Every finding on record at PruittHealth - Carrollton

Based on observations, staff and resident interviews, record reviews, and review of the facility's policy titled Self-Administration of Medications by Patients/Residents, the facility failed to assess two of 27 sampled residents (R) (R44 and R21) to determine whether it was clinically appropriate for them to safely self-administer medications. This deficient practice had the potential to place R44 and R21 at risk for unsafe medication administration. Findings include: Review of the facility's policy titled Self-Administration Protocol, revised 1/28/2020, revealed the Policy Statement stated, Each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patient/resident of the healthcare center. Medication self-administration also applies to family members who wish to administer medication. The Procedure section included . 4. If the patient/resident or family member demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted. 1. Review of the clinical record for R44 revealed diagnoses including, but not limited to, dermatitis (skin inflammation). Review of the Quarterly Minimum Data Set (MDS) assessment for R44, dated 10/21/2025, revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Section M (Skin Conditions) documented that the resident received an application for ointment/medication. Review of the care plan for R44 revealed no documentation for self-administration of medication. There was no order for self-administration of medication. Review of the physician's orders for R44 revealed an order dated 9/9/2025 for nystatin (an antifungal) powder 100,000 units/gram, apply a small amount topically, once a day. Review of the electronic medical record (EMR) for R44 revealed no assessment for self-administration of medication. Observation on 1/9/2026 at 8:30 am revealed a container of nystatin powder on R44's bathroom sink. In an interview on 1/9/2026 at 8:30 am, Registered Nurse (RN) AA stated there were no residents on Hall 100 who self-administer medication. In an observation and interview on 1/9/2026 at 8:45 am, RN AA confirmed the medication was for R44, and it should not be in his bathroom, but instead in the wound care treatment cart. In an interview on 1/10/2026 at 1:23 pm, the Director of Health Services (DHS) stated that prescribed medication should not be in the resident's room unless the interdisciplinary team determines the resident is capable and competent to self-administer the medication. The DHS continued to state that rounds should be conducted by the nurse managers, and they would move forward with educating their nurses. 2. Review of the EMR for R21 revealed diagnoses including, but not limited to, muscle weakness and allergic rhinitis. Review of the admission MDS assessment for R21, dated 12/25/2025, revealed that section C (Cognitive Patterns) documented a BIMS score of 13, indicating little to no cognitive impairment. Review of the physician's orders for R21 revealed no orders for lubricant eye drops or for self-administration of medication Review of the care plan for R21 revealed no care plan for self-administration of medication. Review of the EMR for R21 revealed that a Medication Self-Administration Assessment form had not been completed. Observations on 1/9/2026 at 9:35 am and at 1:23 pm, of R21's room, revealed that a bottle of OTC lubricant eyedrop was sitting on top of the bedside table. In a concurrent observation and interview on 1/10/2026 at 10:01 am, Certified Nursing Aide (CNA) BB confirmed the eye drops in R21's room and stated they should not have been there. In a concurrent interview and record review of the EMR for R21 on 1/10/2026 at 1:23 pm, the DHS confirmed that the eye drops in R21's room should not have been present, as the resident does not have orders to self-administer medications. She stated moving forward, staff will complete assessments, receive education, and she will ensure all nursing personnel understand the self-administration process.

Based on observation, staff interviews, and review of the facility policy titled, Food Ordering, Receiving, and Storage, the facility failed to ensure opened food items were dated. This deficient practice had the potential to affect residents receiving an oral diet. The census was 34. Findings include: Review of the facility policy titled, Food Ordering, Receiving, and Storage, reviewed 8/3/2017, revealed the Storage and Rotation Guideline section stated the facility must date and store all food items received on delivery day. During the initial Kitchen tour on 11/12/2024 at 9:50 am with the Dietary Manager (DM), observation of the walk-in freezer revealed an unlabeled and undated opened bag of frozen sweet potatoes. Observation of the walk-in refrigerator revealed an unlabeled and undated open block of Swiss cheese and one unlabeled and undated carton of heavy cream. During an interview on 11/13/2024 at 1:35 pm, the DM confirmed the unlabeled and undated food items and stated the Dietary [NAME] and Dietary Aides were responsible for labeling, dating, and proper storage of food. She further stated food items should be labeled with storage and opened dates when stored and opened. She stated labeling and dating food items was critical to maintaining food safety.

Based on observations, staff interviews, and review of the facility's policy titled, Medication Administration: Hand Hygiene, the facility failed to maintain infection control practices by not ensuring hand hygiene during two of three medication administration observations. This deficient practice had the potential to increase the potential for cross-contamination and spread of infection. The facility census was 34. Findings include: Review of the facility's policy titled, Medication Administration: Hand Hygiene, review date 10/14/2024, documented Policy Statement: It is the policy of (name of facility) Pharmacy Services that partners will use appropriate hand hygiene during medication administration. Appropriate hand hygiene reduces the spread of germs and decreases the spread of infections. The Procedure section included 1. During medication administration, use hand hygiene before and after touching a patient . after touching a patient's immediate surroundings, and before and after glove removal. Observation on 11/13/2024 at 9:06 am revealed Licensed Practical Nurse (LPN) AA did not hand sanitize before and after administering medications to the residents during the medication pass. Observation on 11/13/2024 at 12:35 pm revealed LPN BB did not hand sanitize before and after administering medications to the residents during the medication pass. In an interview on 11/13/2024 at 1:27 pm, LPN AA confirmed she did not use hand sanitizer or wash her hands before and after administering medications to the residents. She stated she should have hand sanitized because it gets rid of germs and prevents germs from being carried to the residents or between them. In an interview on 11/13/2024 at 1:31 pm, LPN BB confirmed he did not sanitize his hands before and after administering medications to the residents. He stated he did not hand sanitize consistently, and sanitizing hands consistently was about infection control and preventing infection from person to person. He stated it was important to prevent residents from getting infections. In an interview on 11/13/2024 at 1:40 pm, the Director of Health Services (DHS) stated her expectations were for the staff to practice hand washing and sanitizing hands during the care of the residents and for the nurses to sanitize or wash their hands during medication administration. She stated the outcome of not performing hand hygiene could spread germs from one person to another.

