Pruitthealth - Macon

During an interview on 5/14/2025 at 4:47 pm, the Administrator stated her expectation was that each department had adequate staff and that they were adequately trained, and the managers were going back and doing quality checks to make sure that whatever they delegated was being done.

08/27/2025

N o. 0938-0391

IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

05/15/2025 Pruitthealth - Macon 2255 Anthony Road Macon, GA 31204

potential for actual harm

PASARR screening for Mental disorders or Intellectual Disabilities NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 52212 Based on staff interviews and record review, the facility failed to ensure two of 20 sampled residents (R) (R112 and R10) were referred to the appropriate state-designated authority for a review for a Preadmission Screening and Resident Review (PASRR) Level II.

This failure had the potential to place R112 and R10 at risk of not receiving specialized services.

• Review of R112's electronic medical record (EMR) revealed R112 was admitted to the facility on [DATE]

with diagnoses including, but not limited to, bipolar disorder, major depressive disorder, and anxiety.

Review of R112's Admission Minimum Data Set (MDS) assessment, dated 9/22/2023, revealed Section A (Identification Information) documented R10 had not been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition.

Section I (Active Diagnoses) documented diagnoses included psychiatric/mood disorder and depression, other than bipolar.

Review of R112's Quarterly MDS assessment, dated 3/26/2025, revealed Section I (Active Diagnoses) documented diagnoses included psychiatric/mood disorder and depression, other than bipolar.

Review of R112's care plan, dated 10/2/2023, revealed a Problem area of signs and symptoms of mood distress related to a diagnosis of bipolar disorder.

Review of R112's EMR revealed there was no PASRR Level II.

In an interview on 5/15/2025 at 1:30 pm, the Director of Health Services (DHS) confirmed R112 did not have a PASRR Level II and stated she could not explain why it was not completed.

• Review of R10's Quarterly MDS assessment dated [DATE] revealed Section N (Medications) revealed

R10 received antipsychotic, antianxiety, and antidepressant medications.

Review of R10's care plan revealed Problem areas of behavioral symptoms; psychotropic drug use related to antipsychotic, antianxiety, and antidepressant medications; elopement risk; and cognitive loss/dementia.

Review of R10's EMR revealed diagnoses including, but not limited to, schizoaffective disorder and bipolar disorder.

Review of R10's EMR revealed there was no PASRR Level II.

In an interview on 5/1/2025 at 4:00 pm, the Social Worker confirmed R10 should have been submitted for a PASRR Level II based on her diagnoses.

08/27/2025

N o. 0938-0391

IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

05/15/2025 Pruitthealth - Macon 2255 Anthony Road Macon, GA 31204

potential for actual harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Based on observations, staff interviews, record review, and review of the facility's policy titled Care Plan, the facility failed to implement the individualized care plan for one of 50 sampled residents (R) (R52) related to high fall risk.

The deficient practice had the potential to place R52 at risk for safety and injuries, which could lead to hospitalization and a diminished quality of life.

Review of the facility's policy titled Care Plan Policy, revised 7/27/2023, revealed under Policy Statement: It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice.

The policy also revealed under Admission Comprehensive Plan of Care: .4.The care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners.

Short and concise instructions, which can be understood by all partners, should be written and have a relationship to the problem and goal(s), and should include any PASSAR Level II intervention as needed.

Some interventions require all disciplines to be involved in the implementation, while others may only involve specific team members.

When approaches that involve the certified nursing assistant (CNA) have been added to the care plan, those approaches should also be included on the CNA Care Record or Resident Profile/Care Plan.

Review of R52's care plan, last revised on 4/28/2025, for R52 revealed the resident is at risk for falls related to impaired mobility, cerebral vascular accident (CVA) with hemiparesis, behaviors, and a witnessed fall with major injury fracture to the right distal femur on 2/5/2025.

Approaches include placing frequently used items within reach, placing the right leg knee immobilizer to maintain alignment of the right leg until follow up with Ortho (orthopedic), assist resident with getting out of bed when agitated, non-skid socks, fall mats and encourage resident to use call light for assistance. It was noted that the resident refuses to wear the immobilizer.

Observation on 5/12/2025 at 12:09 pm revealed R52 was observed in private room, lying in bed.

There were no fall mats on the floor next to the bed.

