cms_WV
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37 rows where "inspection_date" is on date 2017-09-07
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 107 | 107 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 152 | D | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility staff failed to identify the appointed Health Care Surrogate (HCS) for Resident #84, as designated by the attending physician on 06/05/17. Thus, the designated HCS was unable to exercise the resident rights to the extent provided by state law. Resident identifier: #84. Facility census: 180. Findings include: a) Resident #84 Review of Resident #84's medical records, on 08/30/17 at 11:15 a.m., found the resident was admitted to the facility on [DATE] following a hospitalization . Admission paperwork was completed by the resident's daughter. Further review found a HCS selection form completed 06/05/17, by the attending physician, designating the son as the HCS. No further HCS designation forms could be located in the medical records. Interview with Employee #122, social worker (SW), on 09/06/17 at 9:15 a.m., revealed she thought the daughter was the HCS on admission and had asked to appoint her brother the HCS due to personal issues. When asked, Is there another HCS designation form. She replied, I don't see any in the medical records. On 09/06/17 at 11:00 a.m., Employee #122, SW, provided a HCS designation form dated 05/30/17. She further confirmed this form had been faxed to her on 09/06/17 at 10:35 a.m. This HCS form indicated the Daughter was in fact appointed as the HCS while the resident was in the hospital. However, this HCS became void when the attending physician at the facility appointed Resident #84's son as the HCS on 06/05/17. The facility continued to notify Resident #84's daughter of changes in her condition and had the daughter listed as the health care decision maker on the resident face sheet even after Resident #84's son was appointed HCS on 06/05/17. On 09/07/17 at 10:25 a.m., the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was both notified. No further information was provided. | 2020-09-01 |
| 108 | 108 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 157 | E | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the resident, physician, and/or resident responsible party when a significant change occurred in the residents condition. This deficient practice affected two (2) of twenty-nine (29) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). For Resident #84, the facility staff failed to notify the appropriate Health Care Surrogate(HCS) after 06/05/17, when a new HCS was appointed. Resident #19's responsible party was not notified when there was a change in her medication regimen. Resident identifiers: #84 and #19. Facility census: 180 Findings include: a) Resident #84 Review of Resident #84's medical records, on 08/30/17 at 11:15 a.m., found the resident was admitted to the facility on [DATE] following a hospitalization . Admission paperwork was completed by the resident's daughter. Further review found a HCS selection form completed 06/05/17, by the attending physician, designating the son as the HCS. No further HCS designation forms could be located in the medical records. Interview with Employee #122, social worker (SW), on 09/06/17 at 9:15 a.m., revealed she thought the daughter was the HCS on admission and had asked to appoint her brother the HCS due to personal issues. When asked, Is there another HCS designation form. She replied, I don't see any in the medical records. On 09/06/17 at 11:00 a.m., Employee #122, SW, provided a HCS designation form dated 05/30/17. She further confirmed this form had been faxed to her on 09/06/17 at 10:35 a.m. This HCS form indicated the Daughter was in fact appointed as the HCS while the resident was in the hospital. However, this HCS became void when the attending physician at the facility appointed Resident #84's son as the HCS on 06/05/17. The facility continued to notify Resident #84's daughter of changes in her condition and had the daughter listed as the health care decision maker on the resident face s… | 2020-09-01 |
| 109 | 109 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 159 | E | 0 | 1 | QLZ111 | Based on review of the resident's personal funds accounts and staff interview, the facility failed to notify each resident that receives Medicaid benefits when the amount in the resident ' s account reaches $200 less than the SSI resource limit for one person ($2,000). This deficient practice affected five (5) of ninety (90) residents that have personal funds managed by the facility. Resident identifiers: #307, #286, #256, #229, #224. Facility census: 180. Findings include: a) Residents Personal Funds Account: Review of residents' personal funds account, on 09/06/17 at 2:25 p.m., found five (5) residents had personal funds within $200.00 dollars of the $2,000.00 dollar limit allowed for residents receiving Medicaid benefits. Review of resident individual account balances for 08/06/17 found the following residents within $200.00 dollars of the $2,000.00 dollar limits: --Resident #307- $1,802.10 --Resident #286- $1980.45 --Resident #256- $2,204.38 --Resident #229- $1,907.79 Further review of resident individual account balances for 09/05/17 found the following residents within $200.00 dollars of the $2,000.00 dollar limits: --Resident #224- $2,103.15 --Resident #229- $2,209.79 Upon interview on 09/07/17, at 9:20 a.m., with the Business Office Manager (BOM), she found the computer generated notice when the resident's personal funds reaches $1,800.00 dollar limit. She further confirmed she was unaware she was to provide the notice to the residents and/or responsible party until the corporate offices informed her of the responsibility of printing and providing the resident and/or the responsible party today (09/07/17). On 09/07/17 at 10:25 a.m., the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was both notified. No further information was provided. | 2020-09-01 |
| 110 | 110 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 160 | D | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for the care area of personal funds during Stage 2 of the Quality Indicator Survey (QIS), had her/his personal funds conveyed within 30 days of death to the individual or probate jurisdiction administering the resident's estate. Resident identifier: # 382. Facility census: 180. Findings include: a) Resident #382. Medical records found Resident # 382 expired on [DATE]. On [DATE], a check for the amount of $1,144.03 dollars was made out to Resident #382 and mailed to the family. At 9:20 a.m., on [DATE]. Business Office Manager (BOM) confirmed the personal funds of Resident #382 was not conveyed to the proper individual or probate jurisdiction administering the residents' estate after her death. On [DATE] at 10:25 a.m., the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was both notified. No further information was provided. | 2020-09-01 |
| 111 | 111 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 161 | E | 0 | 1 | QLZ111 | Based on record review and staff interviews, the facility failed to ensure a surety bond was in place in the amount to assure the security of all personal funds of residents deposited with the facility. Specifically, the surety bond that was purchased by the facility was not sufficient to cover the amount of deposits made by the residents in the facility. This practice had the potential to affect all 90 residents who have their money managed by the facility. Facility census: 180. The findings included: a) Record Review On 09/06/17 at 1:47 p.m., a review of the facility accounting records revealed that the personal needs funds on deposit with the facility totaled on the following dates: --04/03/17 - $77,144.71 --06/02/17 - $80,504.19 --07/03/17 - $73,506.75 --07/06/17 - $64,187.41 --07/10/17 - $62,240.07 The current resident fund surety bond in effect, issued 7/1/17, for the amount of $61,000. b) Staff Interview The Business Office Manager (BOM) was interviewed on 09/07/17 at 9:20 a.m. She confirmed that the current surety bond of $61,000 dollars is less than the amount deposited in the personal needs account. On 09/07/17 at 10:25 a.m., the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was both notified. No further information was provided. | 2020-09-01 |
