Pruitthealth - Decatur

Inspectors wroteBased on observations and staff interviews, the facility failed to protect clean linen from cross-contamination. This deficient practice had the potential to affect two of two floors. The census was 135 residents.

Inspectors wroteBased on observations and staff interviews, the facility failed to store potentially hazardous chemicals so that they were not accessible to cognitively impaired residents. Specifically, a can of cleanser powder was left on a handrail accessible to residents on the first floor.

Inspectors wroteBased on observations, staff and resident interviews, and record review, the facility failed to provide dignity to one of two residents (R) (R88) with an indwelling catheter urinary bag. This deficient practice had the potential to cause emotional distress to R88.

Inspectors wroteBased on resident, resident family and staff interviews, record review, and review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to report an allegation of verbal abuse by a staff member to the State Survey Agency (SSA) for one of 50 sampled residents (R) (R144). The deficient practice had the potential for the alleged abuse to continue and to affect other residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the need of a Level II Preadmission Screening and Resident Review (PASARR) for evaluation and determination for specialized services were offered to meet resident needs for one of 50 sampled residents (R)(R14). The deficient practice had the potential for R14's needs and services to go unmet.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled Care Plans, the facility failed to add indwelling urinary catheter irrigation to the care plan for one of 50 sampled residents (R) (R51). This deficient practice had the potential to cause errors in care and omission of service ordered by the physician.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to ensure two of 50 sampled residents (R) (R13 and R38) received timely incontinence care and failed to provide sterile catheter irrigation and follow the irrigation procedure for one of 50 sampled residents (R) (R51). The deficient practices had the potential to affect resident's skin integrity and increase the potential for urinary tract infections (UTI).

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Medication Storage in Healthcare Center, the facility failed to ensure one of two medication carts on the first floor was locked. The deficient practice had to potential for items in the unlocked medication cart to be accessible to residents, staff and visitors.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility's policies titled, Labeling, Dating, and Storage and Foodborne Illness, the facility failed to dispose of expired food items in the kitchen. The deficient practice had the potential to affect the 124 residents (R) receiving food from the kitchen. The facility's census was 130.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility's policies titled, Infection Prevention-Hand Hygiene, Handwashing and Enhanced Barrier Precautions (EBP), the facility failed to place one of 19 residents (R) (R88) with wounds on EBP and failed to perform hand hygiene while serving meals in the dining room. The deficient practices had the potential to cause infection for R88 and other facility residents. The facility census was 130.

Inspectors wroteBased on record review and staff interviews, the facility failed to assure the correct order was on file and medical records reflect the resident's choice per the Physician Orders for Life Sustaining Treatment (POLST) for two of four Resident (R) (R13 and R90) reviewed. The sample size was 55 residents.

Inspectors wroteBased on observations, record review, staff interviews, review of the facility policy titled, Clean Air Filters, review of manufacturer recommendations titled Amana- Packaged Terminal Air Conditioner (PTAC) Manual, and the facility policy titled, Infection Control-Housekeeping Services, the facility failed to maintain two of 67 resident rooms in a clean, sanitary manner. Specifically, the facility failed to ensure that the PTAC was maintained in a clean and sanitary manner for room [ROOM NUMBER] and failed to keep the bathroom in room [ROOM NUMBER] free of bodily fluids. These failures had the potential to compromise the health and safety of the residents sharing those rooms by increasing the risk of infection and negatively impacting their quality of life. The facility census was 130 residents.

Inspectors wroteBased on record review and staff interview, the facility failed to submit for a Preadmission Screening and Resident Review (PASARR) Level II after a new mental illness diagnosis was added for one of one resident (R) (R10) reviewed for PASARR. This deficient practice had the potential to affect the appropriate level of care and services provided for R10.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Transmission-Based Isolation Precautions Policy, the facility failed to ensure infection control measures were appropriately implemented and maintained related to Transmission Based Precautions (TBP) for two out of two residents, Resident (R)44 and R84 who were reviewed for TBP. The facility also failed to ensure that the laundry facility kept clean laundry separated from dirty laundry. These failures had the potential to affect all 131 residents in the facility.

Inspectors wroteBased on record review, staff interviews, family interview, and review of the facility policy titled, Involuntary Transfer and Discharges, the facility failed to ensure four of four residents and or their representatives (Resident (R) 24, R78, R115, and R119) reviewed for facility initiated emergent hospital transfer were provided with written transfer notice that contained all required information. This failure has the potential to affect the resident and/or their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on staff interviews, record review, review of the Resident Assessment Instrument (RAI manual, and review of the facility policy titled, MDS Assessment Accuracy, the facility failed to ensure five of 16 residents (Resident (R) 19, R45, R66, R78, and R120) reviewed for a Minimum Data Set (MDS) assessment had a comprehensive admission/annual assessment completed within the allotted time frame.

Inspectors wroteBased on staff interview, record review, review of the Resident Assessment Instrument (RAI)' manual, and review of the facility policy titled, MDS Assessment Accuracy, the facility failed to ensure nine of 16 residents (Resident (R) 2, R8, R35, R37, R72, R76, R77, R80, and R91) reviewed for Minimum Data Set (MDS) had assessments transmitted within the allotted time frame.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility policies titled, Oxygen Administration and Respiratory Equipment Changeouts, the facility failed to clean the filter and/or the outside casing of the oxygen (O2) concentrator and failed to provide evidence the oxygen tubing was changed weekly for five of six residents (Residents (R)8, R34, R43, R118, and R120) sampled for respiratory services.

Inspectors wroteBased on observation, resident interview, staff interviews, record review, and review of the facility policy titled, Medication Administration: General Guidelines, the facility failed to ensure one of one (Resident (R)109) reviewed for self-administration of medications did not self-administer medications without first being assessed by the facility to determine if the practice was clinically appropriate. This deficient practice had the potential to allow the resident to administer the medication to not receive the correct dose of medication or receive it in an unsafe manner.

Inspectors wroteBased on staff interview, record review, and document review, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), CMS-10055, were signed and dated for two of three residents (Resident (R)132 and 133) reviewed for SNFABN. This deficient practice could potentially lead to uninformed decisions made by the resident or representative about their care.

Inspectors wroteBased on staff interview, record review, review of the Resident Assessment Instrument (RAI) manual, and review of the facility policy titled, MDS Assessment Accuracy, the facility failed to ensure one of 16 residents (Resident (R) 59) reviewed for Minimum Data Set (MDS) assessment had a significant change of status assessment transmitted within the allotted time frame as stated in the Resident Assessment Instrument [RAI] manual.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a Level I Pre-admission Screening Resident Review (PASSAR) was completed correctly for two out of five residents (Resident (R) 6 and R8) that were diagnosed with a mental disorder. This failure had the potential for residents with mental disorders not to receive identified specialized services.

Inspectors wroteBased on record review, staff interviews, and review of the facility policies titled, Care Plans and Occurrences, the facility failed to ensure a Care Plan was updated related to the required number of staff necessary to provide care safely for one of one (Resident (R)111) reviewed for Care Plans of 30 sampled residents reviewed.

Inspectors wroteBased on record review, staff interview, and review of the facility policy titled, Occurrences, the facility failed to ensure one of one (Resident (R) 111) reviewed out of a sample of 30 for accidents had the appropriate number staff members assisting with care, resulting in the resident sustaining a fall.