Pruitthealth - West Atlanta

Inspectors wroteBased on staff interviews, record review, and review of the facility's policies titled Occurrences and Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to thoroughly investigate a serious bodily injury of unknown source for one of ten sampled residents (R) (R7). Specifically, the facility failed to provide evidence of conducting interviews with R7, with staff who provided care for R7, with other residents, and with other pertinent outside agencies to determine the root cause of a serious bodily injury of unknown source. This deficient practice had the potential to put vulnerable residents at risk for injuries of unknown source to recur.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled Care Plans, the facility failed to follow the care plan to prevent complications for one of four sampled residents (R) (R7), who had a care plan focus for nothing by mouth (NPO). This deficient practice had the potential to negatively impact the resident's quality of life, quality of care and services received.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled, admission Orders and Diet Order System, the facility failed to provide the appropriate nutritional treatment and services to prevent complications for one of four sampled residents (R) (R7), with dietary orders for nothing by mouth (NPO). Specifically, the facility failed to properly assess R7's dietary needs and clarify dietary orders on admission in addition to the facility failed to follow NPO dietary orders. This deficient practice placed R7 at risk to not receive the necessary care and services to meet nutritional needs.

Inspectors wroteBased on observations, staff interviews, record reviews and review of the facility's policies titled, Infection Control-Housekeeping Services, the facility failed to ensure staff followed proper infection control protocols when transporting clean linen from the dryers to the folding area. This failure had the potential to contaminate all clean linen and clean laundry. The facility census was 102.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to protect the resident's right to be free from physical abuse by other residents for one of five residents (R) (R 113) reviewed for abuse. The deficient practice had the potential to place residents at continued risk of abuse.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Behavior Management, the facility failed to refer one of 21 residents (R) (R31) reviewed for Preadmission Screening and Resident Review (PASRR) for evaluation by the appropriate State-designated authority. This deficient practice has the potential to place R31 at risk of not receiving necessary care and services.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Occurrences, the facility failed to ensure hazardous chemicals were safely secured for one of four residents (R) (R49) reviewed for accidents. This deficient practice placed residents at risk for avoidable chemical incidents, injuries, and a diminished quality of life.

Inspectors wroteBased on observations, resident, resident representative and staff interviews, record review and review of the facility's policy titled, Patient/ Resident Choice Meals, the facility failed to provide a therapeutic diet that took into account the resident's clinical condition, and preferences with an equally nutritious meal for one vegetarian resident (R) (R48). The deficient practice resulted in the fluctuation of R48s weight and poor appetite.

Inspectors wroteBased on observations and staff interviews, the facility failed to prevent two of two garbage dumpsters from overflowing with excess garbage that prohibited the top lids and side doors from closing causing a potential for pests, rodents, and insects. The facility also failed to ensure one of two garbage dumpsters had a plug-in place to prevent potential leakage of garbage contaminates. The facility census was 101 residents.

Inspectors wroteBased on observations, staff interviews, and review of a facility document titled, Your Rights as a Patient, the facility failed to ensure a dignified dining experience for three of 46 residents (R) (R31, R68, and R608) on the [NAME] Unit. Specifically, the facility failed to ensure timely meal tray delivery for R31 and R608, pulled R68 backwards in his geriatric chair when leaving the dining area, and residents were referred to as feeders in the dining room during lunch.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Bed Hold Acknowledgment Form: Georgia, the facility failed to provide bed hold information, in writing, at the time of transfer or within 24 hours, for three of 45 residents (R) (R106, R68, and R19) who were transferred to the hospital in the last 120 days.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure residents were seen by a physician in the facility at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter, for four of 10 residents (R) (R1, R50, R52, and R72) reviewed for frequency of Physician visits.

