Pruitthealth - Brookhaven

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy titled MDS Assessment Accuracy, the facility failed to ensure Minimum Data Set (MDS) assessments were coded accurately for 4 of 47 sampled residents (R) (R100, R12, R88, and R66). This deficient practice had the potential to place R100, R12, R88, and R66 at increased risk of not receiving care and services according to their needs.

Inspectors wroteBased on record review and staff interviews, the facility failed to submit a Preadmission Screening and Resident Review (PASRR) Level II for one of one resident (R) (R1) reviewed from a sample of 47 residents. This deficient practice had the potential to place R1 at increased risk for not receiving the necessary behavioral health services and support needed to meet R1's needs.

Inspectors wroteBased on observations, record review, resident and staff interviews, and review of the facility policy titled, Care plan, the facility failed to follow approaches described in the care plan for one of 16 residents (R) (R69) receiving Restorative Nursing care. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the policy titled, Restorative Nursing Program, the facility failed to provide services to maintain and or prevent further decrease in range of motion or mobility for one of 16 Residents (R) (R69) receiving Restorative Nursing care. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to ensure one of 47 sample resident's (R) (R41) food preferences/needs were being accommodated, specifically for food allergies.

Inspectors wroteBased on resident and staff interviews, record review and review of the facility's policy titled Resident Trust Fund Policy, the facility failed to provide a quarterly statement to seven residents (R) (R89, R50, R46, R108, R92, R20, R7) and the facility failed to employ proper bookkeeping techniques for two residents (R89 and R46) out of 65 sampled residents. This had the potential to affect residents with trust fund accounts managed by the facility, affect the residents' financial records and overall transparency, potentially leading to confusion or errors in their account balances. Findings Include: [...]

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Advance Beneficiary Notice of Noncoverage, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) to one of three residents (R) (R31) reviewed for Beneficiary Notification who remained in the facility and was discharged from Medicare Part A services.

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to provide a safe environment as evidenced by loose wires were exposed unsecured in the room of one of 65 sampled residents (R) R50. The deficient practice had the potential to increase the risks of an accident.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed and submitted for one of three Residents (R) (R31) reviewed for Beneficiary Notification. Specifically, the facility failed to complete and submit a Part A Prospective Payment System (PPS) Discharge MDS assessment for R31.

Inspectors wroteBased on record reviews and staff interviews the facility failed to screen one of two residents (R) R119 reviewed for Pre-admission Screening and Record Review (PASARR). This deficient practice had the potential to cause R119 to not receive care and services in the most integrated setting appropriate to his needs and have diminished quality of life.

Inspectors wroteBased on staff interviews, record reviews, and review of the facility's policy titled Care Plans, the facility failed to develop a baseline care plan that addressed care and management for a PICC (peripherally inserted central catheter) line within 48 hours of admission for one of four residents (R) R542 reviewed with PICC lines. This deficient practice had the potential to increase the resident's risk of adverse health outcomes related to PICC lines.

Inspectors wroteBased on staff and resident interviews, record reviews, and review of the facility's policy titled Care Plans, the facility failed to develop a resident centered care plan for one of five residents (R) R68 reviewed for unnecessary medication use, that included problem, goals or interventions related to diuretic use, and one of six residents (R101) for enteral feedings received through a gastrostomy tube (G-tube). In addition, the facility failed to develop a comprehensive care plan for one of four residents (R6) with a seizure disorder that included necessary seizure precautions, to ensure the resident's optimal physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, staff interviews and record reviews, the facility failed to provide nail care for one of four residents (R) R101 reviewed for Activities of Daily Living (ADLs). Specifically, the facility failed to and trim R101's long fingernails on both hands and clean fingernails on his left hand. The deficient practice had to the potential to cause skin breakdown and infection to the palm of hands with contractures.

Inspectors wroteBased on observations, staff and resident interviews, record review and review of the facility's policy titled Activities Program, the facility failed to provide an ongoing program of activities based on person-center activities for three of nine residents (R) (R92, R121, and R540) reviewed for activities whose primary language was non-English. Findings Include: Review of the facility's policy titled Activities Program, dated 9/28/2023 under the section titled Procedure revealed, 5. The programming should reflect cultural and ethnic interests of the resident. Review of records revealed the facility had nine residents whose primary language was non-English. 1. [...]

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration: Enteral Tubes, the facility failed to ensure that one of seven residents (R) R101 received enteral feedings, as ordered and to properly label and date the formula bottle, bags, and syringes used to provide the resident with needed nutrients.