Based on record reviews, staff interviews, and review of the facility's policy titled, Care Plans, the facility failed to develop a Baseline Care Plan (BCP) for one of 29 sampled residents (R) (R190). Specifically, the facility failed to develop a baseline care plan that included narcotic administration. The facility census was 34. Findings include: Review of the facility's policy titled Care Plan revised 7/27/2023 documented under Procedure: New Admission Baseline Plan of Care: 1. Upon a new admission, a baseline care plan will be developed by admitting nurse/nurses in conjunction with other IDT, the patient/resident and /or patient/resident representative. The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission. Review of Electronic Medical Records (EMR) revealed R190 was admitted on [DATE] with diagnoses including but not limited to chronic pain. Review of R190's Minimum Data Set (MDS) assessment dated [DATE] documented in Section C (Cognition) a Brief Interview for Mental Status (BIMS) score of 13, which indicated R190 had intact cognition, Section J (Health Condition) experiences pain frequently, Section N (Medications) receives opioids. Review of R190's care plan dated 11/8/2024 documented no focus areas for narcotic administration. Review of Physician Orders for R190 dated 11/7/2024 documented orders included but not limited to hydrocodone-acetaminophen - Schedule II tablet; 10-325 mg (milligrams); amt (amount): 1; oral Three Times A Day 08:00 AM, 12:00 PM, 08:00 PM for chronic pain. Neurontin (gabapentin) capsule; 400 mg; amt: 1; oral Three Times A Day 08:00 AM, 12:00 PM, 04:00 PM for chronic pain. Tizanidine tablet; 4 mg; amt: 1; oral Twice A Day - PRN (as needed) PRN 1, PRN 2 for chronic pain. Interview on 11/14/2024 at 9:26 am with R190 revealed she stated she was admitted to the facility on e week ago. She stated she had constant pain which started after having cervical surgery and chronic lumbar problems. She stated she fell and fractured her right hip and right leg, so she had constant chronic pain. She stated she needed pain medication round the clock and if she did not get it on schedule, her pain got out of control. She stated the staff gives her pain meds on schedule and as needed. Interview on 11/14/24 at 9:39 am with the MDS Director revealed the BCP is to be initiated within 24 hours. Five care areas are to be initiated by nursing staff which includes falls, pain, activities of daily living (ADLs), discharge planning and advance directives. The MDS Director confirmed the BCP was not done. He stated the BCP was an initial driver which showed the direction towards the resident's goals. Interview on 11/14/2024 at 11:50 am with Licensed Practical Nurse (LPN) DD revealed she stated anybody can initiate the care plan and update it. She stated the night nurses usually did it for admissions but if they did not, MDS would check and update it. She stated if a resident's care plan was not updated, the outcome would be inconsistent in the care of the resident. Interview on 11/14/2024 at 11:56 am with the Director of Health Services (DHS) revealed she stated the nurses usually initiated and updated care plans and MDS followed up to ensure it was done. She stated if MDS did not follow up, she would do it. She stated she did not do the BCP for R190. She stated her expectations were for the nurses to update the care plan. She further stated doctor's orders still have to be followed and the care plan was done based on doctor's orders so the resident would not benefit from the doctor's orders if the care plan was not updated.

Based on record reviews, staff interviews, and review of the facility's policy titled, Care Plans, the facility failed to review and revise a comprehensive care plan for one of 29 sampled residents (R) (R5) related to oxygen (O2) therapy. The deficient practice had the potential to cause R5 to not receive the necessary treatment required to provide and meet her needs. Findings include: Review of facility's policy titled Care Plans revised 7/27/2023 documented under Care Plan Review and Update: 1. Care Plan updated/ reviews will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. Review of electronic medical records (EMR) revealed R5 was readmitted to the facility on [DATE] with diagnoses including but not limited to pneumonia. Review of Minimum Data Set (MDS) dated [DATE] documented no information. Review of R5's care plan dated 10/7/2024 revealed no documentation for O2 administration since admission on 11/5/2024 to survey date 11/13/2024. Review of Physician's orders dated 11/9/2024 documented included but not limited to Oxygen: Oxygen at 2-3 LPM (liters per minute) via NC (nasal cannula) to keep sats (oxygen saturation) 90% and above PRN (as needed) Every Shift Days 07:00 AM - 03:00 PM, Evenings 03:00 PM - 11:00 PM, Nights 11:00 PM - 07:00 AM. Review of Nurses Progress Notes dated 11/9/2024 documented Received nurse report on resident returning to facility with DX (diagnosis) Pneumonia and A-Fib (Atrial Fibrillation). New medications updated on MAR (Medication Administration Record) and Dr (doctor) notified. Interview on 11/14/2024 at 9:31 am with MDS Director revealed he stated the nurses initiated care plans on admission and he checked the care plans to ensure it was done. He confirmed the care plan for R5 did not include O2 administration since her readmission to the facility on [DATE]. He stated if the care plan was not updated, the outcome could be delay in care of the resident.

Based on observations, staff interviews, and review of the facility's policy titled, Controlled Substances for HealthCare Centers, the facility failed to maintain the correct narcotic count for one of 29 sampled residents (R) (R190). The deficient practice had the potential to cause drug-control issues and potentially cause negative effects for residents. The facility census was 34. Review of the facility's policy titled Policy Controlled Substances for HealthCare Centers revised 4/30/2024 documented under Policy Statement: . Reconciliation of controlled substances will be performed at the end of each shift by licensed professional nurses . Under Accounting: 1. A physical inventory of all controlled substances is conducted at each shift change by the incoming and outgoing licensed professional nurses. 2. The inventory is documented on the Controlled Drug Shift Audit Sheet. Review of Electronic Medical Records (EMR) revealed R190 was admitted on [DATE] for diagnosis including but not limited to chronic pain. Review of R190's Minimum Data Set (MDS) assessment dated [DATE] documented in Section C (Cognition) a Brief Interview for Mental Status (BIMS) score of 13, which indicated R190 had intact cognition, Section J (Health Condition) experiences pain frequently, Section N (Medications) receives opioids. Review of R190's care plan dated 11/8/2024 documented no focus areas for narcotic administration. Review of Physician Orders dated 11/7/2024 documented orders included but not limited to hydrocodone-acetaminophen - Schedule II tablet; 10-325 mg (milligram); amt (amount): 1; oral Three Times A Day 08:00 AM, 12:00 PM, 08:00 PM for chronic pain. Neurontin (gabapentin) capsule; 400 mg; amt: 1; oral Three Times A Day 08:00 AM, 12:00 PM, 04:00 PM for chronic pain. Tizanidine tablet; 4 mg; amt: 1; oral Twice A Day - PRN PRN 1, PRN 2 for chronic pain. Observation and interview on 11/13/2024 at 12:50 pm revealed during medication administration Licensed Practical Nurse (LPN) AA checked doctor's orders and removed Hydrocodone/acetaminophen 10-325 mg 1 tablet from the medication card and administered it to R190. There were 45 tablets left on the medication card, but the narcotic book documented 46 tablets remaining. The discrepancy was pointed out to LPN AA who stated she was not aware of the discrepancy, and she recounted the tablets and checked the narcotics book again. She confirmed there were 45 tablets left on the medication card, but the narcotic book documented 46 tablets remaining. She stated she did not count the tablets on the medication card at change of shift that morning and she only signed the narcotics book. Interview with the Director of Health Services (DHS) revealed she confirmed there were 45 tablets left on the medication card, but the narcotic book documented 46 tablets remaining. She stated her expectation was that the nurses should count the narcotics and document each count at change of shifts in the Controlled Drug Record. Interview on 11/13/2024 at 5:25 pm with the Administrator revealed she stated her expectations were for the oncoming nurse to check off the narcotics with the outgoing nurse at change of shift. She stated the nurse should ensure the pill count was correct, and it matched the count documented in the narcotic controlled drug log. It was to be signed off by both nurses and if the count was off, the DHS was to be notified. She stated if the narcotics count was not correct, the outcome could be a potentially negative affect for the resident.

