Every finding on record at Pruitthealth - Panama City

Based on observation and interviews, the facility failed to provide residents with a private location to conduct resident council meetings for 1 of 1 observed resident council meetings.The findings include:During the observation of the scheduled resident council meeting on 7/28/26 at approximately 12:30 p.m., the meeting was interrupted on three separate occasions. At approximately 12:35, the Business Office Manager entered to retrieve a resident. At approximately 12:45, the Business Office Manager returned to inform the group the resident would not be returning to the meeting. At approximately 12:50, a third interruption occurred when the Infection Control staff member entered regarding resident care. Residents stopped discussing meeting business during each interruption.On 7/28/26 at approximately 1:49 p.m., an interview was conducted with the Activities Director Assistant, who stated, I did not know meetings should not be interrupted and a sign placed on the door, but I intend to begin putting a sign to Do Not Disturb on the door for further meetings.On 7/28/26 at approximately 2:05 p.m., an interview was conducted with the Activities Director, which stated my assistant has only been with me for a month and I thought I left her with all of the instructions to handle the meeting but I did not tell her about putting a sign on the door.On 7/28/26 at approximately 2:15 p.m., an interview was conducted with the Director of Nursing (DON), who acknowledged the meeting had been interrupted after it had begun and stated the staff had not been adequately instructed to avoid entering resident council meetings and indicated education would be provided. The DON further stated a Do Not Disturb sign would be implemented for future meetings.On 7/28/26 at approximately 2:50 p.m., an interview was conducted with the Resident Council President. She stated interruptions have occurred previously and residents have become reluctant to discuss concerns because meetings are not consistently private.

Based on record review and staff interviews, the facility failed to develop a comprehensive plan of care related to dementia care for 1 of 1 resident sampled for dementia care. (Resident #6)The findings include:The facility policy for Care Plans (revised 10/21/25) states, It is the policy of the health care center for each resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following the completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment (RAI) Manual and resident choice. The comprehensive care plan should describe the following: The services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, any services that would otherwise be required but are not provided due to the resident's exercise of rights including the right to refuse treatment and action taken by the facility staff to educate the resident and resident representative, if applicable, regarding alternatives and consequences. A review of Resident #6's electronic medical record revealed a current diagnosis of Alzheimer's disease. Review of the admission Minimum Data Set (MDS), with an assessment reference date of 6/10/26, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 10 (moderate cognitive impairment) and a diagnosis of Alzheimer's disease. The Care Area Assessment worksheet for the 6/10/26 MDS Cognitive Loss/Dementia dated 6/25/26 revealed the resident had a BIMS score of less than 13. The form also stated Alzheimer's disease or other dementias, confusion, disorientation, forgetfulness, care plan decision: yes, to manage any moods or behaviors. Review of the current physician orders revealed the resident was currently receiving Seroquel 50 mg daily. Seroquel is an antipsychotic medication. Review of the resident's current comprehensive care plans revealed no care plan related to Alzheimer's disease, cognitive loss, or dementia care. An interview was conducted with Employee A (MDS Licensed Practical Nurse) on 7/28/26 at 3:16 PM. Employee A stated that, when a resident has a diagnosis of Alzheimer's disease, they create a care plan regarding cognition and any behaviors. The care plan would speak to orienting the resident, care they are performing, and activities. She stated she thought his BIMS score was 13 and she did not proceed to care plan the Alzheimer's dementia. She confirmed the BIMS score was a 10.An interview was conducted with the Director of Nursing (DON) on 7/28/26 at 3:29 PM. The DON stated, based on the resident's Alzheimer's diagnosis, BIMS of 10, and the CAA worksheet, the resident should have been care planned for dementia.