Observation on 5/14/2025 at 9:03 am revealed R52 sitting up in bed eating breakfast.

Non-skid socks were not on R52.

Fall mats were not in place.

On 5/14/2025 at 1:28 pm, R52 was observed lying in bed.

The bed was in a low position.

Non-skid socks were not on R52's feet.

Fall mats were not in place next to the bed.

Licensed Practical Nurse (LPN) EE entered the room and confirmed that R52 was at high risk for falls due to a recent fall. LPN EE also revealed that high fall risk residents should have their beds in a low position, and items should be in reach.

Residents should be encouraged to use their call light for assistance. He also confirmed that the resident did not have fall mats on the floor nor non-skid socks on.

08/27/2025

N o. 0938-0391

IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

05/15/2025 Pruitthealth - Macon 2255 Anthony Road Macon, GA 31204

potential for actual harm

Interview on 5/15/2025 at 1:39 pm with the Director of Health Services (DHS) revealed that any interventions related to fall risk would be on the care assist dashboard for the Certified Nursing Assistants (CNA) to view the activities of daily living (ADL) profile, nurses would provide the information in report, and that fall risk would also be on the resident's face sheet.

The DHS also confirmed that she expected the CNAs to follow the interventions.

Interview on 5/15/2025 at 1:48 pm with CNA HH confirmed that she would know if a resident were on fall precautions because it would be in the ADL care area of the Care Assist record, but was not sure if interventions were listed. CNA HH also revealed that no shift report was done, but if there was a change with the resident, her nurse would tell her.

08/27/2025

N o. 0938-0391

IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

05/15/2025 Pruitthealth - Macon 2255 Anthony Road Macon, GA 31204

potential for actual harm

Assist a resident in gaining access to vision and hearing services. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 51215 Based on observations, resident and staff interviews, and record review, the facility failed to ensure services for hearing were provided for one of 50 sampled residents (R) (R106).

The deficient practice had the potential to cause a decrease in R106's quality of life.

Review of the admission record revealed that R106 was admitted to the facility with diagnoses that include, but are not limited to, paraplegia, acquired absence of the left leg below the knee, shigellosis, methicillin-susceptible Staphylococcus aureus infection, osteomyelitis, and other lesions of the oral mucosa.

Review of R106's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Section C (Cognitive Patterns) documented a Brief Interview of Mental Status score of 15 (indicating little to no cognitive impairment).

Section B (Hearing, Speech, and Vision) documented moderate difficulty with hearing.

Review of R106's care plan, dated 1/14/2025, revealed a Problem of Resident is noted to be hear [sic] of hearing.

Speaker may have to adjust his/her tone in which resident is able to hear.

And a goal stating Resident will makes his needs known thru next review.

Interventions include Face the resident when speaking.

Provide with materials for written communication.

Repeat phrases as needed.

Rephrase if necessary.

Speak clearly and adjust tone as needed.

Speaker to adjust his/her tone in which resident is able to hear.

Review of R106's Physician's Orders revealed no referral to audiology from the time of admission, nor any order for further assessment or evaluations.

In a concurrent observation and interview on 5/12/2025 at 11:43 am, R106 revealed that he did not have a hearing aid and requested a repeat of the question or statement multiple times. R106 stated he didn't hear well and asked the surveyor to speak louder. R106 also requested that staff remove their mask so he could read their lips during conversation. He stated he had not been evaluated for a hearing device or the cause of his impairment and that no one at the facility had spoken to him about his hearing loss.

In an interview on 5/14/2025 at 2:11 pm, the Social Services Director (SSD) confirmed that R106 was not on her current referral list for audiology consultation and revealed that R106 had not been seen by an audiologist that she was aware of.

The SSD confirmed a note in R106's electronic medical record (EMR) that referred him to audiology in January, and confirmed there was no follow-up or visit to the audiologist.

In an interview on 5/14/2025 at 2:59 pm, the Director of Health Services (DHS) stated the facility provided audiology services and that R106 should have been evaluated on admission and all necessary referrals made.

The DHS confirmed there had been no audiology referrals made for R106 since admission and confirmed that his care plan and MDS both indicated that he was hard of hearing with no interventions of referral to audiology.

08/27/2025

N o. 0938-0391

IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

05/15/2025 Pruitthealth - Macon 2255 Anthony Road Macon, GA 31204

potential for actual harm

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Based on observations, staff and resident interviews, and record review, the facility failed to ensure one of 50 sampled residents (R) (R127) received restorative nursing as ordered by the physician.