Based on observations, resident and staff interviews, the facility failed to maintain a homelike environment related to disrepair of a ceiling on one hall and peeling/dirty wallpaper on three of three hallways (100, 200, and 300 halls). Findings include: Observation on 6/2/2023 at 11:00 a.m. revealed wallpaper peeling from the walls of the 100 hall. Specifically in the following areas: 1. Wallpaper peeling outside room [ROOM NUMBER] and between the therapy office. 2. Wallpaper peeling over the door of the oxygen storage room, janitor closet, and between the health clinic doors. Additionally, wallpaper was seen peeling in front of the nurses' station by the soiled linen room. .Observations on 6/2/2023 at 10:19 a.m. revealed peeling wallpaper from the walls on the 200 hall in the followings places: 1. Above the exit door at the end of the 200 hall. 2. Above room [ROOM NUMBER] door and above room [ROOM NUMBER] door, vertically down the wall between room [ROOM NUMBER] and 212. 3. Above room [ROOM NUMBER] door. 4. Above room [ROOM NUMBER] door, vertically down the wall between room [ROOM NUMBER] and 211. 5. Above room [ROOM NUMBER] door, vertically down the wall between room [ROOM NUMBER] and 208. 6. Above room [ROOM NUMBER] door, vertically down the wall between room [ROOM NUMBER] and 207. 7. Above room [ROOM NUMBER] door, vertically down the wall between room [ROOM NUMBER] and 206. 8. Above room [ROOM NUMBER] door, vertically down the wall between room [ROOM NUMBER] and 204. 9. Above room [ROOM NUMBER] door. There were also some discolored spots throughout on the wallpaper on the 200 hall. Observed disrepair of the ceiling in the hall off of the 200 hall past the exit door on the right. Observation on 6/2/2023 at 1:00 p.m. revealed wallpaper peeling beside and over the doors from rooms 301 to 306 on the 300 hall. Interview on 6/2/2023 at 1:30 p.m. with Staff Personnel AA revealed the facility was doing renovations next door at the Assisted Living building and that was where everything goes for the appearance of the buildings. She further stated that it would take forever to have renovations completed to this facility.

Based on staff interview, record review, review of the facility's policy titled, Care Plan, the facility failed to implement the care plan interventions for weekly weights and to consult with the registered dietician for one of eight Residents (R) (R#21) with a significant weight loss. Specifically, the facility failed to ensure that R#21 was assessed by the Registered Dietician for noted significant weight loss, and to ensure that the plan of care for R#21 addressed current weight status. Findings include: Review of the facility's policy titled, Care Plan dated 12/31/1996 indicated: 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. 3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing, and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial needs that are identified in the comprehensive assessment. Review of the care plan initiated 2/17/2023, revealed that R#21 was at risk for alteration in nutrition/hydration related to dysphagia (difficulty swallowing) and being edentulous (toothless). Interventions to be implemented included monitoring and recording weight. Registered Dietician consults as needed. Interview on 6/4/2023 at 9:42 a.m. with the Director of Health Services (DHS) reviewed the weights for R#21. The DHS confirmed that there were inconsistencies with obtaining R#21's weights per the facility's policy. She also confirmed there were no nutritional assessments completed by the registered dietician for R#21's significant weight loss. Refer to F-tag 692.

Based on observation, resident and staff interviews, record review, and review of the facility's policy titled, Smoke Free Policy, the facility failed to have a process in place to evaluate and monitor the use of a vaping device for one of one Resident (R) (#15). Findings include: Review of the facility's policy titled, Smoke Free Policy revised 10/12/2022 revealed the new smokeless cigarettes', including vapor devices, are not to be used in (inside) the healthcare center. These are to be used . as outlined in this policy for patients/ residents who are . permitted to smoke. Patients/ residents who are grandfathered in will be assessed for risks/hazards prior to smoking .During the assessment for the smoker, the assessor will ensure the grandfathered resident is able to demonstrate use of the smoking device (e-cigarettes' or vaping device) per manufacturers recommendations. An assessment . will be completed quarterly .After completion of the assessment, the care planning team shall review and utilize the assessment when developing the resident's care plan. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#15 had a Brief Interview for Mental Status (BIMS) score of 15 indicating R#15's cognition was intact. R#15 was independent with dressing, eating and personal hygiene. R#15 had diagnoses including progressive neurological condition, dementia, and Parkinson's disease. Review of the clinical record revealed no documented evidence that R#15 had an assessment or care plan related to using a vaping device. Observations on 6/2/2023 at 9:34 a.m. and 6/3/2023 at 2:10 p.m. revealed R#15 with a vaping device. R#15 was not observed using the vaping device at any time throughout the survey. Observation and interview on 6/4/2023 at 10:40 a.m. revealed R#15 was alert and oriented with no impairments to upper extremities. R#15 stated he did have a vaping device and the facility staff knew he had it and would help in any way needed related to the use of the vaping device. R#15 did not currently have a roommate. Interview on 6/4/2023 at 1:13 p.m. with Licensed Practical Nurse (LPN) CC revealed she did know that R#15 had a vape device. She was unsure of how a resident was evaluated for the ability to use a vape device. There was nothing that outlined the expectation of when residents need to utilize a vape. She said she had never seen R#15 vape inside. R#15 usually sat outside to use the vape device and staff had never witnessed him vaping in his room or inside the facility. Interview on 6/4/2023 at 1:57 p.m. with Regional [NAME] President (RVP) BB revealed R#15 was evaluated back in 2020 and denied smoking. She was unable to provide any evaluations, education, or any documentation related to R#15 using a vape device. Phone interview on 6/16/2023 at 2:00 p.m. with the Director of Nursing (DON) revealed that the facility identifies as a non-smoking facility. She stated that the facility does not have any residents in the facility who smoke.

