Pruitthealth - Rome

Inspectors wroteBased on observations, staff and family interviews, record reviews, and review of the facility policy titled Care Plan, the facility failed to develop and implement the care plan for three of 24 sampled residents (R113, R85, and R53) related to (1) developing a care plan for verbalization/refusal of Activities of Daily Living (ADL) care for R113; (2) developing a care plan for Range of Motion (ROM) and implementing a care plan related to nail care and oral care for R85; and (3) implementing a care plan related to nail care for R53. Actual harm was identified to have occurred on 1/13/2026, when Certified Nursing Assistant (CNA) EE failed to implement interventions for R113 during Activities of Daily Living (ADL) care, resulting in R113 sliding from the wheelchair onto the floor and sustaining a right femur fracture.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility policies titled Occurrences and Dementia Care Policy, the facility failed to ensure the safety of one of three residents (R) (R113) reviewed for falls. Actual harm was identified to have occurred on 1/13/2026, when Certified Nursing Assistant (CNA) EE failed to implement interventions for R113 during Activities of Daily Living (ADL) care, resulting in R113 sliding from the wheelchair onto the floor and sustaining a right femur fracture.

Inspectors wroteBased on observation, staff interviews, and review of facility policies titled Labeling, Dating, and Storage, the facility failed to ensure food items, stored in two of the two kitchen refrigerators and one of one freezer were properly dated and labeled; that one of three male kitchen staff wore facial hair restraints during food preparation; two of two fans were dirty and blowing on clear dishes and food preparation area. These failures have the potential to compromise food safety, impair sanitation practices, and increase the risk of foodborne illness for 87 of 89 residents who receive meals prepared in the facility's kitchen.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled Specialty Services: Dental Services, Vision Services, Podiatry, the facility failed to ensure Activities of Daily Living (ADL) care was provided for two of two sampled residents (R) (R53 and R85) related to toenail care.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Restorative Nursing Policy and Procedure, the facility failed to ensure that one of three sampled residents (R) (R85) received restorative services to prevent contractures and/or to prevent a decrease in range of motion (ROM) mobility.

Inspectors wroteBased on observation, interview, record review, Centers for Disease Control and Prevention (CDC) guidance, and policy review, the facility failed to follow the COVID policies regarding how to contain the COVID virus and prevent the spread, in that the policies indicated 1; the door to the COVID positive residents' rooms were to be kept closed and that staff were to wear Personal Protective Equipment (PPE) of a gown, mask, face shield and gloves when upon entering resident's room to provide care to residents positive for COVID; 2. to ensure transported dishes from COVID positive residents were covered and dishes were washed at 120 degrees Fahrenheit (F) temperature to sanitize, and 3. infection control measures during medication pass were to be followed for one resident (R52). [...]

Inspectors wroteBased on policy review, observation, interview, and record review, the facility failed to ensure the dish machine operated at the correct temperature and that equipment and surfaces were kept clean and in good repair. This had the potential to affect 82 of 82 residents who received meals prepared in the facility's kitchen.

Inspectors wroteBased on policy review, interview, and record review, the facility failed to ensure residents and/or their representatives participated in care planning conferences for four of five residents (R) (R26, R7, R51, and R29) reviewed for care conferences. The deficient practice of not inviting residents and/or family members to care planning conferences potentially could decrease resident/family satisfaction with care.

Inspectors wroteBased on policy review, interview, and record review, the facility failed to ensure residents and/or their representatives were informed of the risks of psychotropic medications for five of five residents (R) (R83, R29, R37, R33, and F58) reviewed for psychotropic medications. The deficient practice could potentially cause residents and/or their representatives to make uninformed decisions about their treatment, increasing the risk of adverse reactions.

Inspectors wroteBased on a review of facility policy, record review, observations, and interviews, the facility failed to ensure one of 22 sampled residents (R) (R52) reviewed for self-administration of medication was capable of storing and administering her own medication. This failure created the potential for the resident to experience a medication error related to her inability to properly self-administer the medication.

Inspectors wroteBased on a review of facility policy, record review, and interviews, the facility failed to ensure one of five residents (R) (R58) reviewed for abuse was free from misappropriation of his personal funds when Certified Nursing Assistant (CNA4) wrote checks and cashed checks for herself from R58's personal checking account. This failure created the potential for this and other residents to experience further staff-to-resident misappropriation and created the potential for R58 to suffer negative financial consequences related to the misappropriation.

Inspectors wroteBased on policy review, observations, record review, and staff interviews, the facility failed to ensure one of three residents (R) (R3) reviewed for accidents was appropriate for the use of side rails on her bed. This failure created the potential for the resident to be injured related to potentially unnecessary side rails installed and in use on her bed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a Certified Nursing Assistant (CNA3) provided care as educated through training and in-services for residents in isolation positive for 2019-nCoV, by not applying the appropriate Personal Protective Equipment (PPE) while providing care for two of nine residents (R) (R35 and R58) on special droplet isolation on the long 100 hallway. As a result of this deficient practice, the residents had the potential for harm by spreading the 2019-nCoV to residents who previously tested negative.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide resident-specific activities as interventions for wandering into other resident rooms for one of 22 sampled residents (R) (R77).