PruittHealth - Palmyra

In the surveyor’s words

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

• Immediate jeopardy, patternF656May 29, 2025

  Based on observation, record review, the facility failed to implement the care plan for weekly skin inspections for two residents (R)(R9 and R12) and failed to develop care plan interventions for routine weekly skin assessments for residents (R1, R3, R8 and R11) who were at risk for skin breakdown from a sample of eight residents with pressure ulcers. On May 20, 2025, 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. The facility's Administrator, Nurse Consultant and the Area [NAME] President were informed of the Immediate Jeopardy on May 20, 2025, at 2:49 pm. […]

• Immediate jeopardy, patternF686May 29, 2025

  Based on observations, record review and staff interviews, and review of facility policy titled Documentation of Skin and Wound Care, the facility failed to perform consistent weekly skin assessments for residents at high risk for skin breakdown in order to identify breakdown timely for six residents (R) (R1, R3, R8, R9, R11 and R12) and failed to perform treatments as ordered by the physician and/or recommended by the Wound Care Nurse Practitioner for three residents (R3, R11 and R12) of seven residents reviewed for pressure ulcers. The total sample size was 27. […]

• Immediate jeopardy, patternF835May 29, 2025

  Based on record review, staff interviews and review of the Administrator Job Description and the Director of Health Services Position Description, administration failed to ensure staff were performing weekly skin assessments and wound treatments as ordered and failed to provide oversight and monitoring of the skin integrity program. This deficient practice impacted six residents (R) (R1, R3, R8, R9, R11 and R12) of 29 sampled residents. On May 20, 2025, 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, patternF867May 29, 2025

  Based on staff interviews, record review and review of the Quality Assurance and Performance Improvement policy, the facility failed to have a Quality Assurance and Performance Improvement committee that effectively provided oversight and monitoring to ensure staff were performing weekly skin assessments to ensure timely identification and treatment of pressure ulcers. On May 20, 2025, 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. The facility's Administrator, Nurse Consultant and the Area [NAME] President were informed of the Immediate Jeopardy on May 20, 2025, at 2:49 pm. […]

• No harm, potential for more than minimal, widespreadF801May 29, 2025

  Based on observation, staff interviews, and review of the job description titled Position Description Dietary Manager, the facility failed to ensure the kitchen had a Certified Dietary Manager to oversee the duties and responsibilities of the kitchen staff; and failed to ensure the Dietitian assumed responsibility and accountable for the Dietary Services Department. The facility has 184 of 203 resident that receive oral meals. Findings include: Review of the facility Position Description Dietitian Job Purpose: Responsible for assuming professional responsibility and accountability for the Dietary Services Department in; the provision of nourishing, palatable, well-balanced diets to meet the daily nutritional and special dietary needs of each resident. Key Responsibilities: 12. […]