Pruitthealth - Griffin

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility policy titled, Receipt and Storage of Solutions, Medications and Supplies, the facility failed to ensure an opened multiuse medication vial was dated when opened on one of two medication carts (Cart A). In addition, the facility failed to ensure that one of two medication carts (Cart A) was maintained in a sanitary manner. These deficient practices had the potential to place the residents at risk of receiving outdated medications and medications from an unsanitary environment.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to maintain dignity for three of 41 sampled residents (R) (R27, R21, and R20). This deficient practice had the potential to place R27, R21, and R20 at risk of a diminished quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to regulate the oxygen flow meter to the ordered flow rate for one of seven residents (R) (R23) receiving continuous oxygen. This deficient practice had the potential to place R23 at increased risk of respiratory complications.

Inspectors wroteBased on interviews and record review, the facility failed to ensure money taken from the Resident Trust Account was accounted for and used for resident needs for 30 of 38 sampled residents (R) (R13, R14, R15, R11, R16, R17, R18, R19, R20, R21, R22, R12, R23, R24, R9, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R4, R35, R36, R37, and R38).

Inspectors wroteBased on interviews, record review, and review of the facility policy titled Abuse, Neglect, and Exploitation, Mistreatment and Misappropriation of property, the facility failed to prevent misappropriation of residents funds for thirty of thirty-eight sampled residents (R) (R13, R14, R15, R11, R16, R17, R18, R19, R20, R21, R22, R12, R23, R24, R9, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R4, R35, R36, R37, and R38). This failure had the potential to affect 30 to 45 residents whose funds were managed by the facility.

Inspectors wroteBased on observations, staff interviews, and a review of the facility policy titled, Cleaning Procedure: Kitchen Area, the facility failed to ensure the exhaust hood filters were clean and free of dust; failed to label properly and date opened food items; failed to ensure the kitchen equipment was properly cleaned to prevent cross contamination; failed to ensure the ceiling was free from chipped and peeling sheetrock. This has the potential to affect 55 residents receiving an oral diet.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Infection Control-Linen and Laundry, the facility failed to maintain an effective infection control program by failing to post COVID -19 (Coronavirus Disease) signage at the front exterior entrance to provide notification of active Covid in the facility. In addition, the facility failed to ensure infection control policies were followed during the handling, storage, and processing of linens. These failures had the potential to spread infection due to cross-contamination to 55 residents residing in the facility.

Inspectors wroteBased on record review, staff interview, review of policy titled Infection Prevention and Control Program Surveillance Reporting and Antibiotic Stewardship Program the facility failed to provide evidence of a process for periodic review of antibiotic prescribing practices, and to document follow-up measures in response to the data for ten of twelve months of infection control data reviewed (February 2023 through January 2024). This had the potential to affect any resident who was prescribed an antibiotic. The facility census was 55residents.

Inspectors wroteBased on staff interviews and a review of the facility policy titled, Infection Prevention and Control Program Surveillance Reporting, the facility failed to ensure evidence that a qualified Infection Preventionist (IP) was serving in the position at the facility. This deficient practice had the potential for creating an ineffective infection prevention program that may contribute to the spread of infections for all residents in the facility. The census was 55 residents.

Inspectors wroteBased on observations, record review, resident and staff interviews and review of the facility policy titled, Grievances: Healthcare Centers, the facility failed to ensure resident grievances were addressed for residents attending the Resident Council Meetings and grievances filed through the facility grievance process. The facility census was 51 residents.

