PruittHealth - Pickens

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review, and interviews. The facility failed to inform Resident (R) 1's family member of R1's involvement in a resident-to-resident altercation for 1of 3 Residents reviewed for abuse.Review of facility policy titled, Abuse Prevention & Reporting, with a last revision date of 06/20/25 revealed the following: The assisted living center will not tolerate abuse, neglect or exploitation of its residents by anyone. Such incidents will be reported to all appropriate authorities, agencies, and registries and a written copy as such reports maintained in a central file and resident file.Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to: Alzheimer's, vascular dementia and dysphagia. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/25 revealed a Brief Interview of Mental Status of 99 indicating R1 was unable to complete the interview. Review of a Facility Initial…

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 review, and facility policy review, the facility failed to provide Resident (R)3 with treatment and care according to professional standards of practice, regarding resident transfers for 1 of 3 resident reviewed. Findings included: Review of the facility's procedure titled Two-Person Side-by-Side Transfer with a copyright date of 2019 revealed: Supplies: transfer belt needed. 2. Verify orders . 14. Both nursing assistants should place the hand closest to the resident under the forearm and grasp the resident gently above the wrist. Hold the resident's hand in the other hand with palms facing up . 23. Document procedure per facility policy/protocol . 24. Take appropriate actions for abnormal findings or observations. Review of R3's Face Sheet revealed R3 was admitted to facility on 08/13/19, with diagnoses including but not limited to: unspecified fracture of upper end of left humerus, subsequent encounter for fracture with routine healing, Dementia in other diseases…

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, and review of facility policy, the facility failed to ensure food was properly labeled and sealed to prevent contamination and the potential for development of foodborne illness. This deficient practice had the potential to affect 27 out of 27 residents who receive meals prepared in and served from the facility's kitchen. Findings include: Review of the undated facility policy titled Storage Guidelines Quick Reference documented, All foods must be dated with a received date and once it is opened, an opened date. For items prepared in the kitchen, label item with a use by date. Freezer storage shelf life for meats, 3 months. Review of the facility policy dated 08/12/24, titled, Patients/Residents Personal Food documented, Nursing and housekeeping partners will be responsible for the disposal of outdated food maintained in the . nursing units nourishments refrigerator/freezers will have thermometers and temperatures must be recorded daily on the Food Refrigerator Freezer temp log. During the initial kitchen observation on 11/03/24 AM at 10:10 AM, 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 interviews, the facility failed to coordinate a Preadmission Screening and Resident Review (PASARR) Level II for Resident (R)21, after a change in diagnoses, for 1 of 2 residents reviewed for PASARR. Findings include: On 11/05/24 at 4:42 PM, a request for a facility policy referencing the PASARR was made. Per the Administrator, they did not have a policy that addressed PASARRs. Review of R21's Face Sheet revealed R21 was admitted to the facility on [DATE], with diagnoses including but not limited to: Bipolar affective disorder and obsessive compulsive disorder. Further review of R21's Face Sheet revealed R21 was diagnosed with Schizophrenia on 06/11/20. Review of R21's LifeSource Psychiatry follow up note dated 09/25/24, documented, Associating/modifying factors include chronic medical diagnoses, impaired mobility and living in a SNF [Skilled Nursing Facility]. The psychiatric nurse practitioner noted resident with worsening behaviors of hollowing out/ increase anxiety. A new order 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Wound Journal Ostomy and Continence Nursing (WJOCN), record review, observation and interview, the facility failed to follow infection control standards and clean technique, by placing soiled dressing on a clean field, during a wound observation of Resident (R)22, for 1 of 1 resident observed for pressure ulcers. Findings include: Review of the WJOCN of Clean technique dated March/April 2012, documented, Clean means free of dirt, marks, or stains. 3 Clean technique involves strategies used in patient care to reduce the overall number of microorganisms or to prevent or reduce the risk of transmission of microorganisms from one person to another or from one place to another. Clean technique involves meticulous handwashing, maintaining a clean environment by preparing a clean field, using clean gloves ., and preventing direct contamination of materials and supplies. No sterile to sterile rules apply. This technique may also be referred to as non-sterile. Clean technique is considered most appropriate for…

