Every finding on record at Pruitthealth - Forsyth

Based on observations, staff interviews, and a review of the facility's documents and policy titled, Receipt and Storage of Food and Supplies, the facility failed to discard expired food items. The deficient practices had the potential to place 61 of 62 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings Include:Review of facility's policy titled, Receipt and Storage of Food and Supplies review dated 10/20/2025, documented in Procedure 6. Supplies removed from shipping boxes should be placed on shelves or in proper bins/ containers the day of delivery. All supplies should be labeled and dated with delivery date. 7. The first in, first out (FIFO) method must be used to ensure proper rotation of all food items to help prevent spoilage. 9. Bent and/or damaged cans and/or supplies should not be placed on store room shelves or bins. These items are to be placed in a labeled designated area and stored separately to be picked up by the vendor.During the initial tour on 05/15/2026 at 7:41 AM, with [NAME] AA revealed in the dry storage revealed four 33.8 oz. box cartons of apple juice with an expiration date of 05/09/2026, six 24.5 oz flour tortillas packs with expiration 05/14/2026, six 2 lb. bags of tortilla chips with expiration date 03/22/2026, and three 5 lb. boxes of muffin mix with an expiration date of 11/25/2025. Inside the kitchen between the refrigerator and dishwashing area revealed one diary stand-alone refrigerator with 38 half pint chocolate milks with expiration date of 05/14/2026. The walk-in cooler/refrigerator revealed one box of 125 count apples with expiration date 05/11/2026 and one yellow-like block in one gallon bag identified by [NAME] AA as butter with expiration date 05/10/2026. The walk-in freezer contained two 75 oz. Canadian style bacon with expiration date 05/14/2026.Further inspection on 05/16/2026 at 11:25 AM, revealed that Dietary Aide (DA) CC was using a 104 oz. dented can of sliced apples in the muffins. DA CC acknowledged the usage and promptly discarded the remaining contents of the can. An inspection of the dry storage area uncovered another 104 oz. dented can of sliced apples on the stockroom shelf. DM verified and removed.The interview conducted on 05/16/2026 at 12:08 PM, with DA CC revealed that he overlooked the dent in the can.

Based on observations, staff interviews, and a review of the facility policy titled, Medication Storage in Healthcare Center, the facility failed to properly lock and secure one of two medication carts (A -Hall and C-Hall.) The deficient practice increased the risk of unauthorized access and potential medication diversion.Review of the facility policy titled, Medication Storage in Healthcare Center with a revision date of 03/12/2026 revealed under the section Policy Statement documented medications and biologicals are stored safely, and securely. During an interview and observation on 05/15/2026 at 7:31 AM with LPN FF revealed medication cart for A-hall was unsecured and unattended in the resident care area. LPN FF was coming out of a resident room and confirmed the medication cart was unlocked and the medication cart should be locked immediately before walking away.

Based on resident representative interviews and record review, the facility failed to provide notification of change to the resident representative for one resident (R) 2. The sample size was four.Findings include:Review of the electronic medical record (EMR) revealed resident (R) 2 was admitted to the facility on [DATE] and with diagnoses including but not limited to acute respiratory failure with hypoxia, thrombocytopenia unspecified, unspecified dementia with unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety, and encephalopathy unspecified.MDS: Review of R2 discharge Minimum Data Set (MDS) assessment dated [DATE] section C staff assessment revealed a memory problem; severely impaired cognitive skills for daily decision making. Section GG revealed R2 is dependent with ADLs and mobility.Orders: Review of the Physician's Orders for R2 included but was not limited to: Order dated for G-TUBE: GLUCERNA 1.5 @ 45ML/HR CONTINUOUS Every Shift Days, Night Order dated for 02/23/2026 G-TUBE:TUBE FLUSH 35ML/HR WHILE TF INFUSINGEvery Shift Days, NightReview of Care Plan for R2 dated 02/25/2026 revealed R2 has a peg tube feeding with diagnosis of dysphagia. Goals included but not limited to; patient/ resident will maintain nutrition stability through next review. Interventions included but not limited to flush as ordered, elevate head of bed per protocol, notify medical doctor (MD) of any problems, registered dietitian (RD) to assess as needed, and tube feeding as ordered.Review of progress notes revealed:03/05/2026 at 7:05 PM resident was seen by MD today and order noted for urinalysis and culture and sensitivity (UA C&S) and Seroquel (medication) in the am as well at bedtime. Resident continues to be restless and agitated, attempting to get out of bed. Safety mat on floor next to bed. Call light in reach. Resident also pulls on G-tube tubing. Dependent of staff for all ADL's. e-signed by LPN CC03/06/2026 at 4:08 PM Resident pulled foley out with bulb intact, large amount of urine on bed. Attempted x2 straight cath, with 3 staff members, unable to obtain specimen this shift. Resident uncooperative. e-Signed by LPN GGRecord Review: Resident discharged from the facility on 03/17/2026.Interview on 03/18/2026 at 6:20 PM with the Senior Nursing Consultant and Director of Health Services stated that they did not have a notification of change policy.Record Review: Resident discharged from the facility on 3/17/2026A telephone interview on 03/17/2026 at 1:00 PM with the complainant confirmed that R2 was still in the hospital. No further information was provided.An interview on 03/18/2026 at 10:27 AM with Director Health Services (DHS) confirmed staff should notify representative of falls, behavior, hospitalization, abuse and neglect, resident decline, change in medication, also if a foley, IV or any newly inserted device she expects the family representative to be notified.An interview on 03/18/2026 at 5:55 PM with the administrator revealed that nurses should follow orders when administering medications. A change in condition should be notified to the resident representative. The administrator also stated that foley placement is a change in condition and the resident representative should be notified. Staff should follow up the notification with a progress note

