Pruitthealth-Carolina Point

Inspectors wroteF812 -EBased on observations and staff interviews, the facility failed to label, date, seal and/or remove expired food items stored for use in 1 of 1 walk-in cooler, the dry goods storage room, and 1 of 1 of 1 walk-in freezer and failed to ensure food service equipment was clean. These practices had the potential to affect food being served to residents.

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to provide nail care for Resident #137 who required staff assistance for personal hygiene. This deficient practice affected 1 of 8 dependent residents reviewed for activities of daily living (Resident #137).

Inspectors wroteBased on observations, record reviews, and resident and staff interviews, the facility failed to provide podiatry services to 1 of 1 residents with diabetes who were reviewed for foot care (Resident #104).

Inspectors wroteBased on record review and interviews with the Medical Director, Nurse Practitioner (NP), Assistant Manager of Pharmacy Operations, residents and staff, the facility failed to have effective systems in place to ensure a twice a day dose of an antiseizure oral medication prescribed for the treatment of seizure was administered resulting in a seven-day delay of it being administered. Resident #1 did not change his condition. This occurred for 1 of 1 resident reviewed for significant medication error (Resident #1).

Inspectors wroteBased on facility video recording, record reviews, and interviews with staff, Nurse Practitioner, Medical Director and the resident's responsible party (RP), the facility failed to protect a cognitively impaired and vulnerable female resident's (Resident #2) right to be free from sexual abuse by a cognitively impaired male resident (Resident #1). On 3/2/25 at 2:50 AM, Nurse Aide (NA) #1 walked past Resident #1 in the hallway. Resident #1 was sitting in his wheelchair with no clothes on and only a towel covering his waist. NA #1 did not intervene and/or redirect the resident. On 3/2/25 at 3:18 AM, Nurse #1 observed Resident #1 on Resident #2's bed. Resident #1 was naked and was kneeling on the bed near the foot board, leaning forward and trying to place his left 2nd and 3rd fingers inside Resident #2's vagina. [...]

Inspectors wroteBased on observations, record reviews and staff interview the facility failed to accurately code the Minimum Data Set (MDS) assessments for Level II Preadmission Screening and Resident Review (PASRR) for 4 of 7 residents reviewed for MDS accuracy (Resident #43, Resident # 45, Resident #58, and Resident #61).

Inspectors wroteBased on observations and interviews, the facility failed to maintain the dry goods storage area clean and failed to label and date food in one of one walk-in refrigerator. The facility also failed to ensure dietary staff facial hair coverings during food preparation in the kitchen. These practices had the potential to affect food served to residents.

Inspectors wroteBased on record review, family, Nurse Practitioner, resident and staff interviews, the facility failed to notify the resident and the resident's Responsible Party of a medication change for 1 of 2 sampled residents (Resident #59).

Inspectors wroteBased on record review and staff interviews, the facility failed to develop an individualized, person-centered activities of daily living (ADL) care plan that included how much staff assistance was needed to care for a resident who required total assistance with ADL for 1 of 8 sampled residents reviewed for ADL (Resident #49).

Inspectors wroteBased on observations, record reviews, and interviews with residents and staff, the facility failed to provide a resident with a cream gravy mix on her mechanical soft ground meats as specified on the meal ticket (Resident #68) and failed to provide food cut up into small pieces per the physicians order (Resident #22). This occurred for 2 of 2 sampled residents (Resident #68 and Resident #22).

Inspectors wroteBased on staff interviews and record review of resident trust accounts, the facility failed to convey funds within 30 days and forward the balance of funds to the estate of an expired resident for 2 of 3 residents reviewed for personal funds (Resident #281 and Resident #134).

Inspectors wroteBased on record review and interview of the staff and Police Officer #1, the facility failed to protect a cognitively impaired dependent resident (Resident #1) from sexual abuse by a cognitively intact resident (Resident #2). On 3/19/24 Resident #2 was found in Resident #1's room by Nursing Assistant #1. Resident #2 was observed fondling Resident #1's penis with skin to skin contact from his hand. Resident #1 was unable to stop the sexual abuse due to his limited ability to move and he was non-verbal/unable to call for help. Resident #1 was incapable of consenting to the sexual act and could not express an adverse psychosocial outcome. A reasonable person expects to be protected from abuse in their home environment and sexual abuse would cause emotional trauma. This deficient practice affected 1 of 3 residents reviewed for abuse. [...]

Inspectors wroteBased on record review and staff interviews, the facility's quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification/complaint investigation survey dated 7/13/22 in order to achieve and sustain compliance. This was for a recited deficiency from a complaint investigation survey on 4/9/24. The deficiency was in the area of abuse. The continued failure during federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program.

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to: 1) lock and secure one unattended medication cart for 1 of 2 medication carts observed (300-hall medication cart), 2) label a multi-use medication with resident name and opened date on 1 of 2 medication carts observed (500 Hall medication cart).

Inspectors wroteBased on observations, staff interviews, and record review the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following a recertification and complaint survey in April 2021, recertification and complaint survey in July 2022, complaint survey in June 2023 and subsequently recited in July 2023 on the current recertification and complaint survey. The recited deficiencies were in the areas of 1) develop an accurate assessment (F641) and 2) develop/ implement comprehensive care plan (F656). These deficiencies were recited in the current recertification and complaint survey. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance (QA) Program.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment to reflect a resident's most recent weight obtained during the previous 30-day period for 1 of 5 residents (Resident #392) reviewed for Nutrition.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to develop a baseline care plan which included the minimum healthcare information necessary to properly care for 1 of 12 newly admitted residents reviewed (Resident #242).

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a comprehensive care plan which addressed the use of an anticoagulant medication for 1 of 6 residents (Resident #78) reviewed for unnecessary medications.