Pruitthealth-Neuse

Inspectors wroteBased on observation, record review, and staff and resident interviews, the facility failed to provide a prescribed assistive device, a spouted cup with handle, for 1 of 1 resident reviewed for assistive devices (Resident #65).

Inspectors wroteBased on observation, record reviews, and interviews with the resident, staff, Medical Director and North Carolina Poison Control, the facility failed to ensure the environment was free of hazards when Resident #85 was observed with multipurpose cleaner on her bedside table. This occurred for 1 of 2 residents reviewed for supervision to prevent accidents (Resident #85).

Inspectors wroteBased on record review, staff, and the Responsible Party (RP) interviews, the facility failed to provide copies of a resident's medical records to the resident's RP within 2 working days after a request for 1 of 1 resident reviewed for medical record access (Resident #6).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of smoking for 1 of 3 residents reviewed for MDS accuracy.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure Resident #1 did not smoke inside of the facility in accordance with their smoking policy for 1 of 3 residents sampled for accidents. On 4/13/2025 the resident was observed by staff in the lobby area of the facility lighting and beginning to smoke a cigarette. There were no residents with oxygen in the lobby area and Resident #1 was escorted outside by Nurse #2.

Inspectors wroteBased on record review, and staff and Responsible Party (RP) interviews, the facility failed to notify the RP of a change in condition when the fingerstick blood sugar (FSBS) levels exceeded 500 milligrams per deciliter (a normal blood glucose level is 80-130 milligrams per deciliter) for 1 of 3 residents reviewed for notification of change (Resident #1).

Inspectors wroteBased on record review, staff interviews, Pharmacist, Nurse Practitioner, and Medical Director telephone interviews, the facility failed to administer scheduled antibiotic medication which resulted in 3 doses of the antibiotic being missed for 1 of 3 residents reviewed for medication administration (Resident #1).

Inspectors wroteBased on record review, and staff, resident, family member, Pharmacist, Psychiatric Nurse Practitioner (NP), and Nurse Practitioner (NP) interviews the facility failed to administer prescribed medications for 1 of 1 resident (Resident # 45) reviewed for significant medication errors. Resident #45 was not administered 10 consecutive doses of lorazepam (anti-anxiety medication) during the time period of 7/29/24 through 8/01/24 when the order was erroneously discontinued on the Medication Administration Record (MAR) by the Director of Nursing (DON) which caused Resident #45 to experience increased anxiety. Resident #45 was assessed by the NP on 8/01/24 due to severe anxiety and noted the resident was crying and asking for his medication.

Inspectors wroteBased on record review and staff interviews the facility failed to provide a complete Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF/ABN) by omitting the estimated cost of services for 2 of 2 residents reviewed for beneficiary notices (Resident #286 and Resident #287).

Inspectors wroteBased on record review and staff interview, the facility failed to accurately code a significant change in status Minimum Data Set (MDS) assessment following hospice election for 1 of 1 resident (Resident #56) reviewed for hospice.

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to provide a safe transfer for 1 of 1 resident (Resident #285) reviewed for supervision to prevent accidents. On 8/26/24 Resident #285 was assessed by Physical Therapist #1 to have required a mechanical lift transfer. The mode of transfer had not changed and on 9/5/24 Nursing Assistant (NA) #1 and NA #2 transferred Resident #285 from the bed to a chair without the use of a mechanical lift.

Inspectors wroteBased on observation, record review, staff and Physician interview the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 27 opportunities, resulting in a medication error rate of 7.41%, for Medication Administration. Both errors were for medications received by Resident #77.

Inspectors wroteBased on observations and staff interviews the facility failed to keep medications in a locked treatment cart for 1 of 2 treatment carts observed (Treatment Cart #1).

Inspectors wroteBased on observation, record review and staff interview the facility failed to implement their policies and procedures for hand hygiene when Nurse #1 failed to perform hand hygiene before donning gloves and after glove removal for 1 of 2 Nurses observed for hand hygiene during medication administration.