Based on observation, staff interviews, record review, and review of the facility's policy titled, Weight Monitoring Program, the facility failed to provide evidence that a nutrition assessment was completed by the Registered Dietitian for one of eight Residents (R) (R#21) with a significant weight loss. Specifically, the facility failed to ensure that R#21 was assessed by the Registered Dietician for current weight loss status. Findings include: Review of the facility's policy titled, Weight Monitoring Program dated 6/13/2018 indicated: Policy Statement- It is the policy of the facility for each patient/resident to be weighed once a month unless otherwise ordered by the physician or contraindicated by patient/resident's medical condition. The Weight Team will review patient/resident weights monthly to determine risk of weight loss or weight gain. 3. Hospital Returns: A hospital return weight will be obtained and documented on the Yearly Weight Record Form within 24 hours and then the patient/resident will be weighed weekly times four weeks and/or until the weight is stable. 4. Significant Weight Loss: Patients/residents with a Significant Weight Loss will be weighed weekly and reviewed weekly for a minimum of four weeks until their weight is stable or increasing. All significant weight losses/gains will be addressed on the patient/resident's care plan. The care plan will be updated upon identification of the Significant Weight Loss or Significant Weight Gain. Review of the document titled, Position Description Job Title: Dietary Manager. Job Purpose: Plans, organizes, develops, and directs the overall operation of the Dietary Department in accordance with current federal, state, and local regulations governing the center and as directed by the Administrator. Key Responsibilities: 3. Prepares for visit from Registered Dietitian and comply with recommendations as outlined in company policies and procedures. Review of the document titled Position Description Job Title: Dietitian. Job Purpose: In collaboration with the Dietary Manager and Administrator, allocates department resources in an efficient and economic manner to ensure each resident receives food in amount, type, consistency, and frequency to maintain usual body weight and nutritional values. Key Responsibilities: 2. Completes appropriate clinical documentation in the medical record pertaining to the nutritional needs of the patient in accordance with the patient comprehensive assessment and care plan to comply with regulatory guidelines. 3. Completes and updates dietary assessments as part of the comprehensive resident assessment process. Review of the Face Sheet for R#21 revealed diagnoses of, but not limited to dysphagia, gastro-esophageal reflux, and constipation. Review of R#21's annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 00 which indicated severe cognitive impairment. Section G-Functional Status revealed the resident requires supervision with meals. Section K-Swallowing/Nutritional Status revealed swallowing problems none. The resident height was 65 inches and weighs 237 pounds (lbs.). No weight loss or weight gain. Nutritional Status triggered as an area of concern on the Care Area Assessment Summary (CAAS). Review of R#21's quarterly MDS dated [DATE] revealed a BIMS was coded as 00 which indicated severe cognitive impairment. Section G revealed the resident requires supervision with meals. Section K revealed swallowing problems none. The resident height is 65 inches and weighs 204 pounds (lbs.). A weight loss not on prescribed weight loss regimen. Review of the care plan initiated 2/17/2023, revealed that R#21 is at risk for alteration in nutrition/hydration related to dysphagia (difficulty swallowing) and being edentulous (toothless). Interventions to be implemented included monitoring and recording weight. Registered Dietician consults as needed. Review of the Electronic Medical Record (EMR) Vital Signs: Weight results revealed the following weights: 11/2/2022-241 pounds (lbs.) 11/18/2022-237 lbs. 1/19/2023-217 lbs. 2/10/2023-215 lbs. 3/22/2023-211 lbs. 5/1/2023-204 lbs. There was no documented weights for December 2022 and April 2023. Review of the EMR revealed no documentation of any nutritional assessment for R#21 from a registered dietician. Observation on 6/3/2023 at 8:50 a.m. of R#21 Lying in bed with eyes closed and lightly snoring. R#21's untouched meal tray was in front of her. Observation on 6/3/2023 at 1:58 p.m. during mealtime of R#21 in bed with eyes closed. Interview on 6/3/2023 at 8:52 a.m. with Certified Nursing Assistant (CNA) EE who was in charge of the care for R#21 revealed R#21 needed assistance and prompts with meals. CNA EE stated she attempted several times to wake R#21 for breakfast and was unsuccessful. Interview on 6/3/2023 at 2:15 p.m. with CNA EE revealed R#21 did not eat breakfast or lunch today. Interview on 6/4/2023 at 9:42 a.m. with the Director of Health Services (DHS) confirmed there were no nutritional assessments completed by the registered dietician for R#21's significant weight loss. Phone interview on 6/4/2023 at 12:04 p.m. with Dietary Manager (DM) DD revealed it was her responsibility to make sure the registered dietician nutritional assessments were completed on the high-risk residents which include residents that return from the hospital and with significant weight loss. The DM stated she did not communicate with the registered dietician of R#21's hospital returns and significant weight loss.

