Pruitthealth-Evans, LLC

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure comprehensive care plan included the use of corrective lenses for one of 32 sampled residents (Resident (R) 52) reviewed for care planning. The failure had the potential to affect the resident's psychosocial needs not being met.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled Water Management Program for Building Water System and Standard Precautions, the facility failed to maintain an effective infection control program by not providing evidence that legionnaires testing was done to prevent contamination of the facility water system. In addition, the facility failed to ensure one of one room doors (room [ROOM NUMBER]) was securely closed for a COVID-19 (Coronavirus Disease) positive resident and failed to post COVID -19 signage at the front entrance throughout the facility. In addition, the facility failed to follow infection control procedures during treatment for two of 28 sampled Residents (R) (R38 and R98). The facility census was 119.

Inspectors wroteBased on staff interview, record review, and review of the PBJ (Payroll Based Journal) [NAME] Report for Fourth Quarter (Q4) of fiscal year 2023, the facility failed to accurately report its staffing data to the Centers for Medicare and Medicaid (CMS) related to Registered Nurse (RN) coverage. The facility census was 119 residents.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled Self-Administration of Medications by Patients/Residents, the facility failed to assess and obtain a physician order for one out of 28 sampled Residents (R) (R98) to safely self-administer and store medication at bedside.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Patient/Resident Rights, Accommodations of Needs, the facility failed to ensure visual privacy during treatment for two of 28 sampled Residents (R) (R38 and R98).

Inspectors wroteBased on the observations and staff interviews, the facility failed to ensure that it was maintained in a safe, clean, comfortable environment for three out of 21 rooms (Rooms 132, room [ROOM NUMBER], and room [ROOM NUMBER]). These rooms contained light bulbs out/not working, multiple scuffed walls, and large cracks in the floor.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to assist one of 28 sampled Residents (R) (R38) with necessary arrangements to obtain routine dental services for replacement of her missing dental partial.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to develop policies and procedures to ensure that reasonable suspicion of a crime against any resident was immediately reported to local law enforcement for four of five residents (R) (R#58, R#62, R#86, and R#277) reviewed for abuse. Specifically, the facility failed to ensure sexual assaults perpetrated by R#58 against R#62 and R#86 were reported to the police, and that an allegation of staff-to-resident abuse directed toward R#277 was reported to the police. Subsequently, the abuse continued. On 8/18/22, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to ensure allegations of abuse were immediately reported to the State Survey Agency (SSA) for four of five residents (R) (R#58, R#62, R#86, and R#5) reviewed for abuse. Specifically, the facility failed to ensure allegations of resident-to-resident sexual abuse and staff-to-resident abuse were reported to the SSA immediately. Subsequently, the abuse continued. On 8/18/22, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 8/18/2022 at 5:18 p.m. [...]

Inspectors wroteBased on observations, interviews, record review, document review, and facility policy review, the facility failed to thoroughly investigate allegations of abuse or exploitation involving four of five residents (R) (R#58, R#62, R#86, and R#5) reviewed for abuse. Specifically, the facility: - Failed to thoroughly investigate an incident of resident-to-resident sexual abuse when R#58 was found in R#62's room with his hand inside the resident's gown on 6/20/22. Other residents were not interviewed as to whether they had been exposed to, or had knowledge of R#58's sexually aggressive behaviors as a part of the facility's investigation. Staff who were not on duty at the time of the 6/20/22 incident were not interviewed as to any knowledge they may have had regarding R#58's sexually aggressive behaviors. [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility's administration failed to provide oversight and leadership that ensured: (1) Residents were free from sexual and physical abuse, which affected two of five sampled residents (R) (R#62 and R#86) reviewed for abuse; (2) A thorough investigation of allegations of resident-to-resident sexual abuse and staff-to-resident abuse were completed involving three of five sampled residents (R#58, R#62, and R#5) reviewed for abuse; (3) To report allegations of resident-to-resident sexual abuse and staff-to-resident physical abuse to the local law enforcement for four of five residents (R#58, R#62, R#86, and R#277) reviewed for abuse; [...]

Inspectors wroteBased on observation, interview, record review, document review, and facility policy review, the facility failed to ensure residents were free from resident-to-resident sexual abuse for two of five sampled residents (R) (R#62 and R#86) reviewed for abuse. R#58 displayed behaviors of wandering into the rooms of residents of the opposite sex. The facility failed to develop and implement interventions to address the resident's behavior, and on 6/20/22, staff found R#58 in R#62's room with his hand inside R#62's gown. The facility failed to consistently supervise/monitor R#58 to prevent further incidents of sexual abuse, and on 8/16/22, staff found R#58 in the room shared by R#62 and R#86, with his pants down, genitals exposed, and one leg on R#86's bed. [...]

Inspectors wroteBased on clinical record review, interviews, and facility policy review, the facility failed to ensure a safe discharge for one of three residents (R) (R#125) reviewed for discharge. R#125 was discharged from the facility to home on [DATE] without a confirmation that home health services were in place and that there was a capable family member at home to assist with the resident's continued care needs following discharge.