Inspectors wroteBased on record review and staff interviews, the facility failed to protect the resident's right to be free from misappropriation of a controlled medication, (30 Oxycodone 5 milligram (mg) pills), which were prescribed by the Physician for pain for 1 of 3 residents reviewed for misappropriation of property (Resident #10).

Inspectors wroteBased on record review and staff interviews, the facility failed to submit an initial or investigation (5 day) report to the state regulatory agency and did not notify Adult Protective Services (APS) regarding an allegation of misappropriation of resident property. They further failed to report to Law Enforcement within 24 hours of discovery of misappropriation of resident property for 1 of 3 residents (Resident #10) reviewed.

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint investigation surveys of 4/21/22 and the complaint investigation surveys of 8/30/23 and 2/21/24. This was for 3 recited deficiencies in the areas of Safe/Clean/Comfortable/Homelike Environment (F584), Reporting of Alleged Violations (F609), and Infection Control (F880). The continued failure during 2 or more federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. The tag is cross-referenced to: F584: [...]

Inspectors wroteBased on observations, and staff interviews, the facility failed to implement their enhanced barrier precautions policies and procedures for wearing Personal Protective Equipment (PPE) when 3 of 3 Nursing staff members (Nurse #1, Nurse #2, and Nurse #3) were observed not wearing (PPE) when providing care to 1 of 1 resident (Resident #21).

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to provide a room free of a strong smell of urine which reached out into the hallway. This was evident in 2 of 3 rooms reviewed for a safe, clean, homelike environment (Rooms 307 and room [ROOM NUMBER]).

Inspectors wroteBased on observation, record reviews and family, staff, Medical Director (MD), and Nurse Practitioner (NP) interviews the facility failed to provide care in a safe manner for 1 of 5 residents (Resident #1) reviewed for supervision to prevent accidents. Resident #1 was diagnosed with cerebellar ataxia (a condition that causes poor muscle control that causes clumsy movements), and functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord) and was dependent on staff for assistance with care. [...]

Inspectors wroteBased on record review, and staff, resident, Medical Director (MD), and Nurse Practitioner (NP) interviews the facility failed to administer prescribed narcotic pain medication for 1 of 2 residents (Resident # 3) reviewed for pain management. Resident #3 was admitted on [DATE] and did not receive his prescribed pain medication for 5 days after he was admitted to the facility resulting in the resident experiencing increased pain rated as a 7 on a 0-10 pain scale (on a numeric pain scale designed to evaluate pain in individuals using a number value with 0 being no pain and 10 being the worst pain possible).

Inspectors wroteBased on record review, and staff, resident, Pharmacist, Medical Director (MD), and Nurse Practitioner (NP) interviews the facility failed to obtain narcotic medications from the pharmacy for 1 of 10 resident (Resident # 3) reviewed for pharmacy services. This caused Resident #3 to miss 5 days of pain medication, 4 days of anti-anxiety medication and 3 days of sedative/hypnotic medication that resulted in increased pain, anxiety, and inability to sleep for Resident #3.

Inspectors wroteBased on record review, and staff, resident, famiy, Pharmacist, Medical Director (MD), and Nurse Practitioner (NP) interviews the facility failed to administer prescribed medications for 1 of 10 resident (Resident # 3) reviewed to ensure residents are free from significant medication errors. Resident #3 was admitted on [DATE] and did not receive his prescribed pain medication for 5 days, his anti-anxiety medication for 4 days, and did not receive his prescribed sedative/hypnotic medication for 3 days after he was admitted to the facility which caused Resident #3 to experience pain, anxiety, and inability to sleep.

Inspectors wroteBased on record review, and staff, Dental Hygienist and Physician interviews the facility failed to obtain emergency dental services for 1 of 1 resident (Resident # 5) reviewed for routine and emergency dental services.

