Pratt Health and Rehab

In the surveyor’s words

From the most serious findings on record at Pratt Health and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 3, 2025

  The facility reported a census of 41 residents with three residents sampled for safety related to transportation outside the facility. Based on observation, interview, and record review, the facility failed to ensure that staff provided a safe environment, free of accident hazards during transportation in the facility van. On 03/11/25 at approximately 09:20 AM Certified Nurse Aide (CNA) C failed to ensure Resident (R)1 was safely secured in the facility van before operating the vehicle. CNA C began to drive the van and realized R1 did not have a seatbelt on. CNA C then stopped the vehicle and R1 fell out of the wheelchair onto the floor of the facility van and injured his head, face and left arm. This deficient practice placed R1 in immediate jeopardy. […]

• Immediate jeopardy, isolatedF678Jun 8, 2022

  The facility reported a census of 37, with three residents sampled for cardiopulmonary resuscitation (CPR, emergency medical procedure for restoring normal heartbeat and breathing to victims of heart failure, drowning). Based on interview and record review the facility failed to have an effective code system in place when staff failed to implement CPR on a non-responsive full code Resident (R)1 on [DATE] at 02:20 AM, which placed R1 in immediate jeopardy. Findings included: - The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] Admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The [DATE] Care Plan, revised [DATE], indicated R1 and R1's family desired a full code status for R1. […]

• Actual harm, isolatedF697Jul 28, 2022

  The facility census totaled 43 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to ensure staff identified and promptly responded to signs of pain expressed by cognitively impaired Resident (R)12, when the resident had two fractured ribs and staff did not offer the resident non-pharmacological pain interventions or as needed (PRN) pain medications. Findings included: - Resident (R)12's signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The assessment documented the resident had no pain. The Pain Care Area Assessment (CAA) did not trigger for the 05/18/22 assessment. […]

• No harm, potential for more than minimal, widespreadF880Mar 17, 2026

  The facility had a census of 38 residents. Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions for Resident (R) 8, who had dressing changes to a pressure ulcer daily. The facility also failed to implement a complete water management program for Legionella disease (Legionella is a bacterium spread through mist, such as air-conditioning units in large buildings. Adults over the age of 50 and people with weak immune systems, or chronic lung diseases). […]

• No harm, potential for more than minimal, isolatedF582Mar 17, 2026

  The facility had a census of 38 residents. The sample included 12 residents, with three reviewed for Medicare Liability Notices. Based on record review and interview, the facility failed to provide Resident (R) 8, R10, and R17, or their representative, a Notice of Medicare Non-coverage (NOMNC) when skilled services ended.Findings included:-A review of R8's Electronic Medical Record (EMR) documented that her Medicare Part A episode began on 10/23/25 and ended on 01/09/26. Review of R8's clinical record and facility-provided information lacked evidence that R8 was issued a SNF NOMNC as required. A review of R10's EMR documented that his Medicare Part A episode began on 06/27/25 and ended on 08/21/25. […]