Cabell Healthcare Center

Inspectors wroteBased on record review and staff interviews the facility failed to develop care plans for Post-Traumatic Stress Disorder (PTSD) and diuretic therapy. Additionally, the facility failed to implement a designated fall intervention requiring a reacher tool to be within the resident's reach. This deficient practice was found true for (3) three of 25 residents reviewed for care plan accuracy during the Long-Term Care Survey Process. Resident identifiers: #2, #67, and #7. Facility Census: 88 Findings Include: a) Resident #67 A record review conducted on 07/16/26 at 10:00 AM, revealed a fall intervention care plan for Resident #67. The documented interventions included: [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to follow physician's orders. This deficient practice had the potential to affect (three) of 25 residents reviewed in the long-term care survey sample. Resident Identifiers: #3, #5, and #9. Facility Census: 88.

Inspectors wroteBased on observation, record review, staff interview and resident interview, the facility failed ensure a complete and accurate medical record for a resident by documenting blood pressures being taken in opposite arm. for a resident with an incomplete capacity form, additionally, a resident's TAR being completed for a device she no longer wore and lastly for a resident with an incorrect capacity form. This included Resident's #3, #62, #35 and #46. Facility Census 88.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure residents with indwelling urinary catheters had their urine collection bags concealed with a privacy cover to maintain resident dignity. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for the care area of catheters. Resident Identifiers: #82 and #93. Facility Census: 88.

Inspectors wroteBased on record review and staff interview, the facility failed to document that required information was conveyed to the receiving hospital at the time of the resident's transfer. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of hospitalization. Resident Identifier: #46. Facility Census: 88.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessment in the area of catheters. This deficient practice had the potential to affect (1) of three (3) residents reviewed for the care area of catheters. Resident Identifier: #82. Facility Census: 88.

Inspectors wroteBased on record review, observation, resident interview and staff interview the facility failed to ensure a resident with limited range of motion received appropriate treatment to prevent further decrease in range of motion. This failed practice was found true for (1) one of (3) three residents reviewed for the care area of limited range of motion during the Long-Term Care Survey Process. Resident identifier: #64. Facility Census: 88.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the facility was as free from accident hazards as possible. A treatment cart was unlocked with no staff in attendance. This was a random opportunity for discovery that had the potential to affect more than a limited number of residents. Facility Census: 88.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure catheter treatment and care was provided within accepted standards of practice. For one (1) of three (3) residents reviewed for the care area of catheters, the urinary collection bag was on the floor. Resident Identifiers: #82. Facility Census: 88.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure an error rate of less than five (5) percent. Two (2) errors were observed in 29 medication administration opportunities to give an error rate of 6.9 percent. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for the care area of medication administration. Resident Identifiers: #14 and #60. Facility Census: 88.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure a resident in enhanced barrier precautions (EBP) had proper signage to alert staff and others of the EBP. The facility also failed to maintain infection control practices during medication administration. These were random opportunities for discovery. Resident Identifiers: #93 and #60. Facility Census: 88.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.