Pruitthealth - Holly Hill, LLC

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to protect residents from smoking related accident hazards for two of four residents reviewed for smoking (Residents (R) 86 and R38) out of 24 sampled residents. The facility failed to accurately complete smoking assessments, had inadequate supervision during smoking, failed to secure the residents' smoking materials, allowed residents to smoke in proximity to others with portable oxygen tanks, and failed to enforce its smoking policy. These failures had the potential to cause accidents/hazards during smoking times that could result in bodily injury to those smoking and those near the smoking area. [...]

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to enforce its smoking policy by allowing residents to smoke near others using portable oxygen for two of four residents (Residents (R) 38 and R86) reviewed for smoking out of a total sample of 24 residents. This noncompliance created conditions that posed a risk of serious injury for the residents. The facility's failure to implement their smoking policy by staff allowing residents to smoke near residents with portable oxygen tanks caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/26/26 and was determined to exist on 02/23/26, for 483.90 Smoking Policies at a Scope and Severity (S/S) of a J. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on 02/26/26 at 12:30 PM. [...]

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled Care Plan, the facility failed to develop a person-centered, comprehensive care plan for one resident (R) (R60) out of a sample of 24. This deficient practice had the potential to place R60 at risk of not receiving services to address impaired vision.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to ensure eye care was provided to one resident (R) (R60) from a sample of two reviewed for eye care. Specifically, the facility failed to ensure orders were transcribed and implemented by a contracted eye exam company to provide care and services for R60. The deficient practice had the potential to place R60 at risk of unmet care needs and a diminished quality of life.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure a medication error rate below five percent. There were two medication errors for two residents (R) (R61 and R89) observed out of 25 opportunities, resulting in a medication error rate of eight percent. This deficient practice had the potential to place R61 and R89 at risk of not receiving the correct dosage of medication.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to establish a policy governing food brought in by visitors. In addition, the facility failed to ensure a resident's personal refrigerator was free of expired items and that temperature logs were completed for the freezer for one resident (R) (R7) of 24 sampled residents. These deficient practices placed the residents at risk of foodborne illness.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Dietary Partner Hygiene and Dress Code, the facility failed to ensure hair nets were worn by dietary staff. Specifically, beard guards were not used by male dietary staff during preparation of meals. This had the potential to affect 80 out of 83 residents who received an oral diet.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure that staff's personal food items were not stored in one of one medication storage rooms. The deficient practice had the potential to increase the probability of contamination of medication and storage supplies located in the storage room area.

Inspectors wroteBased on observations, resident and staff interviews, and record reviews, the facility failed to provide care in a manner that maintained or enhanced residents' rights, dignity, and respect. Specifically, the facility failed to ensure that dependent residents were cleaned promptly when needed after eating, and failed to ensure the call light was in reach, for one of 14 residents (R) (R70).

Inspectors wroteBased on observations, resident and staff interviews, record reviews, and review of the facility's policies titled, Self-Administration of Medications by Patients/Residents and Bedside Storage of Medications, the facility failed to ensure unauthorized medications were not stored at the bedside for three of 32 residents (R) (R58, R19, and R67) reviewed. The deficient practice had the potential to allow unauthorized access of unsecured medications to residents and visitors.

Inspectors wroteBased on observations, resident and staff interviews, and record reviews, the facility failed to accommodate the needs of two of 8 residents (R) (R66 and R70) reviewed for accommodation of needs. Specifically, the facility failed to provide a morbid obese resident (R) (R66) with a bed that would accommodate her size; and the facility failed to ensure (R70), who was visually impaired, had a call light within reach.

Inspectors wrote2. R58 was admitted to the facility with diagnoses of but not limited to chronic kidney disease stage 3 and cerebral infarction. Review of the Annual MDS assessment dated [DATE] assessed a BIMS score of 15 which indicated little to no cognitive impairment. Review of R58's November 2024 Physician Order Form dated November 2024 revealed an order for full code status. Review of R58's Advance Directive form dated 11/17/2021 documented that R58 signed the Advance Directive at the time of admission. Continued review of the Advance Directive form, and the resident's medical record revealed no written documentation or evidence to show a form, or discussion being provided to the resident/responsible party regarding a choice to accept or refuse surgical treatment. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, clean, comfortable, and homelike environment on one of five halls (100 hall). Specifically, the facility failed to ensure the toilet base and caulking was not stained dark brown in one shared bathroom between rooms 102, 104, and in room [ROOM NUMBER] and room [ROOM NUMBER]; failed to ensure light fixtures above resident's beds were not rusty brown colored and wall trim was not sticking out toward residents' bed in room [ROOM NUMBER]. The deficient practice caused an unsafe and unsanitary environment and had the potential to place residents at risk for avoidable injury or illness, and a diminished quality of life.