Based on observations, staff interviews, and review of the facility's policy titled Emergency Water Requirements, the facility failed to ensure that chemical test strips for the low-temperature dishwasher and three-compartment sink were not expired. In addition, the facility failed to ensure the emergency drinking water supply was stored in a sanitary manner. Additionally, the facility failed to ensure that cold foods were held at proper temperatures during meal preparation and that dietary staff performed proper hand hygiene. These deficient practices had the potential to place 52 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings included: Review of the facility's policy titled Emergency Water Requirements, dated [DATE], revealed the Policy Statement section included, It is the policy of [corporate name] for each healthcare facility to stock drinking water, available for immediate use per patient/resident as required by the state emergency regulation. The Procedure section included, 1. In an emergency where there is a threat or lack of water supply for the facility, the facility will first use the stored gallons of water for drinking purposes. Each gallon of water will have an expiration date located on the gallon. 1. Observation on [DATE] at 8:40 am revealed that the chemical test strips for the sanitizing solution for the low-temperature dishwasher expired [DATE], and the chemical test strips for the three-compartment sink sanitizing solution expired [DATE], [DATE], [DATE], [DATE], and [DATE]. In an interview on [DATE] at 9:05 am, the Dietary Manager (DM) revealed that he was unaware of the expired test papers used for the low-temperature dishwasher and the three-compartment sink. 2. Observation on [DATE] at 9:10 am revealed that the emergency drinking water supply was stored in a shed adjacent to the facility. Observation of the emergency drinking water revealed that the boxes in which the water was stored were damaged, and water was leaking from the water supply. The DM confirmed the damaged boxes and leaking water from various emergency drinking water supply boxes. 3. Observation on [DATE] at 1:08 pm revealed that the kitchen staff placed individual bowls of salad on the residents' trays before adding the hot food. The salad bowls remained on the residents' trays, in the kitchen, until 1:30 pm. Observation at 1:35 pm revealed the temperature of the salad was 55 degrees Fahrenheit (F). During an interview, the DM stated the salad was too warm to serve the residents and discarded the salads. 4. Observation on [DATE] at 1:26 pm, during the lunch meal preparation, revealed that [NAME] EE changed gloves without performing hand hygiene between removing used gloves and putting on new gloves. In an interview on [DATE] at 3:38 pm, [NAME] EE confirmed she did not practice hand hygiene between glove changes while preparing the residents' lunch meal.

Based on observation, staff interview, and facility recipe review, the facility failed to ensure dietary staff followed recipes for preparing pureed foods to avoid compromising the nutritive value, flavor, or appearance. This deficient practice had the potential to affect residents who received a pureed diet from the kitchen. Findings include: A review of the facility recipe for Puree Potato revealed that the smallest amount to prepare was 34 servings. The recipe ingredients were: 1. Pour four liters (about one gallon plus one cup) of hot water (170-190 degrees Fahrenheit [F]) into a 6-inch deep half steamtable pan. 2. Add all potatoes and stir for 15 seconds 3. Let stand for five minutes, stir, and serve. Observation on 5/14/2025 at 12:00 pm revealed [NAME] EE prepared pureed potatoes for the lunch meal. She placed a small pan and an eight-ounce milk carton on the prep area. [NAME] EE measured mashed potato flakes into a container, added 10 cups of hot water, and whisked. [NAME] EE then added one-fourth cup of butter and an unmeasured amount of milk. She stated she used one-fourth of the carton of milk. [NAME] EE combined all the ingredients and let the potatoes thicken for a minute. The mixture was scraped into a sprayed pan, covered with foil, and placed in the warming oven. In an interview on 5/14/2025 at 3:38 pm, [NAME] EE revealed that the puree recipe for mashed potatoes was located on the back of the potato flake ingredients bag and in a red binder on a shelf next to the food processor. [NAME] EE confirmed she did not measure the milk due to her experience and knowledge of how much milk to add.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure steam table pans were not stacked together while wet to prevent bacteria growth; failed to ensure food items stored in the resident nourishment refrigerator were properly labeled and dated; failed to ensure dietary staff properly used the three-compartment sink for sanitation to prevent cross contamination; and failed to ensure cold food items served to residents were maintained below 41 degrees Fahrenheit (F). The deficient practices had the potential to adversely affect 127 of 138 residents receiving an oral diet. Findings include: 1. Review of facility policy titled Dishroom Sanitation, revised 3/22/2016 revealed the Procedure section line numbered 7 stated: Check all items for cleanliness at the clean end of the dish table. Rewash items that are not clean. Review of the facility policy titled Pot/Pan Washing and Sanitation, revised 4/11/2016 revealed the Policy Statement was: It is the policy of [NAME] Health that equipment and utensils are cleaned and sanitized appropriately after use to maintain a clean and sanitary environment for food preparation. The Procedure section included a line stating: Inspect for cleanliness and store pots and pans inverted in a clean, dry, protected area. Observation on 12/15/2023 at 8:45 am of stacks of steam table pans located on a shelf in the dish area, revealed three square steam table pans stacked together with water observed on the inside of the middle pan. Also observed was a stack of four medium sized rectangle steam table pans with the middle pan observed to have a pea sized area of an off-white-colored substance on the bottom of the pan and an additional pencil eraser sized spot of off-white colored substance on the top of pan. An interview on 12/15/2023 at 8:45 am with the Dietary Manager (DM) confirmed the middle stacked square steam table pan had moisture inside and confirmed the rectangle steam table pan was not properly cleaned and had off-white substance on it. The DM stated that dietary staff should have ensured stacked pans were dry before stacking and should have ensured pans were clean before stacking. Observation on 12/17/2023 at 8:50 am of the steam table pans stacked on a shelf in the dish room revealed a stack of two medium sized pans. When the top pan was turned over, the inside contained moisture. During an interview on 12/17/2023 at 8:50 am the DM confirmed that the rectangle steam table pan was stacked with moisture inside. The DM stated that staff should allow pans to completely dry before stacking. 2. Review of the facility policy titled Residents/Patients' Personal Food, dated September 2001, revealed the Policy Statement was: To attempt to cooperate with the resident/patient and their family regarding food items brought into the healthcare center for resident/patient consumption that will maintain a clean, healthy environment and prevent foodborne illnesses. The Guidelines section stated: (4). Food refrigerated must be labeled and dated and will be discarded after 24 hours. (5). Nursing personnel will be responsible for the disposal of outdated foods maintained in the resident/patient's room and those stored in the nursing unit refrigerators. Observation on 12/16/2023 at 8:05 am of the resident nourishment room revealed a sign adhered to the front of the resident refrigerator that stated all food items need a label and date. Continued observation of the resident refrigerator revealed two four-ounce cups on the top shelf containing an orange smooth textured substance. The two cups were not labeled or dated. Further observation revealed one paper plate covered with foil in a gray colored plastic bag on the bottom shelf without a label or date. An interview on 12/17/2023 at 8:05 am with the DM revealed that nursing staff are responsible for ensuring resident foods items in the resident refrigerator are labeled and dated and should discard items without a label and date. The DM confirmed that the gray colored plastic bag with a foiled covered paper plate and the two four-ounce cups with the orange substance did not have a label or date. The DM stated the two four-ounce cups contained pureed fruit and nursing staff had placed them in the refrigerator from a resident meal tray. The DM revealed that dietary staff does not label or date the portioned food cups for resident meal trays. An interview on 12/16/2023 at 8:15 am with the Director of Nursing (DON) confirmed that nursing staff is responsible for ensuring resident foods stored in the refrigerator are properly labeled and dated. The DON confirmed that the gray colored plastic bag containing a paper plate wrapped in foil did not have a label or date. The DON stated that nursing staff are to view the resident refrigerator every shift and ensure resident foods items are labeled and dated. 3. Review of the facility policy titled Pot/Pan Washing and Sanitation, revised 4/11/2016 revealed the Policy Statement was: It is the policy of [NAME] Health that equipment and utensils are cleaned and sanitized appropriately after use to maintain a clean and sanitary environment for food preparation. The Procedures section included a line stating: Items need to be immersed for 60 seconds in the Quaternary. Review of the Eco Lab Product Specification Document for Multi- Quaternary Sanitizer revealed: Expose all surfaces to the sanitizing solution for a period of not less than 1 minute. Observation on 12/16/2023 at 9:45 am of Dietary Cook AA washing the food processor bowl, lid, and blade using the three-compartment sink, revealed she washed the items, rinsed them in water, placed the food processor blade in the sanitizing solution for only a few seconds and placed the food processor bowl in the sanitizing solution for ten seconds before placing each on a drying rack. An interview on 12/16/2023 at 9:45 am with Dietary Cook AA confirmed that the food processor blade and bowl were not in the sanitizing solution for at least 60 seconds. Dietary Cook AA stated that items need to be in the sanitizing solution for at least one minute, but she did not do this due to nervousness. An interview on 12/16/2023 at 9:45 am with the DM revealed he has not conducted any in-services with dietary staff regarding the three-compartment sink and he assumed that dietary staff knew how to properly use the three-compartment sink. The DM stated that staff should submerge dishware in the sanitizing solution for 30 seconds. The DM confirmed that the facility is using Eco Lab Quaternary sanitizing solution. The DM revealed that he forgot that the contact time for the sanitizing solution was at least 60 seconds. The DM stated that he expects dietary staff to use the three-compartment sink correctly to properly sanitize dishware. 4. Review of the facility policy titled Food Temperatures, revised 2/24/2023, revealed the Policy Statement was: It is the policy of [NAME] Health that the Dietary Manager or designee be responsible for ensuring that all food has reached and continues to maintain proper temperatures prior to tray assembly. The Procedure section revealed line numbered (2): All potentially hazardous cold foods must be held at 41 degrees or less. (12). Potentially hazardous cold food should be held on the line in an ice bath at 41 degrees or below. Observation on 12/16/2023 at 12:30 pm in the kitchen revealed two tall, large racks with pre-assembled resident lunch meal trays. Continued observation revealed that beverages had been placed on the pre-assembled meal trays including cartons of milk. On 12/16/2023 at 1:00 pm food temperatures were checked with the assistance of the DM using the facility's calibrated thermometer. The temperature check of one eight-ounce carton of chocolate milk from one of the pre-assembled resident meals trays revealed a temperature of 48 degrees F. The temperature check of one eight-ounce carton of whole milk on a different pre-assembled resident meal tray had a temperature of 49 degrees F. An interview on 12/16/2023 at 1:00 pm with the DM confirmed that the carton of chocolate milk had a temperature of 48 degrees and the carton of whole milk had temperature of 49 degrees. The DM stated that cold food items should be served at or below 40 degrees. The DM stated that dietary staff should place cartons of milk on resident meal trays after the trays are completely assembled.

