Pruitthealth-Raleigh

Inspectors wroteBased on observation, record review, and interviews with resident and staff, the facility failed to ensure a dependent resident could access a light switch located behind her bed for 1 of 1 resident reviewed for accommodation of needs (Resident #141).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure medications were administered according to the physician's orders and manufacturer's instructions for method of administration for 1 of 10 residents reviewed for medication administration (Resident #118).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to provide an ongoing resident centered activities program in the memory care unit of the facility for 1 of 1 resident reviewed for activities (Resident #27).

Inspectors wroteBased on record reviews and interviews with the Pharmacy Consultant and staff interviews, the facility failed to have effective systems in place for the return of controlled medications to the pharmacy which resulted in the controlled medication being diverted from the medication cart for 1 of 1 resident reviewed for pharmacy services (Resident #13).

Inspectors wroteBased on record review, staff interviews, the facility failed to ensure the medical record was accurate regarding administration of Oxycodone Hydrochloride (HCL) (an opioid medication which is a controlled substance) for 1 of 1 resident (Resident #13) reviewed for accuracy of medical records.

Inspectors wroteBased on record review and interviews with staff, resident, Contracted Transportation Company, and the Physician, the facility failed to protect Resident #1's right to be free of neglect for 1 of 3 residents reviewed for accidents. On 4/25/25 at approximately 4:30 PM during transportation back to the facility from a medical appointment in the contracted transport van the resident's wheelchair flipped backwards landing horizontal on the floor of the van. Resident #1's head hit the van floor and her back sustained impact when the wheelchair backrest (the support structure for the user's back) hit the floor. The Contracted Transport Driver was not qualified to complete a clinical assessment of injury. He asked the resident if she was okay, set the wheelchair upright, secured the wheelchair in the van, and continued the trip back to the facility. [...]

Inspectors wroteBased on record review, interviews with staff, resident, Contracted Transportation Company, and the Physician, the Contracted Transport Driver failed to have Resident #1 assessed for injury by a qualified professional prior to moving the resident following a fall in the transportation van and to notify the facility nursing staff of the fall in order for the resident to be clinically assessed for injuries from the fall. Resident #1 returned to the facility on 4/25/25 at approximately 5:30 pm and notified staff that her wheelchair had flipped backwards while being transported back to the facility and the Contracted Transport Driver lifted her and her wheelchair up from the floor and returned her to the facility. Resident #1 suffered pain rated a 10 out of 10 (with 10 being the worst pain possible) in her neck, shoulders, and back. [...]

Inspectors wroteBased on record review and interviews with staff, resident, Contracted Transportation Company, and the Physician, the facility failed to ensure a resident was safely secured in the contracted transport van during the return trip from an appointment back to the facility. On 4/25/25 the Contracted Transport Driver failed to secure Resident #1's wheelchair in accordance with the manufacturer's instructions prior to departing with the resident from the dialysis clinic. During travel, Resident #1's wheelchair flipped backwards landing with the backrest of wheelchair (the support structure for the user's back) on the floor of the van. Resident #1 remained in the wheelchair during the fall resulting in her head hitting the van floor and her back sustaining impact when the backrest of the wheelchair hit floor. [...]

Inspectors wrote4. Resident # 44 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia. Resident #44's quarterly Minimum Data Set (MDS) dated [DATE] indicated she had severe cognitive impairment, had no behaviors, and needed supervision for ambulating around the unit. The MDS also documented that Resident #44 required a trunk restraint (a restraint on the torso that prevents a resident from getting up out of a chair) once during the observation period. Review of Resident #44's physician's orders from 7/1/24-11/14/24 did not reveal an order for a restraint. Review of Resident #44's progress notes from 7/1/24-11/14/24 did not reveal notes that she had any behaviors or any indications of a need for a restraint. The notes did not document that a restraint was used. [...]

Inspectors wroteBased on record review, and resident, family and staff interviews, the facility failed to offer the resident the right to participate in the person-centered planning process for 2 of 5 residents reviewed for care plans (Residents #96 and Resident #21).

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection for 1 of 2 residents (Resident #5) reviewed with urinary catheters.

Inspectors wroteBased on observations and interviews with staff, the facility failed to complete the daily staff posting sheet for 4 of 4 days observed (11/12 through 11/15/24). The daily staff posting sheet did not include the resident census of the facility.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to have a complete and accurate medication and treatment administration record for 1 of 7 residents (Resident #399) reviewed for medical record accuracy.

Inspectors wroteBased on record review and resident, staff, and Responsible Party (RP) interviews the facility failed to obtain the resident's consent before depositing and withdrawing the resident's personal funds into and from his non-transferring personal funds account. This was for 1 of 1 resident (Resident #52) reviewed for personal funds.