| 112 | 112 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 225 | E | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview the facility failed to thoroughly investigate the background of potential employees prior to or upon their employment at the facility. This was true for Employee # 150 who was hired by the facility on 04/10/17. As of 08/30/17 the facility had not screened Employee #150 through the West Virginia Cares Registry and Employment Screening (WV CARES) program as required by West Virginia State Code 16-49-9. This employee had access to all residents residing at the facility. Also, the facility failed to report three (3) of thirty-five (35) reportable incidents to the appropriate state agency. The facility reported these allegations to the Nursing Home Program even though a nurse aide was identified during the investigation as the alleged perpetrator therefore the allegations should have been reported to the Nurse Aide Program. These reportable incidents involved Resident #322, #372, and #280. Additionally, the facility failed to report all allegations of abuse and/or neglect to the appropriate state agencies for four (4) of fifty-five (55) complaints/concerns completed by the facility for the month of (MONTH) (YEAR). The allegations not reported involved Resident # 84, #110, #233, and #290. Finally, the facility failed to report a verbal allegation of neglect to the appropriate state agency for resident #367. Resident Identifiers: #84, #110, #233, #290, #322. #372, #280 and #367. Employee Identifier: #150. Facility Census: 180. Findings Include: a) WV CARES West Virginia Code 16-49-9 established new criminal background check requirements for applicants for employment as direct access personnel in long-term care facilities. Effective 08/01/15, all nursing home facilities were required to .prescreen all direct access personnel applicants considered for hire for negative findings by way of an Internet search of registries and licensure databases through the WV Cares website. WV CARES is administ… | 2020-09-01 |
| 113 | 113 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 226 | E | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to develop an abuse policy that included all required components. The policy did not address training related to dementia management and resident abuse prevention. The policy also included time frames for reporting abuse that were established from the time the management staff became aware of the allegation and not the actual time the allegation was made. In addition, the facility did not implement its policy as it pertained to the reporting of all allegations of abuse and neglect. The facility failed to report all allegations of abuse and/or neglect to the appropriate state agencies for four (4) of fifty-five (55) complaints/concerns completed by the facility for the month of (MONTH) (YEAR). The allegations not reported involved Resident # 84, #110, #233, and #290. Also there was one allegation of neglect made in regards to Resident #367 which was not written on a concern form and it was also not reported to the appropriate state agencies. Also, the facility failed to report three (3) of 35 reportable's to the appropriate state agency. The facility reported these allegations to the nursing home program even though a nurse aide was identified during the investigation as the alleged perpetrator therefore the allegations should have been reported to the Nurse Aide Program. These reportable instances involved Resident #322, #372, and #280. The failure of the facility to develop a policy that contains all required components and the failure of the facility to implement their current policy has the potential to effect all residents currently residing in the facility. Resident Identifiers: #84, #110, #233, #290, #322, #372, #367, and #280. Facility Census: 180. Findings Include: a) Policy Development 1. Dementia Management and Resident Abuse Prevention. A review of the facility's Abuse and Neglect Prohibition policy with a revision date of (MONTH) (YEAR), at 9:00 a.m. o… | 2020-09-01 |
| 114 | 114 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 241 | E | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, record review, observation and staff interview, the facility failed to ensure residents were treated with dignity and respect. Three (3) residents, residing in separate rooms, did not receive their meals at the same time as their roommates. These random observations were made during the meal service. In addition one (1) of three (3) residents reviewed for the care area of dignity was sent to a physicians' appointment dressed only in a brief and was not wearing his dentures. Resident identifiers: #121, #69, #19, and #73. Facility census: 180. Findings include: a) Resident #121 Observation of the noon meal at 12:34 a.m. on 08/28/17 found the resident's roommate had finished eating her noon meal. Resident #121 did not have her tray. Employee #87, a Registered Nurse (RN) unit manager said Resident #121 requires assistance with eating so she does not have her tray. The tray comes out on another cart. The staff have to pass all trays to residents who can feed themselves, then they return to provide assistance to the residents who can't feed themselves. Resident #121's tray is on the second cart. At 4:00 p.m. on 08/28/17, the Registered Nurse (RN), District Director of Clinical Services, stated, We have always served the residents who can feed themselves first. We are fixing the trays right now so roommates will have their trays at the same time. b) Resident #69 Observation of the morning meal on 08/29/17, at 8:29 a.m. found the resident's roommate had finished eating his meal. Resident #69 did not have a tray. The roommate, Resident #286 stated his roommate does not have a tray yet because someone has to feed him. He gets his tray later. c) Resident #19 Observation of the noon meal on the 400 hallway found Resident #19's roommate had finished eating her breakfast at 8:49 a.m. on 08/29/17. Resident #19 did not have her meal. Nursing assistant (NA) #58 said Resident #19's tray comes out on the second cart. She stated reside… | 2020-09-01 |
| 115 | 115 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 246 | D | 0 | 1 | QLZ111 | Based on observation, resident interview and staff interview the facility failed to ensure once (1) resident received grooming tools to ensure she could perform activities of daily living. During this random opportunity for discovery the resident was observed having long hair on her chin. Resident identifier: #35. Facility census: 180. Findings include: a) Resident #35 On 08/29/17 at 9:12 a.m. an observation of Resident #35 revealed Resident #35 had long chin hairs. Resident #35 said, I'm growing a beard, I use to get them waxed when I went to the beauty shop. They will give you a razor but you have to ask. On 08/30/17 at 9:00 a.m. Resident Care Specialist (RCS) #145 indicated she had been assigned to work with Resident #35. RCS #145 was asked to go to Resident #35's room. Once in the room Resident #35 asked RCS #145 for a razor and RCS #145 said she would get one for her. Upon leaving the room RCS #145 agreed the resident had long hair on her chin and said the resident had never asked her for a razor. On 08/31/17 at 12:55 p.m. Resident #35 said the facility had given her a razor a few months ago but she had broken it and did not want to ask for another one. She said, they should have noticed because I was starting to look like a goat. | 2020-09-01 |