Based on observations, interviews and review of polices titled Labeling, Dating and Storage, the 'Daily' and 'Weekly' cleaning schedules, and the USDA Quick Reference Shelf Life List, the facility failed to properly label food items with a 'USE BY' date; and failed to maintain a clean steam table. This deficient practice had the potential to affect 41 of 41 residents. Findings include: A review of the policy titled Labeling, Dating, and Storage dated 2014 and revised 10/18/17 revealed: It is the policy for all partners who assist in handling, preparing, serving, and storing food and beverage items to follow the proper procedures for labeling, dating, and storage to ensure proper food safety. This applies to all Dietary partners. 1. Food and/or beverage items will be properly labeled with the name of the item, and a use by date. 2. Foods will be stored in their original containers or in an approved container or wrapped tightly with film, foil, etc. and clearly labeled with the name of the item and the use by date. 3. Prepared food and/or beverage items will be discarded according to the USDA Quick Reference Shelf Life List. 4. Those items that require refrigeration and/or require refrigeration once they have been opened will be labeled with a use by date based on the USDA Quick Reference Shelf Life List. 5. All items sent to the floors and taken out of original containers, will have a use by date based on the USDA Quick Reference Shelf Life List. 6. Frozen items such as health shakes will have a use by date. A review of the undated USDA Quick Reference Shelf Life List as referenced in the facility policy: Labeling, Dating and Storage, revealed frozen lean fish storage is good for four months; frozen fatty fish storage for two to three months; frozen hard and soft cheeses up to six months; and frozen beef up to six months. There is no recommendation for frozen hash browns. The list revealed the following for refrigerated items: pork loin and turkey with dumplings - three days; hard cheese - one month; soft cheese - one week; hot foods, left over after meal period - 24 to 48 hours; cold foods left over after meal period - 24 to 48 hours. The Brief Summary Sheet of this document indicated leftovers should only be held for 72 hours, and then discarded. A review of the weekly cleaning schedule dated 2006 revealed the following items to be cleaned weekly by the cook or aide: wash all carts/bins; deep fryer; stove-inside and out; ovens-inside and out; chemical tray dish tray; chemical room-organized and straight; behind stove; under cooler and shelves and de-lime dishwasher. A review of the daily cleaning schedule with an issue date of (MONTH) 2001 revealed the following items to be cleaned daily by the cook and/or aide: clean inside and outside of trash can; restroom-clean sink, replace soap and hand towels as needed, clean inside and outside of trash can; staff office area-organized/no clutter/clean; carts-all cleaned inside and outside and out and dry; floors-all areas (behind and under equipment) - swept/mopped; dishcloths-cleaned and placed to dry, put into laundry; dish room-worktables/shelves clean, three compartment sink clean/dry; dishracks off of the floor; walls/floor clean, no debris; dish-machine-spray heads free of debris and proper chemicals dispensing; dining room tables-cleaned with water and chlorine bleach at 50-100ppm; all items to be re-stocked, juice, drink, milk, coffee; all cooler/refrigerator are to be washed down; microwave every use; stock on Thursday dry goods; cooler/freezer. An observation of the kitchen on 9/16/19 at 9:52 a.m. revealed food debris on the counters (food preparation surfaces) and plate holder. The walk-in freezer revealed Salisbury steak in a zip lock bag with no open date; an open bag of carrots that was not dated and fish with no open or use by date. The walk-in cooler revealed cabbage in a plastic container with a use by date of 9/15/2019; a zip lock bag of eggs with unreadable writing on the bag, and pimento cheese in a zip lock bag with a 'prep date' of 8/9/19 and no use by date on the label; the reach-in refrigerator had an unidentified food product in an unlabeled, undated, partially sealed plastic container with a blue lid. Observation and interviews on 9/18/19 at 12:40 p.m. and 2:16 p.m. with the DM she confirmed the steam table well was dirty with dirty water and food particles in it; build up at the bottom of the steam table pan and heavy build up on the water line, and the cooks and herself are responsible for the steam table and ensuring they are clean and filled to the appropriate level. She reviewed the cleaning schedules for the kitchen and indicated the typed version was confusing to the staff, so they do not use that one. She read the daily and weekly cleaning schedules and confirmed that the steam table was not listed as a piece of equipment to be cleaned on either form. She reported their training is provided on-line by the company and the previous dietary manager trained her, walking her through her responsibilities. During an observation and interview on 9/19/19 at 11:00 a.m. with the DM, she confirmed the missing 'USE BY' dates on the following food items: in the walk-in freezer pimento cheese with no use-by date; in the walk-in refrigerator, shredded cheese in a zip lock bag dated of 9/18/19; cheese in a serving container dated 9/17/19; pasta in a serving container dated 9/17/19 with a 9/16/19 date crossed out; red pimento pepper in a serving container dated 9/17/19; mixed vegetables in a serving container dated 9/18/19; mashed potatoes in a serving container dated 9/18/19 and cheese sauce in a serving container dated 9/16/19.

Based on observation, staff interviews and policy review, the facility failed to discard expired biological's and medical supplies prior to expiration date; also failed to maintain refrigerator used for medication storage in a sanitary manner by not allowing ice formation in the back of the refrigerator. The sample size was 21. Findings include: Review of the facility policy titled Medication Storage in the Healthcare Centers revised 9/15/17, Procedure 3. nurses are required to inspect medication storage facilities, including medication carts. Nursing staff who administer medications are responsible for cleaning and organization of medication carts and storage areas. Procedure 12. Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy. Observation on 9/18/19 at 9:24 a.m. the medication storage room revealed six culterette swabs in a basket on the counter that had expiration date of 6/2019. Further review of medication storage refrigerator revealed one unopened vial of insulin for a resident who was discharged in (MONTH) 2019 and one box of Orencia injectable for current resident that expired 4/2019. There was approximately six inch block of ice formation attached to back of medication refrigerator. Interview on 9/18/19 at 10:02 a.m. with Director of Nursing (DON), stated all nurses are supposed to be checking the refrigerator daily for temperatures and expired medications. When they identify medications that are discontinued or expired, they are to log the medications on a log sheet and keep them in a box, which is kept in the medication room. He stated that the pharmacy picks them up monthly. He stated it is also every nurse's responsibility to keep the refrigerator clean. Interview on 9/18/19 at 4:39 p.m. with DON revealed that Housekeeping/Maintenance staff are to clean out refrigerator every two months. He stated he will remove all meds/supplies from refrigerator before cleaning. He further stated that he expects the nurses to continue to check the refrigerator daily and remove expired medications, and clean it as needed.

