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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 101 | 101 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-08-23 | 695 | D | 0 | 1 | TKSO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that one resident's oxygen therapy was monitored for the need and effectiveness of oxygen therapy and failed to document respiratory signs and symptoms, changes in oxygen administration, and/or results of oxygen therapy. This affected one of one resident reviewed for oxygen therapy in the sample of 28. Resident identifier: #92. Facility census: 176. Findings included: a) Resident #92 Resident #92's medical record was reviewed on 08/22/18 at 02:17 PM. Resident #92 is severely cognitively impaired according to the Minimum Data Assessment, dated 05/24/18. Resident #92 had [DIAGNOSES REDACTED]. Resident #92 had a physician's orders [REDACTED]. The order further stated that the oxygen should be titrated to keep oxygen levels above 92%. There were no oxygen saturation levels documented in the medical record. There were no progress notes regarding the resident's respiratory signs and symptoms, the time or reason oxygen was administered, or the result of oxygen therapy. Resident #92's care plan, target date 08/21/18, listed interventions to observe for signs and symptoms of acute respiratory insufficiency such as anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, and somnolence. Resident #92 was observed in bed receiving oxygen therapy via nasal canula on 08/20/18 at 11:35 AM, 08/21/18 at 01:39 PM, 08/21/18 at 5:45 PM, and 08/22/18 at 10:10 AM at 2 L/M. On 08/22/18 at 02:49 PM Resident #92 was observed receiving oxygen at 3.5 L/M via the nasal canula. On 08/22/18 at 02:49 the Unit Coordinator/Licensed Practical Nurse (LPN) #55 confirmed that Resident #92's oxygen level was set at 3.5 L/M. LPN #55 stated that the order is for 2 L/M as needed, but that the oxygen can be titrated up to keep saturation levels greater than 92% per the physician's orders [REDACTED]. LPN #55 said, There should be oxygen saturation levels for her. LPN #55 obtained Resident #… | 2020-09-01 |
| 102 | 102 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-08-23 | 698 | D | 0 | 1 | TKSO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain effective communication with the [MEDICAL TREATMENT] center and failed to follow-up on communication related to the resident's blood pressure dropping during [MEDICAL TREATMENT]. This affected one of one resident reviewed for [MEDICAL TREATMENT] care in the sample of 28. Resident identifier: #32. Facility census: 176. Findings included: a) Resident #32 On 08/20/18 at 10:39 AM Resident #32 was interviewed in his room. Resident #32 stated that sometimes his blood pressure is low during [MEDICAL TREATMENT] and that he was instructed by the [MEDICAL TREATMENT] clinic not to take his morning blood pressure medication before [MEDICAL TREATMENT]. Resident #32 said he leaves for [MEDICAL TREATMENT] around 06:00 AM and he takes his morning medications before he leaves, but was under the impression that he was not getting his blood pressure medication before he goes to [MEDICAL TREATMENT]. On 08/21/18 at 03:55 PM Resident #32's medical record was reviewed. Resident #32 has intact cognition according to the Minimum Data Sets (MDS), dated [DATE]. Resident #32 had [DIAGNOSES REDACTED]. Resident #32 received [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday, according to the current [MEDICAL TREATMENT] care plan, initiated 05/24/18. The care plan intervention stated, [MEDICAL TREATMENT] Communication Record is sent to the [MEDICAL TREATMENT] center with each appointment and return of form is ensured after appointment is completed. Resident #32 had physician's orders [REDACTED]. [REDACTED]. Resident #32 was scheduled to receive his first doses of [MEDICATION NAME] and [MEDICATION NAME] ER at 0600 (06:00 AM) according to the Medication Administration Record (MAR), dated 08/01/2018 - 08/31/18. Resident #32's progress note, dated 08/5/18, 06:29 read, RES STATED THAT [MEDICAL TREATMENT] NURSE STATES HIS BP IS DROPPING TOO LOW AND NOT TO TAKE HIS BP MEDS PRIOR TO [MEDICAL TREATMENT]. HE… | 2020-09-01 |