| 116 | 116 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 247 | D | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, record review and staff interview, the facility failed to ensure notice was provided to one (1) of four (4) residents reviewed during Stage 2 of the Quality Indicator survey (QIS) who voiced concerns regarding room moves without notification. Resident identifier: #30. Facility census: 180. Findings include: a) Resident #30 At 4:17 p.m. on 08/28/17, the resident's responsible party said the resident had been moved on several occasions and notification prior to room moves was not always provided. Review of resident census found the following dates the resident was moved to other rooms in the facility: --On 12/21/16, the resident was admitted to the facility and was placed in room [ROOM NUMBER] B on the first floor. --On 03/01/17, the resident moved from first room floor 35 B to room [ROOM NUMBER] B also on the first floor. --On 04/05/17, the resident was moved from room [ROOM NUMBER]B on the first floor to third floor, room [ROOM NUMBER] B. --On 05/09/17, the resident was moved from room [ROOM NUMBER] B to fourth floor, room [ROOM NUMBER]. --On 06/02/17, the resident was moved from fourth floor, room [ROOM NUMBER] to third floor, room [ROOM NUMBER]. --On 06/16/17, the resident was moved from room [ROOM NUMBER] to first floor, room [ROOM NUMBER]. --On 06/27/17, the resident was moved to third floor, room [ROOM NUMBER]. --On 07/10/17 the resident was moved from room [ROOM NUMBER] to room [ROOM NUMBER] on the third floor. Record review found the facility provided written forms, entitled, Notification Of Room Change, for the room moves occurring on 04/05/17, 06/02/17, 06/27/17, 07/10/17. The notification was provided to the responsible party. Review of the medical record with the director of nursing (DON) at 10:08 a.m. on 09/06/17, found the facility had no documentation the responsible party/resident was notified of the room moves occurring on 03/01/17, 05/09/17, and 06/16/17. The DON confirmed the responsible party shou… | 2020-09-01 |
| 117 | 117 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 272 | D | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a complete and accurate minimum data set (MDS) for one (1) of twenty-nine (29) residents whose MDS's were reviewed during Stage 2 of the Quality Indicator survey (QIS). Resident #19's MDS was incorrect in the area of diagnosis. Resident identifier: #19. Facility census: 180. Findings include: a) Resident #19 Review of the current residents Medication Administration Record [REDACTED]. On 04/20/17, the pharmacist advised the physician to please consider either documenting more appropriate justification for use of the [MEDICATION NAME] or titrate off this agent until justification is apparent or it is possible to discontinue the agent. At 2:55 p.m. on 08/30/17, the Director of Nursing (DON) provided a physician's progress visit note, completed by Employee #178, the Advanced Practice Registered Nurse. The visit was signed by E #178 on 05/02/17. Documentation noted the resident had a [DIAGNOSES REDACTED]. At 12:12 p.m. on 09/05/17, two (2) Advanced Nurse Practioners, #177 and #178 who visit the resident at the facility, said the resident has always had mental illness. Employees #117 and #178 provided a copy of a visit by a third Advanced Practice Registered Nurse indicating the resident had mental illness on 11/04/16. This visit noted the resident had a [DIAGNOSES REDACTED].#178 said she had spoken to the family members of the resident and she believed the son also told her about the mental illness. E#178 said the third Advanced Nurse Practioner specialized in psychiatric illness. [NAME] #178 did not explain why the [DIAGNOSES REDACTED]. One annual minimum data set (MDS) with an assessment reference date (ARD) of 03/12/17 was completed after the [DIAGNOSES REDACTED]. Section I, of the MDS provides boxes to check for a [DIAGNOSES REDACTED]. and [MEDICAL CONDITION]. The MDS did not reflect the resident had a [DIAGNOSES REDACTED]. The Registered Nurse (RN), Resident Care Manage… | 2020-09-01 |
| 118 | 118 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 278 | E | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure four (4) quarterly minimum data sets (MDS's) were accurately completed for one (1) of twenty-nine (29) residents whose MDS's were reviewed during Stage 2 of the Quality Indicator survey (QIS). Resident #19's quarterly MDS's were incorrect in the area of diagnosis. Resident identifier: #19. Facility census: 180. Findings include: a) Resident #19 Review of the current residents Medication Administration Record [REDACTED]. On 04/20/17, the pharmacist advised the physician to please consider either documenting more appropriate justification for use of the [MEDICATION NAME] or titrate off this agent until justification is apparent or it is possible to discontinue the agent. At 2:55 p.m. on 08/30/17, the Director of Nursing (DON) provided a physician's progress visit note, completed by Employee #178, the Advanced Practice Registered Nurse. The visit was signed by E #178 on 05/02/17. Documentation noted the resident had a [DIAGNOSES REDACTED]. At 12:12 p.m. on 09/05/17, two (2) Advanced Nurse Practioners, #177 and #178 who visit the resident at the facility, said the resident has always had mental illness. Employees #117 and #178 provided a copy of a visit by a third Advanced Practice Registered Nurse indicating the resident had mental illness on 11/04/16. This visit noted the resident had a [DIAGNOSES REDACTED].#178 said she had spoken to the family members of the resident and she believed the son also told her about the mental illness. E#178 said the third Advanced Nurse Practioner specialized in psychiatric illness. [NAME] #178 did not explain why the [DIAGNOSES REDACTED]. Four quarterly MDS's have been completed since the [DIAGNOSES REDACTED]. 02/16/16, 06/05/17, 07/28/17, and 08/18/17. Section I, of the MDS provides boxes to check for a [DIAGNOSES REDACTED]. and [MEDICAL CONDITION]. None of the four (4) quarterly MDS's coded the resident as having a [DIAGNOSES REDACTED]. … | 2020-09-01 |
| 119 | 119 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 279 | D | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview, the facility failed to identify and develop a comprehensive care plan for significant weight loss for one (1) of twenty-nine (29) residents reviewed during Stage 2 of the Quality Indicatior Survey. Resident Identifier: #320. Facility Census: 180 Findings include: a) Resident #320 Resident #320 lost 10.8% (percent) of his body weight, from 04/22/17 to 05/05/17, which represented a severe weight loss. Additionally, Resident #320 lost 13.1% of his body weight from 04/22/17 to 06/04/17, which again represented a severe weight loss. There was no evidence the facility identified these weight losses nor assessed causes and/or provided interventions to prevent additional weight loss. A record review on 09/05/17 at 12:08 p.m., revealed the Nursing Initial Plan of Care completed on 04/22/17, Section E. Nutrition, 1. Focus, 2. Goal, 3. Interventions, and 4. Responsible Disciplines had no responses. It was signed by Employee #87. The Nursing Care Plan completed on 06/06/17, which was the current care plan at the time of this review, stated, Focus: (First name of resident #320) has nutritional problem or potential nutritional problem (skin breakdown) r/t Obesity (weight 277, BMI/IBW 34.6/196-206). Date Initiated: 04/28/2017. Revision on: 04/28/2017. Goal: (First name of resident #320) will have gradual weight loss (1-2 lbs per month) through review date. Date Initiated: 04/28/2017. Revision on: 05/03/2017. Target Date: 08/02/2017. (Resident #320's last name) will maintain adequate nutritional status as evidenced by maintaining weight within (10)% of (196), no s/sx of malnutrition, and consuming at least (50)% of at least (2) meals daily through review date. Date Initiated: 04/28/2017. Revision on: 05/03/2017. Target Date: 08/02/2017. (First name of resident #320) will not develop complications related to obesity, includng skin breakdown, ineffective breathing pattern, altered cardiac output, … | 2020-09-01 |