Based on observation, documentation review, and staff interviews the facility failed to ensure preparation of one pureed food item conserved nutrient value and failed to follow the cycle menu for all oral diets for one meal. This deficient practice had the potential to effect 40 residents receiving an oral diet. Findings include: Observation on 7/22/17 at 10:20 a.m. of Dietary Cook AA puree food items for the lunch meal revealed he place eight scoops of white rice in the food processor bowl and pureed. He opened the lid and added ¼ cup water and pureed again. Interview on 7/22/17 at 10:45 a.m. with Dietary Cook AA revealed that he added the water in order for the rice to be pureed smoothly. He revealed that he was directed by the Dietary Manager to add liquid and thickener to food items as needed in order to have correct pureed consistency. Review of the document How to Puree Foods step 5 stated if required for hot foods add a small amount of hot liquid such as gravy, sauce, or cooking liquid to the cooked hot foods. For cold food, add cold liquid such as milk or fruit juice. DO NOT ADD WATER. Observation on 7/22/17 at 12:30 p.m. of the Dietary Cook CC plating and serving the resident lunch meal revealed she was serving regular diets turkey pot roast, roasted potatoes, and plain steamed baby carrots. Continued observation of Dietary Cook CC plating and serving the lunch meal for puree consistency revealed she served pureed turkey pot roast, pureed white rice, and pureed plain steamed baby carrots. Review of the cycle menu for week 5, Saturday, Spring/Summer 2017 revealed the lunch meal for regular, mechanical soft and pureed diet was to consist of savory turkey pot roast, roasted potatoes, glazed baby carrots, roll, frosted cake, and beverages. Review of the food production sheet for Lunch Saturday July 22 revealed for the cook to prepare the following food items: turkey pot roast with vegetables, rice, roll, frosted cake. The production sheet also stated puree rice, puree bread, and puree turkey. Interview on 7/22/17 at 1:15 p.m. with the dietary manager when asked why the residents were not being served glazed baby carrots as indicated on the cycle menu, he revealed that they were in the freezer but did not pull out for the meal. The DM revealed that he provides the dietary cooks with production sheets with which food items to prepare for each meal. He confirmed that he did not write on the production for the cook to make glazed baby carrots and confirmed that the residents did not receive the glazed baby carrots as indicated on the menu. The Dietary Manager also confirmed that the residents receiving puree consistency received pureed rice and pureed plain steamed baby carrots which were not indicated on the cycle menu. Interview on 7/22/17 at 1:20 p.m. with Dietary Cook CC revealed that she was the evening cook and the morning cook prepares the food items for the lunch meal and she serves what they prepare. She revealed that she did not review the cycle menu to see if the correct food items were prepared for the lunch meal. Interview on 7/23/17 at 1:50 p.m. with the Dietary Manager regarding the rational why the pureed residents received pureed rice instead of pureed roasted potatoes and he was not able to state the reason. He did confirm that they did not serve glazed carrots as indicated on the menu and they should have.

Based on observation, documentation review, and staff interviews the facility failed to label, date, securely wrap food items in the reach-in freezer, reach-in refrigerator, walk-in refrigerator, walk-in freezer, and dry storage area for two of three days of the survey; failed to discard prepared food items three days after preparation; failed to store pans dry; failed to ensure one food item on the steam table was held above 135 degrees Fahrenheit to prevent food borne illness; and failed to properly sanitize the thermometer after testing several food items. This deficient practice had the potential to effect 40 residents receiving an oral diet. Findings include: Initial tour of the kitchen was conducted on 7/21/17 at 9:30 a.m. Observation on 7/21/17 of the reach-in refrigerator revealed the following: 1) One gallon container of buttermilk opened with no date. 2) Container with broccoli salad with date of 7/17/17. 3) Container with pale yellow food item with no label or date. 4) Container with sliced peaches with no label or date. 5) Container with diced cantaloupe and grapes with a date of 7/15/17. 6) Container with apple sauce with no label or date. 7) Container labeled pudding with a date of 7/10/17. 8) Container of pasta salad with no label or date. Observation on 7/21/17 of the reach-in freezer revealed the following: 1) One gallon container of sherbet opened with no date. 2) Two, individual pizzas in clear plastic bag with no label or date. Interview on 7/21/17 at 9:45 a. m. with Dietary Cook AA and Dietary Aide BB revealed dated food items are to be discarded either three or four days from the date placed on them. They both revealed that they are to label and date food items after placing in containers and putting in refrigerator. When asked why food items found did not have labels or dates they stated that they did not put them in the refrigerator. When asked, who is responsible for checking the refrigerator and discarding food items they stated the Dietary Manager is responsible. Observation on 7/21/17 at 9:50 a.m. near the reach-in refrigerator revealed four large storage bins containing corn meal, flour, sugar, and rice. There was no date on any of the storage bins. Observation on 7/21/17 at 9:52 a.m. of the walk-in refrigerator revealed the following: 1) A block of sliced American cheese opened with no date. 2) One case containing six, 32 ounce containers of Vanilla Dannon yogurt with a use by date of July 16, 2017 on the top shelf. 3) A container containing a chunk of ham had a date of 7/15/17. 5) A five pound container of cottage cheese opened with no date 6) A clear plastic container with liquid pasteurized eggs with no label or date Observation on 7/21/17 at 9:55 a.m. of the walk-freezer revealed a clear plastic bag with a pinkish red food item on a shelf with no label or date. Continued observation revealed a clear plastic bag that contained sliced okra was sitting on a shelf with no label or date. Observation on 7/21/17 at 9:58 a.m. of the dry storage area revealed the following: 1) An opened bag of basic muffin mix with no date. 2) An opened bag of gelatin with no date. 3) An opened bag of powdered sugar not wrapped with no date. Observation on 7/21/17 at 10:00 a.m. of the aluminum pans under the food preparation table revealed a stack of six pans and another stack of four pans. When the pans were lifted, and tilted to the side, water drained from the corners. When the pans were un stacked the underside of eight pans were wet. Interview on 7/21/17 at 10:05 a. m. with the Dietary Manager (DM) revealed that food items are to be discarded three days after the date. He revealed that staff are to label and date food items after opening and he expects staff to label and date food items. The DM confirmed some of the food items in the reach-in refrigerator were not labeled, dated, or discarded three days after the date. The DM confirmed the items in the walk-in refrigerator were not dated. He revealed that the case of yogurt was delivered yesterday. When asked if he checks the food items while putting them away he stated that he did not. He confirmed the clear plastic bag in the walk-in freezer with the pinkish red food item was not labeled or dated. The DM confirmed that the stacked pans were wet and not air dried before stacking. Observation on 7/22/17 at 10:45 a.m. of the reach-in refrigerator revealed the container of sliced peaches continued to be unlabeled and undated. Observation on 7/22/17 at 10:50 a.m. of the walk-in freezer revealed the bag of okra on the shelf remained without a date. Observation on 7/22/17 at 10:55 a.m. of the dry storage area revealed the following: 1) Two, opened bags of basic muffin mix with no date 2) One opened bag of gelatin mix, not securely wrapped or dated 3) A one pound bag of powdered sugar opened, not securely wrapped and not dated. 4) One bag of pound cake mix opened and not securely wrapped 5) One bag of brownie mix opened and not securely wrapped. 6) One bag of instant chocolate pudding opened and not securely wrapped. Interview on 7/22/17 at 10:58 a.m. with the DM, when asked why food items remained opened, unlabeled, undated, and not securely wrapped he stated that he was trying to get it done but did not have a chance to get it all completed. Steam table food temperatures were completed on 7/22/17 at 12:50 p.m. using the facility's calibrated thermometer and Dietary Cook CC assisted with taking of the temperatures. Observation revealed when the dietary cook was taking the temperatures of the ten food items on the steam table with the thermometer she did not sanitize the thermometer between food items, she wiped the thermometer with a paper towel. Continued observation of the steam table food temperatures revealed the roasted potatoes had a temperature of 123.4 degrees (°) Fahrenheit (F) which was confirmed by Dietary Cook CC. The dietary cook confirmed that the roasted potatoes were not being held above 135°F on the steam table. Interview on 7/22/17 at 1:00 p.m. with Dietary Cook CC, when asked if that is how she usually takes temperatures of the food items on the steam table she stated that she usually uses an alcohol pad between food items and knew that she should have wiped with an alcohol pad. When asked if she had alcohol pad available the dietary cook showed an entire box of alcohol pads beside the steam table. Review of the Dishwashing policy effective date 9/1/01, revised 3/23/16 revealed procedure #8: allow all items to thoroughly air dry before unloading racks or storing items. Review of the Labeling, Dating, and Storage policy had an effective date of 6/1/16 and revised date of 6/14/16 revealed that 1) food and/or beverages items will be properly labeled with the name of the item, an open date, and a discard date. 2) Foods will be stored in their original containers or in an approved container or wrapped tightly with film, foil, etc. and clearly labeled with the name of the item and discard date. Review of the Receipt and Storage of Food and Supplies with an effective date of 9/1/01 and revised date of 3/24/16 revealed that 1) the dietary Manager or trained designee is accountable for receiving and storage of food and supplies. Review of the policy Food Temperatures revealed that all hot foods served from the steam table must be held at or above 135 degrees. Continued review of the Food Temperature Policy revealed that section how to take temperatures revealed to clean the thermometer shaft with an alcohol pad prior to use. the thermometer shaft must be cleaned with an alcohol pad prior to temping each food item. Review of the dietary in-service conducted on 9/22/16 revealed staff were educated on aides are responsible for the reach in refrigerator and freezer, need to throw away outdated items. Review of the in-service conducted on 10/25/16 revealed dietary staff were educated on the shelf life binder. Review of the dietary in-service conducted on 12/7/16 revealed dietary staff were educated on dish room sanitation, receipt and storage of food and supplies, and food temperature. Review of the dietary in-service conducted on 3/26/17 revealed that the dietary staff were in-serviced on dish room sanitation, food temperatures, all items in refrigerator must be dated and covered, leftovers are kept for 3 days only. Review of the dietary in-service was conducted on 4/26/17 regarding the Kitchen/Food observation (the critical pathway from the CMS website). Review of the Food Shelf Life Recommendations revealed canned food shelf life after opening is 3 days.