| 103 | 103 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-08-23 | 756 | D | 0 | 1 | TKSO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Consultant Pharmacist interviews, the facility failed to ensure that the consulting pharmacist identified drug irregularities related to laboratory (lab) testing levels for one of seven sampled who were reviewed for unnecessary medications. Resident identifier: #84. Facility census: 176. Findings included: a) Resident #84 A review of the admission record for Resident #84 was conducted on 08/22/18 at approximately 4:52 PM. The admission record revealed that Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's policy and procedure entitled Monthly Drug Regimen Review, dated (MONTH) (YEAR), was reviewed on 08/24/18 at approximately 10:45 AM. The policy read in part, The facility contracts with a pharmacist to perform a monthly review of each resident's drug regimen to ensure the necessity and safety of each prescribed medication. Under the section entitled procedure the following entries were noted in part: --The pharmacist reviews resident charts monthly and submits a written report of the irregularities to the attending physician, the Director of Nursing and the facility Medical Director. --The pharmacist's report includes resident' names, relevant drug(s) and identified irregularity(ies). A review of the physician's orders [REDACTED]. The order summary note indicated that Resident #84 was scheduled to have a HgbA1C (a measure of average blood sugar over the past 3 months) every 3 three months d/t (due to) DM (Diabetes Mellitus) - Due (MONTH) (YEAR). Upon further review it was determined that the HgbA1C lab results were not found in the clinical record. An interview was conducted with nurse #28 on 08/22/18 at approximately 4:52 PM regarding the missing HgbA1C level for the month of (MONTH) (YEAR). Nurse #28 stated, It's not in the lab book and the lab doesn't have it in their records either. Nurse #28 shared that she had looked in the both the clinical record and well a… | 2020-09-01 |
| 104 | 104 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-08-23 | 760 | D | 0 | 1 | TKSO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, resident and staff interviews, the facility failed to prevent a significant medication error from occurring for one of 12 sampled residents (Resident #120) who was reviewed for medication administration. Resident #120 was administered long acting insulin that was prescribed for another resident. Resident identifier: #120. Facility census: 176. Findings included: a) Resident #120 An interview was conducted with Resident #120 on 08/20/18 at 11:05 AM. Resident #120 stated that a male nurse (Nurse #4), who she referred to as the medicine man had administered insulin to her in her belly (abdomen) although she is not diabetic. She repeated this again stating that, He gave me an insulin needle in my belly. She also stated that Nurse #4 had administered the insulin injection on the day prior to this interview which was Sunday, 08/19/18. Resident #120 went on to say that she had specifically asked Nurse #4 why was she receiving the insulin injection as she was not diabetic. Resident #120 reported that Nurse #4 gave her the insulin injection anyway and stated, Well, you're supposed to get it. Resident #120 also stated that Nurse #4 checked her blood sugar level after he had administered the insulin injection. She said he told her that the blood sugar reading was 108 and showed it to her on the blood sugar monitor. Resident #120 said that Nurse #4 told her it was fine. Resident #120 stated that Nurse #4 did not check her blood sugar level before administering the insulin injection. Additionally, Resident #120 voiced that she did not report the insulin administration incident to any other facility staff but said she did call her family member and informed him of the incident on the same day that the incident occurred, Sunday, 08/19/18. A review of the clinical record was conducted for Resident #120 on 08/20/18 at approximately 12:05 PM. The admission record, which listed the resident's diagnoses, indicated that Resi… | 2020-09-01 |
| 105 | 105 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-08-23 | 773 | D | 0 | 1 | TKSO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure two of seven residents reviewed for unnecessary medications obtained laboratory services as ordered by the physician. Resident identifiers: #84 and #93. Facility census: 176. Findings included: a) Resident #93 Resident #93 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the admission physician's orders dated 01/23/18, was conducted on 08/22/18 at 2:30 PM and revealed an order for [REDACTED].