PruittHealth- Blythewood

Based on observation, interview, and facility policy review, the facility failed to ensure commercially prepared hard-cooked eggs were not stored for use beyond their use-by-date. This deficient practice had the potential to affect all residents receiving meals from the dietary department. Findings included: Review of a facility policy titled, Label, Dating, and Storage, revised 11/11/2022, specified, 4. Food and beverage items will be discarded according to guidance from a government agency such as the United States Department of Agriculture (USDA) and Food and Drug Administration (FDA). During an initial tour of the facility's kitchen on 09/15/2025 at 9:17 AM, with the Dietary Manager present, the walk-in cooler was observed to contain a white, plastic food-grade bucket of commercially prepared, hard-cooked eggs. The front of the bucket included a 'Use By' date of 09/09/2025. During an interview on 09/15/2025 at 11:09 AM, the Dietary Manager stated that the kitchen staff were supposed to discard all food on their expiration or use-by-dates. During an interview on 09/19/2025 at…

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, record review, and facility document and policy review, the facility failed to ensure wound care orders were transcribed into the electronic medical record at the time of admission for 1 (Resident (R)134) of 3 residents reviewed for wound care. This resulted in one missed wound care treatment on 09/15/2025. Findings include: Review of the facility policy titled, admission Orders, dated 09/2002, specified 5. Once all admission orders have been verified and documented appropriately, they are to be transcribed by the admitting nurse on the appropriate documents in the record (i.e. [id est, that is] MAR [Medication Administration Record], TAR [Treatment Administration Record], etc. [et cetera, other similar things]). Review of an undated facility document titled Dressing a Wound specified Check the individual's medical record for the healthcare provider's order, including the: order for the dressing change, type of dressing, frequency of dressing change, location of wound, cleansing solution, and peri wound protectant. Review of a Resident Face Sheet…

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 review of facility policy, observations, and interviews, the facility failed to ensure foods stored in the main cooler, dry storage, and the preparatory area were labeled, dated, and not expired. This failure could potentially affect all 116 residents in the facility, who consumed food from the kitchen. Findings include: Review of the facility policy titled, Labeling, Dating, and Storage with a complete revision date of 11/11/22, states, 4. Food and beverage items will be discarded according to guidance from a government agency such as the USD and FDA. During an observation on 10/01/24 at 10:35 AM, the following food items were observed in the main cooler and verified by the Certified Dietary Manager (CDM): 5 bags, unopened - NET WT 5 LBS (pounds) per bag of [NAME] Farms Shredded Carrots with Use by date 09/20/24. 1 open bag of [NAME] Farms Shredded Carrots, wrapped in plastic wrap with no date or label. 1 bag Iceberg salad mix with an expiration date of 09/27/24. During an observation on 10/01/24 at…

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 review of facility policy, record review and interview, the facility failed to provide Resident (R)106 ongoing activities designed to meet the resident's interests, hobbies, and cultural preferences to promote physical, mental, and psychosocial well-being for 1 of 2 residents reviewed for activities. Findings include: Review of the undated facility policy titled, Activities Program, states, The Health Care center provides an ongoing program of Activities designed to meet the physical, mental, and psychosocial well-being of each resident while offering a rich array of activities to the residents of the center. The center shall offer a variety of recreational programs to suit the interest and physical/cognitive of the residents that choose to participate. The center shall provide recreational activities that provide stimulation, promote or enhance physical, mental, and or party as well as information obtained by an initial assessment. Review of R106's Face Sheet revealed R106 was admitted to the facility…

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 review of facility policy, the facility failed to offer Resident (R)59, R106, R2, and R79, [NAME] or ice in-between meals and failed to provide a minimum of 16 ounces of fluids on resident's lunch trays. Findings include: Review of the facility policy titled Hydration: Dietary Services with a revision date of 10/18/17, states, All patient/resident will be provided a minimum of 16 OZ of fluids on each meal tray unless contraindicated. Water pitchers are filled with ice/water at least, but not limited to, twice per day. Review of R59's Face Sheet revealed R59 was admitted to the facility with diagnoses including but not limited to: urinary tract infection, quadriplegia, neuromuscular dysfunction of the bladder, and bacteremia. During an observation and interview on 10/02/24 at 11:01 AM, R59 was observed asking Certified Nursing Assistant (CNA)2 for water to drink. CNA2 did not address the resident and walked out of the room. R59 then presses his call light and states that CNA2…

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 review of facility policy, manufacturers instruction for use, observation and interview, the facility failed to ensure a medication error rate less than 5 percent. Specifically, the Humalog Kwikpen and Lantus Solostar Pen for Resident (R)44 was not properly primed prior to administration. The medication error rate was 7.14 percent for 2 of 28 opportunities for error. Findings include: Review of the facility policy titled, Medication Administration: General Guidelines revised on 04/10/19 states, Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Review of the [NAME] Lilly and Company Humalog Kwikpen, revised on 07/2023, instructions for use states,Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures…

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 review of facility policy, observation, and interviews, the facility failed to ensure medications were secured and properly stored for 3 out of 21 residents, Resident (R)20, R23, R43. Findings include: Review of the facility policy titled, Medication Storage in the Healthcare Centers dated 04/09/24 states, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those the supplier. The medication supply is accessible only to licensed nursing personnel and pharmacy personnel . 2. Only licensed nurses and the pharmacy personnel are allowed to access to medications . Medication room, carts, and medication supplies are locked or attended by persons with authorized access. Review of the facility policy titled, Medication Administration: General Guidelines revised on 04/10/19 states, 1. Medications are prepared, administered, and recorded only by licensed nursing, medical, or pharmacy personnel. 2. Medications are administered in accordance with written…

