Pruitthealth - Savannah

Inspectors wroteBased on staff interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment for one of 36 residents (R) (R2) reviewed for MDS completions. The facility census was 132.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled Involuntary Transfer and Discharges, the facility failed to ensure written bed hold policy and transfers notices were provided to the resident or resident representative (RR) for seven of seven residents (R) (R7, R66, R76, R43, R26, R57 and R45) reviewed for emergent hospital transfer out of a total sample of 28 residents. This failure had the potential to affect the resident and/or their RR by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired, and had the potential to contribute to the possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. [...]

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies titled Medication Administration - Insulin Injections and Medication Administration - General Guidelines, the facility failed to ensure insulin injection pens were used as recommended by the manufacturer and medications were administered according to physician's orders, resulting in a medication administration error rate of 13.64 percent with six errors for four residents (R) (R121, R43, R64, and R31) out of a possible 44 opportunities for error. This failure had the potential to affect the accurate dosing of insulin administered or the potential blood bioavailability of multi-dose medications administered per day to the residents.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled Care Plans, the facility failed to review and revise residents' care plans for one of 28 sampled residents (R) (R27). The facility did not ensure care conferences occurred at least quarterly, where R27's care plan would be reviewed and/or revised. This failure placed the resident at risk for unmet care needs.

Inspectors wroteBased on observation, staff interviews, documentation review, review of the facility documents titled Hot Water Sanitizing Upright Door Dish Machine, and Installation and Operating Manual for ECOLAB Models: ES-2000HT INTL, and review of the facility policy titled Dishwashing, the facility failed to ensure the dishwasher rinse temperature was at the proper temperature to sanitize the dishes. The facility further failed to ensure staff performed hand hygiene between handling the soiled dishes and handling the clean dishes. This had the potential to affect 120 of 126 residents in the facility who consumed food from the kitchen. The facility identified six residents who consumed nothing by mouth (NPO).

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled Infection Control - Linen and Laundry, the facility failed to ensure one Laundry Aide (LA)1 donned (put on) proper personal protective equipment (PPE) while sorting soiled resident clothing and bed linens. This deficient practice had the potential to affect the staff and/or all residents which could potentially lead to the development of infectious diseases.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility policy titled Medication Storage in the Healthcare Centers, the facility failed to assess one of 12 sampled residents (R) (R109) reviewed for self-administration of medications. This failure had the potential for the resident not to self-administer the medication properly and for staff not to be aware if they were administered.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled Advanced Directives: Georgia, the facility failed to ensure one resident (R) (R44) of 36 residents reviewed for code status was accurately documented in the medical record to ensure her and/or her responsible party (RP) wishes were honored.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Physician Notification, the facility failed to ensure the physician was notified of a change of skin condition for one of 40 sampled residents (R) (R103). Specifically, the facility failed to notify the physician of a fungal rash that required treatment. This failure had the potential for R103 to not receive the necessary treatment needed to promote the healing of a skin condition.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Advance Beneficiary Notices (ABNs),, the facility failed to issue a Notice of Medicare Non-Coverage Notices (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) to Medicare A recipients when therapy or skilled nursing services were ending for three of three sampled residents (R) (R112, R179, and R379) reviewed for NOMNC and SNFABN. This failure had the potential for residents and/or their representatives not being informed of potential available services and fees for those services or the advisement of the ability to appeal the Resident's discharge from Medicare Part A benefits.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure two residents (R) (R1 and R60) of eight residents reviewed for abuse, were free from resident-to-resident abuse for two separate incidents.

Inspectors wroteBased on staff interview, record review, and review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure that an allegation of abuse was reported to the State Survey Agency (SSA) in a timely manner for one of eight residents (R) (R60) reviewed for abuse. This failure had the potential for other allegations of abuse to not be reported in a timely manner.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure that thorough investigations of resident-to-resident incidents that involved residents (R) (R279, R60, and R1) were completed. There was no evidence the facility interviewed other current residents or staff regarding the allegations of a physical resident-to-resident altercation with R279 and R60. There was no evidence the facility interviewed other current residents or staff regarding the physical resident-to-resident altercation with R279 and R1. The facility's investigation failed to include the names of the residents who were the victims. This lack of investigation had the potential to place other dependent residents at risk for abuse/neglect.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Bed Holds and Room Reserves, the facility failed to ensure two residents (R) (R59 and R110), and/or their responsible party (RP), of four residents reviewed were given a written bed hold policy at the time the residents were transferred/discharged to the hospital.

Inspectors wroteBased on staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to follow the RAI's transmittal requirements, which indicates that within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Center for Medicare & Medicaid Services (CMS) System for one resident (R) (R94) of 40 sampled residents reviewed. Specifically, it has been over 120 days since the quarterly MDS was completed and the MDS had not been transmitted to the CMS System.

Inspectors wroteBased on staff interviews, record reviews, review of facility policy titled MDS Assessment Accuracy, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one resident (R) (R89) of 40 sampled residents, had an accurate Minimum Data Set (MDS) assessment related to anticoagulant use. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the resident.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Care Plans, the facility failed to ensure a baseline care plan was provided for one of nine sampled residents (Resident (R) 329). Specifically, the facility failed to develop a baseline care plan for pressure ulcers. This failure had the potential to cause staff to not receive the necessary instructions needed to provide effective care and meet the needs of residents.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Care Plans, the facility failed to ensure one of one (Resident (R)52) who went to dialysis three times per week, had care plan interventions including to monitor R52's left upper extremity fistula for bleeding or bruising, monitoring of blood pressure, and venipuncture to the left arm. The Care Plan further failed to include R52's liberalized renal diet with Complex Carbohydrates, High Fiber, and Optimal Protein (CCHO) and double portions of protein and whether to provide a to-go breakfast before R52 left the facility for dialysis.