Based on record review, staff interview, and policy review, the facility failed to report all alleged violations of misappropriation of resident property to the State Survey Agency and adult protective services for 1 of 1 sampled allegations of misappropriation of resident property. (Resident #1)The findings include:During a review of the facility investigation documentation for an alleged drug diversion, it was revealed on [DATE] that the Director of Health Services (DHS) was made aware of a possible drug diversion for a card of 59 oxycodone (narcotic pain medication) 10 mg tablets for Resident #1. The card of oxycodone was missing and the narcotic sheet for the oxycodone was located in medical records with a line drawn through the sheet. On [DATE] at 11:56 AM, the DHS called Staff A (Licensed Practical Nurse) and requested she return to the facility for a meeting. On [DATE] at 12:30 PM, Staff A returned to the facility and met with the DHS and Facility Administrator. Staff A was asked where the missing card of 59 oxycodone 10 mg tablets was located. Staff A first stated that she destroyed them in the medication room since the resident had expired. After further questioning regarding Staff A not following the policy for destroying medications, she then stated she took all 59 oxycodone tablets home, and she could go home and get them. On [DATE] at 2:30 PM, Staff A returned to the facility with a full card of 59 tablets of Oxycodone 10 mg tablets which was taped completely on the back of the card with black electrical tape. The tablets were verified to be Oxycodone tablets by the pharmacist. An interview was conducted with the DHS on [DATE] at 3:07 PM. She stated she did not consider the drug diversion an allegation of misappropriation of property and did not report it as a federal report to the State Agency. A follow-up interview was conducted with the DHS on [DATE] at 8:32 AM. She stated the facility did not report the drug diversion to adult protective services because they only followed the adverse incident path. The facility policy for Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property (revised [DATE]) revealed on page 3, .a written report of the investigation and follow-up should be submitted to the appropriate agency within five working days of the occurrence, unless otherwise indicated. If indicated, the Ombudsman and the law enforcement agency should also be notified. Review of the facility policy for Controlled Substances for Healthcare Centers (revised [DATE]) revealed on page 8: any major discrepancy, a pattern of discrepancies, or evidence of apparent criminal activity will be reported to the Administrator and the Consultant Pharmacist. A determination will be made by the Administrator, the Consultant Pharmacist and executive management staff concerning possible notification of police or other law enforcement agencies and any other action to be taken.

Based on observations, record review, and staff interviews, the facility failed to honor the resident's right to dignity by leaving a urinary catheter bag uncovered for 1 of 2 residents reviewed for dignity. (Resident #50) The findings include: Observations of Resident #50 were conducted on 4/6/25 at 1:07 PM, 4/7/25 at 11:48 AM, 4/7/25 at 3:06 PM, and 4/8/25 at 8:29 AM. During all observations, the resident was in bed and had a urinary catheter bag attached to the bedside. The catheter bag was not covered during any of the observations. Another observation of Resident #50 was conducted with the Director of Health Services (DHS) on 4/8/25 at 10:00 AM. The resident was in bed and facing the open doorway to her room. The urinary catheter bag was uncovered, attached to the bed, and visible from the doorway. At this time, the DHS stated the urinary catheter should be covered. A review of the resident's medical record revealed the resident had a current physician order for a urinary catheter. An interview was conducted with the Corporate Nurse Consultant (CNC) on 4/8/25 at 3:15 PM. The CNC reported the facility did not have a policy that refered to covering a urinary catheter.

Based on observations, resident interviews, staff interview, record review, and policy review, the facility failed to ensure the interdisciplinary team assessed and determined residents were capable of self-administration of medications prior to allowing 3 of 20 sampled residents to self-administer medications. (Resident #16, #41, and #56) The findings include: Resident #16 An observation of Resident #16 was conducted on 4/6/25 at 11:41 AM. The resident was up in a wheelchair in his room. A small medication containing 2 white pills was observed to be on the overbed table. (Photographic evidence was obtained.) Resident #16 was interviewed and indicated the pills were Tylenol. An interview was conducted with Employee F (licensed practical nurse) on 4/6/25 at 2:32 PM. She stated she did not leave the Tylenol at the bedside and the resident was assessed to self-administer only his eye drops. An interview was conducted with the Director of Health Services (DHS) on 4/7/25 at 12:59 PM. The DHS stated the resident reported a nurse brought him the Tylenol when he was in the restroom and he asked the nurse to leave them so he could take the Tylenol when he exited the restroom. He reported he forgot to take the Tylenol when he exited the restroom. A review of Resident #16's medical record revealed an observation form for self-administration of medications dated 8/9/24 indicating the resident was only allowed to self administer his eye drops. Resident #56 An observation of Resident #56 was conducted on 4/6/25 at 10:52 AM. The resident was sitting in a chair in his room. A bottle of [NAME] nasal spray was observed to be sitting on the bedside table. (Photographic evidence was obtained) At this time, the resident stated he purchased the nasal spray and was not sure if the nursing staff was aware he had the spray. He stated he had been administering the [NAME] nasal spray to himself. An interview was conducted with Employee F on 4/6/25 at 2:29 PM. Employee F stated the resident was not prescribed [NAME] nasal spray, medications were not supposed to be stored at the bedside, and the resident had not been assessed to self-administer the nasal spray. 50447 Resident #41: On 04/06/25 at 10:53 AM and 1:57 PM, Resident #41 was observed with a medicine cup with medications in it on the bedside table. (Photographic evidence obtained) On 04/06/25 at 02:30 PM, Employee F was interviewed regarding the medications at the bedside. She stated she was very busy at this time. On 04/07/25 at 08:54 AM, Resident #41 was once again observed with a medicine cup with medication in it at the bedside table. Staff K, a Registered Nurse, was interviewed concerning Resident #41. She apologized and proceeded to remove the medications from the bedside table. On 04/07/25 at 01:20 PM, the Director of Health Services (DHS) was interviewed regarding the medications found at the bedside for two days. She stated that Resident #41 was not assessed for self-medication and this should not have occurred. On 04/07/25, a record review of Resident #41 confirmed there was not a physician order or a care plan for medication self-administration. Review of the facility policy for Self-Administration Assessment Form (revised 1/28/20) reveals each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the resident and the other residents of the healthcare center. If the resident desires to self-administer medications, an assessment is conducted by the Licensed Nurse to asses the individual's cognitive, physical, and visual ability to carry out this responsibility. Bedside storage of medications is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer. The manner of storage prevents access by other residents.

