Pruitthealth - Valdosta, LLC

Inspectors wroteBased on interviews, record review, and review of the position description for the Director of Health Services, the facility failed to ensure the Director of Nursing (DON) did not serve as the charge nurse unless the facility had an average daily occupancy of 60 or fewer residents. This failure had the potential to affect 90 of 90 residents.

Inspectors wrote3. Review of the Face Sheet, located in the EMR under the Resident Dashboard tab, revealed R73 was admitted on [DATE] with diagnoses including cerebrovascular disease, contracture left elbow, contracture left hand, muscle weakness, and abnormal posture. Review of R73'sannual MDS, located in the EMR under the RAI tab and with an ARD of 2/26/2025, revealed a BIMS score of three out of 15, which indicated R73 was severely cognitively impaired. Review of the June 202025 Physician Orders, located in the EMR under the Active Orders tab, identified an order, dated 11/21/2024, that read, Apply L [left] Elbow orthosis to L Elbow and L Resting Hand orthosis to L wrist/hand daily as tolerated, with skin inspection following removal for edema, redness, pain or skin irritation. [...]

Inspectors wroteBased on record review, interviews, and review of the facility's policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure allegations of abuse were reported timely to the state agency (SA) for one of three residents (R) (R) (R49) reviewed for abuse out of a total sample of 33. This had the potential to affect resident safety in the facility.

Inspectors wroteBased on record review, interviews, and review of the facility's policy titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure allegations of abuse were thoroughly investigated for one of three Residents (R) (R49) reviewed for abuse out of a total sample of 33. This had the potential to affect resident safety at the facility.

Inspectors wroteBased on observation, interviews, and review of the facility's policy titled, State Minimum Staffing for Healthcare Centers, the facility failed to ensure the posted staffing was in an accessible location and posted before the beginning of the shift for five of five Residents (R) (R57, R50, R72, R65, and R79) interviewed for posted staffing with the potential to affect 90 of 90 census residents. This failure had the potential to affect the resident or resident representative's ability to know the staffing information.

Inspectors wroteBased on observations, staff interviews and review of the facility policy titled, Medication Administration: Guideline, the facility failed to ensure that six residents (R6, R7, R11, R12, R13, R14) of 14 sampled residents' medications were not pre-set on one of four medication carts.

Inspectors wroteBased on observations, staff interview, and review of the facility policy titled, Labeling, Dating, and Storage, the facility failed to ensure proper sanitization of ware washing equipment, food was labeled and dated properly, and food was disposed of properly according to professional standards for food service safety. This failure had the potential to affect all 82 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observations, staff interviews, record review, manufacture's guidelines, and review of the facility policy titled, Glucometer Cleaning and Disinfecting, the facility failed to ensure the glucometer (device used to test blood sugar levels in blood specimens) was adequately cleaned and disinfected and infection control principles were followed for three (Resident (R) 60, R31, and R129) of four residents observed for blood sugar checks. In addition, the facility failed to ensure appropriate hand hygiene principles were followed by two Certified Medication Aides (CMAs) (CMA1 and CMA2) during medication administration for R66 and throughout medication administration observations. These failures had the potential to lead to spread of infection, including bloodborne pathogens, between residents.

Inspectors wroteBased on observation, staff interviews, and resident interview the facility failed to provide privacy by not closing the blinds during incontinence care for one of one resident (Resident (R) 50) reviewed for privacy of 29 sampled residents

Inspectors wroteBased on record review, staff interviews, resident interviews, and the review of the facility policy titled, Documentation of Skin and Wound Care, the facility failed to provide wound care as ordered by the physician for two of two residents (Resident (R)4 and (R)42) reviewed for wound care of 29 sampled residents.

Inspectors wroteBased on observations, staff interview, and record review, the facility failed to obtain a physician order for the use of oxygen for one of four residents (Resident (R) 61) reviewed for Oxygen of 29 sampled residents

Inspectors wroteBased on record review, staff interview, and facility document review, the facility failed to obtain written communication from the dialysis center for one of one resident (Resident (R) 4) reviewed for dialysis of 29 sampled residents

Inspectors wroteBased on observations, staff interviews, resident interviews, record review, and review of the facility policies titled, Self-Administration of Medications by Patients/Residents, and Medication Storage in the Healthcare Centers, the facility failed to ensure medications were not stored unattended in resident rooms for two (Resident (R) 46 and R15) of 29 sample residents. This failure had the potential to lead to missed doses of medications or unsafe use of medications for these two residents.

Inspectors wroteBased on observations, interview, documentation, and review of the policy titled Glucometer Cleaning and Disinfecting the facility failed to protect residents against the potential for blood-borne illness on two of four medication carts on two of four days related to the disinfecting of glucometers as evidenced by not using approved disinfecting wipes, not allowing appropriate dwell time, and failure to use a barrier. The facility also failed to assure that a urinary catheter bag was off the floor for one of five residents (R31) reviewed for catheters.

Inspectors wroteBased on record review, interviews, and policy review titled Advance Directives: Georgia the facility failed to ensure there were no discrepancies between code status and orders related to code status for one of three residents (R58) reviewed for Advanced Directives.

Inspectors wroteBased on observation, interviews, medical record review, and review of facility policy titled Medication Administration: Enteral Tubes, the facility failed to ensure appropriate care of a gastrostomy (g)-tube during medication administration for one resident of four residents (R27) who were observed during the observation of medication administration.

Inspectors wroteBased on observation and interviews, the facility failed to assure medications were locked on the medication cart and inaccessible to unauthorized staff and residents. This failure affected medication carts on one of three wings.