Pruitthealth- Ridgeway

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to keep the kitchen's slicer, walk-in refrigerator's floor and shelves, and two stove top spill pans clean. These failures had the potential to create an environment for food-borne illnesses which could affect 128 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure that the environment for one of six residents (Resident (R) 32) remained free from accident hazards to prevent falls and failed to provide adequate supervision to prevent resident to resident altercations for seven of ten residents (R) 66, 84, 136, 120, 93, 125, and 115) reviewed. These failures placed residents at risk for physical harm.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents seated at the same table ate at the same time for two of two residents (Resident (R)124 and R103) reviewed for dignity in dining out of a total sample of 37 residents. This failure had the potential to cause R103 and R124 to feel less dignified.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure completion of a required PASRR (Pre-admission Screening and Resident Review) when a resident's diagnosis changed. Specifically, for Residents R6 and R9, the facility did not initiate or complete a new or updated PASRR after a change in the resident's diagnosis, which had the potential to affect the residents' need for specialized services. This failure placed residents at risk of not receiving appropriate evaluations, services, and support in accordance with federal requirements.

Inspectors wroteBased on observations, record review, interviews, testing and tasting of food served on a requested test tray and policy review, the facility failed to ensure food was palatable and served hot to four of eight residents (Resident (R) 3, R28, R68, and R75). The failure had the potential to negatively affect 124 residents who consumed food prepared from the facility's kitchen by experiencing dissatisfaction with the meals, not eating the meals, and/or experiencing nutritional concerns.

Inspectors wroteBased on the facility policy, observations, interviews, and The 2017 FDA Food Code, the facility failed to ensure food was served under sanitary conditions during the 200 Hall meal service on 01/26/2025 for 1 of 3 halls observed during meal service.

Inspectors wroteBased on the facility policy, record reviews and interviews, the facility failed to ensure accuracy of staffing posted daily to include the total staff as worked with the census and hours to ensure the resident care and visitors were aware of staffing for each shift as well as each 24 hour period for 10 days from 11/26/2024 through 01/26/2025.

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to accurately document Resident (R)211's advance directives, for 1 of 2 residents. Specifically, R 211 had orders and signed documentation requesting Do Not Resuscitate (DNR), however R 211's Care Plan and Face Sheet documented Full Code.

Inspectors wroteBased on observations, interviews, record review, and review of facility policy, the facility failed to ensure a comfortable and homelike environment was provided for 1 Resident (R)36 of 2 residents reviewed. Specifically, they failed to properly clean R36's room and failed to provide R36 with a clean mattress and linen. Findings Include: Review of facility policy titled, Infection Control-Housekeeping Services last revised 10/16/23, revealed, It is the policy of this facility to ensure housekeeping services will be performed on a routine and consistent basis to ensure an orderly, sanitary, and comfortable environment. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident had received a Preadmission Screening and Resident Review (PASRR) prior to admission to the facility for 1 of 1 resident reviewed, Resident (R)101.

Inspectors wroteBased on the facility policy, record reviews and interviews, the facility failed to ensure the Comprehensive Plan of Care was reviewed and revised for Resident (R)29 and R100 with goals and interventions to ensure an ongoing program of activities for each individual resident based on likes/dislikes and preferences for 2 of 4 residents reviewed for activities.

Inspectors wroteBased on the facility policy, record reviews and interviews, the facility failed to ensure an ongoing program of activities designed to meet the physical, mental, and psychosocial well-being based on their preferences and likes and dislikes for Resident (R)29 and R100, for 2 of 4 residents reviewed for activities. Review of the facility policy titled, Activities Program, states as the policy statement, The Health Care Center provides an ongoing program of Activities designed to meet the physical, mental and psychosocial well-being of each resident while offering a rich array of activities to the residents of the center. The procedure states: 1. The center shall designate a staff member responsible for the development of the recreational program to include responsibility for obtaining and maintaining recreational supplies. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to carry out orders for a splint/palm guard for one (Resident (R)36) of one resident reviewed for range of motion (ROM). This failure had the potential cause further decrease of ROM and/or pain for the resident. Findings Include: The facility Director of Nursing (DON) stated they do not have a policy for splints/devices. Review of R36's Face Sheet revealed R36 was admitted to the facility on [DATE] with diagnoses including but not limited to: persistent vegetative state, stiffness of right shoulder, and contractures of the right elbow, right hand and left hand. Review of R36's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/24 revealed that a Brief Interview for Mental Status (BIMS) was not performed. [...]

Inspectors wroteBased on observations, interviews, record review, and review of facility policy, the facility failed to ensure Resident (R)36, 1 of 3 residents reviewed for enteral tube feedings received the appropriate treatment and services to prevent complications. R36 had two contradicting orders for enteral tube feedings. Findings Include: Review of the facility policy titled, Enteral Nutrition (Tube Feeding) with a review date of 09/12/2024 revealed, The goal is to provide enteral nutrition to the patient/resident in order to achieve and maintain optimal nutritional status. Further review revealed, the physician will write orders prescribing the formula, rate route of administration and flush orders for the individual patient/resident. Review of the facility policy titled, Physician Orders last revised 03/01/24 revealed, Procedures: 3. [...]

Inspectors wroteBased on the facility policy, and the insulin pen instructions from The Institute of Family Health, observations and interviews, the facility failed to ensure a medication administration error rate less than 5 percent. Specifically, the insulin flex pens for Resident (R)108 and R99 were not primed correctly prior to administration for 3 of 30 opportunities for error. The medication administration error rate was 10 percent.

Inspectors wroteBased on review of the facility policy, record review, interviews, and observation, the facility failed to ensure 1 resident, (R)114 out of 1 reviewed for accidents related to falls did not sustain a major injury. Specifically, R114 had an unwitnessed fall in the shower room, was transferred, and admitted to a local hospital which resulted in laceration to the head and a fractured elbow. The lack of adequate supervision placed the resident at risk for physical and or psychosocial harm.

Inspectors wroteBased on review of the facility policy, record review, and interviews, the facility failed to provide dignity to Resident (R) 111 during care for 1 of 2 residents reviewed for dignity.

Inspectors wroteBased on review of the facility policy, record review, and interview, the facility failed to maintain Registered Nurse (RN) coverage on 10/1/22 and 10/15/22 as required by federal regulation.

Inspectors wroteBased on review of the facility policy, observations, record reviews, and interviews, the facility failed to follow their policies and procedures resulting in a significant medication error for one Resident (R) 77 of four residents observed during medication pass. R77 was admitted to the facility on [DATE] with diagnoses including, but not limited to diabetes mellitus with unspecified complications.