Pruitthealth - Palmyra

Inspectors wroteBased on observations, resident and staff interviews, record review, review of the facility provided recipe titled Chicken and [NAME] Casserole and Broccoli and review of the facility's policies titled Puree Policy and Diet Order System, the facility failed to ensure that the puree menu was followed. The deficient practice had the potential to affect the nutritional status for 18 of 18 residents' receiving a puree diet. In addition, the facility failed to follow the diet ordered for one of 51 residents (R) (R10) related to large portions and serving food not on a renal diet placing R10 at nutritional risk.

Inspectors wroteBased on 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 report an injury of unknown origin for one of four residents (R) (R5) reviewed for accidents.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Care Plans, the facility failed to develop and implement care plans for six of 51 residents (R) (R111, R109, R18, R5, R135, and R155). Specifically, the facility failed to implement the care plans for R111, R5, R135, and R155 related to fall mats, for R18 related to oxygen and for R5 related to diet. In addition, the facility failed to develop a care plan for R18 related to oxygen use. This failure had the potential for the residents not to receive treatment and/or care according to their needs.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure assistance devices were placed at bedside to prevent accidents for four of five residents (R), (R111, R5, R135, R155) reviewed for accidents. Specifically, the facility failed to ensure fall mats were placed at bedside for the residents who had a history of falls.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Oxygen Administration, the facility failed to ensure that one of 16 sampled residents (R) (R109) was administered oxygen (O2) therapy in accordance with the physician orders. This failure had the potential to place R109 at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a snack provided to a resident was in accordance with that resident's prescribed diet for one of 18 residents (R) (R5) that resulted in choking.

Inspectors wroteBased on observation, record review, the facility failed to implement the care plan for weekly skin inspections for two residents (R)(R9 and R12) and failed to develop care plan interventions for routine weekly skin assessments for residents (R1, R3, R8 and R11) who were at risk for skin breakdown from a sample of eight residents with pressure ulcers. On May 20, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Nurse Consultant and the Area [NAME] President were informed of the Immediate Jeopardy on May 20, 2025, at 2:49 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on December 24, 2024. [...]

Inspectors wroteBased on observations, record review and staff interviews, and review of facility policy titled Documentation of Skin and Wound Care, the facility failed to perform consistent weekly skin assessments for residents at high risk for skin breakdown in order to identify breakdown timely for six residents (R) (R1, R3, R8, R9, R11 and R12) and failed to perform treatments as ordered by the physician and/or recommended by the Wound Care Nurse Practitioner for three residents (R3, R11 and R12) of seven residents reviewed for pressure ulcers. The total sample size was 27. On May 20, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. [...]

Inspectors wroteBased on record review, staff interviews and review of the Administrator Job Description and the Director of Health Services Position Description, administration failed to ensure staff were performing weekly skin assessments and wound treatments as ordered and failed to provide oversight and monitoring of the skin integrity program. This deficient practice impacted six residents (R) (R1, R3, R8, R9, R11 and R12) of 29 sampled residents. On May 20, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Nurse Consultant and the Area [NAME] President were informed of the Immediate Jeopardy (IJ) on May 20, 2025, at 2:49 pm. [...]

Inspectors wroteBased on staff interviews, record review and review of the Quality Assurance and Performance Improvement policy, the facility failed to have a Quality Assurance and Performance Improvement committee that effectively provided oversight and monitoring to ensure staff were performing weekly skin assessments to ensure timely identification and treatment of pressure ulcers. On May 20, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Nurse Consultant and the Area [NAME] President were informed of the Immediate Jeopardy on May 20, 2025, at 2:49 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on December 24, 2024. [...]

Inspectors wroteBased on observation, staff interviews, and review of the job description titled Position Description Dietary Manager, the facility failed to ensure the kitchen had a Certified Dietary Manager to oversee the duties and responsibilities of the kitchen staff; and failed to ensure the Dietitian assumed responsibility and accountable for the Dietary Services Department. The facility has 184 of 203 resident that receive oral meals.

Inspectors wroteBased on observations and staff interviews the facility failed to ensure that the ice machine was free from black and pink substances; failed to ensure the dishwasher maintained proper water temperature; failed to follow manufactures recommendations regarding sanitation of pots and pans in the three compartment sink; failed to ensure food on steam table maintained food temperature; failed to ensure opened food items were properly dated, labeled, and stored; failed to ensure cleanliness of the kitchen floors; failed to ensure a no touch trash can was near the sink and failed to ensure clean dishes were stored on a clean surface. This deficient practice had the potential to increase the spread of food borne illness for 184 of 203 residents that received an oral diet.

Inspectors wroteBased on record review, and the facility policy Grievances: Healthcare Centers, the facility failed to ensure the grievances from resident council meetings were addressed with resolutions for four of seven months reviewed.

Inspectors wroteBased on observations, staff interview, and record review, the facility failed to ensure that resident meals were served in a timely manner. This deficient practice had the potential to affect 184 of 203 residents that received an oral diet.

