Pulaski Health Care Center

In the surveyor’s words

From the most serious findings on record at Pulaski Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Aug 22, 2025

  Based on observation, record review, and interview, the facility failed to serve food under sanitary conditions related to touching food with gloved hands after touching other items for 1 of 1 kitchen observed. (The Main Kitchen). This had the potential to affect 44 residents who received food from the kitchen. Finding includes: During the follow-up tour of the kitchen on 8/20/25 at 10:01 a.m., [NAME] 1 was observed preparing pureed enchiladas. The cook had donned clean gloves. She had an enchilada prepared in a mixing bowl. Using her gloved hands, she scooped out the enchilada into the blender. She removed a set of gloves, as she had another pair of gloves on underneath. The Dietary Food Manager brought [NAME] 1 a container of broth mix from the cooler. […]

• No harm, potential for more than minimal, patternF584Aug 22, 2025

  Based on observation, record review and interview, the facility failed to provide a safe, comfortable environment related to elevated hot water temperatures in 2 of 5 units observed for water temperatures. (North and Northeast Units)Finding includes:During the initial facility tour on 8/18/25 at 2:45 p.m., observations by hand of the water temperature were felt to be elevated in resident bathrooms on the North and Northeast Units. The Maintenance Assistant checked the water temperature in Rooms NE4, N2 and N3 and indicated it was 130 degrees Fahrenheit.During an interview at that time, the Maintenace Assistant indicated that was hottest he had seen the water temperature. He indicated rooms were checked randomly once a week. […]

• No harm, potential for more than minimal, patternF812Sep 23, 2022

  Based on observation, record review, and interview, the facility failed to maintain a sanitary kitchen related to boxes of food stored on the floor in dry storage and freezer, boxes stacked to the ceiling and around the fan in the freezer and a dirty vent above the food preparation counter. This had the potential to affect 34 residents that received food prepared in the Main Kitchen. Findings include: 1. During the initial kitchen tour with Dietary Aide (DA) 1, on 9/19/22 at 10:15 a.m., the following was observed: - In the dry storage room, there were boxes of applesauce, cups, salt and cherry pie filling sitting directly on the floor. - In the walk in freezer, there were boxes of food items sitting directly on the floor. […]

• No harm, potential for more than minimal, isolatedF585Aug 13, 2026

  Based on record review and interview, the facility failed to file a grievance from a resident's family who voiced concerns about not wanting a staff member to administer a resident's medications for 1 of 1 resident reviewed for grievances. (Resident B)Finding includes:A closed record review for Resident B was completed on 8/13/26 at 11:58 a.m. Diagnoses included, but were not limited to, dementia, congestive heart failure, diabetes mellitus, and tremors.An Employee Communication Form, completed by the Director of Nursing (DON) on 6/10/26, indicated QMA 1 was instructed to not go into a resident's room because the family did not want her to provide care for the resident. She was given the directive on 6/9/26. […]

• No harm, potential for more than minimal, isolatedF686Nov 13, 2025

  Based on record review, observation, and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing related to a lack of treatment change or new interventions implemented timely after the pressure ulcer had worsened for 1 of 3 residents reviewed for pressure ulcers. (Resident C)Finding includes: Record review for Resident C was completed on 11/12/25 at 2:13 p.m. Diagnoses included, but were not limited to, anemia, diabetes mellitus, and end stage renal disease.The Quarterly Minimum Data Set (MDS) assessment, dated 10/13/25, indicated the resident was cognitively intact. The resident was dependent on staff for bed mobility and transfers. The resident was admitted to the facility with two stage 2 pressure ulcers. […]