Based on staff interviews and record review, the facility failed to conduct a Level II Preadmission Screening and Resident Review (PASRR) screening for two residents (R) (R26 and R47) with mental health diagnosis from a sample of 17 residents. This deficient practice increased the potential for R26 and R47 to not receive services and/or care according to their needs. Findings include: 1. R47 was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral palsy, anxiety, and depression. On 3/11/2023 R47 was readmitted from the hospital with a diagnosis of bipolar disorder. Interview on 12/17/2023 at 9:15 am with the Minimum Data Set Coordinator revealed R47's diagnosis of bipolar disorder was added on 3/11/2022 following a hospitalization . She stated she added the diagnosis to R47's clinical record but did not notify any other clinical staff of the new diagnosis. She stated she does not notify staff of new mental health diagnosis. Interview on 12/17/2023 at 11:46 am with the Administrator revealed her expectation for PASRR is for the Admission Coordinator to ensure correct coding is completed on the PASRR form. She further stated she expects residents with a new diagnosis of mental illness to have a new PASRR Level 1 completed at the time of the diagnosis. She stated the facility did not have a PASRR policy. 33548 2. R26 was admitted to the facility on [DATE] with diagnoses including but not limited to bipolar disorder and depression. Review of the medical record revealed that R26 was receiving psychotherapy sessions. The psychotherapy notes stated that R26 had symptoms of depression related to bipolar. Review of the medical record revealed a PASRR Level 1 was completed on 8/9/2023. An interview on 12/17/2023 at 7:55 am with the social worker revealed that R26 was admitted to the facility with a Level 1 PASRR, and she assumed that if a Level II PASRR was needed it would have been completed at the hospital before his admission to the facility. The social worker revealed that she does not reassess newly admitted residents with mental health diagnosis to ensure if a PASRR Level II is needed. During an interview on 12/17/2023 at 9:20 am the Director of Nursing (DON) revealed she expects the social worker to reassess residents that do not have a Level II PASRR that have a mental health diagnosis such as bipolar.

Based on staff interviews, record review, review of the facility policy titled Dialysis Care Pre and Post Dialysis, and review of the facility document titled Dialysis Center Communication Form, the facility failed to ensure communication between the facility and the dialysis center was documented after each dialysis treatment for one of one resident (R) (R44) reviewed for receiving hemodialysis. This failure had the potential to place R44 at risk for complications related to dialysis after dialysis treatments. Findings include: Review of the facility policy titled Dialysis Care Pre and Post Dialysis, revised 8/22/2022, revealed the policy statement of: It is the policy of [NAME] Health organization to initiate the appropriate measures to care for residents pre and post dialysis. Review of the facility document titled Dialysis Center Communication Form, revised 11/28/2022, revealed a section titled To Be Completed by Dialysis Center that contained areas for documentation of the vascular access and shunt site condition, physician orders, occurrence during dialysis, and a Dialysis Representative signature. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section O indicated the resident was receiving dialysis while in the facility. Review of diagnoses included, but was not limited to, End Stage Renal Disease (ESRD) with dependence on renal dialysis. Review of the physician orders revealed an order dated 6/22/2023 for R44 to receive dialysis three times per week on Monday, Wednesday, and Friday. Review of the dialysis communication book revealed the book is kept in R44 room and sent with her to dialysis treatments. Review of the dialysis communication forms for the month of December 2023 revealed the section of the form titled To Be Completed by Dialysis Center were not completed on any of the forms. An interview on 12/16/2023 at 9:05 am with Registered Nurse (RN) Unit Manager (UM) revealed the facility sends the dialysis communication book containing the communication forms with the resident to dialysis and the dialysis center is to complete the bottom portion of the form at completion of treatment and return the book to facility. The RN UM stated the facility staff has a difficult time getting the dialysis center to complete the communication forms, and staff calls the dialysis center to obtain post treatment information and post weight. The RN UM stated that staff should enter a progress note in R44's medical record if they call the dialysis center to obtain post dialysis treatment information. The RN UM confirmed that there were no progress notes entered in December 2023 for the missing post dialysis information. An interview on 12/16/2023 at 11:05 am with the Director of Nursing (DON) confirmed that the dialysis communication forms for the month of December were not completed by the dialysis center. The DON confirmed there were no progress notes in R44's medical record for December indicating that nursing staff had called the dialysis center for R44's post dialysis information.

