Pruitthealth- Columbia

Inspectors wroteBased on review of facility policy, direct observations, and staff interviews, the facility failed to ensure resident meals were served and distributed in a timely manner. This failure to adhere to established meal service protocols had the potential to impact residents' nutritional intake, satisfaction, and overall quality of care. Review of facility policy titled Mealtimes with a revision date of 10/18/2017 revealed: .2. Meals must be established at regular intervals comparable to those in the community. Review of designated mealtimes revealed the following schedule: Breakfast is served from 7:45 AM to 8:45 AM, Lunch from 11:40 AM to 1:00 PM, and Supper from 5:00 PM to 6:15 PM.An observation on 07/16/25 at 9:17 AM revealed a resident in room [ROOM NUMBER] yelling out, Give me something to eat. At the time of the observation, no meal carts or trays were present on the floor. [...]

Inspectors wroteBased on a review of the facility's dietary policies, observations, and staff interviews, the facility failed to ensure proper sanitation of kitchen equipment, maintain overall cleanliness of the main kitchen, and properly label and discard expired foods in the 1/1 main kitchen. This deficiency posed a potential risk to the health and safety of the 140 residents who reside in the facility and consume food prepared in the kitchen. Review of facility policy titled Labeling, Dating, and Storage with a revision date of 11/11/2022 states, 1. Food and beverage items will have an identifying label as well as a received date and opening date, as applicable; for items prepared on site, a 'use by' date will also be indicated. 2. Foods will be stored in their original or approved container and, if opened, shall be wrapped tightly with film, foil, etc. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that Resident (R)90 was provided with a functioning television, compromising the resident's right to a homelike environment. This failure affected 1 of 1 residents reviewed for a homelike environment. Review of R90's Face Sheet revealed R90 was admitted on [DATE] with diagnoses that included but not limited to: displaced fracture of the fifth cervical vertebra, unsteadiness on the feet, difficulty in walking, and central cord syndrome at the specified level of the cervical spinal cord. Review of R90's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/03/25, showed R90 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. [...]

Inspectors wroteBased on review of facility policy, observations and interviews, the facility failed to ensure that the medication refrigerator temperature logs were checked daily in 1 of 4 medication storage rooms. Review of the facility's policy titled Medication Storage in the Healthcare Centers states Medications and biologicals are stored safely, securely, and properly following the manufacturer's recommendations or those of the supplier . Procedure #8, the temperature will be logged daily on the refrigerator and room temperature log. During an observation on 07/16/25 at 03:29 PM, the 200 hall refrigerator revealed a large amount of ice pooled in the freezer. The ice is dripping on the medication. A pool of water is resting at the bottom of the refrigerator in the container with the new insulin. [...]

Inspectors wroteBased on review of facility procedures, observation and interviews, the facility failed to ensure that appropriate infection control procedures related to wound care were implemented for 1 of 1 Residents (R)6 reviewed. Specifically, during a dressing change Registered Nurse (RN)4 was observed removing a soiled dressing from R6's wound and replacing it with a clean dressing, without changing gloves and performing appropriate hand hygiene. Review of the facility's clinical procedure titled, Clinical Procedure: Infection Control-Wound Dressings copyrighted 2025, revealed, Pre-Procedure, Infection control during a dressing change is important to wound care management. By following a standardized protocol, healthcare professionals ensure safety and compliance with evidence-based practices. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide an environment free from potential accident hazards. Specifically, the facility used a mattress to transport Resident (R)1 down the stairwell, when the facility elevators were not working, for 1 of 3 residents reviewed. Furthermore, the facility failed to provide training and documentation related to the safe transportation of resident when the facility's elevator is not working.

Inspectors wroteBased on interview and review of the Facility Assessment, the facility failed to include the use of an elevator as part of the Facility Assessment, as it is utilized to transport residents during daily operations.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure proper sanitation of kitchen equipment and overall kitchen cleanliness in 1 of 1 main kitchen. The facility also failed to discard expired foods in 1 of 1 main cooler.

Inspectors wroteBased on interview, the facility failed to have a qualified Social Worker, on a full-time basis, on site at the facility, for 4 of 4 units.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control (CDC) guidance, and review of the facility policy, the facility failed to ensure appropriate signage or Personal Protective Equipment (PPE) was donned and doffed, for residents (Resident (R)92, R29, R6, R113, and R35.) on Enhanced Barrier Precautions, for 5 of 7 residents reviewed.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure that Resident (R)521's advanced directives were updated as requested by their Resident Representative in a timely manner, for 1 of 1 resident reviewed for advanced directives.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to provide Activities of Daily Living (ADL) care to Resident (R)46, who is dependent on staff, for 1 of 7 residents reviewed for ADL care.

Inspectors wroteBased on review of facility policy, observation, interview, and record review, the facility failed to accurately provide Resident (R)30 with correct oxygen rate per physician orders, for 1 of 1 resident reviewed for respiratory therapy.

Inspectors wroteBased on review of facility policy, observation, and interview, the facility failed to ensure expired medications and biological's were removed from storage in 1 of 2 medication storage rooms.

Inspectors wroteBased on review of facility policy, observation, and interviews, the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters reviewed for garbage disposal. Specifically, trash/garbage was not contained in the dumpster, leaving food and debris surrounding the dumpster.

Inspectors wroteBased on review of facility policy, interview, and record review, the facility failed to protect 6 of 6 residents from misappropriation of controlled substances. Specifically, Licensed Practical Nurse (LPN)1 diverted medications from Residents (R)6, R9, R10, R11, R12, and R13 during the month of [DATE] and December of 2023. Findings Include: Review of the Facility Policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property dated [DATE], states, It is the policy of [NAME] Health and its affiliated entities to actively preserve each patient's rights to be free from . misappropriation of patient property. [...]

Inspectors wroteBased on observation, facility document review, and interview, the facility failed to provide a clean, comfortable, homelike environment for two of three floors of the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to track and trend antibiotic usage, infections, and perform infection surveillance for eight of twelve months reviewed. This failure placed all residents at risk for the potential transmission of infections and communicable diseases. The facility census was 92.

Inspectors wroteBased on interview and record review, the facility failed to provide activities of daily living (ADLs) shower for one Resident (R43) who requires extensive assistance from staff for activities of daily living (ADLs). This had the potential to impact the resident emotionally due to wanting a shower. The facility census was 92 residents. Findings Include: Review of R43's face sheet revealed an admission date of 12/16/20 with diagnoses including but not limited to, chronic obstructive pulmonary disease with (acute) exacerbation, major depressive disorder, anxiety disorder, and difficulty in walking. Review of the Quarterly Minimum Data Set (MDS) assessment of 03/02/22 located on the Electronic Medical Record (EMR) in the MDS tab revealed R43 was assessed as requiring extensive assistance for ADL care including extensive assistance with bathing and dressing. [...]

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to perform wound care treatment according to physician's orders for one resident (R)7 out of 3 reviewed for pressure ulcers.