This deficient practice had the potential to place R127 at risk for medical complications, such as decreased range of motion of her left hand.

Review of the R127's Quarterly Minimum Data Set (MDS) assessment, dated 2/17/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview Mental Status (BIMS) score of 14 (indicating little to no cognitive impairment).

Section GG (Functional Abilities and Goals) documented upper extremity impairment on one side.

Section O (Special Treatments, Procedures, and Programs) documented that the resident did not receive Restorative Nursing or splint/brace assistance.

Review of R127's electronic medical record (EMR) revealed diagnoses including, but not limited to, cerebrovascular accident (CVA), hemiplegia, and hemiparesis.

Review of R127's Physician's Orders revealed an order dated 4/24/2024 for LUE (left upper extremity) hand orthodic three to four hours daily as tolerated.

Observation on 5/13/2025 at 10:00 am revealed R127 had a contracted left hand.

Further observation revealed that R127 did not have a brace on her left hand.

Observation on 5/14/2025 4:50 pm revealed R127 did not have a hand brace on her left hand. In an interview, R127 stated she rarely wore the brace and had not worn it in a couple of weeks.

Observation on 5/15/2025 at 10:42 am revealed R127 did not have a brace on her left hand.

In an interview on 5/14/2025 at 1:45 pm, Certified Nursing Assistant (CNA) NN stated R127 received restorative care for her lower body and did not receive restorative care for her upper body.

In an interview on 5/14/2025 at 2:10 pm, Licensed Practical Nurse (LPN) JJ confirmed R127 had a physician's order for a splint for her LUE.

She further stated she was unsure if the resident ever wore the splint.

In an interview on 5/15/2025 at 12:05 pm, the Director of Health Services (DHS) confirmed R127's physician's order for a left hand splint and stated her expectation was for staff to ensure the splint was applied as ordered.

08/27/2025

N o. 0938-0391

IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

05/15/2025 Pruitthealth - Macon 2255 Anthony Road Macon, GA 31204

potential for actual harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 50374 Based on observations, staff interviews, record review, and review of the facility's policy titled Smoke Free Policy, the facility failed to ensure three of seven residents (R) (R19, R20, and R49) who smoked had complete and accurate smoking assessments. In addition, the facility failed to ensure one of seven R (R19) who smoked had a care plan related to smoking.

These deficient practices had the potential to place R19, R20, and R49 at an increased risk of accident hazards related to smoking.

Review of the facility's policy titled Smoke Free Policy, revised date 12/12/2023, revealed the Assessment and Care Planning section included, . 2.

Grandfathered patients/residents will be assessed, utilizing the Smoking Observation Form in the Electronic Health Record (EHR), by a Licensed Nurse upon admission, re-admission, and/or with a significant change. A re-admission smoking care plan shall be developed by the licensed nurse on the Admission Interim Care Plan Form, or electronically. 3. An assessment utilizing The Smoking Observation Form in the EHR is completed at least quarterly thereafter if the answer to either of the first two (2) questions indicates the resident either smokes or has a history of smoking.

After completion of the assessment, the care planning team shall review and utilize the assessment when developing the resident's care plan.

• Review of R19's Face Sheet revealed an admitted [DATE] with diagnoses including, but not limited to,

dementia, psychotic disturbance, mood disturbance, and anxiety.

Review of R19's Annual Minimum Data Set (MDS) assessment, dated 4/11/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview of Mental Status (BIMS) of 11 (indicating moderate cognitive impairment).

Section J (Health Conditions) documented no tobacco use.

Review of R19's care plan revealed no care plan related to smoking.

Review of R19's clinical record revealed no smoking assessments.

Review of the facility-provided smoking list revealed R19 was identified as a tobacco user.

Observation on 5/12/2025 at 2:30 pm revealed R19 was in the designated smoking area smoking a cigarette.

• Review of R20's Face Sheet revealed an admitted [DATE] with diagnoses including, but not limited to,

major depression disorder, generalized anxiety disorder, delusional disorder, and nicotine dependence.

Review of R20's Quarterly MDS assessment, dated 3/3/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview of Mental Status (BIMS) of 7 (indicating severe cognitive impairment).

Section J (Health Conditions) documented no tobacco use.