Inspectors wroteBased on observations, staff interview, and review of the facility policy titled, Food Temperatures, the facility failed to ensure all food items on the steam table were held above 135 degrees Fahrenheit (F) to prevent bacteria growth. The deficient practice affected nine residents ordered a puree consistency diet from a total of 99 residents receiving an oral diet.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Self-Medication, the facility failed to assess one of 40 sampled residents (R) (R71) for the ability to self-administer medications prior to leaving medications at the bedside. The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents, staff, or visitors.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to one of three residents (R) (103) reviewed that were discharged from Medicare Part A coverage.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to provide specialized psychiatric services for one resident (R) (R19) with a serious mental illness (SMI) as recommended by the Preadmission Screening and Resident Review (PASRR) Level II summary. The sample size was 40 residents.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility policy titled, Care Plans, the facility failed to develop a care plan for one resident (R) (R50) of five reviewed for unnecessary medications and failed to implement care plan interventions for one of four residents (R77) reviewed for food/nutrition. Specifically, the facility failed to develop a care plan for the use of antipsychotic and anti-anxiety medication for R50 and failed to implement a care plan for diet as ordered for R77. These failures created the potential for R50 and R77 to not receive treatment and/or care according to their needs.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to ensure one of 40 sampled residents (R) (R77) was served a lactose free diet as ordered by the physician. The deficient practice caused R77 to be served food items that contained lactose, which R77 was allergic to.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Monitoring of Antipsychotics, the facility failed to ensure that a Gradual Dose Reduction (GDR) assessment was completed at least annually for one of five sampled residents (R) (R50) reviewed for unnecessary psychotropic medication use. This failure had the potential to affect R50's highest practicable mental, physical, and psychosocial well-being.

Inspectors wroteBased on observations, staff interviews, review of the facility policy titled, Medication Storage in the Healthcare Centers, review of the facility-provided documents titled 2024 Insulin Expiration Calendar-28 Day and 2024 Latanaprost and Levemir Expiration Calendar - 6 Weeks (42 Days), and review of manufacturer packet inserts, the facility failed to ensure medications and biologicals were dated when opened, discarded on the discard dates, and stored according to manufacturer recommendations on one of three medication carts (East Unit Cart 2). These deficient practices created the potential for residents to receive medications with altered effectiveness.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Cleaning Procedures: Serving Equipment, the facility failed to ensure the ice scoop bin and beverage dispenser was free from green and black buildup on one of two units (West). The deficient practice had the potential to cause an adverse outcome to those served from the affected ice scoop bin and beverage dispenser.

Inspectors wroteBased on observations, record review, staff interviews, and facility policies the facility failed to ensure two of three residents (R) (R#1and R#9) reviewed for hydration received appropriate services to ensure their highest practicable physical well-being. Specifically, the facility did not follow the physician orders to obtain lab work for R#1 and did not follow the physician orders for enteral feeding and water flushes for R#1. In addition, the facility did not have information available for the Registered Dietician to make an adequate decision as it pertains to the enteral feedings. Actual harm occurred on [DATE] when R#1 was admitted to an acute care hospital with diagnosis of acute sepsis, acute kidney injury, and dehydration with hypernatremia; [...]

Inspectors wroteBased on resident interviews, staff interviews, and the review of the facility policy Resident Trust Policy, the facility failed to provide resident trust fund account quarterly statements for two of three resident (R) A and R B, reviewed. Eighty-seven (87) resident trust fund accounts are managed by the facility.

Inspectors wroteBased on observation, staff interviews, and record review of the Maintenance Director Position Description the facility failed to ensure that it was maintained in a safe, clean, and comfortable, homelike environment on two of two wings (East Wing and [NAME] Wing) related to resident rooms with missing floor tile; peeling paint; peeling base board; missing dry wall; stained privacy curtains; dirty air filters; dirty vents on the Packaged Terminal Air Conditioner (PTAC) units; one resident's bathroom had a broken grab bar and rust around the toilet; and stain and missing ceiling tiles in resident common areas; shower rooms with dirty floors and walls; and the smoke porch aluminum ceiling was rusted with several holes.

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to ensure that the menu was followed to ensure the appropriate nutrition to residents and failed to notify the Registered Dietician for substituted food. This deficient practice affected 88 of the 93 residents in the facility receiving an oral diet.

