PruittHealth-Town Center

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 25, 2024

  Based on record review, observations, staff, and physician interviews, the facility failed to provide care in a safe manner when a resident fell out of bed during incontinence care for 1 of 3 residents reviewed for accidents (Resident #11). Resident #11 sustained a laceration to the right side of his forehead requiring 6 sutures and a C-1 (cervical vertebra #1) fracture that required long-term use of a cervical collar for neck support. Resident #11 did not experience any neurological changes. The findings included: Resident #11 was admitted to the facility 11/6/2019 with diagnoses including Parkinson' disease. […]

• No harm, potential for more than minimal, widespreadF812Jan 26, 2023

  Based on observations and staff interviews, the facility failed to dry 6 of 6 steamer pans before stacking for storage. This had the potential to affect food served to all residents. Findings included: The kitchen was observed on 1/23/2023 at 9:12 AM. A metal shelving unit was noted with stacked steamer pans ready for use. Two medium pans were separated and noted to be wet in between the pans. Two large pans were separated and noted to be wet in between the pans, and two small pans were separated and noted to be wet between the pans. The dietary manager (DM) was interviewed at the time of the observation. The DM reported the pans should have been air dried completely before being stacked for storage and use. […]

• No harm, potential for more than minimal, patternF695Jun 25, 2024

  Based on observations, record reviews, and staff and resident interviews, the facility failed to post precautionary and safety signs that indicated the use of oxygen for 5 of 5 residents reviewed for respiratory care (Resident #47, Resident #55, Resident # 26, Resident # 20, and Resident # 3). The findings included: 1. Resident # 47 was readmitted to the facility on [DATE] with diagnoses that included bacterial pneumonia, chronic systolic (congestive) heart failure and pneumonitis due to inhalation of food and vomit. A review of the most recent Minimum Data Set (MDS) significant change assessment dated [DATE] revealed Resident # 47 was cognitively intact. […]

• No harm, potential for more than minimal, patternF812Jun 25, 2024

  Based on observations and staff interviews, the facility failed to remove a dented canned good item stored for use, seal open-to-air frozen food, ensure pans were dry before being stacked, and cover facial hair for 2 of 2 kitchen observations. These practices had the potential to affect food served to residents in the facility. The findings included: a. The kitchen was toured on 6/16/2024 at 10:55 with the Assistant Dietary Manager. The rack of canned goods was observed, and a can of spaghetti sauce was noted to have a large dent on the side of the can. The dent was approximately 3 inches long and dented approximately 1/2 inch into the can, and the paper label on the can was torn in the dent. […]

• No harm, potential for more than minimal, patternF565Jan 26, 2023

  Based on review of Resident Council Meeting Minutes, resident and staff interviews, the facility failed to resolve repeated concerns voiced at Resident Council meetings regarding call lights not being answered timely and cold coffee being served for 3 of 6 months (10/27/22, 11/30/22 and 1/4/23) reviewed for Resident Council. Findings Included: A record review of the 10/27/22 Resident Council minutes revealed the following concerns: a. Call lights were being turned off and staff stating they would come back, and they would not come back. The response from nursing was that a nursing staff huddle had been completed to address call lights. A record review of the 11/30/22 Resident Council minutes revealed the following concerns: a. Breakfast and Coffee was cold when received by residents. […]