Inspectors wroteBased on observations, resident and staff interviews, and review of the facility's policy titled Oxygen Administration, the facility failed to follow physician orders for oxygen therapy for one of 19 residents (R) (R8) on oxygen therapy. In addition, the facility failed to change nebulizer equipment weekly and cover nebulizer masks when not in use for one of 19 residents (R539) on oxygen therapy. This deficient practice posed significant risks, including potential medical complications, unmet needs, and a diminished quality of life for the resident.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Labeling, Dating, and Storage, the facility failed to label dry goods and discard on or before the expiration date. In addition, the facility failed to label and store frozen food items in the freezer to ensure proper food safety and to maintain proper ice machine cleaning. The facility had a census of 119 residents that received an oral diet from the kitchen.

Inspectors wroteBased on observations, interviews, record review, facility document review, and review of facility policies titled P.I.C.C. (peripherally inserted central catheter) Catheter Dressing Change, P.I.C.C. Infusion Access Device Maintenance, and Infection Prevention-Hand Hygiene policy, the facility failed to follow infection control practices for three of 14 residents (R) (R549, R543 and R16). Specifically, the facility failed to ensure proper hand hygiene and physicians orders for dressing change were followed when providing care of the P.I.C.C. for (R549 and R543) and failed to follow procedure for catheter care for (R16).

Inspectors wroteBased on observations and staff interviews the facility failed to provide a safe and comfortable environment for the residents, staff and the public as evidenced by an unpleasant odor on one hall (South Wing) of three halls. This deficient practice had the potential to cause diminished quality of life. The facility census was 128 residents.

Inspectors wroteBased on observations, record review, staff interviews, and review of the policies titled Infection Prevention and Control Program Surveillance Reporting and Hand Hygiene and Contact Precaution Compliance and review of the RN/LPN Annual Skills Fair 2023, the facility failed to ensure infection control practices were maintained to prevent the potential for infections and cross contamination. Specifically, the infection control data for August 2023 was not analyzed for trends in urinary tract infections that include appropriate corrective actions and staff failed to wash/sanitize hands after glove removal and prior to donning clean gloves during wound care for one resident (R) (R34). The census was 110.

Inspectors wroteBased on observations, interviews, and review of the policies titled Resident Rights and Daily Occupied Resident Room Cleaning, the facility failed to ensure it was maintained in a safe, clean, and comfortable home-like environment in nine resident rooms on two of three halls, including the common areas and the shower rooms and equipment used for showers. The census was 110.

Inspectors wroteBased on observations, record review, staff and resident interviews, and review of the policy titled Activities Program, the facility failed to ensure an ongoing program of activities based on preferences for three of three residents (R) (R8, R35, R19) reviewed for activities. These residents were not provided with person-centered activities that would meet their individual needs.

Inspectors wroteBased on record review, interviews, and a review of the facility policies titled Influenza (Flu) Vaccinations for Health Care Center Residents and Pneumococcal Vaccinations, the facility failed to ensure that five residents (R) (R8, R15, R16, R40, and R45) reviewed for vaccination status, received education, were offered, consented to receive, and/or refused the pneumococcal vaccination, of 44 sampled residents.

Inspectors wroteBased on observations, record review, interviews, and review of the facility's policy titled Medication Administration: General Guidelines, the facility failed to assess and determine if it was appropriate for one of eight sampled residents (R) (R36) to self-administer medications left at bedside. This failure placed the resident at risk for inappropriate and unsafe medication use.

Inspectors wroteBased on record review, interviews, and review of facility policies titled Therapy Evaluations and Specialty Services: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health, the facility failed to accommodate the needs for three of five sampled residents (R) (R15, R39 and R42). Specifically, R15 had order for durable medical equipment (DME) lift chair to accommodate her mobility with transfers to decrease pain; and failed to ensure R39 and R42 had transportation arrangements for follow-up for post-surgical appointments, resulting in need for rescheduling missed appointments.

Inspectors wroteBased on record review, interviews, and review of the facility policy titled Grievances: Healthcare Centers, the facility failed to ensure prompt resolutions for residents' grievances regarding missing items. The census was 110. Findings Include: Review of the policy titled Grievances: Healthcare Centers, revised 1/10/2024, documented the policy is to follow an established process whereby patients and/or other customers may have their grievances and complaints resolved in a prompt, reasonable and consistent manner. A grievance includes complaints with respect to care and treatment that has been furnished to a patient, as well as that which has not been furnished, the behavior of staff and of other patients, and other concerns regarding the patient's facility stay. Procedure: Number 1. [...]

Inspectors wroteBased on record review, interviews, and review of the facility's policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to provide a complete and thorough investigation of allegations of abuse for two of three residents (R) (R10 and R44) reviewed.

Inspectors wroteBased on record review, interviews, and reviews of the policy titled Minimum Data Set (MDS) Assessment Accuracy, the facility failed to ensure that a Significant Change MDS assessment was completed for one resident (R) (R8) who had been placed on Hospice services. The sample size was 44.

