Pruitthealth-Farmville

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to discard out of date leftover resident food items stored in the facility's resident nourishment refrigerator. This deficient practice was for 1 of 1 resident nourishment refrigerators reviewed.

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Pre-admission Screening and Resident Review (PASARR) status and failed to accurately code the Minimum Data Set (MDS) assessment in the area of oral/dental status for 2 of 15 resident MDS assessments reviewed (Resident #4, Resident #21).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement the care planned intervention of a fall mat for 1 of 2 residents (Resident #21) reviewed for accidents.

Inspectors wroteBased on observations, record review, and resident, staff, and Responsible Party (RP) interviews the facility failed to provide or obtain routine dental services for a resident with obvious or likely cavity and broken natural teeth. This was for 1 of 1 resident (Resident #21) reviewed for dental care.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide effective supervision to prevent avoidable falls for 2 of 3 residents reviewed for high risk of falls (Resident #1 and Resident #2). Resident #1, a severely cognitively impaired resident, sustained a collarbone fracture and a hematoma (a solid swelling of clotted blood within the tissues) on the left side of the forehead from a fall that occurred after staff monitoring her fell asleep (Nurse Aide #1) and ignored her attempt to stand (Nurse #1).

Inspectors wroteBased on record review and staff interviews, the facility failed to immediately evaluate a resident for injury after a fall for 1 of 3 residents reviewed for falls (Resident #1). Nurse #1 observed Resident #1 on the floor and instead of immediately assessing the resident she went to find the resident's assigned nurse to complete an assessment.

Inspectors wroteBased on record review, resident interview, staff interview, and police staff interview, the facility failed to protect the right of a resident to be free of misappropriation. The facility was aware Nurse Aide # 1 had a history of forgery and other crimes prior to hiring Nurse Aide # 1. While working at the facility, Nurse Aide # 1 took Resident # 1's money after telling Resident # 1 she could not pay her (NA #1's) personal bills and never reimbursed Resident # 1 as the resident thought would happen when giving Nurse Aide # 1 money. Nurse Aide # 1 also stole the resident's debit card number to pay a utility bill. This was for one (Resident # 1) of one resident reviewed for misappropriation.

Inspectors wroteBased on observations, staff interviews, and record review the facility failed to attempt alternatives prior to installing siderails (also known as bedrails), complete siderail assessments, assess entrapment risk, review the risks and benefits of siderails with the resident /resident representative and obtain informed consent prior to siderail use for 2 of 2 residents (Resident #24, Resident #37) reviewed for siderails.

Inspectors wroteBased on observations, record review and resident, family, staff, Long Term Care Ombudsman, and hospital Emergency Department (ED) Case Manager interviews, the facility failed to allow a resident (Resident #23) to return to the facility to the first available bed after he was transferred to the hospital and cleared by a psychiatric evaluation to return to the facility on 7/25/23. The facility refused readmission, and the resident remained in the in the hospital Emergency Department until 7/27/23 when the State Agency and Long Term Care Ombudsman intervened. This was for 1 of 2 residents whose discharge was reviewed.

Inspectors wroteBased on observations, record review and resident and staff interviews 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 the 2/23/21 focused infection control and complaint investigation survey, the 1/27/22 recertification and complaint investigation survey and the 11/30/22 complaint investigation survey. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to implement an infection surveillance plan for monitoring and tracking infections in the facility. This practice had the potential to affect 49 of 49 residents in the facility.

Inspectors wroteBased on record review and staff interviews the facility failed to develop an infection prevention and control program that established an antibiotic stewardship program with written protocols on antibiotic prescribing, documentation of the indication, dosage, and duration of use of antibiotics. This was evident in 3 of 3 monthly surveillance data reviewed (February 2023, March 2023, and April 2023).

Inspectors wroteBased on record review and staff interviews the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program.

Inspectors wroteBased on record review, observation, resident, and staff interviews the facility failed to provide bathing to residents who were dependent on staff for activities of daily living (ADL) care for 2 of 2 residents (Resident #8 and Resident #24) reviewed for ADL care.

Inspectors wroteBased on record review, resident representative and staff interviews, the facility failed to explain the arbitration agreement to the resident representatives prior to having them sign the agreement. This occurred for 3 of 4 residents (Resident #203, Resident #104, and Resident #253) reviewed for arbitration.

Inspectors wroteBased on observations, record review, and resident and staff interview the facility failed to determine whether the self-administration of medications was clinically appropriate for 1 of 4 residents (Resident #28) reviewed for medication administration.

Inspectors wroteBased on observations, record review and interviews with facility staff the facility failed to accurately code the Minimum Data Set (MDS) Assessment accurately in the areas of oxygen use (Resident #23), pressure ulcers (Resident #29), and discharge destination (Resident #51) for 3 of 18 resident assessments reviewed.

Inspectors wroteBased on record review and resident and staff interviews the facility failed to develop the comprehensive care plan in the area of anticoagulant (blood thinning) medication (Resident #39). This deficient practice was for 1 of 13 residents whose comprehensive care plans were reviewed.

Inspectors wroteBased on observations, interviews with facility staff and record review the facility failed to obtain a physician's order for the use of supplemental oxygen for 1 of 1 resident (Resident #23) reviewed for respiratory care.

Inspectors wroteBased on record review and staff interviews the facility failed to have a policy regarding outside food brought in to residents by family or visitors that allowed for the safe storage of the foods which were brought in for residents. This had the potential to affect all residents.