Pruitthealth - Virginia Park

Inspectors wroteBased on observations, staff interviews, record review, and a review of the facility's policy titled, Care Plans, the facility failed to develop a care plan for one resident(R) (R51) related to wound care for one of 31 sampled residents. Actual Harm was identified on March 21, 2025, when R51 sustained a pressure ulcer to the left ankle due to the facility not conducting routine skin checks while wearing a wander guard.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility policy titled, Wound Observation and Assessment Documentation, the facility failed to perform consistent weekly skin assessments and failed to follow up on identified skin issues for one resident (R) (R51) of thirteen residents. Actual Harm was identified to have occurred on March 21, 2025, when R51 sustained a pressure ulcer to the left ankle due to the facility not conducting routine skin checks while wearing a wander guard.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Medication Administration: General Guidelines, the facility failed to adequately assess one of 31 Residents (R) (R269) for self-administration of medication.

Inspectors wroteBased on observations, interviews, and review of the facility policy titled, Infection Control-Housekeeping Services the facility failed to ensure three of 18 rooms (Rm 306, 307, and 308) on the 300 Hall Packaged Terminal Air Conditioner (PTAC) units air filters were free or dirt and debris. The deficient practice had the probability of diminishing the air quality for the residents residing in rooms 306, 307 and 308.

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to ensure the bilevel positive airway pressure, (BiPAP) was properly stored in a manner to prevent contamination for one of 19 residents (R) (R54). The deficient practice had the potential to increase the risk of respiratory infection.

Inspectors wroteBased on observations, staff interviews, record reviews, review of the facility's policy titled, Covid-19 Isolation and Cohorting Process, and review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic the facility failed to follow droplet transmission-based precautions procedures prior to entering and exiting Covid positive resident rooms on one of four halls.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, the facility failed to assess and obtain a physician order for one of 29 sampled Residents (R) (R75) to safely self-administer and store nebulizer treatments at bedside. This failure had the potential for medication error and to alter the effectiveness of the medication.

Inspectors wroteBased on staff interviews, record review, and review of facility's policy titled, Refusal of Care Against Medical Advice, the facility failed to document the risks and benefits of remaining at the facility, and notification of the physician at the time of discharge for one of 29 sampled Residents (R) (R116) that discharged from the facility Against Medical Advice (AMA).

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Care Plan, the facility failed to ensure that a care plan was developed for one of 29 sampled Residents (R) (R568) reviewed for limitation in range of motion and Activities of Daily Living (ADL) deficits. This failure had the potential for the resident not to receive treatment and care according to her needs.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled Care Plans, the facility failed to revise the comprehensive care plan as needed related to self-administration of nebulizer treatments for one of 29 sampled Residents (R) (R75) following a hospital stay. This failure had the potential for the resident not to receive treatment and care according to her needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one of 29 sampled Residents (R) (R568) reviewed for limited range of motion received passive range of motion exercises as needed to address limited range of motion in her bilateral upper extremities. This failure created a potential for worsening contracture (fixed resistance to passive stretch), pain, or skin breakdown.

Inspectors wroteBased on observations and interviews, the facility failed to maintain the facility at a safe temperature range of 71 to 81 degrees Fahrenheit (F) on four of four hallways, during four out of five survey days. Additionally, the facility failed to maintain a homelike environment for 24 of 63 rooms in the facility. On 6/16/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy (IJ) on 6/16/2022 at 4:53 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 6/13/2022. The IJ is outlined as follows: [...]

Inspectors wroteBased on observations, record review, interviews, and review of the policy titled Quality Assurance and Performance Improvement (QAPI) Plan, the facility failed to have an effective Quality Assurance process to implement action plans for identified systemic quality deficiencies. Specifically, the facility failed to maintain a safe temperature range of 71 to 81°F, during four out of five survey days. The census was 116. On 6/16/2022, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy (IJ) on 6/16/2022 at 4:53 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 6/13/2022. [...]

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to implement/develop care plans for four residents (R) (R#64, R#69, R#96, and R#100) of 41 sampled residents. Specifically, not implementing care plan related to oxygen administration for R#64, R#69, and R#100; and not developing care plan for R#96 for self-administration of medications.

Inspectors wroteBased on observations, record review, interviews, and policy review titled Resident Independent Self-Administration and Medication Assistance of Medication, the facility failed to ensure one of 41 sampled residents (R) (R#96) had a physician's order for self-administration of respiratory medications prior to nebulizer medications being kept at bedside and self-administered by resident.

Inspectors wroteBased on record review, interviews, and review of the Resident Assessment Instrument (RAI,) the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for two of 41 sampled residents (R) (R#46 and R#64).

Inspectors wroteBased on observations, interviews, record reviews, and policy review, the facility failed to ensure medications were administered as ordered for one of 41 sampled residents (R) (R#323).

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure that three residents (R) (R#64, R#69, and R#100) of 11 residents that had tracheostomies with oxygen masks, received the correct physician ordered oxygen concentration. Findings Include: Review of the facility's policy titled Oxygen Administration dated 11/22/21, revealed the policy of [facility name] is to provide oxygen safely and accurately to appropriate patients .Oxygen will be administered by licensed personnel only when ordered by the physician, physician assistant (PA), or Nurse Practitioner (NP). 1. A review of the clinical record for R#64 revealed resident was admitted to the facility on [DATE] with diagnoses of but not limited to subarachnoid hemorrhage, acute respiratory failure, sepsis, and cardiac arrest. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain complete and accurately documented medical records for three of six residents (R) (R#87, R#26, R#47) records reviewed related to advance directives. Specifically, R#87 and R#26's code status levels were listed as Do Not Resuscitate (DNR); however, the physician orders indicated Full Code and R#47's code status was listed as Full Code and the physician orders indicated DNR.