Based on observations, record review, staff interviews, and policy review, the facility failed to revise the plan of care to reflect refusal of treatment for 1 of 2 sampled residents reviewed for limited range of motion. (Resident #35) The findings include: Observations of Resident #35 were conducted on 4/6/25 at 11:03 AM, 4/7/25 at 11:45 AM, 4/7/25 at 3:02 PM, and 4/8/25 at 8:34 AM. The resident was in bed and her left hand was observed to be contracted into a fist during the observations and no splint device was in place. Resident #35's quarterly minimum data set (MDS), with an assessment reference date (ARD) of 2/20/25, indicated that the resident has functional limitation in her range of motion of one upper extremity and that the resident was not receiving any therapy, range of motion services, splinting, or bracing. The diagnosis list revealed that the resident had a diagnosis of contracture to left hand added on 3/23/23. A review of the resident's plan of care dated 10/4/23 and revised 3/4/25 revealed that the resident required splint/brace assistance to her left elbow and hand. The restorative nursing intervention care plan indicated that staff should follow the guidelines of occupational therapy: check for any skin compromised areas, gently extend fingers, place finger separated palm protector hand splint on her left hand, tolerating up to 8 hours once a day. The care plan did not include any resident refusal of the splint treatment. An interview was conducted with Employee H (a Certified Nursing Assistant) on 4/8/25 at 8:51 AM. She stated that Resident #35's left hand was badly contracted and turned outward. The resident holds her left hand to her chest and has a fit if it is stretched. Employee H stated that most of the time she is not able to place the splints on the resident because the resident stated they hurt too much. She stated, at times, the resident's left hand had an odor if staff were not able to clean the hand. An interview was conducted with Employee J (the Registered Nurse in charge of restorative care) on 4/8/25 at 9:11 AM. She stated that Resident #35 was on the restorative program for splinting of the left hand and elbow. She stated that the resident does not like to wear the splints. She reviewed the point of care splinting documentation for the last 13 days and stated the resident had refused the splints on 5 days, the splints were applied 2 days, and the splints were not documented as performed for 6 days. An additional interview was conducted with Employee J on 4/8/25 at 11:14 AM. She stated that Resident #35 had, at times, refused the splints to the hand and elbow since the care plan was initiated in 2023. An interview was conducted with Employee I (the Licensed Practical Nurse in charge of care plans) on 4/8/25 at 11:23 AM. Employee I stated that, if the resident was refusing splinting, the care plan should have been updated to include her refusal of care. The policy for Care Plans (revised 7/27/23) states: Care Plan Review and Update: 1. Comprehensive care plans should be reviewed not less than quarterly according to the OBRA MDS schedule, following the completion of the assessment. Care plan updates/ reviews will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. 2. Discontinued problems, goals or approaches should be indicated directly on the care plan. A line should be drawn through the discontinued item. Updates to the care plans should be made with any changes in condition at the time the change in condition occurred. For MatrixCare users, all updates are made electronically. 3. All updates to care plans are to be dated and signed. The Master Care Plan will be electronically updated and printed following the completion of Comprehensive OBRA assessments. For MatrixCare users, Care Plans are maintained electronically. 4. Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment.

