Cadence Mooresville

The facility failed to ensure that a resident's care plan was signed and dated by their physician within 15 days of the assessment. Specifically, one resident's care plan dated 05/28/24 lacked the required Primary Care Provider signature. There was no established process in place to ensure care plans were returned signed by the physician.

The facility failed to ensure that the preparation and administration of medications and treatments by staff were in accordance with orders by a licensed prescribing practitioner.

The facility failed to administer medications as ordered for one of five sampled residents. For Resident #2, an order for quetiapine to treat anxiety was documented as discontinued in the eMAR from 06/13/24 through 06/30/24 without a corresponding physician's order to stop the medication.

The facility failed to ensure that one of three sampled residents had a completed care plan signed by the Primary Care Provider within 15 days of the assessment. Specifically, Resident #5's care plan dated 05/28/24 lacked the required physician signature.

The facility failed to ensure therapeutic diets, including thickened liquids, were served as ordered by the resident's physician. Specifically, for two residents with orders for nectar-thickened liquids, the facility failed to provide appropriate consistency, evidenced by a resident being served melted ice cream that had lost its intended consistency.

The facility failed to ensure that therapeutic diets were served as ordered by the resident's physician. Specifically, for two sampled residents, the facility failed to provide the required nectar-thickened liquid diet as prescribed.

The facility failed to assure physician notification for 2 of 5 sampled residents with blood pressure measurements outside of ordered parameters. Specifically, for Resident #1, multiple blood pressure readings in December 2018 and January 2019 were outside the physician-ordered limits without evidence of required notification to the Primary Care Provider.

The facility failed to implement physician-ordered infection control measures for a resident with Clostridium difficile (C. diff.). Specifically, the facility did not follow necessary contact precautions and hand hygiene protocols required to prevent the transmission of the infectious agent.