Cabell Healthcare Center

Based on observation, record review and staff interview, the facility failed to assist a dependent resident with activities of daily living (ADLs). This was true for one (1) of four (4) residents reviewed during the survey process. Resident Identifier: #10. Facility Census: 85.Findings Include: a) Resident #10 On 08/04/2025 at 4:14 PM, the resident was observed lying in bed in the resident's room and appeared to be unkempt. On 08/06/25 at 2:00 PM, the facility provided a shower schedule for Lifesteps Hall. The shower schedule indicated the resident was to have scheduled showers on Tuesdays and Fridays during day shift. The review found the resident did not receive a shower or bed bath from 07/25/25 through 08/01/25. This was a total of seven (7) days. On 08/06/25 at 2:30 PM, the Director of Nursing (DON) was asked, Do the nurse aides (NAs) follow the shower schedule? The DON replied, We don't go by that .it's more for the unit managers. However, Regional Registered Nurse (RN) #91 looked in the computer and confirmed Resident #10 should be receiving showers on Tuesday and Fridays, on dayshift. On 08/06/25 at 3:15 PM, the Regional RN #91 confirmed Resident #10 did not receive a shower or bed bath for seven (7) days.

Based on record review, policy review and staff interview, the facility failed to provide an accurate and complete record for Resident #4's weights. This is true for one (1) of three (3) residents reviewed under the care area of nutrition. Resident Identifier: #4. Facility Census: 86.Findings Include:a) Resident #4On 08/04/25 at 3:31 PM, a record review was completed for Resident #4. The review found weights documented from 06/23/25 through 08/03/25. The following weights were documented:--06/23/25 190.8--07/02/25 156.6--07/06/25 154.8--07/20/25 176.7--07/27/25 175.5--08/03/25 173.8On 08/06/25 at 10:30 AM, the Regional Registered Nurse (RN) #91 was notified of the discrepencies in the documented weights. The Regional RN stated, Let look over the record and check and see if something was going on.On 08/06/25 at approximately 2:00 PM, the Regional RN #91 stated, I have reviewed all the weights of the residents throughout this time. I could not find any other issue with weights. I thought maybe something may have been wrong with the scales. The Regional RN #91 then stated, it does look like there was an error in documenting these weights.On 08/06/25 at 2:15 PM, the facility policy regarding weights was reviewed. The facility policy is entitled Resident Height and Weight. Number 3 states, Compare weight to previous weight obtained. If a variance of 5 pounds or more is noted, reweigh the resident to verify weight.

Based on observation and staff interview the facility failed to ensure personal food items were stored at the correct temperature and not expired. This was true for one (1) of five (5) personal refrigerators observed. Resident Identifier: #14. Facility Census: 86 Findings Include: a) Resident #14On 08/04/25 at 12:50 PM it was observed that Resident #14 had a personal refrigerator in her room. Upon observation it was noted that it had not had the temperature checked since 08/02/25. Further observation found that two packages of yogurt expired on 07/20/25. Both findings were confirmed with Registered Nurse #59 on 08/04/25 at 12:55 PM who agreed that they were not in compliance. According to facility policy for storage of resident food it states Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for > or + to 7 days . The dietary staff will monitor refrigerator contents for food safety and reserve the right to dispose of expired, unsafe foods . On 08/04/25 at 1:15 PM it was confirmed with the Director of Nursing and the Corporate Regional Nurse that the refrigerator should have had the temperature checked and recorded daily and the expired food items disposed of.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure all residents were provided with services and assistance to ensure they had no complications of vision loss. Resident #21 was wearing glasses which were in poor repair. She had seen the eye doctor in December, but the facility failed to follow through to ensure she received new glasses. This was true for one (1) of one (1) resident reviewed for the care area of Vision/hearing during the long term care survey process. Resident identifier: #21. Facility Census: 86. Findings Include: a) Resident #21 An observation of Resident #21 at 4:03 PM on 08/04/25 found the right lens of her eyeglasses was either scratched or broken near the center of the lens. A review of Resident #21's medical record found the resident was seen by the eye doctor in house on 12/18/24. A review of the consult found the following, History of Present Illness: 1. Decreased vision The [AGE] year old client presents for evaluation of Decreased vision in the right > left. It affects both near and far vision. The condition is significant. History of trauma with a BB gun per resident od. The consultation contained a prescription for new glasses. Below the prescription the following was written, New glasses will be ordered pending insurance/payer approval.An interview with the Business office manager on 08/05/25 at 12:35 PM confirmed she had not had a remedial (an adjustment the facility can request for the resident to lower her Medicaid resource amount to allow her to pay for the glasses) adjustment for glasses.An additional observation of Resident #21 glasses at 12:45 pm on 08/05/25 with the Regional Director of Clinical Observations #91 confirmed the resident's glasses were in poor repair and needed replacement. An interview with the Director of Nursing (DON) on the afternoon of 08/05/25 found the eye doctor's office sent an invoice for Resident #21's glasses in 12/2024. She stated they had talked to the son, and he did not want to pay for them at the time. The DON was asked if the facility had explained to the son that a Remedial Adjustment could be made to her Medicaid resource amount to cover the amount of the glasses and she stated she did not know what that was and would have to check with the business office. An interview with Resident #21's son Via Telephone on 08/05/25 at 1:31 PM confirmed, no one ever called him about his mom being seen for glasses and he wanted her to have anything she needed, and he would not have said no to that. He stated, I would like her to have new glasses.