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, interviews, record review, and facility document and policy review, the facility failed to ensure an allegation of abuse was reported to the administrator of the facility and to the state survey agency within two hours for 1 (Resident (R)2) of 3 sampled residents reviewed for abuse. Specifically, on 02/14/2024, R2 reported to Licensed Practical Nurse (LPN)5 that Certified Nursing Assistant (CNA)7 was rough when providing care. LPN5 failed to notify the Administrator immediately; subsequently, the allegation was not reported to the State Agency until 02/15/2024 at 7:08 PM, the day after the incident occurred. Findings included: A review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, revised on 07/29/2019, revealed, 1. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider…

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, and interview, the facility failed to provide food storage in a safe and consistent manner. This had the potential to affect 107 of 114 residents who consumed food from the kitchen. Findings include: Review the of facility's policy titled, Food Ordering, Receiving, and Storage dated 08/03/17, indicated, Date all stock items with delivery date. During an observation and initial kitchen walk through with the Dietary Manager (DM) on 09/19/22 beginning at 9:00 AM, the following was observed: 1. In the dry storage area, there was a clear, opened container of peanut butter with no label indicating open date or use by date. DM stated that this item should have been labeled and dated. 2. In the dry storage area, there was a large, clear storage bin containing a bag of breadcrumbs and a bag of meal. Both had been opened and securely closed, but there were no labels on either bag indicating an open or use by date. DM stated that these items should have been labeled. 3. In the dry storage area, there were four large containers of thousand island dressing…

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 review of the facility policy, interviews, and record reviews, the facility failed to thoroughly investigate potential abuse for 2 of 2 residents (Resident (R) 65 and R110) sampled for abuse in a total sample of 30 residents. A lack of investigation has the potential to place other dependent residents at risk for neglect/abuse. Findings include: Review of the facility policy titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, revised October 2020 revealed, Interviews should be conducted of all individuals who have relevant information, utilizing open-ended questions. Written signed statements from any involved parties should be obtained (and notarized, if necessary). Statements should be gathered from the following individuals: the suspect; the person(s) making accusation(s); the patient(s) involved; reliable patients who may have witnessed the incident; and any other persons who may have information. During a screening interview on 09/19/22 at…

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 review of facility policy, record review, and interviews, the facility failed to provide care and services to maintain nutritional status and prevent weight loss for 1 resident (R)413, of 30 sampled residents. Specifically, the facility failed to follow their policy to obtain an admission weight for R413. R413 had significant weight loss and new nutritional interventions were not implemented to prevent additional weight loss. Findings include: Review of the facility's policy Weight Monitoring Program dated 06/13/18 revealed It is the policy . for each patient/resident to be weighed once a month unless ordered by the physician or contraindicated by patient/resident's medical condition. The Weight Team will review patient/resident weights on a monthly basis to determine risk of weight loss or weight gain. In a phone interview with the Resident's Representative (RR) (Family Member (F) 413) on 09/21/22 at 4:15 PM, F413 stated that R413 went from 118 lbs from entry date of 07/11/22 to 98 lbs on discharge…

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 follow the menu by failing to provide a substitution of equally nutritive value for 1 of 1 resident (R)38 reviewed for following menus in a total sample of 30 residents. Findings include: During an observation on 09/20/22 at 12:54 PM, R38 was observed being assisted to eat his lunch meal. During this observation, R38's lunch meal tray included cabbage, stewed tomatoes, rice, cornbread, and sweet tea. Review of R38's lunch meal ticket dated 09/20/22 included the following items: veggie burger, scalloped potatoes, sauteed cabbage, cornbread, sweet tea, canned fruit, fortified juice, and cranberry juice. During an observation on 09/20/22 at 6:06 PM, R38 was observed eating dinner. During this observation, R38's dinner meal tray included noodles, corn, sweet peas, banana pudding, and sweet tea. Review of R38's dinner meal ticket dated 09/20/22 included the following items: veggie burger, buttered parslied noodles,…

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 facility policy review, observations, record review, and interview, the facility failed to accommodate a resident's dietary preferences for 1 of 1 resident (R)38, reviewed for food preferences in a total sample of 30 residents. The facility served R38 foods that were not part of his religious dietary preference. This deficient practice could result in reduced consumption for R38. Findings include: Review of the facility policy titled, Nutritional Screening and Assessment/Food Preferences, reviewed January 2021 revealed, Patient/resident food preferences and choices will be honored within reason according to the patient/resident's diet order and menu selections available. During an observation on 09/20/22 at 9:08 AM, R38's breakfast meal tray was observed to have the following items: scrambled eggs, a slice of toast, a sausage link, grits, skim milk, apple juice, coffee, and Nepro (a commercial nutritional shake). Review of R38's breakfast meal ticket dated 09/20/22 included but not limited to 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 observation, interview, record review, policy review, and review of Centers for Disease Control and Prevention (CDC) recommendations, the facility failed to ensure appropriate personal protective equipment (PPE) was worn into quarantine/isolation resident rooms by two facility contracted staff. This failure had the potential to spread infectious organisms throughout the facility to the 114 current residents and any staff working. Findings include: Review of the CDC's webpage Infection Control Recommendations, updated 02/02/22 revealed HCP [health care professionals] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Review of the facility policy titled…

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.