Inspectors wroteBased on record review, interviews, and review of the policy titled Minimum Data Set (MDS) Assessment Accuracy Policy, the facility failed to ensure that resident's ethnicity and language needs were properly assessed on the MDS for one of one resident (R) (R6) reviewed. Review of the Minimum Data Set (MDS) Assessment Accuracy Policy dated 12/6/2022 documented it is the policy of the healthcare center that each MDS reflect the acuity and the medical status of each patient/resident in accordance with acceptable professional standards and practices. The assessment will be scheduled to accurately account for the acuity and complexity of the patient/resident. Each Assessment Reference Date (ARD) will be chosen to capture services rendered and reflect an accurate clinical profile of each patient/resident. [...]

Inspectors wroteBased on record review, policy review, interviews and review of Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, the facility failed to ensure that services were provided in accordance with professional standards of quality as evidenced by the failure to conduct weekly skin assessments to identify skin breakdown and provide treatments before pressure ulcer development for two of three sampled residents (R) (R26 and R20) reviewed for pressure ulcers.

Inspectors wroteBased on observations, record review, staff and resident interviews, the facility failed to provide activities of daily living (ADL) care for three of 10 residents (R) (R8, R35 and R27) reviewed for ADLs. Specifically, the facility failed to provide showers as scheduled for R8, R35, and R27.

Inspectors wroteBased on record review, interviews, and review of the policy titled Documentation of Skin and Wound Care, facility failed to perform weekly skin assessments to identify potential skin breakdown, and implement interventions in a timely manner to prevent unavoidable pressure ulcers, for two of three residents (R) (R26 and R20) reviewed for pressure ulcers.

Inspectors wroteBased on observation, record review, interview, and review of the policy titled Restorative Nursing Program and Therapy Evaluations, the facility failed to provide restorative therapy services to attain or maintain the highest practicable physical, mental, and psychosocial well- being for two of four residents (R) (R19 and R27) reviewed who were referred for Restorative Therapy Services.

Inspectors wroteBased on record review, interviews, and review of the policy titled Weight Monitoring Program, the facility failed to provide care and services to maintain an acceptable parameter for the nutritional status for one resident (R) (R26), resulting in a 7.82% weight loss in The sample size was 44 residents.

Inspectors wroteBased on record review, interviews, and review of the policy titled Therapy Evaluations, the facility failed to evaluate a therapy recommendation per two different physician's order for one of three sampled residents (R) (R15) related to providing a Durable Medical Equipment (DME) lift chair.

Inspectors wroteBased on staff interviews and a review of the facility's documents titled, Facility Assessment [name of facility] and Facility Assessment [name of facility] 2024, the facility failed to determine its capacity and capability of the clinical staff to provide the necessary care and services for one of 43 sampled residents (R) (R10). Specifically, R10 wore an external cardiac defibrillator, and facility did not have staff educated on how to care for a resident with an external defibrillator.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that the call light communication system was functioning adequately to allow residents to call for staff assistance for five of 27 sampled residents (R) (R28, R30, R31, R35, R38).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that clinical staff were educated related to the use of a wearable cardioverter defibrillator (WCD) for one of 43 sampled residents (R)(R10). This failure had the potential to place R10 at risk of not receiving necessary care and monitoring for cardiac instability.

Inspectors wroteBased on observations, and staff interviews, the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner and failed to ensure the areas surrounding the dumpsters were free of trash debris for two of two dumpsters.

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to develop the appropriate interventions to treat and prevent the development of additional pressures ulcers for one resident (R) (R#104) out of 36 sampled residents. Findings Include: Review of the clinical record revealed that R#104 was admitted to the facility on [DATE] with diagnoses including but not limited to diabetes mellitus, dementia, thrombocytopenia, dysphagia, gastrostomy, and gastroesophageal reflux disease. Review of R#104's care plan revealed a care plan that stated, At risk for skin breakdown r/t (related to) bowel obstruction, atrial fibrillation, acute kidney failure, fecal impaction, dementia history of urinary tract infections, dysphagia, vitamin D deficiency, Alzheimer's, major depression, insomnia actual breakdown sacrum. [...]

Inspectors wroteBased on record review, staff interview, and review of facility policies titled, Controlled Substances for Healthcare Centers, Automated Drug Cabinet, and Ordering Medications from the Pharmacy, the facility failed to follow the physician orders for two residents (R) (R#65 and R#724) related to the administration of scheduled medication for two out of two residents The sample size was 36. Review of a procedure titled Medication Administration undated, revealed 17. Ensure medications are given within one hour prior to or after time ordered. 22. Demonstrate proper action to take if medication not taken or given either by refusal/unavailable medication or other contraindications. Review of a policy titled Controlled Substances for Healthcare Centers revised 4/28/21, revealed 3. [...]