Inspectors wroteBased on observations and staff interviews the facility failed to ensure residents' furniture was in good and functional condition related to one broken dresser drawer. The facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in three of 13 rooms related to missing base boards, a hole in a closet door, and dust buildup on the filters of two packaged terminal air conditioner (PTAC) units.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure staff followed recipes for preparing pureed meals to avoid compromising the nutritive value of food items served to residents on a pureed diet when compared with items served to residents on a regular diet for seven of 55 residents receiving a pureed diet. Findings Include: Review of the lunch menu for 2/23/2024 revealed items which included baked lasagna, mashed potato Garlic bread and brownie. Observation on 2/23/2024 at 12:00 pm with the Dietary Manager (DM) of pureed food items revealed DM placing approximately 8oz (ounces) of lasagna and three slices of bread for seven residents into the food processor. The DM then placed an unmeasured amount of hot water she got from the sink into the food processor. She turned on the food processor. [...]

Inspectors wroteBased on interviews, record review, and review of facility policies titled Influenza (Flu) Vaccinations for Health Care Center Residents, and Pneumococcal Vaccinations, the facility failed to provide evidence that two residents (R) (255 and 106) were offered the Influenza and Pneumococcal vaccine, and two residents (47 and 304) were administered the Influenza and Pneumococcal Vaccine after consenting to receive the vaccines. This deficient practice had the potential to put (R255), (R106), (R47), and (R304) at risk for contracting influenza and pneumococcal.

Inspectors wroteBased on record review, staff interviews, and a review of the facility policy titled admission Policy for Healthcare Centers, the facility failed to ensure that one of 36 residents (R) (50) sampled with a mental illness had a Level I Pre-admission Screening and Record Review completed prior to admission to determine the need for specialized services.

Inspectors wroteBased on observation, staff interview, record review, and a review of the facility policy titled, Care Plans, the facility failed to follow a care plan for one of five residents (R) (28) reviewed for unnecessary medications. The deficient practice had the potential to cause R28 to not receive treatment and/or care according to their needs.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Physician Orders, the facility failed to follow physician orders for one of 36 sampled Residents (R) (R154). Specifically, the facility failed to transcribe the correct doses of Eliquis (a medication to treat and prevent blood clots) into the Electronic Medical Record (EMR) system and administer the medication as ordered.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Monitoring of Antipsychotics, the facility failed to ensure one of five residents (R) (28) reviewed for unnecessary medications received medications as ordered. Specifically, the facility failed to decrease the dose of buspirone (an antianxiety medication) for R28 as ordered by the physician.

Inspectors wroteBased on staff interviews, record review, and a review of the facility policy titled COVID-19 Vaccination Clinics, the facility failed to offer and/or administer the COVID-19 vaccine to two of five residents (R) (255 and 106) reviewed for vaccines.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that the Minimum Data Set (MDS) assessments were transmitted within 14 days of completion of to CMS's (Centers for Medicare and Medicaid Services) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for eight residents (R ) (24, 29, 23, 35, 1, 12, 7, and 18) of 35 sampled residents.

Inspectors wroteBased on record review, staff interviews, and a review of facility policy titled MDS Assessment Accuracy, the facility failed to complete a Quarterly Minimum Data Set (MDS) Assessment not less than every three months for three of 36 residents (R) (2, 21, and 43) of 36 sampled residents.

Inspectors wroteBased on Facility Assessment Review and interview, it was determined the facility did not complete a Facility Assessment, creating the potential that the facility would not adequately evaluate the characteristics of their resident population, community resources, and risks; develop a plan to address these factors, and deploy their resources in the most effective manner to maintain safety and security for all facility residents. This deficient practice had the potential to affect all 40 residents in the facility.

Inspectors wroteBased on observation, interview, review of facility procedure and record review, the facility failed to ensure that four residents (R) (16, 20, 28 and 32) reviewed for assistance with Activities of Daily Living (ADL) in the sample of 20 residents, received assistance to maintain grooming and assistance with wearing the residents' personal clothing, shaving, and nail care.

Inspectors wroteBased on document review, facility policy review and interview, the facility failed to provide evidence of Registered Nurse (RN) coverage in the facility at a minimum of eight hours a day, seven days a week for the period of February 5, 2022, through April 9, 2022. This absence of RN coverage could have a negative impact on all residents residing at the facility.

