Pruitthealth - Old Capitol

In the surveyor’s words

From the most serious findings on record at Pruitthealth - Old Capitol, in the surveyor’s own words.

• Immediate jeopardy, isolatedF726May 23, 2024

  Based on interviews, record review, and a review of the facility policy titled Facility Assessment Tool, the facility failed to provide education for all nursing staff to possess the competencies and skill sets necessary to ensure residents were free of medication errors as well as ensure these competencies and skill sets were monitored on an ongoing basis. As a result, one of 26 residents (Resident (R) 50) out of a total sample of 83 residents was hospitalized after a nurse administered a benzodiazepine (an antianxiety drug that can cause sedation), which was not ordered by the physician, to the resident. […]

• Immediate jeopardy, isolatedF760May 23, 2024

  Based on resident and staff interviews, record review, and a review of the facility policy titled Medication Administration: Oral Medications, the facility failed to ensure residents were free from significant medication errors for one of 26 sampled residents (Resident (R) 50) out of 83 total residents. R50 received a benzodiazepine (an antianxiety drug that can cause sedation), that was not ordered by the physician and contributed to her hospitalization . The facility's failure to ensure residents were free from significant medication errors presented a likelihood of serious harm, injury, impairment, or death to a resident. Immediate Jeopardy was identified on 5/22/2024 in the area of S483.45 Pharmacy Services F760 at a scope and severity (S/S) of J. […]

• Immediate jeopardy, isolatedF835May 23, 2024

  Based on interviews, facility policy reviews, and job description reviews, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to avoid significant medication errors during nursing medication administration. The facility failed to provide continued, effective oversight of the nursing staff's medication administration practices. This failure affected one of 26 residents out of 83 total residents (Resident (R) 50) when R50 received a benzodiazepine (an antianxiety drug that can cause sedation), which was not ordered by the physician and contributed to R50 hospitalization . […]

• No harm, potential for more than minimal, widespreadF812Nov 18, 2025

  Based on observations, staff interviews, and review of the facility's policies titled Labeling, Dating, and Storage, the facility failed to ensure that food was properly labeled and stored. This deficient practice had the potential to place the 88 residents receiving nutrition and hydration from the kitchen at increased risk of foodborne illness.Findings include: Review of the facility policy titled Labeling, Dating, and Storage, dated 11/11/2022, revealed the Policy Statement stated, It is the policy of [Company Name] for all partners who assist in handling, preparing, serving, and storing food and beverage items to follow the proper procedures for labeling, dating, and storage to ensure proper food safety. The Procedure section stated 1. […]

• No harm, potential for more than minimal, widespreadF565May 23, 2024

  Based on resident and staff interviews, review of Resident Council Minutes, and review of the facility policy titled, Patient/Resident Council, the facility failed to ensure a response was provided to the members of the resident council when concerns were identified related to transportation accommodations for outings. During the resident council meeting four residents (R) (R30, R36, R54, and R78) had complaints of transportation not being provided for outings and had not received a response. Findings include: Review of documentation provided by the facility titled Patient/Resident Council Minutes/Report Form, from 8/29/2022 to 4/22/2024, included Old Business/Resolutions [store name] trip is on hold due to [transportation company name] does not have van available at this time. […]