revealed documentation indicating Resident #94 had…

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 attempt alternatives prior to installing side rails for 2 of 4 residents (Resident #18 and Resident #98) reviewed for side rails. Findings included: 1. Resident #18 was admitted to the facility on [DATE] with a diagnosis of diffuse traumatic brain injury. A review of Resident #18's record revealed an assessment titled restraint-adaptive equipment use dated 8/23/24 and completed by Unit Manager (UM) #1 indicated no answer was provided for the question have alternatives to restraint or adaptive equipment been tried in the past?. The choices were yes, no or not applicable. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was moderately cognitively impaired. The MDS indicated Resident #18 required substantial to maximum assistance with bed mobility, transfers, and was non-ambulatory. The MDS revealed Resident #18 had no impairment of both upper and lower extremities. The MDS indicated Resident #18's siderails were…

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 resident, staff and Nurse Practitioner (NP) interviews, the facility failed to assess whether the self-administration of medication was clinically appropriate before leaving medication at the bedside. This was for 1 of 5 residents (Resident #87) reviewed for medication administration. Findings included: Resident #87 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breath). A review of Resident #87's medical record did not reveal a self-administration of medication assessment. A review of Resident #87's physician's orders did not reveal a physician's order to self-administer any medication. A physician's order dated 8/15/24 revealed Trelegy Ellipta (a long term medication to treat COPD) blister with device; 100-62.5-25 microgram (mcg) administer one puff inhalation once daily at 9:00 AM for COPD. A review of Resident #87's 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 record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of falls for 1 of 5 residents reviewed for accidents (Resident #87). Findings included: Resident #87 was admitted to the facility on [DATE]. A review of a nursing progress note for Resident #87 dated 1/25/25 at 4:45 PM written by Nurse #2 revealed Resident #87 had a fall from her bed. Resident #87 had no skin tears, limited range of motion or dizziness after her fall. Resident #87 was complaining of mild pain to her right hip and right knee. A review of Resident #87's quarterly MDS assessment dated [DATE] revealed she had no falls since her prior MDS assessment. On 2/26/25 at 12:46 PM an interview with Nurse #2 confirmed Resident #87 had a fall from her bed on 1/25/25. On 2/26/25 at 1:13 PM in an interview the MDS Coordinator stated she coded the falls section of Resident #87's MDS assessment dated [DATE]. She reported she normally looked at progress notes for information when…

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, record review and staff interview, the facility failed to follow their infection control practices and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a hemodialysis catheter when Nurse Aide (NA) #1 and NA #2 provided a bed bath without wearing gowns for 2 of 20 staff observed for infection control (NA #1 and NA #2). Findings included: The facility policy titled Enhanced Barrier Precautions (EBP) dated 4/30/24 stated in part: EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gowns and gloves use during high contact resident care activities for residents with indwelling medical devices. The policy gave the example of bathing and dressing as a high contact activity. Observation of Resident #103's door on 2/26/25 at 9:03 AM revealed signage for EBP. The signage indicated that staff providing high contact care to Resident #103 were required to wear gowns and gloves. Further observation revealed a caddy outside Resident #103's room that…

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 of pressure ulcer care, staff interviews and record reviews, the facility failed to perform hand hygiene after removing wound dressings, before cleaning the wound, applying the new treatments and when moving from one wound to another for 2 of 2 residents (Residents #1 and #3). Additionally, the facility failed to clean scissors before and after use for 1 of 2 residents (Residents #3) reviewed for pressure ulcer care. The findings included: The facility's policy titled, Guidelines for Cleansing and Observing a Wound, last reviewed on 07/28/2023, revealed as soon as you have finished removing the soiled dressing and cleansing the wound, remove and discard your gloves. Otherwise, everything you touch, including the faucet and handles, will be contaminated by microorganisms on your gloves. Your bandage scissors may transfer pathogens from one resident to th next, as well as to your own hands and pockets. To prevent this, wash your scissors with an alcohol product or soap and water before and after each use. Wash your hands (or use an alcohol cleanser) after removing…

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 label and date resident's personal food items stored in a nursing unit nourishment refrigerator. This was for 1 of 2 nursing unit nourishment refrigerators (First-Floor) observed. Findings included: On 1/10/24 at 11:24 AM an observation of the First-Floor nursing unit nourishment refrigerator with Nurse #2 revealed the following: a. two unlabeled and undated cardboard pizza boxes containing pizza. b. an unlabeled and undated brown paper bag containing tortilla chips and an unlabeled and undated cup of red liquid. c. an unlabeled and undated plastic food storage container of fried chicken, collard greens, and macaroni and cheese. d. an unlabeled and undated plastic food storage container containing corn bread and black-eyed peas. e. an unlabeled and undated plastic food storage container of green beans and black-eyed peas. In an interview at the time of the observation, Nurse #2 stated she was sure the unlabeled and undated food items in the refrigerator belonged to residents. She stated she had not placed the food…

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 speak respectfully to a resident during an interaction (Resident #22) and failed to have a privacy cover on a resident's catheter bag (Resident #37) and for 2 of 6 resident reviewed for dignity. Findings included: 1. Resident #22 was admitted to the facility on [DATE]. A review of Resident #22's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. His hearing was adequate. He exhibited no hallucinations, psychosis, behaviors, or rejection of care during the assessment period. A review of Resident #22's comprehensive care plan revealed in part a problem area initiated on 1/26/23 of behavior symptoms related to verbal behaviors directed towards others that included Resident #22 calling staff names such as stupid and dumb. An intervention was to maintain a calm environment and approach to Resident #22. On 1/10/24 at 11:13 AM an interview with Resident #22 indicated Receptionist #1 was rude 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 and staff interviews the facility failed to keep medications in a locked medication cart for 1 of 4 medication carts observed (Medication Cart #1). Findings included: During observation on 1/8/24 at 2:34 PM Medication Cart #1 was found by the surveyor to be unlocked and unattended outside the nursing station. Two nurse aides were inside the nurse's station and two cognitively impaired residents were observed near the unlocked medication cart. At 2:36 PM Nurse #1 returned to the unlocked medication cart. During an interview on 1/8/24 at 2:37 PM Nurse #1 stated medication carts were to be locked when unattended and she should have locked the medication cart prior to taking medications to a resident. During an interview on 1/9/24 at 8:42 AM the Director of Nursing stated medication carts were to be locked when unattended for resident safety.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and Nurse Practitioner, and Pharmacist interviews, the facility failed to obtain a pain medication from the pharmacy for 1 of 1 resident (Resident #1) reviewed for medications. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included Diabetes Mellitus and dementia. Nurse Practitioner (NP) order dated 8/29/23 read Dilaudid (hydromorphone) (an opioid pain medication) 2 milligram (mg) tablet every 4 hours for terminal pain. The start date was 8/29/23. The order was discontinued 10/26/23 and the end date was 10/26/23. Review of the October 2023 Medication Administration Record (MAR) revealed the Dilaudid 2 mg tablet was documented as not administered as follows: - 10/19/23 2:00 AM - Not Administered: Drug/Item Unavailable - 10/19/23 6:00 AM - Not Administered: Drug/Item Unavailable - 10/25/23 6:00 AM - Not Administered: Drug/Item Unavailable Further review of the October 2023 MAR revealed no order for Dilaudid liquid until October 26, 2023. 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.