Inspectors wroteBased on observation, record review, policy review and interview, the facility failed to ensure that staff performed hand hygiene and disinfected resident equipment contaminated during and after providing a resident (R ) (13) fecal incontinence care. In addition, the facility failed to ensure that all staff were screened for COVID-19 prior to entrance into the facility to work, and that staff donned personal protective equipment (PPE) prior to entering the room of one of two residents (R197) sampled for transmission-based precautions (quarantined for COVID precautions). The facility census was 40.

Inspectors wroteBased on observation, interview, document review and record review, it was determined the facility failed to provide a wheelchair for one of twenty sampled Residents (R) (R7). This failure created the potential that R7 would experience feelings of isolation and depression when she had no means to leave her room.

Inspectors wroteBased on interviews, record review and facility policy review, the facility failed to ensure three of six residents sampled (Resident (R)194, R23 and R28) for advance directives, electronic medical records (EMR) included advance directives (code status) physician orders' consistent with resident's wishes/ desires regarding life-sustaining treatment (CPR). The deficient practice had potential for the facility to provide or withhold (CPR) treatment inconsistent with residents wishes/desires for life-sustaining treatment.

Inspectors wroteBased on observation, document review and interview, the facility failed to ensure the residents' environment was in good repair for two of twenty sampled Residents (R) (R7 and R18) .

Inspectors wroteBased on interview and record review, the facility failed to provide two of four Residents (R) (R26 and R30) and their representative information regarding bed holds when they were transferred to the hospital.

Inspectors wroteBased on observation, record review, interviews, and review of facility policy, the facility failed to ensure the residents' care plan was revised for one residents (R) (13) in the sample of 20 residents. Specifically, R13's care plan did not accurately reflect the resident's lack of compliance with the use of a splint for right upper extremity (RUE) contractures.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that one (Resident (R) 27) of 20 residents reviewed for quality of care received adequate bowel monitoring.

Inspectors wroteBased on observation, interview, policy review and record review the facility failed to ensure that one resident (Resident (R) 13) of three residents reviewed for limited range of motion in the sample of 20 residents was provided planned restorative nursing services to prevent a further decrease in range of motion. R13 entered the facility for rehabilitation therapy for a new onset of right sided hemiparesis (weakness and/or inability to move) and was not provided planned restorative nursing services.

Inspectors wroteBased on interviews, record review and facility policy review, the facility failed to assess for fall risk and implement fall prevention/interventions for two residents (R) (R193 and R26) sampled for accident hazards of 20 sampled residents.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure one Resident (R) (R30) had appropriate indication for ongoing use of a indwelling urinary catheter out of a total of four residents reviewed for catheter usage.

Inspectors wroteBased on observations, interviews, record reviews and facility's policy review, the facility failed to ensure three residents reviewed for respiratory treatments (Resident (R)198, R195 and R28) in the sample of 20 had a physician's order for oxygen administration therapy (including flow rate, route of administration, monitoring, and oxygen equipment maintenance, changing oxygen tubing including labeling with date) prior to administration of oxygen administration therapy.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure two Residents (R) (R28 and R32) residents reviewed for siderails in the sample of 20, were accurately assessed for the use of the side rails, failed to obtain consents for the use of the side rails and failed to attempt alternative use of side rails prior to the use of side rails and failed to assess the resident for entrapment risks.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer three (Resident (R) 13, R31, and 39) of five residents reviewed for flu/pneumonia vaccinations and/or their representatives, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to offer R13 and/or their representative the opportunity to be vaccinated with Pneumococcal 15-valent Conjugate Vaccine (PCV15) or Prevnar 20 (PCV20) in accordance with nationally recognized standards. The facility failed to offer R31 and/or their representative the opportunity to be vaccinated with influenza and pneumococcal vaccination of PPV13 prior to 10/21/21 and/or PVC15 or PCV20 after 10/21/21. [...]