| 120 | 120 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 280 | E | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, family interview and resident interview the facility failed to ensure four (4) of twenty-nine (29) residents whose care plans were reviewed had care plans that were revised as the resident's needs changed. The facility failed to revise Resident #59's care plan in the area of incontinence, Resident #84's care plan was not revised in the area of nutritional status, Resident #284's care plan was not revised in the area of accidents after a resident experienced three (3) falls, and Resident #286's care plan in the area of discharge planning. Additionally, Resident 19's responsible party was not given enough notice to attend care plan meetings. Resident identifiers: #59, #84, #284, #286 and #19 Facility census: 180. Findings include: a) Resident #59 The Minimum Data Set (MDS) review for Resident #59 indicated this resident was assessed as occasionally incontinent on the admission MDS. On the quarterly MDS, completed on 06/02/17, this resident was assessed as frequently incontinent. The care plan review revealed a focus area of occasional incontinence. This focus area was initiated on 03/27/17. The goal for the resident to be continent at all times was revised on 04/18/17 with a target date of 07/17/17. During an interview on 09/07/17 at 10:21 a.m. with Registered Nurse/MDS #46 she confirmed the resident's care plan was not revised to show the resident's decline from occasional to frequent incontinence. b) Resident #84 The medical record review for Resident #84 revealed a weight loss between the dates of 07/11/17 and 08/15/17. The resident weighed 207 pounds (lbs) on 07/11/17 and 180 lbs on 08/15/17. While in the hospital on [DATE] a weight was recorded as 187 lbs. The care plan dated 08/05/17 stated Resident #84 was at nutritional risk related to history of therapeutic diet, [MEDICAL CONDITIONS], hypertension, wound, [MEDICAL CONDITION] and abnormal labs. On 07/11/17 the physician ordered [MEDICATIO… | 2020-09-01 |
| 121 | 121 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 282 | D | 1 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to implement the care plan for two (2) of twenty-nine (29) residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #19 did not receive restorative services according to the care plan. Resident #320's care plan was not implemented for bladder incontinence. Resident identifiers: #19 and #320. Facility census: 180. Findings include: a) Resident #19 Review of the resident's current care plan found the following problem: Resident has limited physical mobility related to disease process dementia, [MEDICAL CONDITION], weakness, revised on 08/24/17. The goal associated with the problem: Resident will remain free of complications related to immobility, including contractures, thrombus formation, skin breakdown, fall related injury through the next review date, revised on 08/24/17. Interventions included; Nursing Rehabilitation/Restorative: Active range of motion, revised on 08/24/17. On 08/22/17, the physical therapist referred the resident to the facility's restorative program. On 08/24/17, the resident began the following restorative program: The goal for restorative therapy was: Maintain strength and functional mobility level Activities to be performed for restorative: 1. Stretching to Bilateral hamstrings and bilateral gastrocnemius muscles 30-45 second hold. (MONTH) do in seated or supine position. 2. Therapeutic exercises for bilateral lower extremities ankle pumps, heel slides straight leg raises, hip abduction/adduction and hip flexions long arc quads, 2 sets of 10 reps; may do in seated or supine. 3. Wheel chair mobility 50-100 feet Bilateral upper extremities and bilateral lower extremities for propulsion, min Assistance to SBA (stand by assistance); instruct patient on safe turning of wheel chair, safe negotiation of obstacles and correct upper extremity and lower extremity placement. At 2:19 p.m. on 08/30/17, the unit manager, … | 2020-09-01 |
| 122 | 122 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 309 | E | 1 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review, resident interview, and policy review the facility failed to ensure that each resident received the necessary care and services to enable them to maintain and or attain their highest practicable physical, mental and psychosocial well-being. For Resident #235 the facility failed to follow a physician order [REDACTED]. The facility failed to ensure Resident #141 received a physician ordered medication to treat a headache. For Resident #284 and #336 the facility failed to assess a pressure ulcer upon admission to the facility. The facility failed to coordinate care between the [MEDICAL TREATMENT] center and the facility for Resident #382. For Resident #19 the facility failed to follow the physician guidance to contact the responsible party in regards to completing further laboratory testing. These failures affected six (6) of twenty-nine (29) sampled Stage 2 residents. Resident Identifiers: #235, #141, #284, #336, #382, and #19. Facility Census: 180. Findings include: a) Resident #235 1. Aspirin A review of Resident #235's medical record at 9:44 a.m. on 09/06/17 found the following physician order [REDACTED]. Increase ASA (Aspirin) dose to 325 mg (milligrams) 1 po (by mouth) qd (every day) for PE (pulmonary embolism). CBC (completed blood count) 1 wk (week). Review of Resident #235's Medication Administration Record [REDACTED]. In fact Resident #235 has received Aspirin 81 mg daily since 01/05/17 with no change in dosage. An interview with the interim Director of Nursing (DON) at 2:41 p.m. on 09/06/17 confirmed Resident #235's aspirin dose was never increased as the physician order [REDACTED]. 2. Pain Management A review of Resident #235's medical record at 9:44 a.m. on 09/06/17 found the following physician note dated 02/21/17 which read under the section titled, Plan: For Chronic pai[DIAGNOSES REDACTED] continue biofreeze . Further review of the record found a physician order [REDACTED]. This order ha… | 2020-09-01 |
| 123 | 123 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 311 | D | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide restorative therapy as ordered by the physician for one (1) of three (3) resident's reviewed for the care area of activities of daily living (ADL's) during Stage 2 of the Quality Indicator Survey. Resident identifier: #19. Facility census: 180. Findings include: a) Resident #19 On 08/22/17, the physical therapist referred the resident to the facility's restorative program. On 08/24/17, the resident began the following restorative program: The goal for restorative therapy was: Maintain strength and functional mobility level Activities to be performed for restorative: 1. Stretching to Bilateral hamstrings and bilateral gastrocnemius muscles 30-45 second hold. (MONTH) do in seated or supine position 2. Therapeutic exercises for bilateral lower extremities ankle pumps, heel slides straight leg raises, hip abduction/adduction and hip flexions long arc quads, 2 sets of 10 reps; may do in seated or supine. 3. Wheel chair mobility 50-100 feet Bilateral upper extremities and bilateral lower extremities for propulsion, min Assistance to SBA (stand by assistance); instruct patient on safe turning of wheel chair, safe negotiation of obstacles and correct upper extremity and lower extremity placement. At 2:19 p.m. on 08/30/17, the unit manager, Registered Nurse (RN) #116 said the restorative aides keep paper documentation of restorative services provided to residents. RN #116 said the resident had not received any therapy and she did not know why. RN #116 called Restorative Aide (RA) #33 to review the restorative therapy services. RA #33 said the resident had not had any therapy because a second aide who normally works this floor had not been working due to an injury. RA #33 said she had not been on this floor since last Thursday because she had been pulled to the floor to work as a nursing assistant. At 12:50 p.m. on 09/05/17, RN #116 was asked if the second restorative aide had r… | 2020-09-01 |
