Pratt Health and Rehab

Inspectors wroteThe facility had a census of 38 residents. Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions for Resident (R) 8, who had dressing changes to a pressure ulcer daily. The facility also failed to implement a complete water management program for Legionella disease (Legionella is a bacterium spread through mist, such as air-conditioning units in large buildings. Adults over the age of 50 and people with weak immune systems, or chronic lung diseases).

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents, with three reviewed for Medicare Liability Notices. Based on record review and interview, the facility failed to provide Resident (R) 8, R10, and R17, or their representative, a Notice of Medicare Non-coverage (NOMNC) when skilled services ended.

Inspectors wroteThe facility identified a census of 38 residents. The sample included 12 residents, with two residents reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 29 and R40 and their representative were provided with a written notification of transfer, that included a statement of the right to appeal and the state ombudsman information, upon their transfer to the hospital as soon as practicable. The facility failed to ensure R40 had a discharge summary and recapitulation of stay completed upon her discharge from the facility.

Inspectors wroteThe facility reported a census of 41 residents with three residents sampled for safety related to transportation outside the facility. Based on observation, interview, and record review, the facility failed to ensure that staff provided a safe environment, free of accident hazards during transportation in the facility van. On 03/11/25 at approximately 09:20 AM Certified Nurse Aide (CNA) C failed to ensure Resident (R)1 was safely secured in the facility van before operating the vehicle. CNA C began to drive the van and realized R1 did not have a seatbelt on. CNA C then stopped the vehicle and R1 fell out of the wheelchair onto the floor of the facility van and injured his head, face and left arm. This deficient practice placed R1 in immediate jeopardy.

Inspectors wroteThe facility reported a census of 41 residents with 16 residents selected for review, which included one resident reviewed for dignity. Based on observation, interview and record review, the facility failed to maintain Resident (R)28's dignity when in bed with only his brief on, to expose himself to the residents, staff and visitors that would go by his room.

Inspectors wroteThe facility reported a census of 41 residents with 16 residents sampled. Based on observation, record review, and interview, the facility failed to revise the care plan with effective interventions for Resident (R)12 related to lack of wheelchair foot pedals and R 18, related to inability to self-administer medications.

Inspectors wroteThe facility reported a census of 41 residents with 16 selected for review with one resident reviewed for activities of daily living for dependent residents. Based on observation, interview and record review, the facility failed to ensure one Resident (R)28 received facial hair grooming opportunities.

Inspectors wroteThe facility reported a census of 41 residents with 16 residents selected for review which included three residents reviewed for skin issues. Based on observation, interview, and record review, the facility failed to monitor and provide sanitary dressing change for one, Resident (R)18's venous ulcer, of the three residents reviewed for skin issues.

Inspectors wroteThe facility reported a census of 41 residents with 16 residents selected for review, that included one resident reviewed for vision. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)14, received vision care.

Inspectors wroteThe facility reported a census of 41 residents with 16 residents sampled, including five residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to safely transport one Resident (R)12 in his wheelchair by failing to have foot pedals in place while propelling him in his wheelchair.

Inspectors wroteThe facility reported a census of 41 residents with 16 residents selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure three Residents (R)18, R34 and R35, of the five residents were monitored for adverse effects of antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medications in a timely manner.

Inspectors wroteThe facility reported a census of 41 residents. Based on observation, interview, and record review, the facility to properly dispose of a used Fentanyl (a skin patch used to treat severe pain) after staff removed the medicated patch from Resident (R)38.

Inspectors wroteThe facility reported a census of 41 residents. Based on observation, interview, and record review, the facility failed to monitor and provide sanitary dressing change for one, Resident (R)18's venous ulcers.

Inspectors wroteThe facility census totaled 43 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to ensure staff identified and promptly responded to signs of pain expressed by cognitively impaired Resident (R)12, when the resident had two fractured ribs and staff did not offer the resident non-pharmacological pain interventions or as needed (PRN) pain medications.

Inspectors wroteThe facility census totaled 43 residents with 12 residents included in the sample. Based on interview and record review the facility failed to provide a bed hold notification with each facility-initiated hospital transfer. (Resident (R)39)

Inspectors wroteThe facility reported a census of 43 residents, with 12 in the sample. Based on interview and record review the facility failed to complete a significant change comprehensive assessment for Resident (R)33.

Inspectors wroteThe facility reported a census of 43 residents with 12 residents in the sample. Based on observation, interview, and record review the facility failed to develop a comprehensive care plan to include the use of oxygen (O2) for R27.

Inspectors wroteThe facility reported a census of 43 residents with 12 residents in the sample. Based on observation, interview, and record review the facility failed to update the care plan to include fall prevention interventions for Resident (R)12 and R33.

Inspectors wroteThe facility census totaled 43 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to ensure the fall prevention interventions were implemented to prevent further falls for Resident (R)12 and R33.

Inspectors wroteThe facility reported a census of 43 residents with 12 in the sample. Based on observation, interview, and record review the facility failed to obtain an order for the oxygen use administered to R27 per nasal cannula.

Inspectors wroteThe facility reported a census of 43 with 12 residents in the sample, five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the licensed nursing staff administrated insulin (hormone which regulates blood sugar) as ordered to Resident (R)27.

Inspectors wroteThe facility census totaled 43 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to administer psychotropic medication as ordered for Resident (R)12's behaviors.