Inspectors wroteBased on observations, resident and staff interviews, record reviews, and review of the facility's policy titled, Care Plans, the facility failed to develop and implement a care plan for five residents (R) (R58, R77, R47, R29, and R338) out of 32 reviewed. Specifically, they failed to create and implement a care plan for R58 for self-administration of medication, and for R47 for oxygen use. The facility failed to follow the care plan for resident R47 reviewed for nutrition related to obtaining admission and weekly weights; and they failed to follow the care plan for three residents (R77, R29, R338) receiving oxygen therapy and ensure the oxygen flow rate for each resident was followed based on physician order.

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to apply splints as ordered for one of 10 residents (R) (R56) receiving splints. This deficient practice had the potential to cause worsening of R56's contractures and a diminished quality of life.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Oxygen Administration, the facility failed to ensure two of 33 residents (R) (R59 and R82) reviewed were free from accident hazards. Specifically, the facility failed to ensure R59 was free from exposure to harmful chemicals and R82 was free from exposure to a free-standing oxygen tank.

Inspectors wroteBased on observations, staff interview, and record reviews, the facility failed to ensure that one of four residents' (R) (R39)'s catheter tubing was not coiled and correctly positioned to prevent obstruction of urinary flow out of four residents with a catheter. This deficient practice had the potential to put residents at risk for complications related to their urinary health with the possibility of urinary tract infections.

Inspectors wroteBased on staff interviews, record reviews, and review of the facility's policy titled, Nutritional Screening and Assessments/Food Preferences, the facility failed to provide evidence that nutrition assessments were completed by the Registered Dietitian (RD) for two of 32 residents (R) (R47 and R77) reviewed. This deficient practice had the potential to place the residents at risk of nutrition problems and weight loss.

Inspectors wrote2. Review of the EMR revealed R77 had diagnoses of but not limited to chronic respiratory failure whether with hypoxia or hypercapnia, and paroxysmal atrial fibrillation. Review of the admission MDS assessment dated [DATE] assessed a BIMS score of 11 which indicated moderate cognitive impairment and was assessed for oxygen use. Review of November 2024 Physician Order Form (POF) revealed an order dated 10/15/2024 for Oxygen at 2 LPM via NC continuous daily. Observation on 11/17/202 starting at 2:05 pm until l3:33 pm, and again at 5:00 pm revealed R77 receiving oxygen therapy by NC at 3 liters from the oxygen concentrator. A closer observation revealed no humidifier bottle attached to the oxygen concentrator. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to lock one of five medication carts when not in use, failed to remove expired medication from the medication cart, and failed to place open dates on insulin and glucometer strips. This deficient practice had the potential to cause unauthorized persons to access medications and cause complications from expired and undated medication use. The facility's census was 83.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Care Plans, the facility failed to ensure that the plan of care was implemented for one of four residents (R) R#68 receiving enteral tube feedings. Specifically, the facility failed to ensure that R#68 tube feedings were administered as ordered by the physician.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Enteral Nutrition (Tube Feeding), the facility failed to change, date and time the nutritional enteral feedings, flush bag, and piston syringes. In addition, the facility failed to provide enteral nutrition and hydration according to current physician orders for one of four residents (R) (R#68) receiving tube feeding in the facility. The deficient practice had the potential for the tube feeding administered to R#68 to exceed the expiration date and time while being administered.

Inspectors wroteBased on observations, record review, staff interview, and review of the facility policy titled, Unnecessary Medications Use and Monitoring, the facility failed to ensure that a psychotropic medication, antianxiety medication, was not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of five residents (R) (R#50) reviewed for unnecessary medications.