Based on observations, interviews, review of the electronic medical record (EMR), and review of the facility's policies and procedures, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 of 19 residents sampled. (Resident #295 and #39) The findings include: Resident #295 On 04/06/25 at approximately 03:39 PM, an observation was made of Resident #295's central venous catheter (CVC) (a long, flexible tube inserted into a vein, to deliver fluids, medications, and blood products) in the right upper extremity (RUE). The transparent dressing on the CVC was dated 3/27/25. On 04/07/25 at approximately 12:28 PM, Resident #295's transparent dressing on the CVC in the RUE still had a date of 3/27/25. When interviewed about it, Resident #295 stated, the nurse is supposed to change the dressing today. However, on 04/08/25 at approximately 09:54 AM, thes CVC dressing was still dated 3/27/25. The resident stated, yesterday the nurse told me she was going to have to find the supplies to change the dressing, but the dressing was not changed. On 04/08/25 at approximately 12:37 PM, an interview was conducted with Staff D, a licensed practical nurse (LPN). The LPN confirmed that the dressing on Resident #295's CVC in the RUE was dated 3/27/25. The LPN confirmed there was not an order in the EMR to change the dressing or orders for care of the central line. On 04/08/25 at approximately 01:05 PM, an interview with the Director of Health Services (DHS) was conducted. The DHS stated, when a resident is admitted with an intravenous catheter (IV) of any type there should be orders to care for the IV. During a review of active and discontinued orders in the EMR, no orders for care of a CVC or dressing changes for the CVC were found. A document found in the EMR named Patient Eval, dated 3/31/25 indicated IV access- (MIDLINE). (photographic evidence obtained). A document found in the EMR named 3008, which was a discharge summary and transfer form from the hospital to the long-term care facility dated 3/27/25, indicated Resident #295 had a Midline inserted 3/27/25. (photographic evidence obtained). The facility policy named Central Infusion Access Devices (effective 11/25/2015, reviewed: 6/18/24 and revised 4/17/19) states that the dressing should be changed once a week, flushing all unused lumen per central vascular access device protocol. 28603 Resident #39 Observations of Resident #39 were conducted on 4/7/25 at 2:07 PM, 4/7/25 at 11:51 AM, and 4/7/25 at 3:09 PM. During these observations, the resident was in bed and an undated pink dressing was observed on her right lower leg. The resident was not able to recall when the dressing was last changed. Another observation of Resident #39 was conducted with the Director of Health Services (DHS) on 4/8/25 at 1:41 PM. The resident was in bed and continued to have an undated pink dressing on her right lower leg. At this time, the DHS confirmed the dressing was not dated and stated all dressings should be dated. A telephone interview was conducted with Employee G (licensed practical nurse) on 4/9/25 at 9:18 AM. Employee G stated she forgot to date the dressing she applied to Resident #39's leg on 4/7/25. A review of the resident's current physician orders revealed an order dated 4/3/25 to cleanse the wound on the right lower leg with normal saline, pat dry, and apply a dry dressing once a day on Monday, Wednesday, and Friday until healed. A review of the undated facility procedure for Dressing a Wound revealed that the dressing applied should be labeled with the date, time and initials of the individual who applied the dressing.

Based on observations and interviews, the facility failed to store all drugs and biologicals in locked compartments for 1 of 3 medication administrations observed on 4/8/2025. The findings include: On 4/8/25 at approximately 9:19 AM, an observation of medication administration was conducted with Staff A, a licensed practical nurse (LPN). The LPN began pulling medications for a resident. The LPN then left the cart in the hall with the cup of medication unsecured on top of the cart while she went into a resident's room to take her temperature. The LPN could not see the medication that was left unattended while she was in the room. When the nurse came out of the room, she acknowledged that she left the medications unsecured and outside of the locked compartment in the medication cart.

Based on observation, interview and record review, the facility failed to ensure the interdisciplinary team assessed and determined a resident was capable of self-administration of medications prior to allowing 1 of 21 sampled residents to self-administer medications. (Resident #54) The findings include: An observation of Resident #54 was conducted on 10/24/22 at 10:35 AM. One [MEDICATION(S)] inhaler and one [MEDICATION(S)] inhaler was observed sitting on the over bed table. The resident stated she forgot to give the inhalers back to the nurse and confirmed the nurse left the inhalers for her to self-administer. She stated the nurse would come back and get them later. An interview was conducted with Employee D (Licensed Practical Nurse) on 10/24/22 at 11:00 AM. She stated she did not know where the [MEDICATION(S)] inhaler came from and has picked up the inhalers from Resident #54's room. She leaves the Incruse in her room to give the resident time to take it, then goes back to the room and retrieves the medication. She is not sure if Resident #54 has been evaluated to self-administer her medications. She did not watch her take the medication. She confirmed the facility does not allow her to leave medications unlocked at the bedside. Review of Resident #54's electronic medical record revealed a quarterly self-administration of medication observation dated 9/3/22 indicating the resident does not want to self-administer medications and staff are to administer the resident's medications. The evaluation section revealed the resident is not appropriate to self-administer any medications. Review of the admission minimum data set with an assessment reference date of 9/7/22 revealed the resident has a BIMS (brief interview for mental status) of 14 indicating she is cognitively intact. Review of the facility policy for Self-Administration Assessment Form (revised 1/28/20) revealed each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the resident and the other residents of the healthcare center. If the resident desires to self-administer medications, an assessment is conducted by the Licensed Nurse to assess the individual's cognitive, physical, and visual ability to carry out this responsibility. Bedside storage of medications is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer. The manner of storage prevents access by other residents.

