Cabell Healthcare Center

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…

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 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.

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…

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 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…

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 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…

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, 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…

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, 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…

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 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…

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 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…

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 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…

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, 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…

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 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…

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 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.

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…

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 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…

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 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…

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 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…

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 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…

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 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…

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.