Based on staff interviews, record review, and review of the facility policy titled Monitoring of Antipsychotics, the facility failed to ensure that psychotropic medications, specifically antianxiety medications, were not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of five residents (R) R14 reviewed for unnecessary medications. Findings include: Review of facility policy titled Monitoring of Antipsychotics, revised 7/20/2020, revealed the Procedure section line numbered 7 stated: PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication. All PRN antipsychotic orders will be automatically stopped after 14 days. Review of physician orders for R14 revealed an order dated 11/26/2023 for alprazolam tablet 0.5 milligrams (mg) (a medication used to treat anxiety and panic disorders) give one tablet by mouth prn for increased anxiety every four hours. There was no evidence of a 14 day stop date or a rationale from the physician for use beyond 14 days. Interview on 12/17/2023 at 9:25 am with Licensed Practical Nurse BB revealed all nursing staff are responsible to ensure psychotropic medications that are ordered PRN have a stop date. Interview on 12/17/2023 9:27 am with Director of Nursing revealed all PRN psychotropic medications should have a stop date. The DON stated the medication should have been stopped after 14 days unless otherwise indicated by the physician.

Based on observation, staff interviews, and recipe review, the facility failed to ensure dietary staff followed recipes for preparing pureed foods to avoid compromising the nutritive value, flavor, or appearance. This deficient practice affected eight of 52 residents receiving an oral diet. Findings include: Review of the recipe for Pureed Cheeseburger Deluxe revealed the smallest amount to prepare was for 50 servings. The recipe ingredients were: 19 pounds of prepared Cheeseburger Deluxe; One quart, three cups, and eight tablespoons of broth; Two cups and eight tablespoons of thickener. Observation on 12/16/2023 at 9:30 am of Dietary Cook AA preparing pureed cheeseburgers for the lunch meal revealed she placed nine cooked hamburger patties in the food processor, added an unmeasured amount of beef broth, and pureed the items. She then added an unmeasured amount of breadcrumbs and pureed the items again. Dietary Cook AA then added breadcrumbs two additional times to achieve the desired consistency. She then placed the pureed hamburger mixture in a steam table pan, covered it with foil, and placed it in the oven. Observation on 12/16/2023 at 10:00 am of Dietary Cook AA pureeing fried onion rings revealed she placed an unmeasured amount of fried onion rings in the food processor, added an unmeasured amount of chicken broth, and pureed the items. She then added an unmeasured amount of breadcrumbs and pureed the items again. Dietary Cook AA added additional breadcrumbs until a desired consistency was achieved. Interview on 12/16/2023 at 10:00 am with Dietary Cook AA revealed that the puree meal for lunch was hamburger and onion rings. She revealed that there were recipes for pureed foods and pointed to a black colored binder on a shelf above the area of the food processor. She further revealed that she reviewed/referenced to the recipes for pureed hamburger and onion rings prior to starting the process. She revealed that due to lack of space on the food preparation table, she did not have the recipe binder open to the actual recipes while pureeing the food items. Interview on 12/16/2023 at 10:10 am the Dietary Manager (DM) revealed that he expects dietary staff to follow all recipes as written. Interview on 12/16/2023 at 11:30 am with the DM revealed that there was not a recipe for puree onion rings. The DM revealed that Dietary Cook AA did not review and follow the cycle menu which stated that puree diets were to receive puree peas instead of puree onion rings. The DM revealed that he expects dietary cooks to review the cycle menu and prepare foods accordingly.

Based on observation, record review and staff interview, the facility failed to maintain infection control standard precautions by not removing gloves and performing hand hygiene during wound care for two residents (R #3) and (R# 20). The sample size was 22 residents. Findings include: 1. During observation of wound care with RN AA on 3/30/22 at 10:39 a.m., she washed her hands and set up supplies on a clean field on the residents overbed tray table. She donned clean gloves and removed the soiled dressing from the resident's sacral area wound. RN AA removed her gloves but did not wash/sanitize her hands prior to donning clean gloves. She cleansed the wound with cleanser and removed one glove and did not wash/sanitize her hand. RN applied clean dressing and applied tape to dressing. She removed remaining glove and discarded soiled dressings. RN washed her hands and removed soiled dressing from residents left buttock area. She removed dressing and did not wash/sanitize her hands before donning gloves and applying Dakin's solution and clean dressing to left buttock wound. After completing dressing on left buttock, RN removed gloves and removed dressing to right heel with ungloved hand. She then applied gloves without washing or sanitizing hand and applied Santyl to right heel before applying gauze to the wound on heel. RN/Treatment nurse failed to wash/sanitize her hands after removing gloves and prior to donning clean gloves during wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Observation of wound care for R#3 on 3/31/22 at 8:55 a.m. revealed Registered Nurse (RN) AA place a clear plastic bag on the floor. RN AA washed her hands, donned gloves, and removed the old dressing to the resident's left heel wound. RN AA washed her hands and donned gloves. RN AA cleaned the wound with a normal saline soaked gauze and patted dry with a clean gauze. She then applied Santyl to wound base, applied 4x4 dry dressing and wrapped left heel with kerlix wrap. RN AA removed gloves then donned one glove to the right hand and applied Vitamin A&D ointment to dry skin on R#3's left leg. RN AA then removed glove and donned one glove to right hand. She then applied Vitamin A&D ointment to dry skin on R#3's right leg. RN AA did not wash/sanitize hands or change gloves after cleaning the wound and before applying the medication. The wound treatments for R#20 and R#3 were performed in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 3/31/22 at 9:15 a.m. with RN AA, after wound care, revealed she stated she did not really mean to wear one glove. RN AA stated it was just A&D ointment. RN AA confirmed that she did not sanitize or wash her hands throughout providing wound care. Interview with the Director of Health Services (DHS) on 3/31/22 at 11:35 a.m. revealed she would expect for the nurse to wash and sanitize her hands before the procedure and if she had to step out to do something. DHS stated she has provided in-services to the nurses on infection control as it relates to wound care. DHS was unable to produce proof of in-services provided.