Based on observations, resident interviews, and staff interviews the facility failed to provide sufficient nursing staff to ensure residents receive required assistance and services in a timely manner for 5 of 12 sampled residents. (Residents 2, 3, 4, 5, and 11) The findings include: During an interview with resident number 3 on 10/4/21, the faceplate of the call light was observed to be hanging from the wall. The surveyor asked the resident to initiate the call light to report the faceplate to staff. The resident initiated the call light at 9:34 AM and the call light was visible outside the door. At 9:46 AM, a housekeeper and maintenance staff passed by the room but did not answer the call light or check on the resident. At 10:10 AM, a therapy staff passed by the room but did not answer the call light or check on the resident. The call light was answered by a certified nursing assistant (CNA) at 10:11 AM. On 10/4/21 at approximately 1:17 PM, the surveyor was walking down the middle hall, the bathroom emergency call light for room [ROOM NUMBER] was observed to be on. At approximately 1:25 PM a nurse was observed to answer the call light and 2 certified nursing assistants were observed to be sitting on the couch in the middle hall TV area near room [ROOM NUMBER]. On 10/4/21 at approximately 2:32 PM, 2 certified nursing assistants were observed to be sitting in the TV room on the middle hall. An interview was conducted with resident number 2 on 10/4/21 at approximately 9:10 AM. She stated at times it has taken 2 hours for staff to answer her call light and assist her. An interview was conducted with resident number 4 on 10/4/21 at approximately 10:47 AM. She stated she uses her call light daily and no one answers, she has to call the main phone line to the facility to get help. She usually needs her pain medication and sometimes has to wait a long time to receive the medications. She indicated it was frustrating to have to wait so long for pain medication. An interview was conducted with resident number 5 on 10/4/21 at approximately 1:19 PM. She stated she had been in the facility about 2 weeks and she had to wait 1 hour and 45 minutes once when she was soiled with diarrhea for the staff to respond to her call for assistance. She stated she has had to wait 30 minutes or more at least 4 times to be changed when she was soiled. 3-4 times per day she waits longer than 30 minutes for staff to answer her call light and assist her. An interview was conducted with resident #11 on 10/7/21 at approximately 3:37 PM. He stated he had been in the facility about 2 weeks and several times he had to wait an hour for the staff to answer his call light, usually to assist him back to bed. Multiple anonymous staff interviews were conducted on 10/4/21, all staff stated they were fearful of losing their jobs if they revealed too much during the interview. In the afternoon on 10/4/21, an interview was conducted with anonymous staff member A, who stated the facility does not have adequate staff to meet the resident needs, but was not aware of care not getting done, the staff member stated that call light response time could be better. The staff member further stated that they had noticed CNAs sitting around and if they had more support from management, they may be able to address this issue. In the afternoon on 10/4/21, an interview was conducted with anonymous staff member B, who stated that legally the facility has enough staff to meet the residents needs but that certain CNAs will sit around and staff have trouble getting the CNAs to work. They need leadership. They need backup. In the afternoon on 10/4/21, an interview was conducted with anonymous staff member C, who stated staffing is terrible, they are always shorthanded, and that many people have quit. The staff member stated some CNAs will stay on the hall and do their jobs while others sit on the porch outside. The staff member further stated that call lights just go off. The staff member offered that the supervisors are aware of it, including the Director of Nursing (DON). The facility has hired a new group of people they just started have not been here 2 weeks. The staff member stated that they cannot do the CNAs job as well as their own and stated the management staff seem to be scared of some CNAs and afraid to discipline staff. In the afternoon on 10/4/21, an interview was conducted with anonymous staff member D, who stated there are problems with staffing here. The staff member also verified that sometimes CNAs will be outside on the porch or in TV area, then other staff have to text them and tell them their call lights are on. There is not a process to sign out for breaks and sign in. The staff member stated some of the CNAs will yell at staff if they say anything.