| 124 | 124 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 312 | D | 1 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, resident interview, record review, and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for the care area of activities of daily living (ADL's) was provided care for oral hygiene. The facility was unaware Resident #90, who had resided at the facility since 02/12/15, had a upper partial. Resident identifier: #90. Facility census: 180. Findings include: a) Resident #90 Observation of the resident's oral cavity at 10:41 a.m. on 08/29/17, found the resident had what appeared to be her own teeth. Some were missing, discolored and were covered with a white, chalky substance that appeared to be plaque. Observation of the resident's oral cavity with the Registered Nurse (RN) unit manager, at 12:57 p.m. on 09/05/17, found RN #116 discovered the resident had an upper partial and, What looks like a cavity on the lower back tooth. The resident said she had a partial. She stated, I am not going to show it to you because you might steal it. Three (3) nursing assistants (NA's) #47, #5 and #58, (all working on the resident's unit) and RN #116 denied knowing the resident had a partial at 1:21 p.m. on 09/05/17. All denied removing the partial for cleaning. RN #116 was asked if she could find any evidence the facility was ever aware the resident had a partial or any documentation the partial had been removed for cleaning. Record review found the resident was admitted to the facility on [DATE]. The most recent minimum data set (MDS), a quarterly, with an assessment reference date (ARD) of 06/29/17 notes the resident requires extensive assistance of 1 staff member for personal hygiene, which includes brushing teeth. Review of the last 3 nursing monthly assessments, dated 06/12/17, 07/12/17, and 08/12/17 noted the resident has her own teeth under the section entitled, Dentition. The form also allowed the nurse completing the assessment to note the resident had a Partial(s) Bridge(s). This section was no… | 2020-09-01 |
| 125 | 125 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 315 | D | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #141 and Resident #320 received the services and assistance necessary to maintain their bladder continence status. Resident #141 and Resident #320 both suffered a decline in bladder continence status since their admission to the facility. The facility failed to consistently provide services to these residents to help them to maintain their bladder continence status. This practice affected two (2) of four (4) residents reviewed for the care area of urinary incontinence during Stage Two (2) of the Quality Indicator Survey (QIS). Resident Identifiers: #141 and #320. Facility Census: 180. Findings Include: a) Resident #141 During a Stage 1 interview with Resident #141 at 11:12 a.m. on 08/29/17, when asked if she received enough fluids between meals Resident #141 replied, they bring me plenty to drink but I watch what I drink because I wet on myself now and I never used to do that and I don't like it so I try not to drink to much. A review of Resident #141's medical record beginning at 8:02 a.m. on 09/07/17, found Resident #141 was admitted to the facility on [DATE] at which time she had an indwelling urinary catheter. Resident #141 continued to have a catheter until 01/27/17 at which time it was removed. A review of the nurse aides documentation pertaining to urinary continence was completed beginning with (MONTH) (YEAR) through 09/07/17. This review found the following ( the review was not started until (MONTH) due to the use of the catheter until 01/27/17): In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 16.25 percent (%) of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 16.48 % of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 5.19 % of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 79.57 % of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 83.70 … | 2020-09-01 |
| 126 | 126 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 323 | D | 1 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to ensure the resident's environment, over which the facility had control, was free from accidents. Resident #350's over the bed table was sitting on a fall mat. Resident #214's grab bars in the bathroom were loose. This was true for one of three residents reviewed for the care area of accidents during Stage 2 of The Quality Indicator survey (QIS) and one random observation. Resident identifiers: #350 and #214. Facility census: 180. Findings include: a) Resident #350 Record review found the resident was admitted to the facility on [DATE]. The resident's current care plan, included a problem for: Being at risk of falls related to CVA (cerebral vascular accident) with aphasia, incontinence, muscle weakness, impaired balance, impaired cognition, history of falls. The goal associated with the problem is: Resident will not sustain serious injury through the review date Interventions included: Low bed with bilateral floor mats per MD (physician) order The resident needs a safe environment with (even floor free from spills and or clutter, etc.) Record review found the resident had seven (7) falls since his admission: --06/09/17 - Resident up in wheelchair in room attempted to stand and fell in floor no injuries noted. --06/13/17 - Resident seen by nurse sliding off edge of bed onto the floor on his knees. --06/20/17 - Resident found lying on his left side on the floor mat beside his bed. --06/22/17 - at 5:30 a.m., Resident noted sitting in floor on mat beside his bed --06/22/17 - at 1:15 a.m., Resident observed sitting in the floor next to his bed --08/21/17 - Resident found lying in front of his wheelchair in the day room. --08/27/17 - Resident found sitting on the left side of his bed on floor mat, obtained a skin tear to the upper part of the back of his right and left arm. Five (5) of the falls occurred when the resident fell from bed. On 06/28/17, the physical ordered a low bed wit… | 2020-09-01 |
| 127 | 127 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 325 | D | 1 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, resident interview and staff interview, the facility failed to identify and address a severe weight loss for one (1) of three (3) residents reviewed for the care area of nutrition during Stage 2 Quality Indicator Survey. Resident #320 lost 10.8% (percent) of his body weight, from 04/22/17 to 05/05/17, which represented a severe weight loss. Additionally, Resident #320 lost 13.1% of his body weight from 04/22/17 to 06/ , which again represented a severe weight loss. There was no evidence the facility identified these weight losses nor assessed causes and/or provided interventions to prevent additional weight losses. As no interventions had been implemented, the weight loss could not be determined to be unavoidable. This represents actual harm to resident #320. Resident Identifier: #320. Facility Census: 180 Findings Include: a) Resident #320 A record review on 08/30/17 at 8:28 a.m., revealed the following weights for Resident #320: -- 04/22/17: 277.0 pounds -- 05/05/17: 247.0 pounds (-10.8%, -30.0 pounds) -- 06/04/17: 240.8 pounds (-13.1%, -36.2 pounds) The resident's percentage of weight loss from 04/22/17 to 05/05/17 and from 04/22/17 to 06/06/17 were calculated using the following formula % of weight loss = (usual weight - actual weight) / (usual weight) x 100. -- From 04/22/17 to 05/05/17, the resident lost 10.8% of his body weight. -- From 04/22/17 to 06/04/17, the resident lost 13.1% of his body weight. Review of resident #320 physician's orders [REDACTED]. Dietary supervisor clarified this order as Controlled Carbohydrate Diet, No Added Salt Diet, Regular Texture, Regular Consistency. Review of resident #320 medical record found a Minimum data set (MDS) with an assessment reference date of 06/17/17. Section K of this MDS Swallowing/Nutritional Status K0300: Weight Loss of the MDS, indicated Resident #320 had not had a Loss of 5% or more in the last month or loss of 10% or more in last 6 months. Further … | 2020-09-01 |