08/27/2025

N o. 0938-0391

IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

05/15/2025 Pruitthealth - Macon 2255 Anthony Road Macon, GA 31204

potential for actual harm

Review of R20's care plan revealed R20 was at risk for injury related to going outside for supervised smoke breaks.

Review of the facility-provided smoking list revealed R20 was identified as a smoker.

Review of R20's Smoking Observation Form, dated 4/23/2024, revealed the assessment was incomplete and marked as in process.

• Review of R49's revealed diagnoses including, but not limited to, unspecified dementia, schizophrenia,

major depressive disorder, peripheral vascular disease, unspecified glaucoma, heart failure, unspecified, chronic obstructive pulmonary disease (COPD), drug induced subacute dyskinesia, major depressive disorder, mild cognitive impairment, intermittent explosive disorder, Alzheimer's disease with early onset, and major depressive disorder.

Review of R49's Quarterly MDS assessment, dated 5/1/2025, revealed Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 3 (indicating severe cognitive impairment).

Review of R49's Annual MDS assessment, dated 3 19/2024, revealed Section J (Health Conditions) documented tobacco use.

Review of R49's care plan revealed a Problem area of The resident is noted to be at risk for injury related to the resident is a smoker.

The resident requires supervised smoke breaks.

Last Reviewed/Revised: 04/22/2025.

The Long Term Goal Target Date 07/22/2025 revealed The resident will not have any injuries related to smoking thru [sic] the next review.

Interventions included 5/14/2019 cigarettes and lighters in the activities office, educate the resident of the smoke breaks, notify the md [sic] (medical doctor) as needed, provide the resident with a smoking apron to prevent injury.

Review of R49's Quarterly Observation dated 2/10/2025 revealed the resident had a past history of smoking, but currently not smoking.

Observation of R49 on 5/12/2025 at 2:30 pm revealed R49 in the designated smoking area, smoking a cigarette.

Observation of R49 on 5/13/2025 at 2:05 pm revealed him smoking in the designated area.

During an interview on 5/15/2025 at 10:15 am, the Director of Health Services (DHS) confirmed R19 did not have a smoking assessment or an area for smoking on the care plan, R20 did not have a completed and updated quarterly assessment, and confirmed that R49's quarterly assessment related to smoking was not accurate.

The DHS continued to state that smoking assessments were completed by the nursing staff and should be done quarterly and annually.

She revealed that if a resident was not assessed or accurately assessed, and if care plan interventions were not in place, staff would not know what to monitor.

08/27/2025

N o. 0938-0391

IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

05/15/2025 Pruitthealth - Macon 2255 Anthony Road Macon, GA 31204

potential for actual harm

Provide safe and appropriate respiratory care for a resident when needed.

Based on observations, staff interviews, and record reviews, the facility failed to ensure oxygen (O2) was administered as prescribed by the physician for two of 20 residents (R) (R22 and R95) receiving O2.

This deficient practice had the potential to place R22 and R95 at risk of respiratory complications and a diminished quality of life.

• Review of R22's electronic medical record (EMR) revealed diagnoses including, but not limited to,

sarcoidosis, shortness of breath, and eosinophilic asthma.

Review of R 22's Quarterly Minimum Data Set (MDS) assessment, dated 3/14/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment).

Section O (Special Treatments, Procedures, and Programs) revealed R22 received O2 therapy.

Review of R22's care plan, last reviewed/revised 4/29/2025, revealed Problem area stating the resident was at risk for respiratory complications related to diagnosis of asthma and shortness of breath.

The Approach revealed O2 has an ordered flow rate.

Review of R22's Physician's Orders included an order dated 1/16/2024 for O2 at 3 liters per minute (LPM) via a NC as needed (PRN).

Observation on 5/13/25 at 9:33 am revealed R22 in her bed, wearing oxygen via a NC.

Observation revealed that the flow rate of the O2 was set between 1.5 and 2 LPM. R22 stated she could not feel the O2 flowing through the NC and called for a nurse.

• Review of R95's EMR revealed diagnosis, including but not limited to, acute respiratory failure with

hypoxia.

Review of R95's Quarterly Minimum Data Set (MDS) assessment, dated 3/14/2025, revealed Section O (Special Treatments, Procedures, and Programs) revealed R95 received O2 therapy.