Inspectors wroteBased on resident and staff interviews, record review, and review of a policy provided by the facility titled Care Plan, the facility failed to ensure four residents (Residents (R) R280, R60, R52, R51) and/or their representative was invited to participate in their quarterly care plan meetings out of a total sample of 40 residents. This failure had the potential to affect the residents' care needs.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled, Care Plans, Documentation of Skin and Wound Care, and Physician Orders, the facility failed to ensure pressure ulcer care was provided according to professional standards for one of four sampled residents (Resident (R) 329) out of a total sample of 40 residents. Specifically, the facility failed to transcribe physician treatment orders in the electronic medical record (EMR), conduct pressure ulcer assessments per the facility policy, develop a baseline care plan for pressure ulcers, and document treatments administered in the EMR. This failure had the potential to cause the resident not to receive the necessary care needed to promote healing of pressure ulcers.

Inspectors wroteBased on resident and staff interviews, record reviews, and facility documentation reviews, the facility failed to ensure showers were provided for one of seven sampled residents (Resident (R) 103) out of a total sample of 40 residents. Specifically, the facility failed to ensure R103 received showers per the developed shower schedule. This failure had the potential to cause residents' personal hygiene needs to not be met.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policies titled Specialty Services: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health, and Documentation of Skin and Wound Care, the facility failed to implement dental orders for one (Resident (R)89) to treat pain and a potential dental abscess. The facility further failed to conduct an assessment and provide treatment for a change in skin condition for R103. Specifically, the facility failed to conduct an assessment and obtain a treatment for an identified fungal rash. This failure had the potential for the resident to not receive the necessary care needed to promote healing of a skin condition.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility's policies titled Physician Orders, and Documentation of Skin and Wound Care, the facility failed to ensure that nursing staff followed the recommendations of the Wound Nurse Practitioner (WNP2) and document verbal and telephone orders in R113's medical record after making rounds with the WNP2 or after reviewing the WNP2's documented progress notes regarding the treatment plan for the areas for one of three residents (R) R113 reviewed for pressure ulcers. In addition, the facility failed to ensure that nursing staff provided care to R103's right heel as ordered by the wound consultant. Additionally, the facility nursing staff failed to assess R329's sacral and right hip pressure ulcers from admission on [DATE] until 1/17/2024 and failed to obtain orders for treatment.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide respiratory care per standards of practice for one of two sampled residents (Resident (R) 7). Specifically, the facility failed to ensure respiratory equipment was stored properly for R7. The failure to store respiratory equipment consistent with professional standards had the potential to cause contamination and damage to the respiratory equipment.

Inspectors wroteBased on record review and staff interview, the facility failed to communicate with the dialysis center prior to the resident arriving at the dialysis center and failed to obtain communication documentation from the dialysis center after the resident completed dialysis and returned to the facility for one of one resident (Resident (R) 52) who attended dialysis three times per week. The failure of the facility to communicate with the dialysis center prior to and after dialysis could affect the care of the resident as well as prevent continuity of care.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility's policy titled Diet Order System, the facility failed to ensure that one of one resident (Resident (R) 52) received her diet as ordered by the attending physician. This failure had the potential for the resident to receive inadequate nutrition.

Inspectors wroteBased on observations, staff interview, and a review of the facility's policy titled State Minimum Staffing for Healthcare Centers, the facility failed to ensure that the daily nurse staffing document included the name of the facility, the facility's census, and the total number and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. This deficient practice had the potential to affect all 125 of the 125 residents and visitors of the facility.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure that opened items were resealed and labeled with a date in the walk-in freezer. and reach-in refridgerator. One of one kitchen. Observation of kitchen on 10/17/2023 at 11:00 a.m. with the dietary manager, one open carton of milk in reach-in refrigerator opened with no date. Observation of walk-in freezer on 10/17/2023 at 11:04 a.m with the dietary manager., the following items were opened and exposed to air; pizza dough, hamburger patties, fish patties and corn on cob. None of these items were sealed and dated with an opened or use by date. Interview with Dietary Manager EE on 10/17/2022 at 11:07 a.m., the staff member stated that all items that are opened in the dietary department are required to be resealed and dated. [...]

Inspectors wroteBased on observation, interviews, and policy review, the facility failed to conduct outbreak testing for Coronavirus (COVID-19) for all staff and residents in accordance with the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) requirements, after one staff member tested positive for COVID-19 on 6/26/22. The facility did not maintain testing logs, line listing forms for the residents or staff, or a log of community transmission levels. The census was 101. Findings Include: A review of facility policy dated 2014 titled Coronavirus- COVID-19 Infection Prevention and Control Practices revealed the following: 1. Once COVID-19 has been identified, outbreak prevention and control measures are to be implemented immediately. The location will also follow the directions from the DPH (department of public health). 2. [...]

Inspectors wroteBased on interview, record review, and review of facility policy titled COVID-19 Infection Prevention and Control Practices, the facility failed to notify the residents, families, and their representatives by 5:00 PM the next calendar day following the occurrence of a resident or staff that tested positive for COVID-19 on 6/26/22. The census was 105.