| 128 | 128 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 329 | E | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure two (2) of six (6) residents reviewed for the care area of unnecessary medication use were free from unnecessary medications. Resident #19 was receiving an excessive dosage of an anti-anxiety medication, identified by the pharmacist, without justification. In addition, the resident was receiving two (2) antidepressant medications without physician justification. Resident #350's insulin was not administered according to physician's orders [REDACTED]. In addition, Resident #350 received a mood stabilizer and an antidepressant without evidence of non-pharmacological interventions attempted before stating the medications. Resident identifiers: #19 and #350. Facility census: 180. Findings include: a) Resident #19 1. [MEDICATION NAME], an anti-anxiety medication On 11/25/16 the physician prescribed, [MEDICATION NAME] 1 milligram (mg.), every six (6) hours for agitation. A total of four (4) mg's in a twenty-four hour period. On 01/09/17, the prior order was discontinued and the physician ordered: [MEDICATION NAME] 1 mg., every six (6) hours for increased agitation, yelling, cursing, secondary to anxiety. The pharmacist reviewed the resident's medications on 01/13/17 and provided the following information in a written report to the physician: (Name of Resident) receives [MEDICATION NAME] 1 mg. at a total daily dose which is greater than the usual recommended maximum. Recommendations: Please consider re-evaluating continued use of [MEDICATION NAME] at this dose. If this therapy is to continue, its is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; and b) the facility interdisciplinary team ensure ongoing monitoring for effectiveness and potential adverse consequences. The physician responded with the following comments: I have re-evaluated this thera… | 2020-09-01 |
| 129 | 129 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 334 | D | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the staff failed to obtain a consent prior to administering the [MEDICAL CONDITION] vaccine in (YEAR) for three (3) of five (5) residents reviewed. Resident identifiers: #19, #95, and #190. Facility census: 180. Findings include: a) Resident #19 According to the Medication Administration Record, [REDACTED]. However, no informed consent was obtained before the [MEDICAL CONDITION] vaccine injection on 10/27/16. b) Resident #95 According to the Medication Administration Record, [REDACTED]. On 09/07/17 at 1:35 p.m., Unit Manager (UM) #87 was unable to locate any documentation that consent for the [MEDICAL CONDITION] vaccine had been obtained from Resident #95 or his representative at any time. c) Resident #190 According to the Medication Administration Record, [REDACTED]. On 09/07/17 at 1:35 p.m., Unit Manager (UM) #87 was unable to locate any documentation that consent for the [MEDICAL CONDITION] vaccine had been obtained from Resident #190 or her representative at any time. According to the facility's policy and procedure entitled Immunizations: Influenza (Flu) Vaccination of Residents, Staff, and Volunteers, Informed consent in the form of a discussion regarding risks and benefits of vaccination will occur prior to vaccination. According to the facility's policy and procedure entitled Standing Orders for Administering Influenza Vaccine to Adults, Provide all patients with a copy of the most current federal Vaccine Information Statement (VIS). You must document in the patient's medical record or office log, the publication date of the VIS and the date it was given to the patient. UM #22 and UM #87 were interviewed on 09/07/17 at 1:35 p.m. UM #22 stated verbal consent was obtained from the resident or the resident's representative prior to administration of the [MEDICAL CONDITION] vaccine. UM #87 stated that written consent is obtained. The Director of Nursing (DoN) was also interviewed… | 2020-09-01 |
| 130 | 130 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 353 | E | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, policy review, and observation, the facility failed to ensure qualified nursing staff provided day to day care to meet the resident's needs in an environment which promoted each resident's physical, mental, and psychosocial well-being, to enhance their quality of life. The facility failed to ensure all employees were thoroughly screened prior to employment (Employee #150 was not screened through West Virginia (WV) Cares as required by law.) For Residents #322, #372, #280, #84, #110, #233, #290 and #367's allegations of abuse/neglect was not thoroughly investigated and reported to the appropriate state agencies. For Resident #235, the facility failed to follow physician orders [REDACTED]. For Resident #141, the facility failed to follow physician orders [REDACTED]. For Residents #284 and #336 the facility failed to assess pressure ulcers present on admission. For Resident #382, the facility failed to correlate care and services for a resident receiving [MEDICAL TREATMENT] treatments. For Resident #19, the facility failed to follow physician's guidance to contact the responsible party in regard to completing lab tests. For Resident #19, the facility failed to provide restorative services as ordered by the physician. For Resident #90, the facility failed to have the knowledge needed to provide oral care for a dependent care resident. For Residents #141 and #320, the facility failed to provide the necessary services for each resident to restore and/or maintain the resident's bladder functioning. For Residents #350 and #214, the facility failed to ensure the residents environment was as free of accident hazards as possible. For Resident #320, the facility failed to ensure acceptable parameters of nutrition was maintained. For Resident # 350, the facility failed to administer insulin as ordered. These deficient practices had the potential to affect more than an isolated number of resident… | 2020-09-01 |
| 131 | 131 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 356 | B | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the nurse staff posting contained the correct date. This practice had the potential to effect more than a limited number of residents and or family members wishing to view the posting. Facility census: 180. Findings include: a) Staff posting Upon entrance to the facility for the initial tour, at 11:14 a.m. on 08/28/18, observation found the staff nursing posting was dated 08/27/17. Employee #104, the [MEDICAL CONDITION] program manager, confirmed the date on the posting was incorrect. Employee #111, a Licensed Practice Nurse (LPN) said she put the incorrect date in error because she had been working all night. The staff posting was corrected immediately. At 1:26 p.m. on 09/06/17, the administrator was advised of the above findings. The administrator provided no comment. | 2020-09-01 |
| 132 | 132 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 362 | E | 0 | 1 | QLZ111 | Based on observation and staff interview the facility failed to ensure one (1) resident observed through random opportunity received the lunch meal on 08/28/17 in a timely manner. Resident #85 received her tray 50 minutes after trays were delivered on her floor. Resident identifier: #85. Facility census: 180. Findings include: a) Resident #85 On 08/28/17 at 1:00 p.m. an observation revealed Resident #85 in her room in bed. She appeared to be sleeping. Her eyes were closed. Lunch trays were delivered to fourth floor and were passed to residents at 1:00 p.m. on 08/28/17. Continued observations of Resident #85 continued until 1:30 p.m. on 08/28/17. The observations revealed the resident did not have a lunch tray and remained in bed with her eyes closed. At 1:30 p.m. Licensed Practical Nurse (LPN) #55 was asked if Resident #55 would be getting a lunch tray. LPN #55 said Resident #85 typically ate in the dining room and they had asked for her tray to be brought to fourth floor. At 1:50 p.m. on 08/28/17, LPN #131 delivered Resident #85's tray. On 09/06/17 at 4:26 p.m. the district director of clinical services stated the facility staff could have been trying to get the resident to attend dining in the dining room and that could have caused the delay in delivering her tray. | 2020-09-01 |