Based on observation, staff interview, policy review, and Centers for Disease Control (CDC) website review, the facility failed to ensure staff conduct coronavirus testing in a separate location and apply appropriate personal protective equipment (PPE) prior to obtaining specimens for testing during 1 of 1 observation of coronavirus staff testing. The findings include: An observation of the Infection Preventionist (registered nurse) obtaining a nasal swab specimen intended for coronavirus testing from a staff member was conducted on 6/29/2021 at 11:35 AM. The Infection Preventionist (IP) was observed to wear a surgical mask and gloves to collect a nasal specimen from the employee. The IP did not wear a gown or eye protection during the specimen collection. The IP was observed to collect the specimen from the employee in an open hallway in front of the skilled care unit nurse's station with no barriers or curtains in place. Three residents were observed to be across the hall from the nurses station in the dining area. An interview was conducted with the IP on 6/29/2021 at approximately 11:38 AM. The IP stated she was not aware of the CDC guidelines as to where testing should be conducted. The IP stated she was not aware of any facility policy regarding COVID-19 testing. She confirmed she wore only a mask and gloves to swab the staff member. She stated she would only have to wear a gown on a COVID unit to test an individual. Review of the facility COVID-19 Partner Testing Protocol (revised 6/17/2020 Version: 2) revealed on page 2, #4: Location and Equipment Preparation: The specimen collection and testing will be conducted in a clinically safe and appropriate manner. Only the Testers and individual being tested should be in the room/area when the specimen collection is being performed. The Tester will be responsible for donning appropriate PPE and for cleaning, at appropriate intervals, all surfaces used to conduct specimen collection. Review of the CDC website regarding Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing last updated on February 26, 2021, retrieved on 7/01/2021 at approximately 2:00 PM, from https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html https://www.cdc.gov, revealed healthcare providers collecting specimens or working within 6 feet of patients suspected to be infected with [CONDITION(S)]-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown. The website also indicated for indoor specimen collection activities, designate separate spaces for each specimen collection testing station, either rooms with doors that close fully or protected spaces removed from other stations by distance and physical barriers, such as privacy curtains and plexiglass.

Based on interview and review of the facility's policy and procedure, the facility failed to maintain an antibiotic stewardship program that included protocols and a system to monitor antibiotic use. The findings include: On 01/30/2020 at approximately 2:05 PM, an interview was conducted with the Infection Control Nurse (ICN) regarding facility's Infection Control Program which includes the facility's Antibiotic Stewardship program. The ICN was not familiar with the facility's antibiotic stewardship program and protocols. She thought maybe the Consultant Pharmacist led this program, however, there was no data or system in place to monitor the facility's antibiotic use. A review of the facility policy and procedure entitled Antibiotic Stewardship Program, last revised- 06/13/2018, indicates As part of the Infection Prevention and Control Program, PruittHealth will implement and maintain an Antibiotic Stewardship Program (ASP). Under the direction of the Medical Director and Director of Health Services (DHS), the ASP is designed to promote appropriate use of antibiotics and improve patient health outcomes. The goal of ASP is to promote appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use.

Based on record review, staff interview, and policy review the facility failed to develop a baseline care plan to include the minimum information necessary to properly care for a newly admitted resident for 1 of 6 sampled newly admitted residents. (resident #272) The findings include: Review of resident #272's record revealed she was admitted to the facility on [DATE]. The resident was admitted with a [DIAGNOSES REDACTED]. The resident was currently receiving antipsychotic medications, anti-anxiety medications, and antidepressant medications. Review of the resident's baseline care plan revealed the care plan included nutrition, activities, advanced directives, and discharge planning. No other care plans were in place for the resident. An interview was conducted with Nurse J, a Licensed Practical Nurse, on 1/29/20 at 1:15 PM. Nurse J stated when the resident is admitted , the nurses on the floor start the baseline care plan and the interdisciplinary team finishes the plan within 48 hours. Then they present a copy to the family or resident. She reviewed the record and confirmed the baseline care plan did not include hospice or medications, nor the minimum information necessary to care for the resident. Review of the facility policy regarding Care Plans revealed the policy of the facility was for each resident to have a person-centered baseline care plan completed and implemented within 48 hours of admission.