Based on record review and staff interview, the facility failed to implement care plan interventions for weekly body audits and descriptive wound documentation for one resident (R) (#2) with a pressure ulcer from a sample of three residents. Findings include: R#2 had the following but not limited Diagnoses: [REDACTED]. Review of the 11/18/2020 Significant Change Minimum Data Set (MDS) revealed the resident had severely impaired cognition, had no behaviors, required total assistance with bed mobility, transfers and hygiene, was frequently incontinent of bladder and was always incontinent of bowel, the resident had one unstageable pressure ulcer with slough/eschar and one unstageable Deep Tissue Injury (DTI). Review of the resident's care plan dated 11/18/2020 revealed the resident was at risk for skin breakdown related to immobility with interventions for weekly body audits by nursing and pay particular attention to the bony prominences. Continued review of the care plan revealed the resident had a pressure ulcer related to decreased mobility and incontinence to the right heel and one unstageable sacral wound with an intervention to assess the pressure ulcer for location, stage, size (length, width, and depth), presence of granulation tissue and epithelization weekly. Review of the 10/23/2020 Hospice Narrative Note revealed the resident had new skin breakdown to her sacral region. The note further indicated that during the visit, the facility wound care nurse assessed the area and found blood to the resident's bottom and the area was being treated with wound cream and dry dressings. There was no indication the wound on the resident's sacrum was measured or staged at that time. It also lacked descriptive documentation. Review of the Resident Progress Note dated 11/3/2020 revealed that the Certified Nursing Assistant alerted the nurse of the wound to the resident's sacral area. It further noted the Hospice aide stated that the wound had been there, and the prior treatment nurse had been treating it with a dressing. The nurse documented the resident had a sacral wound measuring 3 x 7 x 0.3 centimeters (cm) and had an irregular shape, draining a moderate amount of serosanguinous exudate. The note documented the wound bed appeared to have red tissue and the center of the wound had a small amount of slough. There was no indication the wound had been staged at that time. Review of the 11/7/2020 Body Audit Form revealed the sacrum was unstageable measuring 9 cm x 7 cm with 40% eschar, 30% slough and 30% granular. Although the facility started weekly wound assessments on 11/7/2020 through 1/19/2021 that included measurements and noted the wound as being unstageable, the documentation did not include the percentage of necrotic tissue that covered the wound bed or the appearance of the necrotic tissue. On 1/19/2021 the pressure ulcer on the sacrum was staged a Stage IV. There was also no documentation of weekly skin assessments until 11/7/2020. During an observation of the sacral wound on 1/22/2021 at 11:00 a.m., the wound was a Stage IV pressure ulcer that measured 5.2 cm x 4 cm x 2.3 cm with 100% red granulation present. During an interview with Director of Health Services on 1/25/2021 at 11:45 a.m., she confirmed the wound documentation was not descriptive and did not include the percentage of necrotic tissue in the wound, odor, and drainage. She also stated she started making the staff document the weekly skin assessments and weekly wound assessments on the Body Audit Forms in November 2020.

Based on observation, record review and staff interview, the facility failed to perform weekly skin assessments and failed to do descriptive wound documentation for one resident (R) (#2) with a pressure ulcer from a sample of three residents. Findings include: Review of the policy titled Lippincott Procedures- Wound Assessment, with a revision date of November 11, 2016 noted to record the general appearance of the patient's skin and bony prominences; the location, size, and appearance of the wound site; and whether drainage is present. Include the color, type, amount, and odor of any drainage. R#2 had the following but not limited Diagnoses: [REDACTED]. Review of the 11/18/2020 Significant Change Minimum Data Set (MDS) revealed the resident had severely impaired cognition, had no behaviors, required total assistance with bed mobility, transfers and hygiene, was frequently incontinent of bladder and was always incontinent of bowel. The resident had one unstageable pressure ulcer with slough/eschar and one unstageable Deep Tissue Injury (DTI). Review of the resident's care plan dated 11/18/2020 revealed the resident was at risk for skin breakdown related to immobility with interventions for weekly body audits by nursing and pay particular attention to the bony prominences. Continued review of the care plan revealed the resident had a pressure ulcer related to decreased mobility and incontinence to the right heel and one unstageable sacral wound with an intervention to assess the pressure ulcer for location, stage, size (length, width, and depth), presence of granulation tissue and epithelization weekly. Review of the clinical record revealed the resident was placed under Hospice services on 9/19/2020 with a primary [DIAGNOSES REDACTED]. Review of the 10/23/2020 Hospice Narrative Note revealed the resident had new skin breakdown to her sacral region. The note further indicated that during the visit, the facility wound care nurse assessed the area and found blood to the resident's bottom and the area was being treated with wound cream and dry dressings. There was no indication the wound on the resident's sacrum was measured or staged at that time. It also lacked descriptive documentation. There was also no indication the Physician was notified regarding the sacral wound. Although the Hospice nurse documented the sacral wound was treated with wound cream, the nurse did not specify the name of the cream or how often it was being applied. Review of the October 2020 Treatments Administration History form revealed the only cream that was being applied was a moisture barrier to the resident's buttocks every shift and as needed since 6/20/2020. There was no documentation that a wound cream and a dry dressing was applied specifically to the resident's sacral region until 11/3/2020. Review of the Resident Progress Note dated 11/3/2020 revealed that the Certified Nursing Assistant alerted the nurse of the wound to the resident's sacral area. It further noted the Hospice aide stated that the wound had been there, and the prior treatment nurse had been treating it with a dressing. The nurse documented the resident had a sacral wound measuring 3 x 7 x 0.3 centimeters (cm) and had an irregular shape, draining a moderate amount of serosanguinous exudate. The note documented the wound bed appeared to have red tissue and the center of the wound had a small amount of slough. There was no indication the wound had been staged at that time. The Physician was notified, and new orders were obtained to cleanse the area to the sacrum with wound cleanser and blot dry. Apply calcium alginate, cover with dry dressing every day and as needed. Review of the 11/7/2020 Body Audit Form revealed the sacrum was unstageable measuring 9 cm x 7 cm with 40% eschar, 30% slough and 30% granular. Although the facility started weekly wound assessments on 11/7/2020 through 1/19/2021 that included measurements and noted the wound as being unstageable, the documentation did not include the percentage of necrotic tissue that covered the wound bed or the appearance of the necrotic tissue. On 1/19/2021 the pressure ulcer on the sacrum was staged a Stage IV. There was also no documentation of weekly skin assessments until 11/7/2020. During an observation of the sacral wound on 1/22/2021 at 11:00 a.m., the wound was a Stage IV pressure ulcer that measured 5.2 cm x 4 cm x 2.3 cm with 100% red granulation present. During an interview with Director of Health Services on 1/25/2021 at 11:45 a.m., she confirmed the wound documentation was not descriptive and did not include the percentage of necrotic tissue in the wound, odor, and drainage. She also stated she had identified problems with the wound care program when she started working in the facility in September 2020 and placed the wound care in the facility's Process Improvement Plan (PIP). Review of the facility PIP for skin and wound care, which was implemented on 11/13/2020 noted the goal was to improve facility wound care program by ensuring weekly skin assessments are completed to identify any new or worsening skin issues. Ensure all wounds identified have physician's orders [REDACTED]. Ensure wound treatment orders are being followed per physician's orders [REDACTED]. Although the facility had the skin and wound care in PIP, the PIP did not identify problems with the lack of descriptive documentation of wounds which continued through January 2021.