Based on observation, record review and staff interviews, the facility failed to monitor and document behaviors and side effects for one resident (R) #20 who received [MEDICATION NAME], a psychoactive medication, from a sample of 22 residents. Findings include: Resident #20 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident's cognition was intact. Continued review of the MDS revealed under section N, Medications the resident received an antipsychotic seven day a week and an antidepressant six days a week during the look back period. Review of the physician orders [REDACTED]. The physician orders [REDACTED]. Continued review of the medication orders revealed the resident was to receive [MEDICATION NAME], antidepressant, 10mg by mouth once daily. Review of the Medication Administration Record [REDACTED]. Review of the medical record revealed there was no evidence that a behavior monitoring sheet was initiated and conducted until July 2017. Interview with Licensed Practical Nurse (LPN) Unit Manager on 7/23/17 at 10:00 a.m. revealed that they were unable to find a behavior monitoring sheet for R#20 for the month of June 2017. She further revealed that they looked in the old and duplicate files and were unable to locate the document. Continued interview revealed that when a resident is a new admission to the facility the orders are handwritten and sent to the pharmacy. Any residents receiving antipsychotic medications must have a [DIAGNOSES REDACTED]. Further interview revealed that the Unit Manager reconciles the MAR indicated [REDACTED]. Interview with the Administrator on 7/23/17 at 1:40 p.m. revealed that after admission the chart should have been brought into the interdisciplinary team meeting. She stated that the chart for R#20 should have been reviewed for anything that was missing like the behavior sheet.

Based on record review and staff interviews the facility failed to ensure the Situation, Background, Assessment, Recommendations (SBAR) Communication form for a fall was completed and available to review for one resident (R), #69 from a sample size of 22. Findings include: Resident #69 was an [AGE] year old long term care resident that was admitted to the facility on [DATE]. She is alert, oriented, and able to make her needs known. Her [DIAGNOSES REDACTED]. During stage one staff interview on 7/21/17 at 2:15 p.m., Licensed Practical Nurse (LPN) Unit Manager she revealed the resident had a fall this morning. The LPN revealed that the resident was reaching for her eye glasses that were in her dresser and she fell forward out of her wheelchair. The LPN stated the resident was able to tell her about the fall and what had happened. She stated the resident was assessed by the nursing staff and the resident had sustained skin tears to both forearms as well as the forehead. The LPN revealed that the resident was not sent to the hospital for evaluation but they started neuro checks and will monitor the resident. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) Score of 13 indicating the resident was cognitively intact. Continued review of the MDS assessment revealed the resident required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The resident was assessed as requiring supervision for locomotion on and off the unit. Review of the resident's Care Plan for falls revealed it was updated on 7/22/17 to indicate the resident had a fall with skin tear to right forearm, left forearm, and left hand. Review of the incident log for the past six months revealed that the resident had one fall on 7/22/17. Review of the Nurse's Notes dated 7/21/17 at 10:45 p.m. revealed resident continues with lump to left side of forehead to and skin tear to right forearm from previous fall, neuro checks with normal limits (WNL) will continue to monitor. Review of the Neurological Observation Form revealed nursing staff had completed neuro checks. Interview on 7/22/17 at 5:40 p.m. with the Corporate Nurse revealed that she was not able to locate the SBAR Communication Form for the resident's fall on 7/21/17. She stated she had contacted the nurse that was to have completed the SBAR form and that nurse reported to her that she did not complete the SBAR form because she thought it only needed to be completed if the resident was going to be transferred to the hospital for evaluation. The Corporate Nurse revealed that the nurse did not realize that the SBAR form needed to be completed with any change in condition and a fall is considered a change in condition. The Corporate Nurse revealed that she expects the nursing staff to complete an SBAR after each fall. The Corporate Nurse revealed that the nurse told her that she documented the fall on a skilled therapy form and placed it in the 24 hour book. The Corporate Nurse confirmed there was no evidence of documentation of resident's fall. Interview on 7/23/17 at 7:50 a.m. with the Director of Nursing (DON) revealed he is not sure what happened to the report, the nurse stated to him that she had completed it and placed it in the 24 hour nurse binder. The DON revealed that he requested the nurse to come back to the facility and complete the SBAR form for the fall that occurred on 7/21/17.