Review of R95's Physician's Orders revealed an order dated 4/30/2025 for O2 at 3 LPM continuous.

Observation on 5/12/2025 at 1:06 pm revealed R95 lying in bed with an NC not in place in his nostrils, and the flow meter was set on 2.5 LPM.

Observation on 5/13/2025 at 9:41 am observed R95 lying in bed, appeared asleep, and with the O2 not in place.

Observation on 5/14/2025 at 8:52 am revealed R95 lying in bed with O2 in place, and the flowmeter was set on 1 LPM.

08/27/2025

N o. 0938-0391

IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

05/15/2025 Pruitthealth - Macon 2255 Anthony Road Macon, GA 31204

potential for actual harm

In an interview on 5/14/2025 at 9:15 am, Licensed Practical Nurse/Unit Manager (LPN/UM) EE reviewed O2 orders for R22 and R95 and confirmed the physician's orders were for O2 at 3 LPM continuous for both residents. LPN/UM EE stated that it was his expectation for nursing staff to review the physician orders and ensure the O2 settings were correct each shift.

In an interview on 5/15/2025 at 11:54 am, the Director of Health Services (DHS) revealed that she expected nursing staff to review and monitor O2 orders each day.

08/27/2025

N o. 0938-0391

IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

05/15/2025 Pruitthealth - Macon 2255 Anthony Road Macon, GA 31204

potential for actual harm

Provide and implement an infection prevention and control program.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Infection Prevention and Control Plan, the facility failed to ensure staff followed infection control practices during wound care for one of 18 residents (R) (R106) with pressure ulcers. In addition, the facility failed to properly store personal care supplies in one of 11 resident restrooms observed.

These deficient practices had the potential to place R106 at increased risk of infection related to cross-contamination, and had the potential to increase the risk of cross-contamination to the residents residing in room A1.

Review of the facility's policy titled Infection Prevention and Control Plan, revised 6/21/2024, revealed the Procedure section included A.

Infection Control Administrative Structure . 10.

Partners are responsible for implementing the Infection Prevention and Control Policy and Procedures.

• Review of R106's Quarterly Minimum Data Set (MDS) assessment, dated 3/20/2025, revealed Section M

(Skin Conditions) documented the resident had three stage four pressure ulcers, and received pressure ulcer care, applications of nonsurgical dressings, and application of ointments/medications.

Review of R106's care plan revealed a Problem area for impaired skin integrity and has pressure ulcers to the sacrum, right buttock, left hip/buttock, right leg, and right foot.

Approach included treatment and wound care per the provider's orders.

Review of R106's diagnoses included, but not limited to, pressure ulcer of the sacral region, unspecified open wound, and osteomyelitis.

Observation of wound care on 5/14/2025 at 11:21 am with Licensed Practical Nurse (LPN) AA revealed that she prepared supplies on a lined bedside table. LPN AA washed her hands and donned her gown and gloves.

She cleaned the right ischial wound, removed her gloves, and donned (put on) another pair of gloves without performing hand hygiene.

She then applied the dressing, removed her gloves, and work surface.

LPN AA went on to perform a dressing change to the sacral wound.

She donned gloves and did not perform hand hygiene between removing the previous gloves and donning the new gloves.

After cleaning the wound, LPN AA removed her gloves and used sanitizer before donning clean gloves.

She then assisted with removing fecal matter from the bed with a gloved hand, removed the glove from that hand, did not perform hand hygiene, and donned a new glove before continuing the wound care.

In an interview on 5/14/2025 at 1:40 pm, the Infection Preventionist (IP) and the Director of Health Services (DHS) stated that all staff have been educated on several occasions on the importance of infection control and hand hygiene.

The DHS stated that it is her expectation that all nursing staff follow infection control practices.

08/27/2025

N o. 0938-0391

IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

05/15/2025 Pruitthealth - Macon 2255 Anthony Road Macon, GA 31204

potential for actual harm

• Observations on 5/12/2025 at 9:55 am, 5/14/2025 at 2:55 pm, and 5/15/2025 at 12:10 pm revealed one

wash basin and one urinal in the restroom of room A1, unlabeled, uncovered, and exposed to the environment.

In a concurrent observation and interview on 5/15/2025 at 12:39 pm, the DHS confirmed that the basin and urinal should be covered and labeled.

She stated they would be thrown away.

08/27/2025