Based on record reviews, policy reviews, and interviews, the facility failed to develop care plans for 6 of 20 residents sampled (#54, #34, #48, #42, #3, and #229). The findings include: Resident #54 During a record review, Resident #54 was identified as having difficulty with hearing and had a hearing aid. A review of progress notes identified the resident was very hard of hearing. The care plan reviewed did not include a care plan to address the resident's difficulty with hearing. During an interview with the Social Services Director on 1/29/20 at 5:13PM, the Social Services Director reviewed the record of Resident #54 and agreed there was no care plan to address difficulty with hearing and one should have been created based upon the Minimum Data Set (MDS) assessment. Resident #34 A record review for Resident #34 revealed an admission MDS assessment which included 1 stage I pressure ulcer and 2 stage II pressure ulcers. Further documentation revealed the pressure ulcers had healed. Review of the care plan did not include a care plan related to skin integrity. An interview on 1/29/20 at 1:31PM, with the Regional Nurse Consultant confirmed there was no care plan related to skin integrity. The wound care nurse confirmed, in an interview on 1/30/20 at 8:45AM, Resident #34 should have a care plan addressing skin integrity. During an interview on 1/30/20 at 11:41AM, Nurse J, an MDS coordinator, the record for Resident #34 was reviewed and she confirmed the resident was coded for pressure injuries and should have had a care plan related to skin and there was no skin care plan in the record. Resident #48 A record review for Resident #48 indicated an MDS assessment which identified resident #48 had a need for oxygen therapy, [DIAGNOSES REDACTED].#48 as having pain with as needed pain medication orders. There was no care plan for Resident #48 related to respiratory concerns or pain. During an interview on 1/30/20 at 11:41AM, Nurse J, an MDS coordinator, confirmed there were no care plans related to respiratory concerns or pain for Resident #48 and care plans for both care areas should have been developed based on the MDS assessment. Resident #42 Review of Resident #42's record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The admission minimum data set with an assessment reference date of 12/24/19 revealed a [DIAGNOSES REDACTED]. An interview was conducted with Nurse L (minimum data set registered nurse) on 1/30/20 at 11:57AM. She stated the resident care plans did not include diabetes or list interventions related to diabetes. Resident #3 Resident #3 was admitted [DATE]. A review of the resident's most recent Quarterly MDS, 10/12/2019, under Section H - Bowel and Bladder indicates the resident is frequently incontinent of bladder, and always incontinent of bowel. A review of Resident #3's current care plans, last revised 10/01/2019, revealed that there was no care plan developed to address the resident's bowel and bladder needs. Resident #229 Resident #229 was admitted on [DATE] following Orthopedic surgery. A review of the resident's most recent MDS, 12/28/2019, under Section J - Health Conditions - indicated the resident had received pain medication within the last 5 days. The resident did not have a care plan for pain. On 01/29/2020 at approximately 1:20PM, Resident #229's care plans and MDS were reviewed with the MDS Coordinator. The MDS Coordinator, Nurse L, stated the resident should have had a care plan for pain.

Based on observation, record reviews, and interviews, the oxygen tubing and water canisters for humidified oxygen were not changed for 3 of 3 residents observed using oxygen concentrators (#5, #8, #48). The findings include: On 1/27/20 during initial tour observations, the oxygen concentrator for Resident #8 was observed to have no date on the water canister or nasal cannula tubing in use. The water canister for Resident #5 was dated 1/20/20 and the nasal cannula tubing in use was not labeled with a date. The water canister for Resident #48 was dated 1/13/2020 and there was no label dating the tubing for the nasal cannula in use. Orders for Resident #48 included change oxygen supplies weekly. Further observations revealed the canisters and tubing for residents #5, #8, and #48 continued to be used from 1/27/20 through observations on 1/29/20 and the canisters remained with the dates and lack of labeling initially identified on 1/27/20. On 1/29/20 at approximately 10:30AM, Nurse N and the nurse Unit Manager both stated the process for oxygen tubing and water canisters is to change them weekly on Sundays. Following the interview, Nurse N observed the tubing and canisters for residents #5, #8, and #48 and confirmed the canisters and tubing were not dated appropriately and did not indicate having been changed. The water canisters for residents #5 and #8 were observed to be empty during the observations with Nurse N on 1/29/20.