Inspectors wroteBased on resident interviews and staff interviews, the facility failed to ensure that three residents (R) (R14, R28, R29) of six residents who wanted to vote were assisted with obtaining absentee ballots or was registered to vote in the November 2024 election.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the physician was notified of abnormal vital signs for one resident (R)(R5) and failed to notify the responsible party of diagnostic test results and impaired skin for R17 of 29 sampled residents.

Inspectors wroteBased on record review, staff interview, and review of policy titled Procedure: Indwelling Urinary Catheter the facility failed to obtain a physician's order to continue an indwelling catheter for one resident (R) (R3) who was admitted from the hospital with an indwelling urinary catheter from a sample of 29 residents.

Inspectors wroteBased on observation, resident interview and policy Nutritional Screening and Assessments/Food Preferences, the facility failed to ensure food preference was honored for one resident (R14) of three sample residents.

Inspectors wroteBased on staff interview, record review and review of the facility's policy titled, Wound Observation and Assessment Documentation, the facility failed to thoroughly and consistently assess pressure ulcers for one resident (R) (R2) from a sample of 24 residents.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled, Occurrences the facility failed to ensure one of 19 residents (R) R7 was free from a slip and fall related to a water leak from the ceiling on the Memory Care Unit.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled, Weight Monitoring Program, the facility failed to ensure that one of three resident's (R) (R3) was monitored for excessive weight loss. Specifically, the facility failed to ensure R3's weights were monitored, and the resident was referred to Speech Therapy (ST) services for further evaluation after excessive weight loss was identified.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure Kesimpta (injectable medication used to treat multiple sclerosis) was ordered timely for one of two residents (R) (R10).

Inspectors wroteBased on observations and staff interviews, the facility failed to follow the 3 Compartment Sink manufacture recommendations regarding sanitation of pots and pans. This deficient practice had the potential to increase the spread of food borne illness for 187 of 204 residents that received an oral diet.

Inspectors wroteBased on observations, resident interview, staff interviews, record review, and review the facility policy titled, Patient/Resident [NAME] of Rights, the facility failed to ensure one of six residents (R) R45 was provided privacy while receiving a care in the resident community shower on Hall 3. The facility also failed to ensure privacy was maintained for one of six residents R94 that utilized an indwelling catheter. Specifically, the facility failed to ensure privacy was provided for R45 while receiving care in the facility shower room on Hall three, the facility also failed to ensure R94 catheter was placed in a privacy bag and the contents were not visible to other residents and visitors.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Self -Administration of Medication by Patients/Residents the facility failed to ensure Unauthorized medications were not stored at the bedside for four of 57 residents (R) (R158, R18, R50, and R71). The deficient practice increased the potential for other residents and visitors to have unauthorized access to the unsecured medications that were stored at the residents bedside.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Restraint Use, the facility failed to ensure that one of 57 residents (R) R78 was free from physical restraints while in the facility. The deficient practice had the potential to prevent R78 from attaining and maintaining their highest practicable well-being and ensuring that their dignity and quality life was maintained.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility policy titled, Care Plans, the facility failed to develop and implement a care plan for one of five Residents (R48) with documented psychotropic drug use. The deficient practice had the potential to potential to prevent R48 from receiving care according to the residents care needs.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Oxygen Administration, the facility failed to obtain an order for oxygen therapy for two of 42 Residents (R) (R361 and R349) that were receiving oxygen therapy. The deficient practice had the potential to increase the probability of R361 and R349 to encounter respiratory difficulties.

Inspectors wroteBased on observations, staff interview, and record review, the facility failed to ensure that resident meals were served in a timely manner. This deficient practice had the potential to affect 187of 204 residents that received an oral diet.

Inspectors wroteBased on observations, interviews, review of the facility policies COVID-19 Isolation and Cohorting Process and Visitation During COVID-19, and review of a procedural document regarding the donning and doffing of personal protective equipment (PPE), the facility failed to ensure PPE was properly worn by staff and visitors in one (Level II COVID-19 Observation Unit) out of four units to help prevent the spread of infection.

Inspectors wroteBased on observations, interviews, record review, and review of a procedural document titled Nail Care, the facility failed to provide nail care for two of seven residents (R) #60 and R#251, reviewed for activities of daily living (ADL) care provided for dependent residents.

Inspectors wroteBased on observations, staff and resident interviews, document review of the Patient/Resident Council Minutes/Report Form, and review of the facility policy, Food Temperature, the facility failed to provide food and beverages that were palatable for four residents (Resident (R) #33, R#38, R#46 and R#129) of 22 sampled residents. Specifically, the facility served beverages that were watered down by melted ice, and the lids of the insulated containers for the dishware did not close completely to cover the hot food that was served. The residents were served in Styrofoam take-out containers on the first day of the survey. The residents were served glass dishware with insulated tops that did not fit resulting in the food being cold when served the remainder of the survey. [...]