Inspectors wroteBased on observation, staff interviews and record review, the facility failed to provide meals that were prepared by methods that conserve nutritive value, flavor, and appearance and provide meals that were palatable, attractive, and at a safe and appetizing temperature for affected 88 of 93 residents in the facility receiving an oral diet.

Inspectors wroteBased on observation, staff interviews, and review of the Dietary Manager Position Description, the facility failed to maintain the kitchen in a clean and sanitary condition. This deficient practice had the potential to affect 88 of the 93 residents receiving an oral diet.

Inspectors wroteBased on observation, staff interviews, and review of the policy Sanitation Checklist Form, the facility failed to properly maintain the area around the dumpster grounds. This practice created the potential for transmission of disease by pests/rodents, and insects.

Inspectors wroteBased on observations, staff interviews, and the facility documents, the facility failed to promptly fix water leak problems throughout the facility that resulted in mold in the resident rooms and resident common areas. This had a potential to effect 93 out of 93 immune compromised residents.

Inspectors wroteBased on staff interviews and review of the facility policy titled Partner Background Screening to Prevent Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to have onsite two out of twelve employee files selected for review. The file for License Practical Nurse (LPN) AA and Certified Nursing Assistant (CNA) FF were not in the facility for thirty-six days of the survey. The facility had a census of ninety-three residents.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to assess one of 31 sampled residents (R) (R#17) for the ability to self-administer medications prior to leaving medications at the bedside.

Inspectors wroteBased on record review, interviews, and the facility Policy titled Resident Trust Fund, the facility failed to honor two out of three residents (R A and R B) requests for access to their funds within the same day.

Inspectors wroteBased on record review, interviews, and the facility Policies titled Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Mission Statement and Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to safely protect two of 31 sampled residents (R) (R#4 and R#29) from Misappropriation of funds. Specifically, the facility permanently used R#4 money without the resident's consent and R#29 had unauthorized purchases on her personal credit card.

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 notify the State Agency (SA) within the required two hours of an incident involving an elopement of one resident (R) (R#17) of 31 sampled residents.

Inspectors wroteBased on observations, record reviews, interviews and the facility policy titled Documentation: Charting Activities of Daily Living (ADLs) and the Certified Nursing Assistant Position Description the facility failed to provide oral care for one of three sampled residents (R) (R#8) dependent on staff for activities of daily living (ADL) care.

Inspectors wroteBased on observations, record review, staff interviews, and the facility policy titled Hydration: Dietary Services the facility failed to ensure that water was within reach for one of three residents (R) (R#8) reviewed for hydration.

Inspectors wroteBased on observation, record review, interview, and the facility policy titled Specialty Services: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health and the Social Services Position Description, the facility failed to ensure two of 31 sampled residents (R) (R#5 and R#11) received adequate assistance and support from social services department. Specifically, R#11 missed two scheduled oral surgeries and three outside ophthalmologist appointments and R#5 missed three scheduled psychiatry appointments.

Inspectors wroteBased on observation, record review, staff, and resident interviews the facility policy titled Nutritional Screening and Assessments/Food Preferences, Hydration: Dietary Services and the Dietary Manager Position Description the facility failed to honor preferences for two of fourteen residents (R) (R#4 and R#5) with likes, dislikes, and preferences.

Inspectors wroteBased on staff interviews and review of facility documents, the facility failed to follow the code of conduct by not maintaining accurate documentation and providing false documentation.

Inspectors wroteBased on interview and record review, the facility failed to protect the rights one of ten sampled residents (Resident [R] #66) reviewed for choices. Specifically, R#66 chose to have a shower once per week and the facility failed to provide a shower for the resident and only assisted the resident with bed baths.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident with a newly diagnosed serious mental illness was referred for a level II Preadmission Screening and Resident Review (PASRR). This effected one (Resident [R] #72) of six residents reviewed for PASRR.

Inspectors wroteBased on record review and staff interview, the facility failed to include serious mental illness diagnoses on the level I Pre-admission Screening and Resident Review (PASRR) screening completed prior to admission for two of six sampled residents (Resident [R] #68 and R#43) reviewed for PASRR.