| 133 | 133 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 412 | D | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family interview, staff interview, and record review, the facility failed to provide a medicaid resident routine dental services when the resident lost her dentures. This was true for one (1) of three (3) residents reviewed for dental care during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #19. Facility census: 180. Findings include: a) Resident #19 During a telephone interview with the resident's responsible party at 9:56 a.m. on 08/29/17, the responsible party expressed concern because the resident's bottom dentures were missing. The responsible party said she was unsure how long the dentures had been missing. The responsible party stated she could not afford to replace the dentures and the facility did not offer to assist with replacing the dentures. At 10:27 a.m. on 08/29/17 the resident was observed in her room without any upper or lower dentures and no natural teeth. At 12:10 p.m. on 08/30/17, Employee #15, the social services manager, said she was unaware the resident's bottom denture was missing. She stated the admission agreement specifies the facility does not replace lost or missing items. At 12:20 p.m. on 08/30/17, the resident was observed to be up in her wheelchair sitting at the nurses station. She had no lower or upper dentures. At 2:23 p.m. on 08/30/17, the unit charge nurse, Registered Nurse (RN) #116 was asked if the resident had dentures. She stated, I knew she had uppers and apparently they are missing now. I just found out, we are looking for them. An interview with the resident's nursing assistant, (NA) # ///, at 2:29 p.m. on 08/30/17 found she knew the resident had upper dentures. I don't know how long they have been missing, I don't remember the last time I saw them. At 2:35 p.m. on 08/30/17 an interview with [NAME] #15 found she was unaware the residents upper dentures were now missing. When asked if the facility arranges for financial assistance to replace the dentures, … | 2020-09-01 |
| 134 | 134 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 425 | E | 0 | 1 | QLZ111 | Based on observation and staff interview, the facility failed to ensure that expired medication was not administered to residents. One (1) of three (3) residents observed during medication administration was found to have an expired medication. Resident identifier: #103. Facility census: 180. Findings include: a) Resident #103 Medication administration was observed for Resident #103 on 08/30/17 at 8:55 a.m. Sertraline Hydrochloride, an antidepressant, 100 mg every day was ordered for Resident #103. The medication was supplied in a pack containing thirty (30) individual blisters. Each individual blister contained one (1) tablet. The medication expiration date was printed on the front of the pack. The medication expiration date was also printed on the back of each blister. The medication expiration date was 07/31/17, indicating that the medication was expired. The pharmacy label affixed on the front of the pack indicated that the medication had been supplied to the facility by the pharmacy on 08/17/17. Nine (9) of the tablets from the individual blisters were missing, having been dispensed to Resident #103 on previous days. The medication administration to Resident #103 was performed by Licensed Practical Nurse (LPN) #176. On 08/30/17 at 8:55 a.m., LPN #176 agreed the Sertraline Hydrochloride for Resident #103 had expired on 07/31/17. On 08/30/17 at 9:00 a.m., Unit Manager (UM) #22 also agreed the Sertraline Hydrochloride for Resident #103 had expired on 07/31/17. UM #22 also stated that all medications in the medication cart would be audited to ensure that no other medications were expired. UM #22 obtained Sertraline Hydrochloride 100 mg with a current expiration date from the facility's medication dispensing system, and this tablet was administered to Resident #103. During an interview on 08/30/17 at 2:00 p.m., the Director of Nursing stated she had already been notified by nursing staff about the expired Sertraline Hydrochloride for Resident #103. | 2020-09-01 |
| 135 | 135 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 428 | D | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the pharmacist identified and reported irregularities during the monthly medication regimen review for one (1) of six (6) residents reviewed for unnecessary medications. The pharmacist did not identify Resident #350's insulin was not administered according to physician's orders [REDACTED].#350. Facility census: 180. Findings include: a) Resident #350 The resident was admitted to the facility on [DATE]. Review of the resident's (MONTH) Medication Administration Record [REDACTED] Novolog Flex Pen Solution Pen-injector 100 units (ML (insulin Aspart). Inject 10 units subcutaneously before meals related to Type 2 Diabetes Mellitus with Hyperglycemia, hold for Blood sugar (BS) less than 150. Order date 08/03/17. On 08/22/17 the order was changed to Novolog Flex pen Solution Pen-Injector 100 unit/ML (insulin Aspart). Inject 5 units subcutaneously before meals related to Type 2 Diabetes Mellitus with Hyperglycemia, hold for blood sugar less than 150. Novolog was administered on the following ten (10) dates and times when the resident's blood sugar (BS) was less than 150: --08/05/17, at 5:00 p.m., BS was 148. --08/07/17, at 7:00 a.m. BS was 122 --08/09/17, at 7:00 a.m. BS was 130 --08/13/17, at 7:00 p.m. BS 147 --08/14/17, at 7:00 a.m. BS was 127 --08/17/17, at 7:00 a.m. BS was 112 --08/19/17, at 11:00 a.m. BS was 146 --08/20/17, at 11:00 a.m. BS was 144 --08/23/17, at 7:00 a.m. BS was 124 --08/29/17, at 7:00 a.m. BS was 127 At 9:47 a.m. on 08/31/17, the DON, compared the recorded blood sugars to the MAR. The DON verified the insulin was administered on the above dates and times, when the insulin should have been held. The DON said a performance improvement plan was started on 07/07/17 to correct the above issue. She said, I thought the problem had been corrected but I guess not. On 08/16/17, the pharmacist completed a monthly medication regimen review and reported no irregulari… | 2020-09-01 |
| 136 | 136 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 441 | E | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to follow infection control practices to prevent the spread of disease. Staff failed to provide a barrier between a box and bottle of medication and the bedside table for Resident #103, who was one (1) of three (3) residents observed during medication administration. Additionally, beverages were left uncovered on a cart in the hallway before distribution to residents. This practice had the potential to affect more than a limited number of residents. Resident identifier: #103. Facility census: 180. Findings include: a) Resident #103 Licensed Practical Nurse (LPN) #176 was observed during morning medication administration on 08/30/17. Resident #103 was ordered [MEDICATION NAME], a nasal spray supplied in a bottle intended for multiple uses by the resident. The [MEDICATION NAME] nasal spray bottle is contained in a box. On 08/13/17 at 8:55 a.m., LPN #176 removed the [MEDICATION NAME] box from the medication cart. She carried the box into Resident #103's room. LPN #176 removed the [MEDICATION NAME] bottle from the box, and placed both the box and the bottle directly on Resident 103's bedside table. She did not place a barrier between the [MEDICATION NAME] box and bottle and the bedside table. Resident #103 declined [MEDICATION NAME] administration. LPN #176 placed the [MEDICATION NAME] bottle back into the box, and then placed the box back into the medication cart. During an interview with LPN #176 at 9:00 a.m., she stated she should have used a barrier, such as a paper towel, between the [MEDICATION NAME] box and bottle and Resident #103's bedside table. On 08/30/17 at 2:00 p.m., the Director of Nursing was notified of the above findings. b) Noontime meal observation On 08/28/17 at 12:30 p.m., two surveyors performed meal observation of residents on the fourth floor. At 12:30 p.m., beverages in uncovered glasses were noted on a cart in the hallway. The beverages remained uncovered on … | 2020-09-01 |
| 137 | 137 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 463 | D | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure one (1) of 40 residents had a functioning call light system. Resident identifier: #84. Facility census: 180. Findings include: a) Resident #84 08/29/17 at 11:51 a.m. Resident #84's call light was observed not functioning. It did not light up above the resident's door when the button was pushed. Resident #84 did have the ability to use the call light. Nurse Aide #134 verified this light was not working. Resident #84's brief interview for mental status (BIMS) completed on the admission minimum data set ((MDS) dated [DATE] revealed the resident's BIMS score as 15. A score of 15 indicated the resident was cognitively intact. | 2020-09-01 |
