Pruitthealth- Rock Hill

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure sanitary conditions were maintained in the kitchen by positioning a garbage/refuse cart containing visible waste in close proximity to clean food service items during active tray assembly in one (1) of one (1) kitchen observed. This practice created the potential for contamination of clean trays and plate covers and increased the risk for foodborne illness and infection transmission.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to maintain the refuse disposal area in a sanitary and safe manner by failing to ensure dumpster doors remained closed in two (2) of two (2) dumpsters observed. The facility's failure to keep refuse container doors closed had the potential to attract pests and create unsanitary conditions, increasing the risk of environmental contamination.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain 1 of 1 laundry washers in a safe operating condition. Specifically, the facility failed to ensure that 2 filters were cleaned daily for the UniMac washer.

Inspectors wroteBased on review of the facility policy, record review, and interviews, the facility failed to ensure the Electronic Medical Record (EMR) accurately reflected the Resident's Advance Directives. Specifically Resident (R)23 and (R)128 did not have advance directives that matched their Physician Orders.

Inspectors wroteBased on record review, review of the facility policy and interviews, the facility failed to ensure written notification of the bed hold policy, including reserve bed payment requirements, was provided to the resident and/or the resident's representative for one of one Resident (R)1 reviewed for hospitalization. Findings Include:Review of the facility policy titled, Bed Hold Authorization Form: South Carolina last revised 12/6/22 revealed, Two notices related to the healthcare center's bed hold policy will be issued. The first notice of bed hold policies is given during this admission, which is well in advance of any transfer. The second notice, which specifies the duration of the bed hold policy will be issued at the time of any transfer. [...]

Inspectors wroteBased on review of facility policy, record reviews and interviews, the facility failed to complete the admission Minimum Data Set (MDS) within 14 calendar days after admission for Resident (R)130 1 of 1 residents reviewed for comprehensive assessment and timing.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to initiate a baseline care plan related to therapy services and wound care for Resident (R)123 one of three residents reviewed for wound care.

Inspectors wroteBased on review of the facility policy, record review, observations, and interviews, the facility failed to ensure a care plan was completed and implemented for Resident (R)2 related to activities for one of three residents reviewed for care plans.

Inspectors wroteBased on review of the facility's policy, record review, observations, and interviews, the facility failed to ensure a dependent resident (R)83 received adequate Activities of Daily Living (ADL) care to match her preferences.

Inspectors wroteBased on review of the facility policy, record review, observations, and interviews, the facility failed to assess Resident (R)2 for the needs and/or provide activities that met her interests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide snacks for 2 residents, reviewed R 8 and R22.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure appropriate infection control practices were followed related to urinary catheter care for one of two Residents (R) 120 reviewed for catheter care. Specifically, the facility failed to prevent a resident's urinary drainage bag from being placed directly on the floor, creating a potential risk for contamination and infection.

Inspectors wroteBased on observations, interviews and record review, the facility failed to prevent accidents and hazards for one (1) out of three (3) sampled residents (Resident (R)7).

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to report an allegation of resident-to-resident verbal abuse that occurred between Resident (R)16 and R17, for 2 of 8 residents reviewed for resident-to-resident altercations.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure a resident with a history of falls had Care Plan interventions implemented for 1 (Resident (R)9) of 3 residents reviewed for falls. This had the potential for R9 to sustain a fall with injury.

Inspectors wroteBased on observation, interviews, record review, document review, facility policy review, and review of manufacturer's information for the facility's wheelchair securement system, the facility failed to properly secure Resident (R)225 in the facility's transportation van while transporting the resident back to the facility following an appointment. On 10/14/2022, at approximately 2:30 PM, the Van Driver placed R225 in the facility van, securing the wheelchair in the back, locking the wheelchair brakes, and placing the lap belt on the resident, but did not secure the front of the wheelchair. Upon leaving the parking lot, the van stopped at a red light that was on an incline, and when the van started to move, the resident's wheelchair flipped backwards, causing a skin tear to the resident's right hand, abrasion to the forearm, and a knot to the back of the resident's head. [...]

Inspectors wroteBased on observations, interviews, record review, and review of facility policy,the facility failed to assess 1 (Resident (R)25) of 4 residents to determine their capability to self-administer medications.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to provide written notice to the resident and/or the resident's representative prior to a room change for 1 (Resident (R)223) of 1 sampled resident reviewed for a room change.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to assist a resident in filing a grievance related to missing personal property and failed to ensure prompt efforts were made to resolve the issue for 1 (Resident (R)42) of 6 sampled residents reviewed for missappropriation of property.

Inspectors wroteBased on record review, interviews, facility document review, and facility policy review, it was determined that the facility failed to thoroughly investigate an incident of injury of unknown origin for 1 (Resident (R)173) of 11 residents reviewed for abuse and/or neglect.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to timely complete a significant change in status Minimum Data Set (MDS) for 1 (Resident (R)173) of 33 residents whose MDS assessments were reviewed. Specifically, the facility failed to complete a significant change MDS assessment after R173 had a decline in activities of daily living due to a fall that resulted in a hip fracture on 08/23/2022.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan that addressed all resident care needs for 3 (Residents (R)19, R42, and R67) of 33 sampled residents whose care plans were reviewed. Specifically, the facility failed to ensure the comprehensive care plan addressed pain management for R19, oxygen therapy for R42, and the rationale, behavioral symptoms and non-pharmacological interventions related to antipsychotic medication use for R67.