Pruitthealth - Fort Oglethorpe

Inspectors wroteBased on observations, resident and staff interviews and record review, the facility failed to promote care in a manner that maintained or enhanced each resident's dignity, respect, and rights for one of 46 sampled residents (R) (R4).

Inspectors wroteBased on observations and staff and resident interviews, the facility failed to provide the right to communicate in their preferred language for one of three residents (R76) reviewed for communication. The deficient practice had the potential for R76 not to receive needed care and services.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, HVAC (Heating, Ventilation, and Air Conditioning), PTAC (Packaged Terminal Air Conditioner Clean Air Filters, the facility failed to maintain a safe, clean, and homelike environment by not ensuring PTAC units were clean, intact, and free of debris, rust, and damage in two of 14 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) on the 200 Hall. The deficient practice had the potential to affect resident comfort, air quality, and environmental cleanliness.

Inspectors wroteBased on observations, record review, resident and staff interviews, and review of the facility's policy titled, Documentation: Charting Activities of Daily Living (ADLs), the facility failed to adequately provide Activities of Daily Living related to bathing for three of 46 dependent sampled residents (R) (R21, R33, and R84). The deficient practice had the potential to cause discomfort and compromise personal hygiene.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Smoke Free Policy, the facility failed to adhere to the smoking times and to provide supervision during smoking for one resident (R) (R80) who was grandfathered in.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies titled, Receiving and Storage of Food and Supplies and Hand Washing, the facility failed to ensure food stored in the kitchen was labeled, dated, and not expired. Additionally, staff failed to perform adequate hand hygiene when leaving and returning to food preparation area after touching the lid of trash can. This had the potential to increase the spread of foodborne illness and infection for 108 out of 109 residents that received meals from the kitchen.

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to provide a written notice of a transfer to the resident and/or resident's Responsible Party (RP) for three of three residents (Resident (R) 80, R32, and R73) reviewed for hospitalization out of a sample of 32 residents. This had the potential for the resident and or RP not knowing where and why a resident was transferred.

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to offer residents hand hygiene prior to meals for five of five residents observed (Residents (R)24, R68, R99, R105, and R37) out of a total sample of 32 residents. This had the potential for the risk of transmission of infections.

Inspectors wroteBased on review of the facility's surveillance video, staff interview, record review, and review of the facility's policy titled, Prevention of Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure one (Resident (R)62) was free from sexual abuse by R50 out of a sample of 32 residents. This had the potential for further sexual abuse for the resident and other residents by R50.

Inspectors wroteBased on observation, staff interview, record review, and review of the facility's policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to complete a thorough investigation for two incidents of resident to resident sexual abuse for one (Resident (R) 62) by R50 out of three residents reviewed for abuse out of 32 residents reviewed in the sample. This failure had the potential for unknown other incidents of sexual abuse for R62 or any other residents.

Inspectors wroteBased on observations, 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 protect the resident's right to be free from sexual abuse by another resident by failing to report an alleged allegation of abuse to the state agency timely for one of 15 sampled residents (R) (R6). Specifically, R6 was allegedly sexually abused by R5.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure the comprehensive care plan addressed the need for pain management prior to and/or during wound care for one of three sampled residents (R) (R#94) reviewed for pain management. The resident was observed to exhibit signs and symptoms of pain throughout a wound care procedure on 1/11/23 but did not receive pain medication until the surveyor intervened.

Inspectors wroteBased on observation, interviews, record reviews, and facility policy review, it was determined the facility failed to ensure pain medication ordered on an as-needed (PRN) basis was administered prior to and/or during wound care for one of three sampled residents (R) (R#94) reviewed for pain during wound care. Specifically, no pain medication was administered to R#94 prior to wound care, and when the resident exhibited signs and symptoms of pain, the licensed nurse continued the wound care without administering pain medication until the surveyor intervened. This failed practice resulted in R#94 repeatedly exhibiting signs and symptoms of pain while wound care was provided.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure that two of four residents (R) (R#19 and R#47) were treated in a dignified manner related to transportation assistance (R#19 and R#47) and addressing a resident by his preferred name (R#19).

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to thoroughly investigate and resolve grievances for two of two residents (R) (R#21 and R#48) reviewed for resident rights. Specifically: 1. R#21's grievance was filed on 11/23/22 regarding missing dentures and clothes without documentation or evidence of complete resolution or verbal or written notification of the resident regarding the summary of the grievance and resolution and; 2. R#48's grievance was filed on 12/27/22 regarding alleged interactions with a staff member on 12/25/22. There was no documentation of interviews with other residents regarding their interactions with the staff member. Additionally, there was no documentation of complete resolution or verbal, or written notification provided to the resident regarding the summary of the grievance and resolution.

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) was conducted for one of three sampled residents (R) (R#51) reviewed for PASARR. Specifically, the facility failed to refer R#51 to the appropriate state-designated authority for a Level II evaluation following a new mental illness diagnosis.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure planned fall prevention interventions were promptly and consistently implemented to reduce the risk of further falls for one of one sampled resident (R) (R#94) reviewed for accidents.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, it was determined the facility failed to promptly refer a resident with lost dentures for dental services for one of one sampled resident (R) (R#21) reviewed for dental services. This resulted in the resident being without dentures for approximately four months.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a change in a resident's Physician Orders for Life Sustaining Treatment (POLST) status was communicated between the hospice provider and the facility for one of five sampled residents (R) (R#20) reviewed for POLST accuracy/communication.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure oxygen tubing was covered and stored when not in use, to prevent potential infection for two of four sampled residents (R) (R#20 and R#65) reviewed for oxygen use.