Based on interview and record review the facility failed to indicate a duration for as needed medications for 4 of 5 residents sampled for unnecessary medications (#13, #42, #272, and #227). The findings include: Resident #13 A review was conducted of Resident #13's medications which revealed an order for [REDACTED]. A review of the pharmacy recommendations and physician response was conducted which revealed a recommendation on 1/29/2020 which stated that the resident was on an as needed [MEDICATION NAME] and that regulation required a timeframe for the order. The physician's documented response was, Patient is doing well on current treatment, continue as ordered. There was no further explanation regarding why the as needed medication needed to continue and there was no clarification for an end date. On 1/30/20 at 10:16 AM, an interview was conducted with the Regional Nurse Consultant. At that time she stated that the order should have had an end date and that any new orders for these types of medications should be no longer than 14 days. She then stated, I discussed that yesterday with the nurse practitioner. Resident #42 Review of resident #42's record revealed the resident had a current physician order dated 1/3/2020 for [MEDICATION NAME] 0.5 mg by mouth once a day as needed (prn) for anxiety. The record revealed no stop date for the [MEDICATION NAME] and no provider rationale for the need to extend the as needed [MEDICAL CONDITION] mediation beyond a 14 day period. An interview was conducted with the regional nurse consultant on 1/30/2020 at 12:51 PM. She observed the prn [MEDICATION NAME] order and stated it should not extend beyond 14 days unless a rationale is provided from the prescriber. Resident #272 Review of resident #272's record revealed the resident had current physician orders dated 1/21/2020 for [MEDICATION NAME] 1 ml (mililiters) oral every 6 hours prn and [MEDICATION NAME] 1 mg by mouth every 6 hours prn. The record revealed no stop date for the [MEDICATION NAME] and [MEDICATION NAME], and no provider rationale for the need to extend the as needed [MEDICAL CONDITION] mediation beyond a 14 day period. An interview was conducted with the regional nurse consultant on 1/29/2020 at 12:36 PM. She stated any prn [MEDICAL CONDITION] med should be written with a 14 day stop date; the stop date does not automatically come from the pharmacy. Resident #227 Review of resident #227's record revealed the resident had a physician order dated 01/21/2020 for [MEDICATION NAME] 1 mg one tablet by mouth three times a day as needed for anxiety. The physician order failed to include a 14 day limitation without rationale for extended use. Review of the facility policy for Monitoring of Antipsychotics (revised 7/23/19) revealed #7. PRN (as needed) orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication. All PRN antipsychotic orders will be automatically stopped after 14 days.

Based interview and record review the facility failed to complete the required facility assessment for 1 of 1 assessments required. The findings include: A review of facility assessment was conducted which revealed no mention of staffing numbers or mention of percentage of staff with appropriate competencies and appeared incomplete. On 1/30/2020 at 4:10 PM, an interview was conducted with the Administrator. At that time he stated that he was aware that the facility assessment was not complete. He agreed that it was missing documentation about the type and amount of staffing needed along with needed competencies.

Based on record review and staff interviews the facility failed to maintain a complete and accurately documented medical record for 1 of 5 sampled residents reviewed for unnecessary medications. (resident #42) The findings include: Review of resident #42's record revealed no bowel movement (BM) had been documented for the resident from 1/17/20 -1/30/20. The resident had a [DIAGNOSES REDACTED]. An interview was conducted with employee M (certified nursing assistant) on 1/30/20 at 12:13 PM. She stated the resident had a small bowel movement on 1/29/20 and she did not document the BM. She then stated the resident usually had a good BM about every other day. An interview was conducted with employee N (licensed practical nurse) on 1/30/20 at 12:18 PM. Employee N stated the nurses are to pull a BM report, but she was not sure how often. She stated she was not aware of any process the facility had to monitor resident BMs.

Based on record review, policy review and interview, the facility failed to provide abuse prevention and reporting training to 8 non-clinical staff members. The findings included: Upon review of facility documentation, 8 non-clinical staff members, staff E, S, Y, Z, AA, BB, CC and DD were identified as not having training for abuse prevention and reporting. On 1/29/20 at 1:09PM, in an interview, the administrator stated staff education records were reviewed and found some staff had not completed abuse education. On 1/29/20 at approximately 4:45PM, the administrator provided copies of a staff roster with titles, hire dates, and red ink notations identifying those who had not completed abuse training. Staff [NAME] was not on the list and the administrator was asked specifically about this staff member and confirmed staff [NAME] had no abuse training. The administrator explained staff Y, Z, BB, and S had the training completed on 1/29/20 after it was brought to the facility's attention the training was required. The administrator added someone was going to the home of staff AA in the evening to complete training, staff CC would be trained upon returning to the facility and staff DD was off for the week. Staff R, a registered nurse in the role of the clinical competency coordinator, was identified as being responsible for training within the facility. On 1/30/20 at 9:07AM, staff R confirmed not having provided training to non-clinical staff regarding abuse and was not aware whether non-clinical staff had been trained. A policy titled Training on Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, with a most recent review date of 1/8/2019 identified the policy for training applied to all new partners and volunteers of the corporation and training should occur during initial orientation and have mandatory on-going in-service training at least annually.