Pulaski Health Care Center

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing related to a lack of treatment change or new interventions implemented timely after the pressure ulcer had worsened for 1 of 3 residents reviewed for pressure ulcers. (Resident C)

Inspectors wroteBased on observation, record review, and interview, the facility failed to serve food under sanitary conditions related to touching food with gloved hands after touching other items for 1 of 1 kitchen observed. (The Main Kitchen). This had the potential to affect 44 residents who received food from the kitchen.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide a safe, comfortable environment related to elevated hot water temperatures in 2 of 5 units observed for water temperatures. (North and Northeast Units)

Inspectors wroteBased on record review and interview, the facility failed to ensure documentation for residents' transfer to the hospital was complete and accurate related to lack of documentation of preparation for transfer or discharge, assessment of the resident at the time of transfer, and notification to the physician at the time of transfer for 2 of 3 residents reviewed for hospitalization. (Residents 8 and 45)

Inspectors wroteBased on record review and interview, the facility failed to ensure to send the facility's bed-hold and reserve bed payment policy before and upon transfer to the hospital and transfer or discharge form to the resident and/or representative. The facility also failed to ensure appropriate information was conveyed to the receiving provider for 3 of 3 residents reviewed for hospitalization. (Resident 3, 8, and 45)1. Resident 3's record was reviewed on 8/21/25 at 12:28 p.m. Diagnoses included, but were not limited to, chronic respiratory failure, chronic obstructive pulmonary disease, heart failure, and high blood pressure. The Quarterly Minimum Data Set assessment, dated 7/7/25, indicated the resident was cognitively intact. She was dependent on staff for toileting, showering, bed mobility, and transfers. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive care plan was developed and in place for resident receiving an antidepressant medication for 1 of 13 care plans reviewed. (Resident 2)

Inspectors wroteBased on record review and interview, the facility failed to ensure a speech therapy evaluation was completed as ordered for 1 of 4 residents reviewed for nutrition and also failed to ensure there was documentation and interventions in place for bowel management for 1 of 5 residents reviewed for unnecessary medications. (Residents B and D)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a splinting device was in place as ordered for a resident with a limited range of motion for 1 of 1 resident reviewed for range of motion. (Resident 13)

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were accurate and complete related to incomplete meal intakes, snack intakes and fluid intakes for 3 of 13 resident records reviewed. (Residents B, E, and C)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents that received antibiotics met the criteria of a true infection or provide a rationale for use if infection criteria were not met for 2 of 2 residents reviewed for antibiotic stewardship. (Residents 51 and 2)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services to promote healing, related to treatments not completed as ordered for 1 of 3 residents reviewed for pressure ulcers. (Resident D)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 1 and CNA 2) when providing care to residents (Resident G and Resident D) who were in Enhanced Barrier Precautions (EBP), for two random observation for infection control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's privacy was respected, related to Terminated Employee 1 using her private cell phone to take a video of a resident (Resident C), without the approval of the resident or the resident's representative, for 1 of 1 resident reviewed for privacy. The deficient practice was corrected by 8/1/24, prior to the start of the survey, and was therefore past noncompliance. The facility thoroughly investigated the recording and posting of the video. CNA 1 was terminated. CNA 2 was disciplined. Staff were re-educated on the cell-phone and confidentiality policy of the facility and staff re-signed acknowledgement of the policies.

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive care plan was developed and in place for anticoagulant and antiplatelet medication use for 1 of 18 resident care plans reviewed. (Resident 7)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received the necessary treatment to prevent contractures (a fixed shortening or hardening of muscles or tendons) or decreased range of motion, related to passive range of motion not completed as recommended and a splinting device not in place as ordered for 2 of 2 residents reviewed for range of motion (ROM). (Residents 14 and 12)

Inspectors wroteBased on record review and interview, the facility failed to ensure adequate monitoring was in place for a resident receiving scheduled opioid medication (pain medication) for 1 of 5 residents reviewed for unnecessary medications. (Resident 24)

Inspectors wroteBased on record review and interview, the facility failed to report an allegation of abuse to the State Agency for 1 or 1 residents reviewed for abuse (Resident B)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's protective arm sleeves were applied as ordered by the physician, and discolorations were assessed and monitored for 2 of 3 residents reviewed for non-pressure skin condition. The facility also failed to ensure neurological checks were initiated following a fall for 1 of 2 residents reviewed for falls. (Residents 24, 42, and 7)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure oxygen was being administered at the correct flow rate for 1 of 1 residents reviewed for oxygen. (Resident 7)

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, related to not monitoring blood pressure and pulse before a blood pressure medication was administered for 1 of 5 residents reviewed for unnecessary medications. (Resident 32)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, including those to prevent and/or contain COVID-19, related to staff not using personal protective equipment (PPE) while in a transmission based precautions (TBP) room during a random observation for infection control. (CNA 1)