PruittHealth-Evans, LLC

In the surveyor’s words

From the most serious findings on record at PruittHealth-Evans, LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF608Aug 21, 2022

  Based on interview, record review, and facility policy review, it was determined the facility failed to develop policies and procedures to ensure that reasonable suspicion of a crime against any resident was immediately reported to local law enforcement for four of five residents (R) (R#58, R#62, R#86, and R#277) reviewed for abuse. Specifically, the facility failed to ensure sexual assaults perpetrated by R#58 against R#62 and R#86 were reported to the police, and that an allegation of staff-to-resident abuse directed toward R#277 was reported to the police. Subsequently, the abuse continued. […]

• Immediate jeopardy, patternF609Aug 21, 2022

  Based on interview, record review, and facility policy review, it was determined the facility failed to ensure allegations of abuse were immediately reported to the State Survey Agency (SSA) for four of five residents (R) (R#58, R#62, R#86, and R#5) reviewed for abuse. Specifically, the facility failed to ensure allegations of resident-to-resident sexual abuse and staff-to-resident abuse were reported to the SSA immediately. Subsequently, the abuse continued. On 8/18/22, 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. […]

• Immediate jeopardy, patternF610Aug 21, 2022

  Based on observations, interviews, record review, document review, and facility policy review, the facility failed to thoroughly investigate allegations of abuse or exploitation involving four of five residents (R) (R#58, R#62, R#86, and R#5) reviewed for abuse. Specifically, the facility: - Failed to thoroughly investigate an incident of resident-to-resident sexual abuse when R#58 was found in R#62's room with his hand inside the resident's gown on 6/20/22. Other residents were not interviewed as to whether they had been exposed to, or had knowledge of R#58's sexually aggressive behaviors as a part of the facility's investigation. […]

• Immediate jeopardy, patternF835Aug 21, 2022

  Based on observations, interviews, record reviews, and facility policy review, the facility's administration failed to provide oversight and leadership that ensured: (1) Residents were free from sexual and physical abuse, which affected two of five sampled residents (R) (R#62 and R#86) reviewed for abuse; (2) A thorough investigation of allegations of resident-to-resident sexual abuse and staff-to-resident abuse were completed involving three of five sampled residents (R#58, R#62, and R#5) reviewed for abuse; (3) To report allegations of resident-to-resident sexual abuse and staff-to-resident physical abuse to the local law enforcement for four of five residents (R#58, R#62, R#86, and R#277) reviewed for abuse; and (4) To report allegations of resident-to-resident sexual abuse and… […]

• Immediate jeopardy, isolatedF600Aug 21, 2022

  Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure residents were free from resident-to-resident sexual abuse for two of five sampled residents (R) (R#62 and R#86) reviewed for abuse. R#58 displayed behaviors of wandering into the rooms of residents of the opposite sex. The facility failed to develop and implement interventions to address the resident's behavior, and on 6/20/22, staff found R#58 in R#62's room with his hand inside R#62's gown. The facility failed to consistently supervise/monitor R#58 to prevent further incidents of sexual abuse, and on 8/16/22, staff found R#58 in the room shared by R#62 and R#86, with his pants down, genitals exposed, and one leg on R#86's bed. […]