Inspectors wroteBased on observation, record reviews and family, Responsible Party, Pharmacist, Medical Director, Nurse Practitioner (NP) and staff interviews, the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the focused infection control and complaint investigation survey of 10/4/21, the recertification and complaint investigation survey of and 4/21/22, and the recertification and complaint investigation survey of 7/13/23. This was for re-cited deficiencies in the areas of Notification of Change (F580), Free of Accident Hazards/Supervision/Devices (F689), Significant Medication Errors (760). The continued failure during three federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on record review and staff interviews, the facility failed to have a transfer agreement in place for transferring residents to the local hospital for evaluation and treatment, which had the potential to effect 90 of 90 residents who resided in the facility.

Inspectors wroteBased on staff interviews and record review, the facility failed to submit a two hour Initial Allegation Report for an allegation of staff to resident abuse to the State Survey Agency within the required timeframe for 1 of 3 residents reviewed for abuse (Resident #2).

Inspectors wroteBased on record review, resident, and staff interviews, the facility failed to maintain a resident's dignity by not answering a call light and allowing the resident to sit on the floor for an extended period causing Resident #31 to feel afraid, neglected, shaky, and upset. This occurred for 1 of 8 residents reviewed for dignity (Resident #31).

Inspectors wroteBased on record review and resident, staff, and resident representative interviews the facility failed to protect Resident #8's right to be free from abuse for 1 of 3 sampled residents reviewed for abuse (Resident #8). On an unknown date in October 2022, Nursing Assistant (NA) #7 was witnessed by NA #8 to have grabbed hair on the top of Resident #8's head and pulled the resident's hair after Resident #8 had allegedly made derogatory statements to NA #7. A reasonable person would have experienced feelings such as intimidation, fear, humiliation, embarrassment, and/or dehumanization (deprivation of human qualities such as compassion).

Inspectors wroteBased on record review, resident, and staff interviews, the facility failed to implement their abuse policy and procedure in the area of reporting when Nursing Assistant (NA) #8, NA #9, and NA #10 did not immediately report an allegation of abuse between a staff (NA #7) member and a resident (Resident #8) resulting in a lack of protection for Resident #8 and other facility residents. The facility also failed to report to the state agency within the required two-hour time frame. This occurred for 1 of 1 resident (Resident #8) reviewed for abuse.

Inspectors wrote2. Resident #44 was admitted to the facility on [DATE] with diagnoses which included hypertension and rheumatoid arthritis. Review of Resident #44's physician orders dated 8/29/22 revealed an order for clopidogrel (Plavix) 75 milligrams once a day for heart disease. Review of Resident #44's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment and was coded as receiving an anticoagulant 7 days during the 7-day look back period. Review of Resident #44's care plan last revised on 6/12/23 revealed she was care planned for anticoagulation usage and no diagnosis was noted. Review of Resident #44's medication administration record revealed no anticoagulant administration during the 7-day look back period. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to update the care plan to accurately reflect the code status (Resident #73 and Resident #76) and the current diet order (Resident #76) for 2 of 25 residents whose care plans were reviewed.

Inspectors wroteBased on observations, record review and resident and staff interviews the facility failed to provide nail care for 1 of 8 residents (Resident #73) reviewed who were dependent on facility staff for activities of daily living (ADL) care.

Inspectors wroteBased on record review, staff, and resident interviews the facility failed to have a complete and accurate medical record related to documentation of a resident assessment following a fall. This occurred for 1 of 1 resident (Resident #31) reviewed for accidents.

Inspectors wroteBased on observations, record review and resident, staff, Nurse Practitioner (NP), and Medical Doctor (MD) 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 4/21/22 recertification/complaint survey and the 10/4/21 and 2/9/21 focused infection control and complaint investigation surveys. [...]

Inspectors wroteBased on record review and staff, Nurse Practitioner (NP), and Medical Doctor (MD) interviews, the facility failed to notify the MD of the resident's medication refusals for 1 of 1 resident (Resident #11) reviewed for notification.