Based on record review and staff interview, the facility failed to identify and provide needed care and services for two (2) of eight (8) residents. Resident #4 did not have a follow-up appointment after a hospitalization. One (1) of eight (8) residents did not have follow up care after blood glucose readings were crticially low. Resident Identifier: #4 and #70. Facility Census: 86.
Findings include:
a) Resident #4
On 08/05/25 at 2:00 PM, a record review was completed for Resident #4. The review found the resident was discharged from the acute care facility on 07/01/25 with the diagnoses of prostatitis, urinary tract infection with hematuria, hydronephrosis and hydroureter. On 08/05/25 at 3:00 PM, the Director of Nursing (DON) was asked when the resident's urology follow up appointment from discharge from the hospital was. The DON stated, Let me find out.
On 08/05/25 at 4:05 PM, the resident was observed with a urinary foley catheter in place. The urinary drainage bag was noted with dark tea-colored bloody urine. On 08/05/25 at 4:10 PM, the nursing staff at the nursing station, was asked about this observation. The nursing staff at the desk stated, the resident pulled the foley catheter out with the balloon intact last night (08/04/25).
On 08/05/25 at 4:10 PM, the DON stated, The office is closed .we have tried to call three (3) times, and we haven't gotten an answer.
The resident was discharged from the acute care facility on 07/01/25. No follow up appointment was scheduled until after Surveyor intervention.
On 08/06/25 at 9:15 AM, the DON stated, I don't know what happened with the communication. We have a call into the urologist. They show no follow up needed. The Surveyor asked the DON, Do you think the resident needs a follow up appointment, especially since he pulled out the urinary foley catheter with the balloon intact? The DON responded, Let me see what the office says.
On 08/06/25 at approximately 11:00 AM, the DON stated, The follow up appointment is scheduled on 08/08/25 at 11:30 AM.
b) Resident #70
On 08/07/25 at 11:10 AM record review shows that on 07/28/25 at 9:55 PM Resident #70 had a blood glucose documented as twenty nine (29). Further review shows no progress notes or communication with the Physician they were contacted. There was no glucose recheck documented on the level. There is no documentation that the resident was given anything to increase her blood glucose level. It was documented on the Vitals Summary as well as the Medication Administration on 07/28/25 as 29. The Care Plan shows the resident is at risk for hypoglycemia.
Upon conversation with the Director of Nursing on 08/07/25 at 1:10 PM, she stated she recalled the incident and had spoken with the nurse on duty that documented the level of 29. She stated that the nurse stated I must have forgotten to add the zero on the end of it making it 290 and not 29. There is no documentation availabel to confirm this. There was no error documented with the corrected blood sugar.
From the documentation available it appears the resident had the low glucose level and nothing was performed to increase it. This was confirmed with the Director of Nursing (DON) on 08/07/25 at 1:30 PM at which time she agreed.

Based on record review and staff interview, the facility failed to provide a Pre-admission Screening (PAS) which included all psychiatric diagnoses for Resident #10. This was true for one (1) of one (1) resident reviewed during the survey process. Resident Identifier: #10. Facility Census: 86. Findings Include:a) Resident #10On 08/07/25 at 9:00 AM, a record review was completed for Resident #10. The review found the PASARR dated 02/22/24 did not include all psychiatric diagnoses. The diagnoses not included were Generalized Anxiety Disorder documented as of 02/08/17 and Hallucinations which was documented as of 01/02/25. The resident is being treated with Klonopin (antianxiety) and Seroquel (antipsychotic) for bipolar disorder, which includes hallucinations.On 08/07/25 at 10:41 AM, the Social Services Director (SSD) #48 confirmed all the diagnoses were not listed on the PAS.