#93 to have his vitamin D level monitored every 6 months. The physician's orders documented the vitamin D level was to be performed in (MONTH) (YEAR). Further review of the clinical record revealed there was no evidence Resident 93's laboratory test for a vitamin D level was obtained in (MONTH) (YEAR). Interview with Licensed Practical Nurse (LPN) #170 on 08/22/18 at 2:18 PM revealed they were not able to find the physician ordered Vitamin D laboratory test results from (MONTH) (YEAR). A call was made to the laboratory responsible for conducting the test and the facility was informed the Vitamin D laboratory test for Resident #93's had never been completed. Staff #170 stated they were unsure of why Resident #93 failed to have the ordered laboratory testing to monitor his vitamin D level. During an interview with LPN Staff #170 again on 08/23/18 at 8:48 AM at the 400 nurses station revealed they had done more research but were still not able to determine why the vitamin D level was not obtained for Resident #93. Staff #170 stated the process for obtaining laboratory tests is the order for the test is obtained and the information is relayed to the laboratory for them to collect the blood sample. He verified Resident #93 was admitted to the facility with an order for [REDACTED]. During an interview with the Director of Nursing and the Administrator on 08/23/18 at 10:35 AM, they both verified Resident #93 failed to have his vitamin D laboratory test complete… | 2020-09-01 |
| 106 | 106 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-08-23 | 880 | D | 0 | 1 | TKSO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed ensure that staff properly changed gloves and performed hand hygiene during personal care to maintain good infection control practices and failed to ensure the urine drainage bag was positioned properly so that it did not touch the floor. This affected one of two residents reviewed for urinary catheter in the sample of 28 residents. Resident identifier: #92. Facility census: 176. Findings included: a) Resident #92 Resident #92's medical record was reviewed on 08/22/18 at 02:17 PM. Resident #92 is severely cognitively impaired according to the Minimum Data Assessment, dated 05/24/18. Resident #92 has multiple [DIAGNOSES REDACTED]. Resident #92 had a physician's orders [REDACTED]. On 8/22/18 at 10:10 AM Certified Nursing Assistant (CNA) #44 was observed providing peri care to Resident #92. After gathering the care supplies, CNA #44 washed her hands and applied gloves prior to starting peri care. As CNA #44 was cleansing the peri area, she removed a small amount of feces using the washcloth. Each time she cleansed the peri area, which was four times, she touched the feces soiled washcloth with gloved hands. After completing peri care CNA #44 did not change her gloves. CNA #44 then touched the resident's gown, arms, legs, hands, pillows, back of the resident's head, and bed control mechanism while still wearing the same feces contaminated gloves. CNA #44 was interviewed afterwards and said that she should have changed her gloves after the peri care was complete. On 08/20/18 at 11:34 AM, 03:57 PM, on 08/21/18 at 01:38 PM and on 08/22/18 at 08:44 AM, the Resident #92's urine catheter bag was in contact with the floor. Resident #92's bed was in the low position and the catheter bag was hooked to the bed frame. The bottom of the urine catheter bag was in direct contact with the floor. On 08/22/18 at 08:44 AM Unit Manager/Licensed Practical Nurse (LPN) #55 confirmed that the urine … | 2020-09-01 |
| 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 |
| 144 | 144 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 550 | E | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to treat each resident with respect and dignity for 4 out of 35 residents. For Residents #104, #94, and #9, the facility failed to provide a dignified dining experience. For Resident #177, the facility failed to provide privacy when administering an injection. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #104, #94, #9, and #177. Facility census 182. Findings included: a) Resident #104 On 10/07/19 at 12:30 PM, resident meal delivery / tray pass began on the OB Park unit. On 10/07/19 at 12:40 PM, Resident #104 had not received a tray. On 10/07/19 at 12:54 PM, Resident #104's tray was delivered. During an interview on 10/07/19 at 12:55 PM, Employee #199 was asked why Resident #104 did not receive a tray during the initial meal delivery on the unit. Employee #199 stated I can't tell you why he didn't get his tray with everyone else. The tray must have been shoved up too high and the staff didn't see it. On 10/09/19 at 8:22 AM, an interview with the Administrator and the Director of Nursing (DON) did not reveal any further information. b) Resident #94 On 10/07/19 at 12:30 PM, resident meal delivery / tray pass began on the OB Park unit. On 10/07/19 at 12:37 PM, