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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 12/11/2015, 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 [NAME] 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 [NAME] 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.