Based on record review, staff interview and resident interview, the facility failed to provide an ongoing activity program to support the physical, mental, and psychosocial well-being of each resident, and to accurately assess residents for activity preferences related to a significant change in condition. This failed practice was found to be true for two (2) of five (5) residents looked at for activities during the Long Term Care Survey Process. Resident identifiers: # 37, and # 53. Facility census 88.
Findings Included:
a) Resident #37
During an interview on 02/12/24 at 2:00 PM Resident #37 stated, I really don't go to activities much, they don't do much, I do like church but they never have it.
A record review on 01/13/24 at 2:30 PM of Resident #37's Activity Participation for the months of 12/2023, 01/2024, and 01/2024 revealed she attended 10 activities in 74 calendar days.
Further record review of Resident # 37's Minimum Data Set (MDS) section F, dated 11/02/23 shows under H, it is very important for her to participate in religious services or practices.
The record review also revealed that for the months of 12/2023, 01/2024 and 02/2024 religious activities were scheduled, but according to the participation records for the same time frame, Resident #37 was not asked nor did she attend these church services.
During an interview on 02/14/24 at 10:00 AM Resident #37, said she would love to go to church if she knew when it was.
A record review on 02/14/24 of the facilities scheduled one on one in-room visits reveals that resident #37 was not receiving one on one visits.
A review on 02/14/24 at 12:30 PM of the facilities policy titled Activities Program, under procedure letter f, section ii, it reads reflects the cultural and religious interest of the residents.
During an interview on 02/14/24 at 1:00 PM with the Activity Director, she confirmed the resident has low activity participation, has not been invited to church and needs to be added to the one on one in-room visits.
b) Resident # 53
A record review on 02/12/24 at 2:00 PM, Resident #53 was placed on Hospice care on 01/29/24 which triggered a significant change.
Further record review on Resident # 53 revealed an Activity Preference Assessment was not completed after significant change was triggered on 01/29/23.
On 02/13/24 at 2:15 PM while conducting staff interview with Activity Director (AD) states she only does an Activity Preference Assessment on admission and annually or when it's triggered on the User-Defined Assessments (UDA) dashboard.
Further record review of activity care plan and one on one list on 02/14/24 at 10:42 AM also found there were no one on one schedules or one on one visits care planed for Resident #53
02/14/24 11:28 AM staff interview was conducted with Director of Nursing (DON) #11. When asked if there was a review of activity care plan or an activity assessment done on Resident # 53 when the significant change was initiated on 01/29/24 she states not that I can see in the system there neither was revised or done.
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, resident and staff interview, the facility failed to follow the physician's orders. This was true for one (1) of twenty four (24) residents reviewed during the Long-Term Care Survey Process. Resident Identifier: #78 Facility Census: 88
Findings Included:
a) Resident #78
On 02/12/24 at 11:15 AM Resident #78 stated she did not always get her medications on time. On 02/13/24 at 11:50 AM a review of the Medication Administration Audit Report found there were missing and late orders on the report as listed below.
Facility Policy #NS-1197-05 for Medication Administration states .Procedure . ff. Medications will be administered within the time frame of one hour before up to one hour after time ordered
This was confirmed with the Director of Nursing on 02/14/24 at 9:30 AM.
Missed orders:
12/25/23 7:00 AM Behavior Monitoring - Antidepressant: Document Number of Episodes per shift of target behavior 1. crying 2. picking at skin 3. feeling of hopelessness every shift for Behavior Monitoring
12/25/23 7:00 AM Behaviors 1. picking skin 2. anxiousness Non-Pharmacological Intervention 1. encourage resident to express feeling 2. maintain consistent daily routine 3. provide a calm environment, limit over stimulation 4. provide diversional activities every shift for Behaviors
01/14/24 7:00 AM Behavior Monitoring - Antidepressant: Document Number of Episodes per shift of target behavior 1. crying 2. picking at skin 3. feeling of hopelessness every shift for Behavior Monitoring
01/14/24 7:00 AM Behaviors 1. picking skin 2. anxiousness Non-Pharmacological Intervention 1. encourage resident to express feeling 2. maintain consistent daily routine 3. provide a calm environment, limit over stimulation 4. provide diversional activities every shift for Behaviors
01/18/24 scheduled at 7:00 AM, Hemoglobin A1C for diabetes
01/18/24 7:00 AM Behavior Monitoring - Antidepressant: Document Number of Episodes per shift of target behavior 1. crying 2. picking at skin 3. feeling of hopelessness every shift for Behavior Monitoring
01/18/24 7:00 AM Behaviors 1. picking skin 2. anxiousness Non-Pharmacological Intervention 1. encourage resident to express feeling 2. maintain consistent daily routine 3. provide a calm environment, limit over stimulation 4. provide diversional activities every shift for Behaviors
02/13/24 7:00 AM Behavior Monitoring - Antidepressant: Document Number of Episodes per shift of target behavior 1. crying 2. picking at skin 3. feeling of hopelessness every shift for Behavior Monitoring
02/13/24 7:00 AM Behaviors 1. picking skin 2. anxiousness Non-Pharmacological Intervention 1. encourage resident to express feeling 2. maintain consistent daily routine 3. provide a calm environment, limit over stimulation 4. provide diversional activities every shift for Behaviors
Late orders:
11/21/23 at 12:00 PM ordered time for Hydroxyzine HCL 10 milligrams (mg) Give 1 tablet by mouth four times a day for anxiety. Not given until 1:24 PM 24 minutes late.
11/21/23 at 12:00 PM Nystatin Powder apply to abdomen topically three times a day for rash. Not given until 1:24 PM 24 minutes late.
11/21/23 at 12:00 PM Dicyclomine HCL 10 mg Give 1 capsule by mouth four times a day for IBS. Not given until 1:24 PM 24 minutes late.
11/26/23 at 7:00 AM Knee High compression stockings to be worn during daytime as resident tolerates every day shift for swelling. Not given until 08:37 PM 37 minutes late.
11/26/23 at 7:00 AM Antidepressant side effect monitoring not limited to: Dystonia: torticollis (stiffness of neck), Anticholinegic symptoms: Dry mouth, blurred vision, constipation, urinary retention, Hypotension, Sedation/drowsiness, Increased falls/dizziness, Cardiac abnormalities (tachycardia, bradycardia, irregular H.R: NMS). Anxiety/agitation, blurred vision, [NAME]/rashes, headache, urinary retention/hesitancy, Weakness, tremors, appetite change/weight change, insomnia, confusion, tardive dyskinesia, suicidal ideation's every day shift and night shift. Not monitored until 8:52 PM 52 minutes late.
11/26/23 at 7:00 AM AntiAnxiety side effect monitoring but not limited to: Dystoria: torticollis (stiffness of neck), Aticholinegic symptoms: Dry mouth, blurred vision, constipation, urinary retention, Hypotension, Sedation/drowsiness, Increased falls/dizziness, Cardiac abnormalities (tachycardia, bradycardia, irregular H.R: NMS). Anxiety/agitation, blurred vision, [NAME]/rashes, headache, urinary retention/hesitancy, Weakness, hangover effect every day shift and night shift. Not monitored until 8:52 PM 52 minutes late.
11/26/23 at 7:00 AM Behaviors 1. picking skin 2. anxiousness Non-Pharmacological Intervention 1. encourage resident to express feeling 2. maintain consistent daily routine 3. provide a calm environment, limit over stimulation 4. provide diversional activities every shift for Behaviors. Not monitored until 8:52 PM 52 minutes late.
12/02/23 at 7:00 AM Behaviors 1. picking skin 2. anxiousness Non-Pharmacological Intervention 1. encourage resident to express feeling 2. maintain consistent daily routine 3. provide a calm environment, limit over stimulation 4. provide diversional activities every shift for Behaviors. Not monitored until 11:05 PM 15 hours and 5 minutes late.
12/02/23 at 7:00 AM AntiAnxiety side effect monitoring but not limited to: Dystoria: torticollis (stiffness of neck), Aticholinegic symptoms: Dry mouth, blurred vision, constipation, urinary retention, Hypotension, Sedation/drowsiness, Increased falls/dizziness, Cardiac abnormalities (tachycardia, bradycardia, irregular H.R: NMS). Anxiety/agitation, blurred vision, [NAME]/rashes, headache, urinary retention/hesitancy, Weakness, hangover effect every day shift and night shift. Not monitored until 11:05 PM 15 hours and 5 minutes late.
12/02/23 at 7:00 AM Antidepressant side effect monitoring not limited to: Dystoria: torticollis (stiffness of neck), Aticholinegic symptoms: Dry mouth, blurred vision, constipation, urinary retention, Hypotension, Sedation/drowsiness, Increased falls/dizziness, Cardiac abno. Anxiety/agitation, blurred vision, [NAME]/rashes, headache, urinary retention/hesitancy, Weakness, tremors, appetite change/weight change, insomnia, confusion, tardive dyskinesia, suicidal ideation's every day shift and night shift. Not monitored until 11:05 PM 15 hours and 5 minutes late.
12/02/23 at 7:00 AM Knee High compression stockings to be worn during daytime as resident tolerates every day shift for swelling. Not assessed until 11:10 PM 15 hours and 5 minutes late.
12/02/23 at 7:00 AM Monthly weights every day shift starting on the 1st and ending on the 7th every month. Not assessed until 9:30 AM 1 hour and 30 minutes late.
12/16/23 at 5:00 PM Estrogen Conjugated Tablet 0.9 mg Give 1 tablet by mouth one time a day for history of hysterectomy. Not given until 8:37 PM 2 hours 37 minutes late.
12/16/23 at 5:00 PM Hydroxyzine HCL 10 milligrams (mg) Give 1 tablet by mouth four times a day for anxiety. Not given until 8:37 PM 2 hours 37 minutes late.
12/16/23 at 5:00 PM Dicyclomine HCL 10 mg Give 1 capsule by mouth four times a day for IBS. Not given until 8:37 PM 2 hours 37 minutes late.
12/16/23 at 5:00 PM Estrace Oral Tablet 2 mg (Estradiol) Give 0.5 tablet by mouth one time a day for history of hysterectomy. Not given until 8:37 PM 2 hours 37 minutes late. rmalities (tachycardia, bradycardia, irregular H.R: NMS)

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Based on observation, record review and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Medications were left at the bedside and lacked one half of a tablet of Zoloft. This was a random opportunity for discovery. Resident Identifier: #78 Facility Census: 88.
Findings Included:
a) Resident #78
On 02/14/24 at 10:05 AM it was observed that Resident #78 had a cup of medications at her bedside. Licensed Practical Nurse (LPN) #59 was called to the room. Upon further communication, it was determined that he had pulled the medications from the medication cart and was short one half (1/2) of a pill for the one of the ordered medications. The resident had been waiting for him to return to her room.
The facility Policy and Procedure #NS-1197-05 Medication Administration states: . Procedure: bb. Remain with the resident until the medication is swallowed. cc. Do not leave medications at bedside .
It was confirmed with LPN #59 the following medications were in the medicine cup at bedside:
Loratadine 10 mg 1 tablet
Tegretol 200 mg 1.5 tablets
Lisinopril 20 mg 1 tablet
Dicyclomine 10 mg 1 capsule
Furosemide 20 mg 1 tablet
Hydroxyzine HCL 100 mg 1 tablet
Zoloft 100 mg 1.5 tablets (Physician's order is for 100 mg X two (2) tablets)
The findings were confirmed with Unit Manager Registered Nurse (RN) #20 and LPN #59 on 02/14/24 at 10:07 AM and the Director of Nursing on 02/14/24 at 10:12 AM.

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Based on observation, record review, and resident and staff interview, the facility failed to change the oxygen tubing and humidifier, as ordered, for Resident #42. This was a random opportunity for discovery. Resident identifier: #42. Facility census: 88.
Findings included:
a) Resident #42
At approximately 12:38 PM on 02/12/24, during an interview with Resident #42, the oxygen tubing and humidifier was observed as being dated for 02/04/24. Upon further investigation, the humidifier bottle was empty. Resident #42 stated, I need some more water in that thing but they don't bring it in unless I ask, my nose is dry.
At 11:28 AM on 02/13/24, the humidifier bottle on Resident #42's oxygen concentrator was still empty, with the same bottle, dated 02/04/24.
At 11:40 AM on 02/13/24, a record review was conducted for Resident #42. It was discovered that Resident #42 has an order for the oxygen tubing and humidifier to be changed every week, on night shift, on Sundays, or as needed. The order was as follows:
Oxygen: Change humidifier bottle, tubing, and foam ear protectors and clean filters of oxygen concentrators Q (every) Week and as needed every night shift every Sun (Sunday).
At 3:38 PM on 02/13/24, the humidifier bottle on Resident #42's oxygen concentrator was still empty and the same bottle, dated 02/04/24, was still present on the concentrator. Resident #42 was complaining of a dry nose and mouth and stated they had asked a staff member for a new humidifier earlier that day, but they were told the current one, dated 02/04/24, still had water in it and there was no need for a new one at that time.
At approximately 3:42 PM on 02/13/24, Unit Manager RN (UMRN) #22, was made aware of the empty humidifier, acknowledged it was empty, dated for 02/04/24, and the orders that are in place for it to be changed once a week, or as needed, were not followed.

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Based on record review and staff interview, the facility Pharmacy failed to provide the appropriate medication dosage. This was a random opportunity of discovery. Resident Identifier: #78 Facility Census: 88
Findings Included:
a) Resident #78
On 02/14/24 at 10:05 AM it was observed that Resident #78 had a cup of medications at her bedside. Licensed Practical Nurse (LPN) #59 was called to the room. Upon further communication, it was determined that he had pulled the medications from the medication cart and was short one half (1/2) of a pill for one of the ordered medications. The resident had been waiting for him to return to her room.
On 02/14/24 at 10:06 AM during an interview with LPN #59, he states he knew this residents' medications and had worked on Monday, 02/12/24, and knows she is to get two (2) 100 mg tablets of her Zoloft, as he gave her the medications on Monday. He had intended to obtain the other 50 mg from the Pyxis to make the correct dosage but was unable to.
Resident #78 has a Brief Interview for Mental Status (BIMS) of 15 and writes down what medications she receives daily. She confirmed that she is to get two (2) 100 mg of Zoloft and states the nurse on duty on Tuesday, 02/13/24 only had one and a half (1 1/2) tablets yesterday. She stated LPN #42 had gotten the other 1/2 tablet from an emergency stock. Therefore, the Resident did receive her 200 mg of Zoloft on 02/13/24.
On 02/14/24 at 10:30 AM during an interview via telephone with LPN #42, she states the pre-package medications from the Pharmacy only had 1 1/2 100 mg tablets of Zoloft in it on Tuesday 02/13/24. She then broke one of the 100 mg tablets intended for administration on 02/14/24 and made the missing 1/2 tablet to equal 200 mg of Zoloft. This left only 1 1/2 tablets in the package for today's administration.
According to an telephone interview on 02/14/24 at 11:10 AM between the Director of Nursing and a Pharmacist at (Named pharmacy company) the medications are dumped in a packing machine and packed by the machine. The pill could have broken in half when the bottle was dumped in the machine. They are inspected by a Pharmacist prior to delivery. He stated the Pharmacist that inspected it could have missed it.
The facility Policy and Procedure #NS-1197-05 Medication Administration states: . Procedure: u. Do not split or alter tablets, Contact pharmacy for correct dosage .
On 02/14/24 at 10:10 AM, the Unit Manager Registered Nurse #20 obtained two (2) 25 mg Sertraline tables from the Pyxis and the Resident received her ordered dosage of 200 mg of Zoloft.
It was confirmed with LPN #59 the following medications were in the medicine cup at bedside:
Loratadine 10 mg 1 tablet
Tegretol 200 mg 1.5 tablets
Lisinopril 20 mg 1 tablet
Dicyclomine 10 mg 1 capsule
Furosemide 20 mg 1 tablet
Hydroxyzine HCL 100 mg 1 tablet
Zoloft 100 mg 1.5 tablets (Physician's order is for 100 mg X two (2) tablets)
The above findings were confirmed with Unit Manager Registered Nurse #20 and LPN #59 on 02/14/24 at 10:07 AM and the Director of Nursing on 02/14/24 at 10:12 AM.
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Based on observation and staff interview, the facility failed to provide Resident #10 with the proper assistive devices during meals. This was a random opportunity for discovery. Resident identifier: #10. Facility census: 88.
Findings included:
a) Resident #10
At approximately 12:33 PM on 02/13/24, while observing staff pass trays to residents in their rooms, Nurse Aide (NA) #36 stated, Resident #10 needs a two handled cup but all we have on the cart are Kennedy cups, I'm just going to give [them] one of those.
NA #36 stated in an interview that The kitchen probably doesn't have any two handled cups back there anyway, so I figured I would just use the Kennedy cup.
At approximately 2:40 PM on 02/13/24, an interview was conducted with Culinary Director (CD) #56. During the interview, CD #56 verified the tray ticket for Resident #10 listed a two handled cup for all meals, and that one should have been sent out with the drink cart. CD #56 confirmed the dietary department had enough two handled cups in stock, but that it had been forgotten to be sent out.
At approximately 3:00 PM on 02/13/24, a record review was conducted for Resident #10. During the record review it was determined that Resident #10 had an order for a two handled cup with meals. The order typed as written:
Two handle cup with meals
At approximately 11:40 AM on 02/14/24, the Director of Nursing (DON) was made aware of the two handle cups not being sent out with the drink cart for Resident #10. The DON acknowledged the order for the two handle cups for meals for Resident #10.

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Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. These deficient practices had the potential to affect any resident receiving nourishment from the kitchen. Facility census: 88.
Findings included:
a) Kitchen tour
During the kitchen tour on 02/12/24 at 11:30 AM, it was discovered the drip pan to the stove was heavily soiled and needed to be cleaned. The floors to the walk-in freezer and cooler had debris under the storage racks and the beverage pitchers were stored rim down on a rusted shelf.
The Dietary Manager observed the issues on 02/12/24 at 11:40 AM and verified the drip pan and floors needed to be cleaned. He also verified the beverage pitchers were stored rim down on a rusted shelf.

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Based on record review and staff interview, the facility failed to maintain accurate medical records in accordance with accepted professional standards of care for medication administration. This was a random opportunity for discovery. Resident identifier: #78 Facility Census: 88
Findings Included:
a) Resident #78
On 02/14/24 at 10:05 AM it was observed that Resident #78 had a cup of medications at her bedside. Licensed Practical Nurse (LPN) #59 was called to the room. Upon further communication, it was determined that he had pulled the medications from the medication cart and was short one half (1/2) of a pill for one of the ordered medications. The resident had been waiting for him to return to her room.
Upon review of the Medication Administration Audit Report (MAAR) for 02/14/24 it was determined that the following medications were due to be administered at 8:00 AM. Administration time was documented on the MAAR as being administered at 8:12 AM. However, the resident was sitting in her bed with the pills at bedside at 10:05 AM.
The MAAR is also charted as administering Zoloft 100 mg X two (2) tablets when it was observed to only be one and one half (1.5) tablets. It was confirmed with LPN #59 that he was aware the other half tablet was missing and he had intended to get the additional 1/2 tablet (50 mg) from the Pyxis but there were none in the system.
The facility Policy and Procedure #NS-1197-05 Medication Administration states: . Procedure: bb. Remain with resident until the medication is swallowed. cc. Do not leave medications at bedside .
It was confirmed with LPN #59 the following medications were in the medicine cup at bedside:
Loratadine 10 mg 1 tablet
Tegretol 200 mg 1.5 tablets
Lisinopril 20 mg 1 tablet
Dicyclomine 10 mg 1 capsule
Furosemide 20 mg 1 tablet
Hydroxyzine HCL 100 mg 1 tablet
Zoloft 100 mg 1.5 tablets (Physician's order was for 100 mg X two (2) tablets)
The above findings were confirmed with Unit Manager Registered Nurse #20 and LPN #59 on 02/14/24 at 10:07 AM and the Director of Nursing on 02/14/24 at 10:12 AM.

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Based on observation, record review and staff interview the facility failed to follow Enhanced Barrier Precautions for a resident with a history of Extended Spectrum Beta-Lactamase (ESBL). This failed practice was found true for (1) one of 11 residents reviewed for infection control during the Long Term Care Survey Process. Resident identifier: # 22. Facility Census: 88.
Finding included:
a) Resident # 22
An observation on 02/13/24 at 2:00 PM revealed that Resident # 22 had signage on the door that read:
Enhanced Barrier Precautions
Everyone must clean their hands, including before entering and when leaving the room
Doctors and staff must wear gloves and a gown for the following high contact resident care activities
* Dressing
* Bathing/showering
* Transferring
* Changing Linens
* Providing Hygiene
* Changing briefs or assisting with toileting
* Device care or use
A record review on 02/14/24 at 10:30 AM of Resident # 22's current care plan under interventions reads {Enhanced barrier precautions related to (ESBL) wound care. When dressing/bathing/showering/transferring/personal hygiene/changing linens, toileting and peri care, providing care to residents with history of or colonized mulit-drug resistant organisms.}
Further record review of Resident #22's current orders reveals that she has an order for Enhanced Barrier Precautions and has a diagnosis that includes history of ESBL.
During an observation, on 02/14/24 at 10:57 AM, Nurse Aide (NA) # 94 went into Resident #22's room and shut the door, when she came out of the room she had a bag with dirty sheets in it.
An interview on 02/14/24 at 10:57 AM with NA # 94 she stated, I just changed her, I wore gloves. No, I did not wear a gown. I didn't know I was supposed to
An interview, on 02/14/24 at 1:15 PM the Director of Nursing (DON), confirmed the proper Personal Protective Equipment (PPE) was not worn, for Enhanced Barrier Precautions.

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Based on observation, resident interview, and staff interview, the facility failed to treat each resident with dignity and respect by failing to knock, announce themselves, and receive permission from each resident before entering their rooms. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Resident Identifier: #12. Facility census: 88.
Findings included:
a) Resident #12
At approximately 11:51 AM on 02/12/24, Resident #12 expressed concern that staff would enter the room without knocking first. Resident #12 stated, Most of the time I don't know when they're coming in here. I'll be by myself one second, and when I look up, there will be a staff member, and I never knew they were coming in here.
During the interview with Resident #12, the door to the room opened and Nurse Aide (NA) #36 entered unannounced, without knocking. When NA #36 realized an interview was taking place with Resident #12, NA #36 stated Sorry, I didn't know anyone else was in here, I'll wait out in the hallway.
An interview was conducted with NA #36 at the end of the resident interview in which the NA #36 stated I just flung the door open and went in, I know I'm supposed to knock before I go in the rooms, I just didn't.

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Based on resident and staff interviews, the facility failed to protect each resident's property from being lost or stolen. The facility did not follow proper processes when Resident #82 reported a puzzle missing. This was true for one (1) of three (3) residents reviewed for personal property during the Long-Term Care survey process. Resident identifier: #82. Facility census: 88.
Findings included:
a) Resident #82
At approximately 12:58 PM on 02/12/24, an interview was conducted with Resident #82. Resident #82 stated during the interview that there were issues with their personal property disappearing and staff failing to follow up on their concerns. Specifically, Resident #82 stated a puzzle that was brought to them by a family member was taken and thrown away while the resident was working on it. Resident #82 stated they reported the puzzle to Nurse Aide (NA) #93 and NA #104 during the evening shift a couple weeks ago. Resident #82 stated there was no grievance form filled out, nor was there any follow up from the facility.
At approximately 9:30 AM on 02/13/24, an interview was conducted with Social Services Designee (SSD) #70 and Social Worker (SW) #62. During the interview, both SSD #70 and SW #62 stated they were unaware of any issues regarding the puzzle for Resident #82, stating they would check into the issue immediately.
At approximately 9:43 AM on 02/14/24, an interview was conducted with SSD #70 and SW #62 regarding the missing property of Resident #82. SSD #70 and SW #62 stated they had not followed up on the concern, nor had they met with Resident #82 to have them fill out a grievance form.

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Based on record reviews and staff interviews, the facility failed to ensure the completion of a new Preadmission Screening and Resident Review (PASRR) for a resident with a newly added psychiatric diagnosis. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the PASAAR care area. Resident identifier: #61. Facility census: 88.
Findings included:
a) Resident #61
A medical record review, on 02/12/24, revealed Resident #61 had a new diagnosis of hallucinations on 09/03/23 and major depressive disorder on 08/28/23. There was no evidence a new PASRR had been completed for these new diagnoses.
During an interview with the Director of Nursing (DON) on 02/13/24 at 11:25 AM, verified there was no new PASRR completed for the newly added diagnosis of hallucinations on 09/03/22 and major depressive disorder on 11/28/23.
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Based on record reviews and staff interviews, the facility failed to ensure a resident's 30 day Preadmission Screening and Resident Review (PASRR) reflected the pre admission diagnoses. This was true for two (2) of five (5) residents reviewed for the PASRR care area during the Long-Term Care Survey Process. Resident identifiers: #8 and #28. Facility census: 88.
Findings included:
a) Resident #8
During a medical record review on 02/13/24, for Resident #8 revealed admitting diagnoses on 03/03/22 included the following:
-major depressive disorder
-schizoaffective disorder
-hallucinations
-anxiety disorder
There was no evidence a 30 day PASRR was completed to reflect the admitting diagnosis, once it was determined Resident #8 was to remain in the facility long term.
In an interview with the Director of Nursing, on 02/13/24 at 11:47 AM, the DON verified there was no 30 day PASRR completed to include the admission diagnoses.
b) Resident # 28
A record review on 02/13/24 at 1:30 PM found Resident #28 was admitted with diagnoses of major depression disorder and seizure disorder on the PASRR from the transferring hospital completed on 09/26/22.
On 02/13/24 at 2:13 PM the Social Worker (SW) #62 confirmed no PASRR was completed within 30 days after admission from hospital.
The purpose of a Level II evaluation was to determine if residents with mental disorders or intellectual disabilities are offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting,) and receive the services they need in those settings.
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Based on record review and staff interview, the facility failed to implement a care plan related to one (1) on one (1) in room visits. This failed practice was found true for (1) one of 24 residents reviewed for care plans during the Long Term Care Survey Process. Resident identifier #37. Facility census 88.
Findings Included:
a) Resident # 37
A record review on 02/13/24 at 2:30 PM of Resident # 37's activity care plan revised on 02/05/24 reads under interventions: Provide 1:1 in room visits if unable to attend out of room events.
A further review of Resident #37's Activity Participation Record for 12/2023, 01/2024, and 02/2024 revealed that Resident #37 attended 10 group activities in the past 74 calendar days. Resident #37 did not have any documented one on one in room visits.
A review of the one on one activity visits schedule shows that Resident #37 was not assigned one to one in room visits.
During an interview on 01/14/24 at 1:00 PM with the Activity Director (AD), she stated, No she is not scheduled for one on one visits.

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Based on record review, resident interviews, and staff interviews, the facility failed to revise care plans for an intervention no longer needed for Resident #80 and a change in activity status for Resident #53. This was true for two (2) out of twenty-four (24) residents reviewed for care plans during the long-term care survey process. Resident identifiers: #80, #53. Facility census: 88.
Findings included:
a) Resident #80
At approximately 4:03 PM on 02/13/24, a record review was conducted for Resident #80. During the review, it was discovered that Resident #80 had an intervention for a stop sign at the door to their room. The intervention is written as typed in the care plan:
The resident has expressed preference to have a stop sign to doorway for privacy Date Initiated: 04/21/2023 Revision on: 04/21/2023
The resident's right to privacy will be honored through next review date Date Initiated: 04/21/2023 Revision on: 04/21/2023 Target Date: 03/26/2024
Provide stop sign to doorway for privacy Date Initiated: 04/21/2023 Revision on: 04/21/2023.
At approximately 11:30 AM on 02/14/24, an interview was conducted with Resident #80. Resident #80 stated There was a lady that kept coming into my room in the last room I was in and a stop sign was the only way I could keep her out. I don't need it now, though, since I have switched rooms.
At approximately 11:40 AM on 02/14/24, the Director of Nursing (DON) was made aware of, and acknowledged the failure to revise the care plan, stating that the stop sign was, in fact, no longer needed for Resident #80.
b) Resident #53
A record review on 02/12/24 at 2:00 PM, Resident #53 was placed on Hospice care on 01/29/24 which triggered a significant change.
Further record review on Resident # 53 revealed an activity care plan was not updated/revised after significant change was initiated 01/29/24
A record review of activity care plan and one (1) on one(1) list on 02/14/24 at 10:42 AM found there were no one (1) on one (1) schedules or care planed for Resident # 53
On 02/14/24 at 11:28 AM a staff interview was conducted with the Director of Nursing (DON). When asked if there was a review of activity care plan or an activity assessment done on Resident # 53 when the significant change was initiated on 01/29/24 she stated not that I can see in the system there nether was revised or done.

Based on record review, policy review and staff interview the facility failed to administer medications according to the Physicians order. This was true for two of five resident records reviewed for late or missed medication administration. Resident identifiers: #35 and #74. Facility Census: #89.
Findings included:
On 09/13/23 at 10 AM medication administration record review for the time period of 09/01/23 through 09/12/23 for the following residents found medications to have been administered late according to policy review.
According to the facility Medication Administration Policy and Procedure 1. General Procedure (ff. Medications will be administered within the time frame of one hour before up to one hour after time ordered.
This deficiency was confirmed with the Administrator on 09/13/23 at 2:30 PM.
a) Resident #35
Physician orders missed:
Scheduled date: 09/05/23 at 7:00 PM
Monitor effectiveness of melatonin as evidenced by resident is free of sleeplessness.
Monitor for absence of side effects related to antidepressant medication trazodone as evidenced by resident is free of urinary retention, nausea, dry mouth/taste disturbance and/or increased confusion.
Monitor for absence of side effects related to melatonin as evidenced by resident is free of increased confusion, nauseam and/or worsening memory impairment
Monitor for absence of side effects related to antidepressant medication remeron as evidenced by resident is free of urinary retention, nausea, dry mouth/taste disturbance and/or increased confusion.
Behavior monitoring - Antidepressant: Document Number of Episodes per shift of target behavior (Specify) 1. crying 2. c/o anxiety 3. feeling hopelessness
Physician orders administered late 7 AM- 7 PM
Scheduled date 09/03/23 at 9:00 AM. Administered at 1:04 PM which was three (3) hours and four (4) minutes late on all medications
Slow-Mag DR 71.5-119 milligram (mg) Give 1 tablet two times a day
Hiprex 1 gram 1 tablet two times a day
Vitamin d 1.25 mg once a day administered at 1:04 PM
Lasix 20 mg one time a day administered at 1:04 PM
Carvedilol 6.25 mg two times a day administered at 1:04 PM
Poly iron 150 two times a day administered at 1:04 PM
Hydralazine HCL 5 mg two times a day administered at 1:04 PM
Oxybutynin Chloride 5 mg two times a day administered at 1:04 PM
Januiva 25 mg one time a day administered at 1:04 PM
Nasonex Nasal Suspension 2 sprays in both nostrils two times a day administered at 1:04 PM
Cochicine 0.6 mg once a day administered at 1:04 PM
Scheduled date 09/10/23 at 9:00 AM. Administered at 11:05 AM which was was one (1) hour and five (5) minutes late on all medications:
Slow-Mag DR 71.5-119 milligram (mg) Give 1 tablet two times a day
Hiprex 1 gram 1 tablet two times a day
Vitamin d 1.25 mg once a day administered at 1:04 PM
Lasix 20 mg one time a day administered at 1:04 PM
Carvedilol 6.25 mg two times a day administered at 1:04 PM
Poly iron 150 two times a day administered at 1:04 PM
Hydralazine HCL 5 mg two times a day administered at 1:04 PM
Oxybutynin Chloride 5 mg two times a day administered at 1:04 PM
Januiva 25 mg one time a day administered at 1:04 PM
Nasonex Nasal Suspension 2 sprays in both nostrils two times a day administered at 1:04 PM
Cochicine 0.6 mg once a day administered at 1:04 PM
Oxygen: Deliver oxygen continuously at bedtime as needed @ 2 liters/minute via nasal cannula. Obtain 02Sa every shift on room air and as needed:
This order was scheduled at 9:00 PM on 09/04/23 and administered at 11:51 PM, one (1) hour and fifty-one (51) minutes late.
Scheduled at 9:00 PM on 09/06/23 and administered at midnight, two (2) hours late.
Scheduled at 9:00 PM on 09/10/23 and administered at 11:13 PM, one (1) hour and thirteen (13) minutes late.
b) Resident #74
Physician orders missed:
Scheduled date: 09/01/23 at 7:00 AM, 09/02/23 at 7:00 AM, 09/07/23 at 7:00 AM
Monitor weights every day shift starting on the 1st and ending on the 7th every month
Scheduled 09/05/23 at 7:00 AM
Behavior monitoring - antidepressant: document Number of episodes per shift of target behavior (Specify) 1. crying 2. hopelessness 3. loss of appetite every shift for behavior monitoring.
Physicians orders administered late: 7 AM - 7 PM
09/01/23 10 AM Ensure Plus 237 millimeters two times a day Administered at 11:55 AM, 55 minutes late
09/04/23 10 AM Ensure Plus 237 millimeters two times a day Administered at 11:44 AM, 44 minutes late
Physicians orders administered late: 7 PM - 7 AM
09/01/23 8 PM Ensure Plus 237 millimeters two times a day Administered at 11:05 PM, 2 hours and 5 minutes late
09/01/23 9 PM Mirtazapine 7.5 mg one tablet at bedtime Administered at 11:05 PM, 1 hour and five minutes late
Senna Plus 8.6-50 mg one tablet two times a day Administered at 11:05 PM, 1 hour and five minutes late
09/02/23 8 PM Ensure Plus 237 millimeters two times a day Administered at 9:53 PM, 53 minutes late
09/03/23 8 PM Ensure Plus 237 millimeters two times a day Administered at 9:42 PM, 42 minutes late

