PruittHealth - Shepherd Hills

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Nov 20, 2025

  Based on observations, staff interviews, record review, and review of the facility policies titled, Infection Prevention-Hand Hygiene and Infection Control-Linen and Laundry, the facility failed to ensure that staff consistently followed appropriate hand hygiene and sanitation practices. Specifically, staff failed to perform hand hygiene and sanitize surfaces during wound care for 1 of 14 residents (R)(R51) and failed to perform hand hygiene between resident contacts. These deficient practices placed residents at increased risk for infection transmission and cross-contamination.Findings include:Review of the facility's policy titled Infection Prevention-Hand Hygiene revised 10/15/2024 revealed under section D. Indications Requiring Hand Wash or Hand Rub, number 5. […]

• No harm, potential for more than minimal, widespreadF880Jul 11, 2024

  Based on observations, staff interviews, record review, and review of the facility policies titled, Glucometer Cleaning and Disinfecting, Infection Control, Linen and Laundry, and review of the manual for the blood glucose monitoring system, the facility failed to use proper infection control practices for one of 24 diabetic residents (R) (R61) during blood glucose monitoring, not properly covering clean linen during transport through the facility, and not properly securing an indwelling catheter. The deficient practice had the potential to spread microorganisms. […]

• No harm, potential for more than minimal, isolatedF677Jul 29, 2026

  Based on record review, resident and staff interviews, and review of the facility's policy titled Care Plans, the facility failed to provide assistance with showers/baths for one of three Residents (R) (R1) reviewed for Activity of Daily Living (ADL) care. The deficient practice increased the potential for poor hygiene, odor and compromised psychosocial well-being. Findings include:Review of the policy titled, Care Plans, revised 10/21/2025, documented Definitions: .Person-Centered Care-Focus is on the patient/resident as the center of control. Supports each resident in making his or her own choices . Documented under admission Comprehensive Plan of Care, .3. […]

• No harm, potential for more than minimal, isolatedF609Nov 20, 2025

  Based on staff interview, record review, and review of the facility policy titled, Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Mission Statement, the facility failed to report physical abuse by staff to the State Survey Agency (SSA) within the required timeframe for one of six sampled residents (R) (R21) reviewed for abuse and neglect. The failure of the facility to report this incident has the likelihood of leading to future unreported injuries of unknown origin, with the potential to affect resident's quality of life.Findings include: Review of the policy titled Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Mission Statement revised 112/1/2016, revealed the policy of the facility to… […]

• No harm, potential for more than minimal, isolatedF641Nov 20, 2025

  Based on records review and staff interviews, the facility failed to ensure accurate Minimum Data Set (MDS) assessment for one of 40 sampled residents (R) (R21). Specifically, the facility failed to accurately code Section P (Restraints and Alarms) for R21. The deficient practice resulted in not accurately representing R21's health status. Findings include:Review of R21's electronic medical record (EMR) admission Record under the MDS tab revealed R21 was admitted to the facility with diagnoses that included but not limited to, dementia with other behavioral disturbances and depression.Review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/27/2025 indicated R21 does not use wander/elopement alarm.Review of the quarterly MDS with an Assessment… […]