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, observation, interview and record review, the facility failed to ensure Resident (R)17 was free from pain for 1 of 3 residents reviewed for pain. Findings include: Review of the facility policy titled Pain Assessment Forms with a revised date of 10/06/15 revealed, The nurse will assess the residents pain at regular intervals, initially the intervals will be will be hourly with the interval increasing as the residents pain is controlled. Review of R17's Face Sheet revealed R17 was admitted to the facility on [DATE], with diagnoses including but not limited to: vascular dementia, moderate, with mood disturbance, paroxysmal atrial fibrillation, pain in left hip and non-displaced fracture inferior pubic ramus. Review of R17's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/18/24, revealed R17 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, indicating R17 had severe cognitive impairment. Review of R17's Situation Background Assessment…

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 facility observations and staff interviews, the facility failed to ensure the kitchen sanitation was maintained in food preparation areas. Findings include: Facility Policy on Pot/Pan Washing and Sanitation, last reviewed 11/16/20, was provided on 9/30/22. It stated in pertinent part: It is the policy of (facility company) that equipment and utensils are cleaned and sanitized appropriately after use to maintain a clean and sanitary environment for food preparation. Inspect for cleanliness and store pots and pans inverted in a clean, dry, protected area. Keep pots and pans area clean and free of clutter. Facility Policy on Dishroom Sanitation, last reviewed 8/3/17, was provided on 9/30/22. It stated in pertinent part: Keep floor mats in place during dishwashing. Doors to the dish room should remain closed during dishwashing operations. Keep dishwashing area separate from prep area. Kitchen Observations: On 9/29/22 from 12:00 p.m. - 1:00 p.m.: -The magnetic knife holder was observed with 10 cutting knives attached. The blades faced upwards, uncovered. The knives were near 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 observations, interviews, record reviews and review of the facility policy, the facility failed to develop an individualized and comprehensive care plan for two (2) of 14 residents (R) sampled (R2 and R21). Findings include: Review of the facility policy titled, Care Plans dated 7/21/21, documented the Comprehensive Care Plan would described the following: the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Review of R2's clinical record revealed an admission date of 12/17/21 and the diagnoses included: Spastic Quadriplegic Cerebral Palsy, Stage 3 Pressure Ulcer, History of Urinary Tract Infections (UTIs), Urinary Calculus, Chronic Obstructive Pyelonephritis, and Hydronephrosis with Renal and Ureteral Calculous Obstruction. Review of R2's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 6/10/22 revealed R2 had a catheter. Review of R2's Care Plan dated 7/29/22 revealed there was not a Care Plan for the catheter usage. Review of R2's Physician's Orders…

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, and record review, the facility failed to provide services to increase the mobility status of one (1) of one (1) resident sampled for activities of daily living (ADL) (Resident (R)95). Findings include: Review of R95's clinical record revealed an admission date of 9/12/22 and the diagnoses included: Cognitive Communication Deficit, Muscle Weakness, Lack of Coordination and Anxiety Disorder. Review of R95's admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 9/14/22 revealed R95 had short and long-term memory difficulties and modified impaired decision-making skills. The MDS documented the resident only ambulated one (1) of two (2) times with one (1) person assistance and the activity of locomotion did not occur. The resident was not steady on their feet and only able to stabilize with staff assistance with moving from a seated to standing position, walking, turning around, moving on and off the toilet and surface-to surface transfers. The resident had no decrease in range of motion and utilized a wheelchair. 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, and record review, the facility failed to assess and provide timely interventions for the presence of dry crusted matter on the scalp and face of one (1) of 14 residents sampled (Resident (R)95). Findings include: Review of R95's clinical record revealed an admission date of 9/12/22 and the diagnoses included: Cognitive Communication Deficit, Cellulitis of Gastric Tube and Anxiety Disorder. Review of R95's admission Minimum Data Set (MDS) assessment dated [DATE] revealed R95 had short and long-term memory difficulties, had modified impaired decision-making skills and no skin breakdown. Review of R95's Care Plan dated 9/13/22 listed the intervention for a Body Audit weekly. Review of R95's admission assessment dated [DATE] at 4:35 PM revealed the resident had extremely dry skin but did not document the dry crusted matter on the scalp and upper sides of his/her face. Review of R95's Weekly Body Audit dated 9/24/22 at 10:40 PM lacked any documentation regarding the resident's skin.…

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, resident, and staff interviews, the facility failed to ensure that a resident who is continent of bladder and bowel receives the necessary services and assistance to maintain continence for one (1) of one (1) resident reviewed (Resident (R43) for continence, and one (1) of two (2) residents reviewed (Resident (R21) for catheter care services out of twenty-four (24) sample residents. Specifically, the facility failed to ensure: -A physician order for a urinary analysis was completed, and a urology consultation appointment was ordered for R43; and, -Appropriate catheter care was provided for R21. Findings include: 1. Facility Policy on Diagnostic and Laboratory Services: Procedures for Processing, last reviewed 10/24/18, was provided on 9/30/22. It stated in pertinent part: Each healthcare center will maintain a system for processing, monitoring and reporting patient/resident diagnostic and laboratory test results. Upon receipt of a new provider radiology or other diagnostic order, 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 observations, interviews, and record review, the facility failed to label the oxygen tubing for one (1) of two (2) residents reviewed for respiratory care (Resident (R)10). Findings include: Review of R10's clinical record revealed the admission date of 6/26/20 and the diagnoses included: Chronic Obstructive Pulmonary Disease (COPD), Chronic Respirator Failure with Hypoxia, Congestive Heart Failure (CHF) and Bipolar Disease. Review of R10's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 9/8/22 documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS identified the resident had shortness of breath with exertion and inaccurately coded the resident did not receive oxygen. Review of R10's Physician Orders included: 1/27/21 - change respiratory circuit/supplies weekly on Sunday nights; 1/27/21 - oxygen at two (2) liters per minute via nasal cannula continuously; 5/10/21 - check oxygen saturation every shift and as needed, two (2) times a day. Review of R10's Care Plan dated…

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, interviews, and record review the facility failed to maintain consistent communication with the dialysis facility and failed to follow physician's orders for monitoring of one (1) of one (1) resident reviewed for dialysis (Resident (R)95). Findings include: Review of the policy titled, Dialysis Care Pre and Post Dialysis, dated 8/22/22 documented: Procedure: I. Pre-Dialysis: 1. Verify Physician Orders. 2. Take and record resident blood pressure and pulse and observe shunt access prior to resident transport to dialysis. II. Post Dialysis: 1. Verify Physician Orders. 2. Upon return from dialysis, take and record resident blood pressure, pulse, and observations of the dressing at the access site. 6. Monitor vascular integrity distal to the shunt sites. Check temperature of extremity involved - color and capillary refill. Review of R95's clinical record revealed an admission date of 9/12/22 and the diagnoses included: Diabetes, Chronic Kidney Disease, Congestive Heart Failure, Hypertension,…

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, and record review, the facility failed to administer medications without errors for two (2) of four (4) residents observed (Resident (R)94 and R95). There were 29 medications administered with two (2) errors, equaling a 6.9 percent error rate. Findings included: Review of the policy titled, Medication Administration: General Guidelines dated 5/20/22 documented: Procedure: 2. Medications are administered in accordance with written orders of the attending physician. 10. Medications are administered within 60 minutes before or after scheduled time, except for medications ordered to be taken with food and before or after meals, which are administered precisely as ordered. Observation on 9/27/22 at 3:47 PM revealed Licensed Practical Nurse (LPN)2 administered Carafate to R94. Observation revealed R94 had Jevity infusing via the gastrostomy tube (g-tube) at 50 cubic centimeter (cc) per hour. LPN2 stopped the g-tube feeding and administered 30 cc of water through the g-tube, administered 10 cc of Carafate (100 milligrams (mg) per 1cc), flushed the tubing…

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.