Pruitthealth - Richmond, LLC

Inspectors wroteBased on observations, staff interviews, records review, and review of the facility's policy titled, Antibiotic Stewardship Program, the facility failed to ensure the antibiotic stewardship program promotes and monitors the appropriate use of antibiotics using evidence-based criteria with tracking. The deficient practice had the potential to decrease the probability that antibiotics are given for the correct indication and increase the development of antibiotic-resistant organisms. The facility census was 82. Findings Include:Review of the facility's policy titled, Antibiotic Stewardship Program revised 10/3/2024, revealed that, under the Policy Statement, The facility will implement and maintain an Antibiotic Stewardship Program that is designed to promote appropriate use of antibiotics and reduce possible adverse events associated with antibiotic use. [...]

Inspectors wroteBased on observations, staff interviews, records review, and review of the facility's policy titled, Covid-19 Infection Prevention and Control Practices, the facility failed to implement procedures to ensure Covid-19 vaccines were offered to residents and staff. The deficient practice had the potential to increase the probability of an outbreak within the facility. Facility census was 82.

Inspectors wroteBased on observations and resident and staff interviews, the facility failed to ensure one of 65 sampled residents (R) (R22) was provided with a call device to accommodate their needs. This deficient practice had the potential to place R22 at risk of unmet care needs and a diminished quality of life.

Inspectors wroteBased on observations interviews, record review, and review of the facility's policy titled 'Behavior Management', (emergency department records and the sheriff's report for 8/16/2025 were requested but not received), and review of the Facility Incident Report for 8/16/2025, the facility failed to ensure R1 resided in a safe environment related to exiting the facility through an unlocked door on the morning of 8/16/2025. The resident was located at the emergency room later that same morning by the Director of Health Services (DHS). The sample size was three residents.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, MDS Assessment Accuracy, facility failed to ensure the Minimum Data Set (MDS) assessments were completed and transmitted timely for 13 of 34 Residents (R), (R25, R63, R5, R57, R66, R53, R24, R59, R44, R8, R276, R279, and R22).

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies titled, Labeling, Dating, and Storage and Cleaning schedule, the facility failed to ensure food items were properly labeled and dated. Specifically, the facility failed to ensure opened food items in the dry storage room were properly labeled and dated and to ensure that kitchen equipment used for food preparation was kept clean and sanitary. The deficient practice had the potential to affect 77 of 79 residents receiving an oral diet from the kitchen.

Inspectors wroteBased on record review, staff interviews, and review of the Payroll Based Journal (PBJ) [NAME] Report for the first quarter (Q1) of Fiscal Year 2024, the facility failed to accurately report direct care staffing data to the Centers for Medicare and Medicaid (CMS). The facility census was 79 residents.

Inspectors wroteBased on staff interviews, record review, and review of the facility policies 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 three of twelve months of infection control data reviewed (January 2024 through March 2024). The deficient practice had the potential to prevent an action plan from being developed related to identified infection concerns within the facility by the Infection Control Committee.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure that one of two medication carts on the Richmond Hall were locked and secured when not in use. The facility census was 79 residents. Findings Include: Observation on 4/27/2024 at 8:40 am revealed cart one on the Richmond Hall was observed unlocked and unattended with a plastic 30 Milliliter (ml) medicine cup with pills on top of the cart. The Electronic Health Record (EHR) was open, and the resident's information was visible on the computer screen. Continued observation on 4/27/2024 at 8:44 am revealed Licensed Practical Nurse (LPN) FF, returned to the medication cart and confirmed that he left the medication cart unlocked and unattended with a cup of pills on top of the cart and with the EHR information visible on the computer screen. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and review of the facility's document titled, Patient's Rights, the facility failed to honor one of four sampled residents (R) (R26) the choice for scheduled times to be gotten out of bed to accommodate the preference of the resident. This failure had the potential to affect the resident's psycho-social being.

Inspectors wroteBased on observations, staff interviews, and review of policy titled, Infection Control Housekeeping Services, the facility failed to ensure a safe, clean, and comfortable home-like environment on one of three halls (Richmond Hall), as evidence by a lingering malodorous smell throughout the hall.

Inspectors wroteBased on staff interviews, record review, and the facility policies titled, Care Plans and Discharge Planning, the facility failed to develop a baseline care plan which included essential components based on the resident stay for two of eight Residents (R), (R74 and R176). Specifically, the facility failed to ensure R74 had a baseline care plan developed after admission, and R176 had a care plan that addressed the residents' essential care needs as well as to develop a discharge care plan to include residents' goals leading up to discharge from the facility.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Care Plans, the facility failed to develop a comprehensive care plan to address nutrition, behaviors, and psychotropic medication use for one of five residents (R) (R276) and implement a discharge care plan for one of three residents (R126). The deficient practice had probability of R126 and R276 needs to not be meet by facility staff according to their individual care needs.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Care Plans the facility failed to revise the comprehensive care plan related to pressure ulcers for one of seven residents (R54).

Inspectors wroteBased on record review and staff interviews, and review of the facility policy titled, Discharge Planning, the facility failed to reconcile all pre-discharge medications with the resident's post-discharge medications both prescribed and over the counter for one of four residents (R), R126. In addition, the facility failed to provide documentation that R126's medications were transferred with her at the time of discharge.

Inspectors wroteBased on observations, staff and resident interviews, record reviews, and review of the facility's policy titled, ''Activities Program the facility failed to ensure one of 23 Residents (R) (R22) reviewed for activities were provided with an individualized activities program to meet their individual needs.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Medication Administration: Oral Medications , the facility failed to follow physician orders for one of five Residents (R) (R22). Specifically, the facility failed to administer medication to R22 as prescribed by the physician to take medications whole.

Inspectors wroteBased on observation, staff interviews, and review of the facility provided recipe titled, Hamburgers, the facility failed to ensure puree recipes were followed to conserve nutritive value of food items served to eight of eight residents receiving a puree consistency diet from the kitchen.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to provide restorative therapy services for one resident (R) (R#6) reviewed for limitations in range of motion (ROM), by not providing daily passive ROM and hand rolls and palm guards to bilateral hands as ordered. The sample size was 21.

Inspectors wroteBased on observation, review of the facility policy titled Nursing Services Policy and Procedure Manual for Long-Term Care Skin and Wound Management, and staff interviews, the facility failed to wash/sanitize hands and change gloves during wound treatment for one resident (R) R#52, reviewed for pressure ulcers. The sample size was 21 residents.