Based on interviews and record reviews, the facility failed to maintain an infection control program that included thorough and complete surveillance for four residents (#12, #7, #11 and #8) of six residents treated with an antiparasitic medication between (MONTH) and (MONTH) 2019. Finding include: During an interview on 10/29/19 at 10:00 a.m. the Administrator confirmed that the facility had some residents who had experienced rashes and that the facility was thinking the cause was environmental. A review of the timeline of interventions implemented by the facility revealed that the following interventions had been implemented: 1)The concentration of detergent used in washing machine for laundry was decreased on 5/31/19 2) The washing machine was serviced to ensure proper chemical flushing on 5/31/19 3) Dermatologist consultations were obtained as ordered 4) Steroid medications were implemented as ordered 5) Body audits were completed on all residents on 9/15/19 6) Topical medication treatments were obtained as ordered 7) Ivermectin (antiparasitic) medication use was implemented as ordered 8) Deep cleaning of rooms as scheduled 9) Mattresses were inspected 10) Medications were reviewed verbally with the pharmacist the week of 10/14/19 11) [MEDICATION NAME] baby products including soap and lotion were added to the affected residents 12) Hospice Certified Nursing Assistants (CNA's) were asked not to bring in products 13) Ecolab was consulted for the use of any other available detergents A review of the pharmacy list of residents who were dispensed Ivermectin, an antiparasitic medication, for use, revealed five Residents (R) (#3, #10, #11, #12, and #7). A sixth resident, R#8, was also identified as receiving Ivermectin between (MONTH) 2019 and (MONTH) 2019. A review of the Line Listing for Infections, a part of the facility's Infection Control Program, revealed that R#3 and R#10 were included in the (MONTH) and (MONTH) line listings respectively for the use of the anti-parasite medication, Ivermectin, for a rash. R#3 visited the dermatologist on 3/27/19 and returned with an order to take six 3 milligram (mg) Ivermectin tablets in one single dose, then repeat it in one week and wash all bed linens the morning after taking the medication. A 3/27/19 Nurse Practitioner (NP) note documented that the resident had a papular rash to the neck, trunk and upper extremities. The NP also documented the rash was possibly scabies and that the resident saw the Dermatologist that day and received orders for Ivermectin. R#10 had a 4/17/19 NP note that documented a papular rash to the anterior trunk and extremities. On 4/22/19 the physician documented that the rash was still present and would be treated empirically for scabies with Ivermectin. A physician's orders [REDACTED]. R#12 was included in the line listing for (MONTH) for a symptom of itching. However, the listing for R#12 was not complete to include the medication treatment. In addition, R#7 and R#11 also received treatment with Ivermectin in (MONTH) 2019 but were not included in the line listing for that month. In addition, R#8 is not included in the line listing for (MONTH) 2019. 1. A review of the clinical record for R#12 revealed a 7/8/19 12:10 p.m. nurse note that documented the physician was notified of continued itching and small red rash-like bumps covering all extremities and trunk. A new order for Ivermectin was obtained. The physician ordered to administer six, 3 mg tablets of Ivermectin in one single dose, and repeat the dose again in one week. A review of the Medication Administration History for (MONTH) 2019 confirmed that the resident received the ordered doses of Ivermectin on 7/9/19 and 7/16/19. A review of the infection control program's Line Listing of Infections form for (MONTH) 2019 revealed that R#12 is included on the list for a symptom of itching. However, the remaining information on the line listing is incomplete. The entry does not include information on cultures, treatment, if the treatment was [MEDICATION NAME], if there is a true infection, the site of the itching or if it was a nosocomial or community acquired infection. 2. R#7 had physician's orders [REDACTED]. The resident was seen by a dermatologist on 5/1/19 and 5/15/19 and [DIAGNOSES REDACTED]. The orders for the [MEDICATION NAME] cream and [MEDICATION NAME] cream continued. A review of the 6/26/19 NP notes revealed that the NP documented the resident had no rash during that visit. However, on 7/8/19, the NP documented complaints of pruritic rash to the trunk and upper extremities. An [DIAGNOSES REDACTED]tous rash and scratch marks were noted to the trunk and upper extremities. The NP note documents that the resident was seen by dermatology twice and diagnosed with [REDACTED]. The NP notified the physician and documented they would treat with Ivermectin to see if there was any improvement. An order was written on 7/8/19 for licensed nursing staff to administer six 3 mg tablets of Ivermectin once on 7/8/19 and repeat the dose on 7/15/19. A review of the Medication Administration History for (MONTH) 2019 confirmed that the resident received the ordered doses of Ivermectin on 7/8/19 and 7/15/19. A further review of the clinical record after the completion of the Ivermectin revealed no further evidence of a recurrence of the rash. A review of the infection control program's Line Listing of Infections form for (MONTH) 2019 revealed that R#7 was not included in the listing for the rash and treatment with Ivermectin. 3. R#11 was examined by the NP on 7/2/19. A review of the 7/2/19 NP progress note revealed that the resident had a complaint of itching and rash. The skin was documented as having an [DIAGNOSES REDACTED]tous papular rash to trunk and extremities. The assessment and plan section noted pruritis and [MEDICAL CONDITION], scratching non-stop. A 4 mg intramuscular dose of [MEDICATION NAME] was ordered and six, 3 mg tablets of Ivermectin were ordered for a one-time dose, and to be repeated in one week. A follow up NP note on 7/8/19 documented that the resident's contact [MEDICAL CONDITION] rash and pruritis had improved with Ivermectin and that the next dose was due that week. Additional physician's orders [REDACTED]. An additional follow up NP note for a 7/16/19 visit documented that the contact [MEDICAL CONDITION] had resolved with treatment. A further review of the clinical record after the completion of the Ivermectin revealed no further evidence of a recurrence of the rash. A review of the infection control program's Line Listing of Infections form for (MONTH) 2019 revealed that R#11 was not included in the listing for the rash and treatment with Ivermectin. 4. R#8 was examined by the NP on 5/21/19. A review of the 5/21/19 NP progress note revealed that the resident complained of pruritis and had a papular rash to the arms and anterior chest wall. The note includes that the issue was discussed with the physician and a decision was made to treat the resident with Ivermectin. A physician's orders [REDACTED]. A review of the Medication Administration History for (MONTH) 2019 does not include documentation that the resident received the medication as scheduled. On 6/4/19, the physician visited the resident and documented that the resident continued to complain of an itching rash. His note included that the family indicated it seemed to have started after clothes were washed at the facility, instead of at home and that the family would wash the resident's clothes at home again. An order was written for [MEDICATION NAME] 1% cream to be applied twice daily. On 6/23/19 the NP visited and documented that the resident had no complaints of a rash that day and that the facility was washing laundry in a special detergent and to continue with [MEDICATION NAME] cream as needed. On 7/15/19 the NP documented that the rash had resolved. On 8/24/19 the NP again documented few erythemous, papular [MEDICAL CONDITION] noted on the trunk with a [DIAGNOSES REDACTED].#8 continued to complain of itching and a dermatology referral was made. The presence of the [MEDICAL CONDITION] was also noted on an 8/28/19 NP note. The resident visited the Dermatologist on 9/18/19. A 9/18/19 3:53 p.m. nurse's note entry documented that the resident returned from the appointment with new orders for [MEDICATION NAME] cream for suspected scabies. The note further includes that the NP called the dermatologist and the dermatologist stated that no scabies were seen. On 9/20/19 the NP documented that the resident had no rash noted but had scaly [MEDICAL CONDITION] to the dorsal surface of both hands. The NP noted that R#8 went to the dermatologist earlier in the week and was given a prescription for [MEDICATION NAME] cream for suspected scabies. The note includes that the resident was previously treated with Ivermectin. The NP note documents that the issue was discussed with the resident's family and the family declined treatment with the [MEDICATION NAME] cream and that nursing staff were to continue to use Lac-Hydrin lotion, cortisone cream and [MEDICATION NAME] medications as needed. On 10/30/19 the NP documented that the [MEDICAL CONDITION] had resolved. A review of the infection control program's Line Listing of Infections form for (MONTH) 2019 revealed that R#8 was not included in the listing for the rash and treatment with Ivermectin.

