Person Memorial Hospital

Inspectors wroteBased on record reviews, and staff and physician interviews, the facility failed to limit the duration of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) ordered on an as-needed (PRN) basis to 14 days and/or indicate the duration and rationale for extending the PRN order beyond 14 days. This occurred for 1 of 5 residents whose medications were reviewed (Resident #36). Findings Included:Resident #36 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder. On 5/9/25, the physician ordered one (1) milliliter (ml) of Lorazepam Intensol Oral Concentrate (Lorazepam) 2 milligrams/milliliter (mg/ml) to be administered via Percutaneous Endoscopic Gastrostomy (PEG) tube every 2 hours as needed (PRN) for anxiety. Lorazepam is a psychotropic and controlled substance medication. [...]

Inspectors wroteBased on record reviews and staff, consultant pharmacist, and physician interviews, the facility failed to act on recommendations made by the consultant pharmacist and failed to document a response to the pharmacist's findings and recommendations in the resident's medical record for 2 of 5 residents whose medications were reviewed (Resident #36, and Resident #4).

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain 2 of 2 double-door ovens and 1 of 1 grill clean and free of grease. The facility also failed to label and date leftover food in 1 of 1 reach-in refrigerator and 1 of 1 walk-in refrigerator. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to post an updated daily nurse staffing sheet for residents and visitors on 1 of the 4 days during the survey period (12/14/25). The facility failed to provide upon demand the posted daily nurse staffing sheets for 10 of the 45 daily nurse staffing sheets reviewed (11/8/25, 11/13/25, 11/16/25, 11/17/25, 11/18/25, 11/20/25, 12/2/25, 12/3/25, 12/12/25, and 12/13/25). In addition, of the 35 daily nurse staffing sheets reviewed the facility failed to complete 3 daily nurse staffing sheets with information related to Nursing Assistants (11/2/25, 11/9/25, and 11/29/25).

Inspectors wroteBased on observations, record review, and staff, Family Member, and Physician Assistant interviews, the facility failed to provide care in a safe manner when a resident rolled off the raised bed while incontinence care was being provided. The resident had a history of stroke with residual left side weakness. Nurse Aide #1 turned the resident away from her onto her left side with the resident holding the upper side rail with her right hand. While care was being provided Resident #1 stated she could not hold on anymore and rolled out of the bed landing on her knees and immediately complained of pain in her knees, back and legs. Resident #1 was transferred to the local hospital by emergency medical services (EMS) for evaluation and a CT scan (computed tomography scan) confirmed distal right femur (thigh bone just above the knee joint) fracture. [...]

Inspectors wroteBased on record reviews and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 2 of the 33 days reviewed for staffing.

Inspectors wroteBased on observation and staff interviews, the facility failed to post the daily nurse staffing information for residents and visitors on 1 of the 4 days of the survey period. The facility also failed to update the daily staffing information to reflect actual staffing changes for 6 of 33 days reviewed for posted nurse staffing information.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to remove an expired multi-dose vial of insulin for 1 of 3 medication administration carts, failed to date opened multi-dose vials of insulin medication for 2 of 3 medication administration carts, and discard loose pills in the medication cart drawer for 2 of 3 medication administration carts (rehabilitation hall, short and long halls). Findings Included: 1a. On 9/15/24 at 9:15 AM, an observation of the medication administration Rehabilitation Hall cart with Nurse #1 revealed one opened and undated multi-dose vial of Insulin Glargine. A review of the manufacturer's literature indicated to discard Glargine multi-dose vial 28 days after opening. 9/15/24 at 9:40 AM, during an interview, Nurse #1 indicated that the nurses, who worked on the medication carts, were responsible to discard expired multi-dose vials. [...]

Inspectors wroteBased on record review, family and staff interviews, the facility failed to provide a written grievance summary for 1 of 1 residents (Residents #24) reviewed for grievances.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to provide fingernails and toenails care for 2 of 2 residents, dependent on staff for activities of daily living (ADL) care. (Resident # 37 and Resident #24)

Inspectors wroteBased on observations, staff interview and record review, the facility failed to provide an on-going activity program that met the individual interest and needs for 3 of 3 cognitively impaired residents reviewed for activities(Resident #22, Resident #27 and Resident #28).

Inspectors wroteBased on observations, residents and staff interviews, the facility failed to post the notice of location and make accessible the facility survey results for residents in a wheelchair. This was observed on 4 of 5 days of the survey.

Inspectors wroteBased on resident and staff interviews and review of resident council minutes, the facility failed to provide regular resident council monthly meetings (February 2023, March 2023, April 2023, and May 2023) for 4 consecutive months.

Inspectors wroteBased on observations, staff interview and record review, the facility failed to provide an on-going activity program that met the individual interests and needs to enhance the quality of life for 1 of 2 residents reviewed for activities (Resident #45).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to remove an expired multi-dose vial of insulin and discard loose pills in the medication cart drawer for 2 of 3 medication administration carts (200 short hall and 200 long hall). Findings Included: 1. On 8/20/23 at 9:10 AM, an observation of the long hall medication administration cart on 200 hall with Nurse #2 revealed in the second draw of the medication cart there were noted one white loose capsule and two blue round shape loose pills. On 8/20/23 at 9:20 AM, during an interview, Nurse #2 indicated that she could not identify what each of the pills were but stated the nurses were responsible for checking and cleaning their medication administration carts each shift. Nurse #2 did not clean the cart before her shift. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to keep food service equipment clean, free from debris, grease buildup, and/or dried spills during two kitchen observations. This practice had the potential to affect food served to all residents.

Inspectors wroteBased on observations, staff interviews, and record review the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following a recertification and complaint survey on 1/7/22 in order to achieve and sustain compliance. This was for a recited deficiency on a recertification survey on 8/23/23. The deficiency was in the area of medication storage and kitchen sanitary condition. The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete Minimum Data Set (MDS) assessments within the regulated time frame for 2 of 8 reviewed for resident assessment (Resident # 63, and Resident # 210).

Inspectors wroteBased on record review and staff interviews the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours (hrs.) a day for 1 of 30 days reviewed. (7/23/23).

Inspectors wroteBased on staff interviews, the facility failed to complete performance evaluations of nurse aides at least once every 12 months and provide in-service education based on the outcome of these reviews for 2 of 2 Nurse Aides (NA) (NA #3 and NA #5).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to transmit Quarterly and Annual Minimum Data Set (MDS) assessments within the required time frame for 6 of 8 residents (Resident # 45, Resident # 44, Resident #19, Resident #24, Resident #46, and Resident # 49) reviewed for Resident Assessments.

Inspectors wroteBased on observation and staff interviews, the facility failed to post the daily nurse staffing information to residents and visitors for 2 of the 4 days of the survey period.