Inspectors wroteBased on record review and resident, staff, and Responsible Party (RP) interviews the facility failed to deliver a residents personal mail unopened. This was for 1 of 1 residents (Resident #52) reviewed for privacy of communication.

Inspectors wrote2. The facility's Smoke Free Policy dated 2014 stated fire igniting materials and smoking materials should not be kept in a resident's possession. Resident's igniting smoking materials would be maintained at the nurse's station for safety of smokers. The policy also stated residents who were grandfathered-in would be assessed for risk and hazards prior to smoking in designated areas and shall be supervised as necessary based on the smoking observation form located in the electronic medical record. The smoking observation form was completed at least quarterly if questions indicated the resident smoked or had a history of smoking. Resident #12 was admitted to the facility on [DATE], and diagnoses included multiple sclerosis (an unpredictable disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body). [...]

Inspectors wroteBased on record review, observation, resident interviews and staff interviews, the facility failed to provide breakfast meal trays at a regular scheduled mealtimes comparable to normal breakfast mealtimes in the community for 3 of 8 halls (100, 200 and 300 Halls).

Inspectors wroteBased on observations, record review and staff interview 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 complaint surveys of 2/10/21and 10/27/21. The deficiencies were in the areas of ADL Care Provided for Dependent Residents (677), Quality of Care (684), Free of Accident Hazards/ Supervision/Devices (689), Sufficient Nursing Staff (725), Resident Records-Identifiable Information (842), Increase/Prevent Decrease in ROM/Mobility (688) and Free from Abuse and Neglect (600). 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 observations, record review, and resident and staff interviews the facility failed to complete a self-administration of medication assessment, obtain a physician's order, and care plan self- administration of medication before leaving medication at the resident's bedside. This was for 1 of 1 residents (Resident #17) reviewed for self-administration of medication.

Inspectors wroteBased on observations, record review and resident and staff interviews the facility failed to accommodate a resident's request to try the new type of television (TV) the facility had when he was no longer able to use the control buttons on his old TV to change the channels. This was for 1 of 1 resident (Resident #52) reviewed for the accommodation of needs.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to keep dependent residents' fingernails trimmed for 1 of 6 residents reviewed for activities of daily living care (Resident #19).

Inspectors wroteBased on record review, staff, and wound care Physician interviews the facility failed to assess and receive Physician orders for a resident who had a wound to the back of her right leg. This occurred for 1 of 1 resident (Resident #248) reviewed for wound care.

Inspectors wroteBased on record review and staff interviews the facility failed to place skin protection under the bridge (a section of a wound vac system used to connect the dressing to the vac) of a wound vac (Resident #8) and failed to complete weekly skin audits (Resident #397) for 2 of 4 residents reviewed for pressure ulcer care.

Inspectors wroteBased on record review and staff interviews the facility failed to provide restorative services for 1 of 2 residents reviewed for rehab and restorative (Resident #19).

Inspectors wroteBased on record review and staff interviews the facility failed to provide sufficient nursing staff to provide restorative services for 1 of 2 residents reviewed for therapy and restorative (Resident #19).

Inspectors wroteBased on observations, resident and staff interviews and record review, the facility failed to secure medications for 1 of 2 residents (Resident #500) observed with medications at bedside and failed to keep unattended medications in a locked medication cart for 1 of 4 medication carts observed (600-hall medication cart). Findings Included: 1. Resident #500 was admitted to the facility on [DATE]. Diagnosis included, in part, dementia. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #500 had severely impaired cognition. The Self-Administration of Medication assessment, dated 9/12/23, indicated Resident #500 was not appropriate to self-administer any medication. A review of the medical record revealed there was no order for Resident #500 to self-administer medication. An observation of Resident #500's room was completed on 9/25/23 at 11:49 AM. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to have a complete and accurate medical record related to documentation of a resident's wound. This occurred for 1 of 1 resident (Resident #248) reviewed for wound care.

Inspectors wroteBased on record review and staff interviews, the facility failed to administer the pneumococcal vaccine to 2 of 5 residents reviewed for immunization (Resident #144 & #70).

Inspectors wroteBased on record review and staff interviews the facility failed to post the daily staffing sheet and post daily staffing census from May 2023 through September 2023 for 80 of 153 days reviewed for daily posted staffing.

Inspectors wroteBased on record review and staff interview the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of Pre-admission Screening Resident Review (PASRR), contraindication of a gradual dose reduction of antipsychotic medication, antibiotic use, anticoagulant use, and sedative/hypnotic use for 3 of 51 resident MDS assessments reviewed (Residents #11, #70, and #44).