Based on observation and staff interview the facility failed to post up-to-date data for nurse staffing. During the tour for a complaint survey, it was discovered the Daily Staff Posting Report had not been updated on 09/13/23. A current Daily Staff Posting Form must be posted for public access. The deficient practice had the potential to affect more than a limited number of residents and visitors. Facility census: 89.
Findings included:
a) Staff Postings
During an observation on 09/13/23 at 9:15 AM, it was discovered the staff posting for public view had not been updated for 09/13/23. The Daily Staff Posting Form had a date of 09/12/23.
An interview with the Nursing Home Administrator on 09/13/23 at 9:15 AM, verified the Daily Staff Posting Report had not been completed by the on coming day shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based observation, policy, and staff interview, the facility failed ensure all multi-dose vials which have been opened or accessed (e.g., needle-punctured) are dated with the initial date they were opened or accessed. This was a random opportunity for discovery and had the potential to affect more than a limited number of newly admitted . Facility census 80.
Findings included:
a) Policy
Facility policy titled, (Named the facility pharmacy used) Pharmacy Policy. effective date: 09/01/20.
Certain medications or package types, such as IV solutions, Multiple dose injectable vials, opthalmics, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require both an open date and expiration date, which may shorter than the manufacture's expiration date to ensure medication purity and potency.
b) Medication storage room [ROOM NUMBER] hall.
An observation of the medication storage on the 200 hall at 11:41 AM, on 07/13/22, found a house stock Tuber sol injection 5/0.1/ml which did not have a date on the vial or box to indicate the date it was first opened and/or accessed. This was witnessed by Licensed Practical Nurse (LPN) #38.
On 07/13/22 at 11:55 AM, the above findings were reported to Administrator.
On 07/13/22 at 12:18 PM, Director of Nursing provided four pages with Staff names on it and stated the Tuber sol was administered to staff only.
During a review of Medical Administration Records (MAR) of three (3) newly admitted residents on the 200 hall it was also discovered they had received the Tuber sol injections:
Resident # 233 received the Tuber-sol injection on 07/07/22.
Resident #237 received the Tuber-sol injection on 07/07/22.
Resident #73 received the Tuber-sol injection on 07/02/22.
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Based on record review and staff interview the facility failed to ensure Resident #62's drug regimen was free from unnecessary psychotropic medications. Resident #62 was administered as needed Haldol an antipsychotic medication on three (3) separate occasions when non pharmacological interventions were not tried to redirect the target behaviors prior the administration of the medication. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during the long term care survey process. Resident Identifier: #62. Facility Census: 80.
Findings Included:
a) Resident #62
A review of Resident #62's medical record found a physician's order dated 07/06/22 for Haloperidol 2 milligrams Give one (1) tablet by mouth every eight (8) hours as needed for agitation for two (2) weeks. This was an active order at the time of this review.
A review of the Medication Administration Record (MAR) for the month of 07/2022 found Resident #62 received this medication on five (5) occasions. On three (3) of those occasions, 07/06/22 at 8:06 PM, 07/07/22 at 8:49 am and 07/08/22 at 3:54 PM the medical record was void of any documentation related to nonpharmalogical interventions attempted prior to the administration of the as needed Haloperidol.
An interview with the Director of Nursing (DON) at 9:26 am on 07/13/22 confirmed the medical record did not contain any information to indicate non pharmalogical interventions were attempted prior to administering the medication. She indicated those interventions should be documented in the nursing progress notes, but they were not.
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Based on Record review and staff interview the facility failed to ensure residents receive timely vaccines and that the medical record includes information/education regarding the benefits and risks of immunization and the administration or the refusal of or medical contraindications to the vaccine. The facility failed to give an Influenza vaccine to Resident #66. This was true for one (1) of three (3) Residents reviewed during the long term care survey process. Resident Identifier: # 66.
Facility Census: 80.
Findings Included:
a) Resident# 66
A review of Resident # 66's medical record found the Influenza vaccine marked as refused in the immunization tab of the chart. A further review of Resident # 66's medical record found no consent or refusal form for the influenza vaccine.
On 07/12/22 at 1:23 PM, when asked about Resident # 66's influenza vaccine refusal consent. Infection Preventionist (IP) provided a form labeled Influenza Vaccination Consent Form 2021-2022 dated 3/16/22 and signed by Resident #66's MPOA. IP stated that Resident # 66 did have a consent to have the influenza Vaccine but did not receive the influenza Vaccine. IP stated she did not receive the flu shot. It was my bad. I hit the wrong button in the computer.
07/12/22 at 1:55 PM, The Administer acknowledged Resident #66 did not receive the Influenza vaccine.
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to ensure Resident #53's wishes regarding Cardiopulmonary Resuscitation (CPR), medical interventions at end of life, and medically administered fluids were not changed by the Health Care Surrogate upon Resident #53's incapacity to make medical decisions. This was true for one (1) of one (1) resident reviewed for the care area of advance directives during the Long Term Care Survey Process (LTCSP). Resident Identifier: #53. Facility Census: 80.
Findings Included:
A) Resident #53
A review of Resident #53's medical record on [DATE] found the following capacity evaluations for Resident #53:
-- Capacity evaluations completed on [DATE] and [DATE] both indicated the resident was capable of making his own healthcare decisions.
-- Subsequent capacity statements completed on [DATE], [DATE], and [DATE] indicated the resident was not capacitated to make his own health care decisions due to his impaired cognitive status.
Further review of the medical record found a Health Care Surrogate Selection (HCS) form completed by the attending physician on [DATE] appointing the Department of Health and Human Resources (DHHR) as the resident's HCS.
Also contained in the medical record was two (2) Physician Orders for Scope of Treatment (POST) forms.
The first POST form was completed on [DATE]. This form was signed by Resident #53. The form was completed with the resident when he possessed the ability to make his own health care decisions. This POST form was reviewed and found Resident #53 wished to have CPR performed should he be found with no pulse and not breathing. It also indicated he wanted full medical interventions performed as indicated. Including being transferred to the hospital, being placed in the intensive care unit, and providing all medically indicated treatment including mechanical ventilation. The POST form also indicated Resident #53 wanted IV fluids and a feeding tube long term if indicated.
This form contained the following statement under section D of the form:
Initial Box if you agree with the following statement: If I lose decision making capacity and my condition significantly deteriorates, I give permission to my MPOA (Medical Power of Attorney) representative/surrogate to make decisions and to complete a new form with my MD/DO/APRN/PA inaccordance with my expressed wishes for such a condition or, if these wishes are unknown or not reasonably ascertainable, my best interests.
This box was not initialed by Resident #53, therefore indicating he did not authorize his HCS to make changes to his POST form in the event of his incapacity.
The second POST contained in Resident #53's medical record was completed by his HCS on [DATE]. This form indicated Resident #53 did not want CPR should he be found without a pulse and not breathing. The form further indicated resident was to receive comfort focused treatments which means healthcare professionals should avoid treatment listed in the full or select treatment sections unless consistent with comfort. The resident should only be transferred to the hospital if comfort can not be met at the facility. Finally the form indicated Resident #53 would not receive artificial means of nutrition should his condition require it.
An interview with the Director of Nursing (DON) on [DATE] at 8:22 am confirmed Resident #53's code status and end life wishes were changed by the HCS on [DATE]. After reviewing both post forms she agreed the HCS did not have Resident #53's authorization to complete a new POST form with conflicting choices in regards to his end of life care.
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Based on record review and staff interview the facility failed to immediately inform the resident; consult with the resident's physician; and notify, his or her resident representative(s) when there was a significant change in the resident's conditions or clinical complications. This was true for one (1) of two (2) residents reviewed for weight loss. Resident Identifier: Resident # 13. Facility census 80.
Findings included:
a) Resident # 13
A review of the medical record for Resident # 13 revealed the following. On 06/05/22, Resident #13 weighed 128.4 pounds (lbs) and on 07/04/22, the resident weighed 113.8 pounds which was an 11.37 percent (%) weight loss. Resident # 13's medical record contained a capacity form dated: 04/16/22, that indicated Resident # 13 lacks capacity to make medical decisions.
During a brief interview on 07/12/22 at 9:25 AM, the Director of Nursing (DON) was asked if there was any documentation of physician and family notification of a significant weight loss.
On 07/12/22 at 11:30 AM, the DON provided a nursing note with an effective date of 07/07/22 at 6:04 PM, (named last name of the facility attending physician) notified of Registered Dietitian (RD) recommendations;
1) Recommend to d/c Suplena w/carbsteady 237 ml Twice a day (BID).
2) Recommend to reimplement Suplena w/ carbsteady 237 ml three times a day (TID).
(Named last name of the facility attending physician) aware and agreeable to above orders. Resident and RD aware and agreeable.
Review of the medical chart reviewed above nursing note was created on 07/12/22 at 10:06 AM by the DON which was after the surveyor requested information regarding physician and family notification.
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Based on food temperature measurement, resident council meeting interview, and staff interview the facility failed to ensure food served to residents was palatable. This failed practice had the potential to affect more than an isolated number of residents. Facility Census: 80.
Findings included:
a) Palatability of food
During the resident council meeting held on 07/12/22 at 3:00 PM the residents complained the food at the facility needed a lot of work. They indicated it just was not good at all and it really needed improved.
On 07/13/22 during the noon time meal the food temperatures of two (2) trays were tested on two (2) separate hallways. The temperatures were obtained by the Certified Dietary Manager (CDM) using his thermometer. The following temperatures were obtained:
200 hall at 12:26 PM on 07/13/22. These were temperatures of pureed food:
Pureed Mixed Vegetables: 109 degrees Fahrenheit (F)
Pureed Spaghetti: 91 degrees F
Pureed Meat Sauce: 101 degrees F
Pureed Carrots: 110 degrees F.
Pureed Cheesecake: 55 degrees F.
-- 300 hall at 12:28 PM on 07/13/22. These were temperature of a regular consistency diet:
Mixed Vegetables: 92 degrees F
Spaghetti Noodles: 91 degrees F
Meat Sauce: 89 degrees F
Cheesecake: 55 degrees F.
The CDM when asked what the temperatures should be he stated, Hot food should be 135 degrees or higher and the cold food should be less than 45 degrees. He agreed all temperatures were outside of the preferable range.
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