Based on observation, interviews and policy review, the facility failed to discard expired medications stored in the medication room. The sample size was 24. Findings include: Observation of the medication room on 12/17/18 at 2:10 p.m., revealed eight bags of [MEDICATION NAME] one gram (gm), and 100 milliliters (ml), normal saline (ns), intravenous (IV), expired on 11/3/18, two bags of two grams (gm), of [MEDICATION NAME] and 100 milliliters (ml), of normal saline (ns), expired on 11/19/18, and one bottle of [MEDICATION NAME]-B Injection 20 microgram (mcg), equal to milliliters (ml), generic [MEDICAL CONDITION] Vaccine (Recombinant) revealed discard after 3/3/18. Review of the facility policy titled Medication Storage, with review dated effective from (MONTH) 1, 1998, reviewed (MONTH) 30, (YEAR) revealed 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, if current order exists. An interview on 12/17/18 at 2:22 p.m. with Licensed Practical Nurse (LPN) BB, stated night nurses are supposed to check the refrigerators every night, and Consultant Pharmacist to come every month to audit and check the medication room refrigerators. She further revealed that she could not explain why this was staff had not been done. An interview on 12/17/18 at 2:25 p.m. with the Director of Nursing (DON) revealed that she started at the facility three weeks ago. She further revealed that she spoke with the Pharmacy Consultant (PC) who stated he came two weeks ago to audit all medications in the refrigerators. An interview on 12/17/18 at 2:30 p.m. with the Administrator, DON and the Nurse Consultant (NC) the Administrator contacted the PC at 2:35 p.m. via telephone, the Administrator called Pharmacy Consultant (PC) on phone, revealed that the PC had completed an audit of all refrigerators in the medication room two weeks ago and reported that no expired medication was found. At this time, it was revealed that the PC was only aware of two refrigerators, one for resident's food, and the second for medications and that he did not check a third refrigerator which was were the expired drugs were located.

Based on observations, staff interviews, record review and policy review titled Blood Glucose Monitoring, the facility failed to ensure that a glucometer device used to measure blood sugar levels was disinfected after each resident's use to prevent possible cross-contamination. The sample size was 24 residents. Findings include: During observation of medication administration on 12/17/18 at 4:28 p.m. on B hall, with Licensed Practical Nurse (LPN) AA revealed that LPN AA removed a glucometer from a drawer in the medication cart without disinfecting it before, and she used it to perform a finger stick blood sugar (FSBS) for Resident (R) #56. Further observations revealed that LPN AA, then exited the resident's room, discarded the lancet and placed the glucometer on the top of the medication cart, wiped it with alcohol pad, without disinfecting it first. LPN AA proceeded with obtaining FSBS from another resident, R#36. She did not clean glucometer prior to use for R#36. She placed the glucometer back in her medication cart after she wiped the glucometer with alcohol pad. An interview on 12/17/18 at 4:35 p.m., with LPN AA, revealed that she was not sure what the policy on cleaning the glucometer recommended. She also stated they usually disinfect the glucometer at the beginning of the shift, and at the end of the shift. LPN AA revealed that she wipes the glucometer with alcohol pad between each resident. LPN AA revealed that the facility has Three glucometers, one on each cart and one reserved for emergency. An interview on 12/17/18 at 4:40 p.m. with Director of Nursing (DON) stated her expectation was that all Licensed staff should follow the facility policy and procedure for using and disinfecting glucometers. She also stated all Licensed staff were in-serviced two weeks ago on glucometer cleaning. Review of the facility policy from Lippincott Procedures titled Blood Glucose Monitoring revised 12/18/2018 revealed, if one device must be used to monitor several residents, it must be cleaned and disinfected after every use following the manufacturer's instructions to prevent carryover of blood and infectious agents. Review of the glucometer manufacture guidelines revealed that glucometer should be cleaned and disinfected between each patient.