Based on record review and staff interview the facility failed to ensure a signed written agreement with the outside agency that provided [MEDICAL TREATMENT] services for one (1) resident (#62) from twenty one (21) sampled residents. Findings include: Record review for resident #62 revealed the resident began receiving [MEDICAL TREATMENT] services from an outside agency on 10/13/2014. Interview with the Administrator conducted 02/11/15 at 10:30a.m revealed the facility was not able to provide a signed contract with the [MEDICAL TREATMENT] center where resident #62 receives [MEDICAL TREATMENT]. She further indicated that the resident was admitted back to facility in October 2014 with the outside [MEDICAL TREATMENT] services pre-arranged by the discharging hospital. She was not aware that the facility did not have a contract with this [MEDICAL TREATMENT] center.

Based on record review, and staff interview the facility failed to ensure a laboratory test was performed timely in accordance with physician's order for one (1) resident (#87) from a sample of twenty one (21) residents. Findings include: Review of the physician's orders for resident #87 revealed an order dated 1/21/15 to repeat Basic Metabolic Profile (BMP) in two (2) weeks. Review of The Daily Laboratory Draw Form revealed this BMP was scheduled to be obtained on 2/4/15. Further review of the of the medical record revealed no evidence that the repeat BMP had been done. Interview with the Director of Nursing (DON) on 2/12/15 at 1:14pm revealed the BMP ordered for 2/4/15 was not done.

Based on observations, review of the facility's policy, and staff interviews, the facility failed to ensure that foods were served at the appropriate temperatures and stored appropriately in the dry storage area. Thirty-six (36) of thirty-eight (38) residents receiving food prepared in the facility's kitchen. Findings include: Food temperatures taken with the Dietary Manager "AA" on 11/11/13 at 7:50am, during serving of the breakfast meal, revealed the following foods were being served below the proper holding temperature: Scrambled Eggs were 110 degrees Fahrenheit (F), Sausage Patties were 90 degrees F., Oatmeal was 130 degrees F. Food temperatures were taken again with the Dietary Manager "AA", during serving of breakfast on 11/12/13 at 7:40am, revealed the following foods were being served below the proper holding temperature: Scrambled Eggs were 120 degrees F., Sausage was 115 degrees F., Puree Eggs were 122 degrees F. An interview with dietary manager "AA" on 11/12/13 at 8:00 AM revealed there was no problem with the steam table. She indicated the steam table temperatures are checked every meal and written on a menu. Review of the facility's policy on food temperatures revealed all hot foods served from the steam table must be held above 140 degrees F.. Interview with the dietary manager 11/12/13 at 10:15 AM revealed she was going to check the water temperatures on the steam table before using it for lunch. Follow up interview with the dietary manager conducted 11/12/13 at 12:10 PM revealed she had checked the water temperatures on the steam table and they were 190 degrees F. On the initial kitchen observation conducted 11/10/13 at 10:15am, of the dry storage area revealed an open bag of dry white cake mix, which was dated as opened 10/18. There was also an open bag of cracker crumbs. A second observation of the dry storage area conducted 11/11/13 at 8:25am revealed an opened, unsealed clear plastic bag of uncooked bow tie pasta, which was dated as opened 10/16. An interview with Food Service Director conducted 11/11/13 at 8:30am revealed the open bags of dry cake mix, cracker crumbs, and pasta should have been closed and not left open

Based on record review, staff interview, review of the Medication Administration Records (MARs) and review of inservices for licensed nurses, the facility failed to follow physician's orders [REDACTED]. Finding includes: Record review for resident #8 revealed a physician order [REDACTED]. Check fingerstick blood sugar before meals and at bedtime. Sliding Scale coverage was the blood sugar minus one hundred (100) divided by twenty-five (25) equals the number of insulin units to be administered. Review of the MARs for September and October 2013 revealed the following: 9/5/13 6:30 am blood sugar was 175, three (3) units of insulin should have been administered but no insulin was given. 9/8/13 and 9/26/13 at 11:30 am has no evidence that the blood sugar was done as ordered. 10/11/13 8:00 pm blood sugar was 272, resident should have received seven (7) units of insulin. There was no evidence that any insulin was given. 10/16/13 6:30 am blood sugar was 290, resident should have received eight (8) units of insulin, but there was no evidence that any insulin had been administered. 10/20/13 8:00 pm there is no evidence that the resident's blood sugar was checked. Interview with Senior Care Partner Licensed Practical Nurse "BB" conducted 11/12/13 at 1:37 pm revealed that she is responsible for reviewing MARs monthly and follow-up with nursing staff. Issues with MARs related to medications being held or failure to document medications are discussed and in-services are conducted. Staff have been inserviced on reviewing the MARs to ensure all medications are given and the date and time are documented. Review of a inservice conducted on 9/12/2013 for licensed nursing staff revealed that staff were trained to: 1. Always review patients' MAR, that you have given all ordered medications and that you have signed off all medications, routine & as needed (PRN). 2. Insulin- Always make sure you have given all insulin as ordered using site rotation with site documented. Also, if blood sugar is less than 60 or greater than 400, you must address the blood sugar immediately and make sure to notify MD, family and document. Always review MAR-No Holes!