| 138 | 138 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 465 | D | 0 | 1 | QLZ111 | Based on observation and staff interview the facility failed to ensure the heating and air conditioning unit in one (1) of 38 rooms observed during Stage 1 of the quality indicator survey (QIS) was in good repair. The heating/air condition unit in Room #409 had broken vents in the top of the unit. Room number: #409. Facility census: 180. Findings include: a) Room #409 On 08/29/17 at 2:39 p.m. an observation of the heat/air unit in Room #409 revealed the unit had broken vents in the top. The entire section of the top of the unit where the heat/air unit was missing. During an observation with Maintenance Supervisor #34, on 08/30/17 at 10:24 a.m., he agreed the unit needed replaced. | 2020-09-01 |
| 139 | 139 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 497 | D | 0 | 1 | QLZ111 | Based on staff interview, observation, and review of employee personnel records, the facility failed to ensure a performance review was completed every twelve (12) months for two (2) of five (5) nurse aides reviewed during the extended survey. Employee identifiers: #74 and #126. Facility census: 180. Findings include: a) Review of personnel files At 10:58 a.m. on 09/07/17, the Director of Nursing (DON) and the Human Resources Director, #183, confirmed Nurse Aides (NA's) #74 and #126 did not have a performance review completed within the past twelve (12) months. | 2020-09-01 |
| 140 | 140 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 498 | F | 0 | 1 | QLZ111 | Based on staff interview and employee personnel files review, the facility failed to ensure five (5) of five (5) nurse aides (NA) were able to demonstrate competency in skills and techniques necessary to care for residents' needs. Employees: #56, #74, #126, #131, and #99. Facility census: 180. Findings include: a) Personnel Records Review At 2:00 p.m. on 09/06/17, review of the active employee list provided by the facility, found the following employees and their dates of hire: --NA #56, hire date, 04/24/15; --NA #74, hire date, 08/27/15; --NA #126, hire date, 09/15/14; --NA #131, hire date, 09/15/14; --NA #99, hire date, 10/02/12. At 2:56 p.m. on 09/06/2017, the director of nursing (DON) confirmed the facility did not have any documentation to substantiate nurse aides had demonstrated competency in skills necessary to provide daily resident care. The DON said she had realized this was an issue last week and she had started a performance improvement plan. | 2020-09-01 |
| 141 | 141 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 502 | D | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to obtain a physician ordered laboratory test for Resident #235. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey. Resident Identifiers: #235. Facility Census: 180. Findings Include: a) Resident #235 A review of Resident #235's medical record at 9:24 a.m. on 09/06/17 found the following physician progress notes [REDACTED]. Plan: For Pneumonia- completed [MEDICATION NAME] 2 days ago. Cough and Congestion have improved. Will Continue [MEDICATION NAME] for 5 more days and monitor. EXG - NSR, [MEDICAL CONDITION] resolved at this time but will continue to monitor heart rate. Will Check CBC (complete blood count) and CMP in the AM. The Interim Director of Nursing (DON) shortly after this review was asked to provide the results of the CBC and CMP which should have been obtained on 06/23/17. At 11:46 a.m. on 09/06/17 the interim DON reported she did not have the requested lab results. She stated, there was never an order put in for it and they never obtained it. | 2020-09-01 |
| 142 | 142 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 514 | D | 0 | 1 | QLZ111 | Based on record review and staff interview, the facility failed to ensure the resident's medical record was correct in the area of Health Care Surrogate (HCS) and whom to notify when Resident #84 experienced a change which would require notification of the appropriate responsible party. The facility had conflicting contact information on Resident #84's face sheet concerning responsible party. Resident identifier: #84. Facility census: 180. Findings include: a) Resident #84 Review of Resident #84's face sheet, on 09/06/17 at 9:00 a.m, found under section titled, Contacts , the residents daughter was listed as the first contact and it was indicated she was the Power of Attorney (POA) and his son was listed as secondary contact. Further review found a HCS selection form completed 06/05/17, by the attending physician, designating the son as the HCS. No further HCS designation forms could be located in the medical records. Additionally, the daughter is not his PO[NAME] Interview with Employee #122, social worker (SW), on 09/06/17 at 9:15 a.m., revealed she thought the daughter was the HCS on admission and had asked to appoint her brother the HCS due to personal issues. When asked, Is there another HCS designation form. She replied, I don't see any in the medical records. On 09/06/17 at 11:00 a.m., Employee #122, SW, provided this surveyor with a HCS designation form dated 05/30/17. She further confirmed this form had been faxed to her on 09/06/17 at 10:35 a.m. This HCS form indicated the Daughter was in fact appointed as the HCS while the resident was in the hospital. However, this HCS became void when the attending physician at the facility appointed Resident #84's son as the HCS on 06/05/17. The facility continued to notify Resident #84's daughter of changes in her condition and had the daughter listed as the health care decision make on the resident face sheet even after Resident #84's son was appointed HCS on 06/05/17 and Resident #84 does not have a power of attorney. | 2020-09-01 |
| 143 | 143 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 520 | E | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, observation, and employee personnel record review the facility failed to ensure that there Quality Assessment and Assurance (QA & A) committee identified and corrected quality deficiencies in which it did have knowledge of or should have had knowledge of. This failure has the potential to effect more than an isolated number of residents. Resident Identifiers: Resident #87, #307, #286, #256, #229, #224, #322, #372, #280, #84, #110, #233, #290, #367, #19, #121, #284, #336, and #382. Employee Identifiers: #150, #74, #126, #56, #131, and #99. Facility Census: 180. Findings Include: a) Facility Management of Personal Funds Review of residents' personal funds account, on 09/06/17 at 2:25 p.m., found five (5) residents had personal funds within $200.00 dollars of the $2,000.00 dollar limit allowed for residents receiving Medicaid benefits. Review of resident individual account balances for 08/06/17 found the following residents within $200.00 dollars of the $2,000.00 dollar limits: --Resident #307- $1,802.10 --Resident #286- $1980.45 --Resident #256- $2,204.38 --Resident #229- $1,907.79 Further review of resident individual account balances for 09/05/17 found the following residents within $200.00 dollars of the $2,000.00 dollar limits: --Resident #224- $2,103.15 --Resident #229- $2,209.79 Upon interview on 09/07/17, at 9:20 a.m., with the Business Office Manager (BOM), she found the computer generated notice when the resident's personal funds reaches $1,800.00 dollar limit. She further confirmed she was unaware she was to provide the notice to the residents and/or responsible party until the corporate offices informed her of the responsibility of printing and providing the resident and/or the responsible party today (09/07/17). On 09/07/17 at 10:25 a.m., the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was both notified. No further information was provided. b) Investigate… | 2020-09-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );