PruittHealth- Dillon

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and procedure guide review, the facility failed to notify a physician of a high blood sugar level for one of five residents (Resident (R) 50) reviewed for unnecessary medication of 27 sample residents. The facility failed to notify the resident's physician of a significant change in the resident's blood glucose levels. Findings include: Review of the facility's procedure guide titled, Change in Condition reporting parameters, dated June 2018 and provided by the Director of Health Services (DHS), revealed that staff were to report to the resident's physician any Blood Glucose levels greater than 300mg/dl (milligrams/ deciliter) or less than 70mg/dl. Review of R50's face sheet located under the Resident tab of the electronic medical record (EMR) revealed the resident was admitted to the facility from the hospital on [DATE], with diagnoses that included pneumonia, overactive bladder, type two diabetes mellitus, and Alzheimer's disease. Review of R50's care plan, located under 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 record review and interview, the facility failed to accurately complete Pre-admission Screening and Resident Review (PASARR) as required for one of one resident (Resident (R) 25) reviewed for PASARRs of 27 sample residents. R25 did not have an accurate PASARR Level I which failed to identify that the resident had intellectual disabilities prior to his admission to the facility. This deficient practice resulted in R25 not being evaluated for and/or provided specialized care and treatment. Findings include: Review of a document for R25 located under Resident titled PASARR - Level I Screening Form, dated 02/27/25, failed to indicate the resident had a diagnosis of intellectual disabilities. Review of R25's electronic medical record (EMR) titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of unspecified intellectual disabilities. Review of R25's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 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 interview and record review, the facility failed to contain specific language into the facility's arbitration agreement for three of three residents (Resident (R) 5, R15, and R45) reviewed for arbitration agreement of 27 sample residents. Specifically, the facility failed to ensure that residents and/or their representatives were informed of the opportunity to agree on a neutral arbitrator and convenient location for the arbitration to be held. Findings include: 1. Review of R5's Resident Face Sheet found in the electronic medical record (EMR) under the dashboard, indicated the resident was admitted to the facility on [DATE]. Review of a document provided by the facility titled, Arbitration Agreement, signed 12/10/19, indicated R5's representative signed the agreement. The arbitration agreement indicated .The parties intend that Miles Mediation and Arbitration Services (CMMAS') shall be the Arbitration Service Provider . The document did not expressly state that the residents and/or their representative…

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, interview, and facility policy review, the facility failed to adhere to infection control practices and policies for three of three residents (Resident (R)5, R50, and R73) reviewed for infection control of 27 sample residents. The facility failed to wear a gown and implement Enhanced Barrier Precautions (EBP) for R5 and failed to ensure the residents' catheter was not touching the ground for R50 and R73. The deficient practice increased the risk of infection for the residents. Findings include: Review of the facility's policy titled, Enhanced Barrier Precautions (EBP), revised 04/30/24, indicated Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .Initiation of Enhanced Barrier Precautions .An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds…

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 facility policy, observation, interview, and record review, the facility failed to ensure: accurate labeling and dating of foods and removal of expired foods from 1 of 1 main kitchen. Findings include: Review of the facility policy title Labeling, Dating, and Storage dated 2014, revealed, Policy Statement: It is the policy of PruittHealth for all partners who assist in handling, preparing, serving, and storing food and beverage items to follow the proper procedures for labeling, dating, and storage to ensure proper food safety. During an observation on 06/18/24 at 10:47 AM, with the Dietary Manager (DM), revealed the cooler contained the following: 2 rotten heads of cabbage, dated 05/08/24, 3 cucumbers undated in a box that contained potatoes, 1 jar of reliance Italian dressing, opened 06/03/21 with an expiration date of 04/30/24, 1 large container of Apple Sauce dated 06/10/24, no expiration date. During an interview on 06/19/24 at 12:48 PM, the Kitchen Manager-Dietary Manager (DM) revealed labeling, storing, discarding of expired items are done by all staff 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 interview, record review, and review of facility policy, the facility failed to implement care plan interventions for Resident (R)55 for oxygen use, for 1 of 3 residents reviewed for care plans. Findings include: Review of the facility policy titled Care Plans last revised on 07/21/21, revealed, It is policy of the health care center for each patient/residents to have a person centered baseline care plan followed by a comprehensive care plan developed following the completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. Comprehensive care plans should be reviewed not less than quarterly according to the MDS schedule, following the completion of the assessment. Care plans updates/reviews will be performed within seven days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. Care plans will be updated by…

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, interview, and record review, the facility failed to ensure a resident who was dependent on staff for Activities of Daily Living (ADLs) received the necessary services to maintain personal hygiene, specifically nail care, bed baths and showers, for 1 of 7 sampled residents (Resident (R) 2). Findings include: Review of the facility policy titled, Charting Activities of Daily Living (ADLs) with a date of 2014, revealed, Definitions: Activities of Daily Living (ADLS's): The task of everyday life. The ability or inability to perform ADL's is a measurement of the functional status of a person. Review of R2's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/24, indicated R2 was admitted to the facility from the hospital on [DATE], with diagnoses including but not limited to: chronic obstructive pulmonary disease with (acute) exacerbation, chronic diastolic (congestive) heart failure, malignant neoplasm of upper lobe, left bronchus or lung,…

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 interview, record review, and review of facility policy, the facility failed to maintain complete and accurate medical records for Resident (R)55, in accordance with accepted professional standards and practices, for 1 of 5 residents reviewed. Findings include: Review of the facility policy titled Maintenance of Medical Records last revised on 12/06/22 revealed, It is the policy of the facility to maintain a medical record for each patient/resident in the healthcare center/agency that is to be accurate, complete, and systematically organized. Review of R55's Face Sheet revealed R55 was admitted to the facility on [DATE], with the diagnoses including but not limited to: respiratory syncytial pneumonia, sleep apnea, type 2 diabetes, and muscle weakness. Review of R55's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 06/05/24, revealed R55 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that she is cognitively intact. Further 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.

Based on review of the facility policy, observations, interviews, recorded reviews, the facility failed to utilize appropriate hand hygiene during serving of meals on 1 of 3 units. Findings include: Review of the facility policy titled Infection Prevention - Hand Hygiene dated 2014, revealed, D. Indication Requiring Hand Wash or Hand Rub: 9. Passing meal trays to residents. During an observation on 06/19/24 at 8:18 AM, revealed on the Northside, staff not sanitizing their hands while passing out breakfast trays to residents. During an observation on 06/19/24 at approximately 12:37 PM, Certified Nursing Assistant (CNA)3 was not sanitizing her hands while passing out lunch meal trays. During an observation on 06/20/24 at 5:37 PM, CNA4 was not sanitizing her hands while passing out dinner meal trays. During an interview on 06/19/24 at approximately 2:37 PM, CNA3 revealed the policy and procedure for sanitizing hands while passing out meal trays is to always sanitize hand before going in the room and coming out of the residents' room, no exceptions. During an interview on 06/20/24 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 observations, interviews, record reviews, and review of facility policy, the facility failed to ensure four (Residents(R)8, R21, R42, and R48) of four reviewed were assessed for the use of side rails, failed to accurately complete the side rail consents, and failed to attempt alternative use of bed rails prior to the use of side rails. Findings include: Review of the facility's policy titled Bed Rails dated 02/01/18, revealed prior to installing or using bed rails on a patient's bed, the patient should be assessed by the admitting nursing and/or interdisplinary team (IDT) .the patient and/or the patient's representative should be educated on the proper use of bed rails as well as the risks of using bed rails, which should include, but not limited to, the risk of entrapment. The nurse should complete the initial/annual observation for physical device form in determining whether the bedrails should be considered an enabler or a restraint for the patient. 1. Review of R8's undated Face Sheet located in…

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, staff interview, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, the facility failed to ensure the assessment accurately reflected the resident's status for one of 20 residents (Resident (R)42). Specifically, R42's comprehensive assessments revealed the resident was not accurately assessed for existing skin problems. Findings include: Review of CMS's RAI Version 3.0 Manual Section M1040: Other Ulcers, Wounds and Skin Problems Skin wounds and lesions affect quality of life for residents because they may limit activity, may be painful, and may require time-consuming treatments and dressing changes. Many of these ulcers, wounds and skin problems can worsen or increase risk for local and systemic infections .The presence of wounds and skin changes should be accounted for in the interdisciplinary care plan .1. Review the medical record, including skin care flow sheets or other skin tracking forms. 2. Speak…

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, review of hospital records, interview and review of the facility policy, the facility failed to ensure one (Resident (R)42) of 20 residents reviewed for comprehensive care plans had a care plan revised to include the resident's newly diagnosed skin cancer. This deficient practice had the potential for R42 to experience skin complications that could worsen or increase risk for local and systemic infections. Findings include: Review of the facility's policy titled Care Plans dated 12/31/96 directs It is the policy of the health care center for each patient/resident to have a person centered [sic] baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice . The comprehensive care plan should describe the following- - The services to be furnished to attain or maintain 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, interview, and record review, the facility failed to provide services based on acceptable standards of practice, by specifically failing to accurately assess an oral health status for a resident upon admission (Resident (R) 201) in a sample of 20. Findings include: Review of R201's Face Sheet located under the Resident then Face Sheet tab of the electronic medical record (EMR) revealed R201 was admitted to the facility on [DATE] and included the following diagnoses: cerebral infarction (stroke) and dysphagia (difficulty swallowing). Review of R201's Oral Cavity Observation document dated 02/22/22 and located under the Resident then Observations tab of the EMR revealed R201's tongue was pink and smooth. Review of R201's admission Note dated 02/22/22, located under the Resident then Progress Notes tab in the EMR revealed, Patient requires total care for all Activities of Daily Livings (ADLs). Review of R201's Point of Care History, provided to the survey team by the facility, revealed oral…

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, record review, and facility policy review, the facility failed to provide necessary respiratory care and services in accordance with professional standards of practice, by specifically failing to change oxygen tubing as ordered, administer oxygen at the ordered level, and safely store respiratory equipment for one (Resident (R) 44) of two residents reviewed for respiratory care. Findings include: Review of R44's Face Sheet located under the Resident then Face Sheet tab of the electronic medical record (EMR) revealed R44 was admitted to the facility on [DATE] and included the following diagnoses: functional quadriplegia and chronic respiratory failure with hypoxia (decreased oxygen). Review of R44's Orders located under the Resident then Orders tab, revealed the following physician's order dated 09/17/21: Oxygen: Change respiratory circuit/supplies weekly. Once a day on Sat (Saturday) days. An additional physician's order dated 09/17/21 revealed the following: Oxygen at 2 LPM…

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.