Based on observation, policy review and staff interview, the facility failed to ensure opened food items in the dry storage area were clean of food debris; failed to discard food items by expiration date; failed to date and label opened food items in cooler. In addition, the facility failed to maintain sanitary conditions of the Diet Pantry on one of one units. The census was 68. Findings include: 1. During observation on 11/20/17 at 10:03 a.m., revealed two 12 count packages of hamburger buns with expiration date of 11/13/17 on top shelf of dry storage room. 2. During observation on 11/20/17 at 10:12 a.m., revealed expired ham slices in clear container, stored in cooler with use by date of 11/17/17. 3. During observation on 11/20/17 at 10:15 a.m., revealed an opened and unlabeled bag of shredded cheese, stored in the cooler. 4. During observation on 11/20/17 at 10:18 a.m., revealed an opened gallon canister of peanut butter with slimy brown substance around the rim of the container and lid. Review of policy titled Labeling, Dating and Storage with reviewed date of 10/18/2017, revealed that Food and/or beverage items will be properly labeled with the name of the item, and a use by date, and prepared food and/or beverage items will be discarded according to the USDA Quick Reference Shelf Life. Interview with Dietary Manager (DM) on 11/20/17 at 10:18 a.m., verified the jar of peanut butter in the dry storage did have slimy substance around the rim and lid, as well as opened and undated shredded cheese and expired sliced ham in the cooler, as well as expired hamburger buns in the dry storage room. During observation on 11/21/17 at 4:34 p.m., resident pantry on the nursing unit, revealed the freezer packed full of unlabeled food items, including frozen pizza, frozen microwave meals, frozen macaroni and cheese, frozen ice water bottles, and two tubs of ice cream. The freezer was dirty with food particles on the base of freezer . The refrigerator had opened and unlabeled food items, including 1/2 gallon juice partially consumed, plastic bag with sweet cake in it, plastic bowl with two slices of pie, three opened and partially consumed bottles of water, two unopened bottles of water, and white styrofoam tray/plate unlabeled and undated. There was also a staff member insulated lunch bag in the bottom shelf of the refrigerator. Review of policy titled Patients/Residents' Personal Food with a reviewed date of 11/21/2016, revealed that foods requiring refrigeration must be stored in the nursing unit refrigerator or the patient/residents' personal refrigerators. Those items stored in the nursing unit refrigerator must be kept to a minimum due to limited space. Food requiring refrigeration must be labeled and dated and will be discarded after 48 hours. Further, frozen foods must be stored in the nursing unit freezer or the patient/residents' personal freezers. Those items stored in the nursing unit freezer must be kept to a minimum due to limited space. Frozen food must be labeled and dated and will be discarded after 14 days. Interview with Director of Health Services (DHS) on 11/21/17 at 4:47 p.m., stated that the lead Certified Nursing Assistant (CNA), is responsible for keeping the refrigerator cleaned out. She stated she thinks she cleans it twice per week. Interview with Lead CNA on 11/21/17 at 5:03 p.m., stated she assumed the responsibility of cleaning the pantry refrigerator. She stated she tries to clean it out two times per week, but admits she hasn't cleaned it in a few weeks. She verified the condition of the freezer and fridge with unlabeled and undated food items and states she is not sure who they belong to and is not sure how they got into the kitchen, because it stays locked and only the nurses have a key to the room.

Based on record review and staff interviews the facility failed to follow the care plan related to behavior monitoring for one resident (R#80) who was receiving [MEDICAL CONDITION] medications of 20 sampled residents. Findings include: Review of facility policy titled Monitoring of Anxiolytics with a revised date of November 21, 2016, revealed that every patient/resident on a [MEDICAL CONDITION] medication will have a behavior monitor guide printed on the Medication Administration Record [REDACTED]. This must be filled out as accurately as possible as it will be used in the assessment of gradual dose reduction of the [MEDICAL CONDITION] medication. A review of the clinical record for R#80 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of care plan dated 10/6/17, revealed that R#80 had alteration in behavior related to resident having anxious with fearful behavior and at risk for side effects related to resident receiving an anti-anxiety and antidepressant medications. It further noted the following interventions: observe and report changes in behavior to physician and evaluate effectiveness of medications. Review of the October 2017 MAR indicated [REDACTED]. The order was changed on October MAR indicated [REDACTED]. There was no evidence that behavior monitoring was handwritten to the October MAR, or any other form of behavior monitoring being used. During an interview on 11/22/17 at 2:00 p.m., Director of Health Services (DHS) stated that each medication nurse is supposed to be doing behavior monitoring on their shift for all residents on [MEDICAL CONDITION] drugs. DHS stated that she is responsible for overall compliance. She is not sure how the behavior monitoring was omitted for this resident for the month of October. During an interview on 11/22/17 at 2:36 p.m., with Unit Manager (UM) stated she was the nurse who took the order for R#80 [MEDICAL CONDITION] medications on October 11. 2017. She stated the pharmacy usually sends a behavioral monitoring sheet along with new orders for [MEDICAL CONDITION] medications. She assumed one was there, but there was not. She further stated that each nurse is supposed to check their own MAR's at the end of their shift for completeness. The 3-11 Supervisor is the back-up for checking behind the med nurses, and the error should have been noticed by the someone. Cross refer to F329

Based on record review and staff interview, the facility failed to monitor for behaviors and side effects for one resident (R) #80, who was receiving the antipsychotic drug [MEDICATION NAME] ([MEDICATION NAME]), of 20 sampled residents. Findings include: A review of the clinical record for R#80 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of October Medication Administration Record [REDACTED]. After two days on the 0.5 mg dose, the dosage was decreased to 0.25 mg by mouth twice a day. Review of facility policy titled Monitoring of Anxiolytics with a revised date of November 21, 2016, revealed that every patient/resident on a [MEDICAL CONDITION] medication will have a behavior monitor guide printed on the Medication Administration Record [REDACTED]. This must be filled out as accurately as possible as it will be used in the assessment of gradual dose reduction of the [MEDICAL CONDITION] medication. Review of the October 2017 MAR indicated [REDACTED]. The order was changed on October MAR indicated [REDACTED]. There was no evidence that behavior monitoring was handwritten to the October MAR, or any other form of behavior monitoring being used. During an interview on 11/22/17 at 2:00 p.m., Director of Health Services (DHS) stated that any nurse can take orders from Doctors and/or Nurse Practioners. She further stated each medication nurse is supposed to be doing behavior monitoring on their shift for all residents on [MEDICAL CONDITION] drugs. During an interview on 11/22/17 at 2:36 p.m., with Unit Manager (UM) stated she was the nurse who took the order for R#80 [MEDICAL CONDITION] medications on October 11. 2017. She stated that each nurse is supposed to check their own MAR's at the end of their shift for completeness, including behavior monitoring.

Based on clinical record review and staff interview, the facility failed to ensure that a care plan intervention was followed for a resident receiving anticoagulant therapy for one resident (R) 10. The sample size was 20 residents. The findings include: Review of the medical records for R10 revealed an admission date of [DATE]. The resident was noted to have the following documented Diagnoses: [REDACTED]. Review of the resident most recent care plan revealed R10 was care planned for the Risk of abnormal bleeding related to anticoagulant therapy. Further review of the care plan revealed that one of the approaches included on the residents care plan included: labs as ordered. Review of the physician orders [REDACTED]. Further review of the physician orders [REDACTED]. A review of the resident's laboratory results revealed the residents last PT/INR was dated 10/18/16 and there was no evidence that any other lab work had been obtained for this resident. According to the physician's orders [REDACTED]. An interview was conducted with the Assistant Director of Nursing (ADON) on 11/16/2016 at approximately 3:37 p.m. The ADON confirmed that the PT/INR labs were not obtained as ordered.