Pruitthealth- Bamberg

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to store food properly in one of two designated resident refrigerators on the hallways and failed to serve milk at a temperature of 41 degrees Fahrenheit (F) or below from the kitchen's lunch tray line. These failures had the potential to create an environment for food-borne illnesses which could affect the 42 residents who resided on the 100 hallway and/or who were served milk during the lunch meal.

Inspectors wroteBased on observation, review of the monthly resident council meeting minutes, and interviews, the facility failed to ensure reports with respect to the most recent Federal or State survey inspection results, certifications, complaint investigations, and any plans of correction during the three preceding years were readily accessible to residents and/or family members. The facility failed to ensure this information was posted in areas of the facility that are prominent and accessible to the public. This failure had the potential to affect all 80 residents residing in the facility. This had the potential to cause residents and visitors to be uninformed of survey, certification, and complaint investigation findings.

Inspectors wroteBased on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure two resident's Minimum Data Set (MDS) assessments were accurately coded regarding having a feeding tube and receiving intake by an artificial route for one resident (Resident (R)67), and having a pressure ulcer over a boney prominence for R77 out of 23 sampled residents. This failure had the potential to affect the care planning and provision of needed services. Review of the Long-Term Care Facility Resident Assessment Instrument [RAI] Instrument 3.0 User's Manual, dated October 2025 and located at https://www.cms.gov/files/document/final-mds-3-0-rai-manual-v1-20-1-october-2025.pdf indicated, . In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure ongoing communication was taking place and documentation was provided regarding updates, referrals made to other skilled nursing facilities regarding the potential discharge, placement, and transition of care for one resident (Resident (R)71) in attaining and maintaining the resident's highest practicable well-being out of 23 sampled residents. This failure had the potential to affect the resident in a negative way by not receiving information from the Social Services Director (SSD) regarding her requests.

Inspectors wroteBased on observation, record review, interview, and review of the Academy of Nutrition and Dietetics Diet Manual, the facility failed to provide food in a form to meet the needs for one resident (Resident (R)23) out of two reviewed for nutritional status out of 23 sampled residents. This failure had the potential to cause nutritional needs to go unmet for residents who had a physician's diet order to be served finger food prepared from the facility's kitchen.

Inspectors wroteBased on review of facility policy, record reviews, and interviews, the facility failed to properly account for and reconcile controlled medications to prevent potential loss, diversion, or accidental exposure. This deficiency is evidenced by the missing controlled drug record sheet for Resident (R)4, 1 of 3 residents reviewed. Review of a facility policy titled, Controlled Substances for Healthcare Centers, last reviewed 04/01/25 revealed, It is the policy of PruittHealth Pharmacy that medications listed as controlled substances (Schedules I-V) under federal or state regulations will be properly stored with maintained accountability. Reconciliation of controlled substances will be performed at the end of each shift by licensed professional nurses. This policy applies to all nursing staff in a healthcare center serviced by PruittHealth Pharmacy. Records . 5. [...]

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety, in 1 of 1 kitchen.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure food was at appropriate temperature and palatable for four of five residents (Resident (R) 22, R26, R81, and R35) reviewed for the food palatability of 25 sample residents. This failure had the potential for residents who disliked a meal to experience nutritional problems or dissatisfaction with their meals.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure medications in the resident's room were deemed safe for self-administration for one of 22 Initial Pool residents (Resident (R) 22) observed for medications in the room. This failure placed R22 at risk for medication errors, accidental overdose, or misappropriation of her medications.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure that an allegation of injury of unknown source was reported to the State Survey Agency (SSA) within two hours of discovery for one of four residents (Resident (R) 2) reviewed for abuse of 25 sample residents. The failure to timely report the incident created a risk for potential further abuse or injury.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the status of two of 25 sample residents (Resident (R) 32 and R48) whose MDS indicators were reviewed in Initial Pool. These failures created a potential for lack of identification of current problems and resident needs, leading to an incomplete or ineffective plan of care.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure staff, and a visitor used the proper personal protective equipment (PPE) when in contact with one of one resident (Resident (R) 82) who was on transmission-based precautions (TBP) out of a census of 79 residents. This failure had the potential to spread infection among the visitors, staff, and other residents.

Inspectors wroteBased on observation and interview, the facility failed to have adequate equipment to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. Specifically, the call light system did not function in residents' rooms 102, 103, 108, 109, 111, 113, 117, 128, 210, 215 and the facility did not provide residents in these rooms an alternate means to communicate with nursing staff, such as a manual bell to ring when the resident's required assistance from nursing staff. The facility also failed to have a policy and procedure to direct staff when call lights malfunction, and to ensure that another method to call for assistance was implemented.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure care plan interventions were implemented for one of three sampled residents (Resident (R) 22) reviewed for pressure ulcers. Specifically, the facility failed to implement the interventions of off-loading to a pressure ulcer on the left heel as indicated in the care plan. This failure had the potential for the resident to not receive the necessary care needed to promote healing of a pressure ulcer.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to protect and prevent misappropriation of Resident (R)1's personal funds.

Inspectors wroteBased on review of facility policy, observation, interview, and record review, the facility failed to assess and administer Resident (R)4's medications in a clinically appropriate manner, for 1 of 1 resident reviewed for medication.