PruittHealth-Rockingham

In the surveyor’s words

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

• Immediate jeopardy, patternF689Mar 26, 2021

  Based on observations, record review, and resident, staff, nurse practitioner, and facility physician interview, the facility allowed a resident to smoke in his room for over a year (9/1/2019 through 3/24/2021) in a building where oxygen was used and stored or 1 of 4 sampled residents (Resident #23) which was a fire hazard. There was a high likelihood for a fire to occur while this resident smoked in his room and oxygen was in use in the facility. The facility also failed to lock the wheels on the sit to stand lift device during transfer with a mechanical lift (Resident #41), and failed to implement fall interventions (Residents #50) for 2 of 5 sampled residents reviewed for supervision to prevent falls. Immediate Jeopardy began on 9/8/2019 for Resident #23. […]

• No harm, potential for more than minimal, patternF585Feb 24, 2025

  Based on record review and staff interviews, the facility failed to maintain documentation of resolved grievances and evidence of the results of all grievances for 9 of 13 months reviewed (December 2023 to August 2024). Findings included: During an interview with Administrator #1, the current administrator, on 2/17/25 at 4:20 PM she stated the grievances from December 2023 through August 2024 were not available and could not be reviewed because she did not have the grievances. On 2/17/25 at 4:30 PM the Social Worker was interviewed. She stated the former administrator, Administrator #2, would not allow her to assist in the grievance process. […]

• No harm, potential for more than minimal, patternF602Feb 24, 2025

  Based on record reviews, and pharmacist and staff interviews, the facility failed to protect the resident's right to be free from misappropriation of narcotic medications (oxycodone and hydrocodone) prescribed to treat pain. This affected 6 of 6 residents reviewed for misappropriation (Residents #6, #54, #223, #55, #27, and #224. The findings included: A review of the facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property effective 12/1/01, revised 10/27/20 and reviewed 1/11/24, revealed it is the policy of PruittHealth and its affiliated entities to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation,… […]

• No harm, potential for more than minimal, patternF658Feb 24, 2025

  Based on record reviews, Pharmacist, and staff interviews, the facility failed to follow professional standards to prepare and administer medications to residents one at a time and had pre-poured pills in medication cups left on top of a medication cart (D hall) prepared by Nurse #6 for dispensing during the 9:00 PM medication pass. This affected 13 of 27 residents residing on D hall (#40, #226, #228, #58, #54, #227, #223, #225, #7, #36, #224, #55, and #20). The findings included: A review of the facility policy titled Medication Administration: General Guidelines effective 4/1/98, revised 4/10/24 and reviewed 7/22/24 read in part under the headline titled Procedure: Medications are administered at the time they are prepared. Medications are not pre-poured/pre-set/pre-crushed. […]

• No harm, potential for more than minimal, patternF636Nov 16, 2023

  Based on record reviews and staff interviews, the facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required time frame for 4 of 19 residents selected to be reviewed for Resident Assessments (Residents #20, #178, #180 and #182). The findings included: A. Resident #20 was admitted to the facility on [DATE]. A record review was completed 11/15/2023. Resident #20's most recent annual MDS was dated 10/5/23. The electronic medical record indicated this assessment was in process and had not been completed. B. Resident #178 was admitted to the facility on [DATE]. A record review was completd 11/15/2023. Resident #178's most recent MDS was dated 10/9/23 and was coded as an admission assessment. […]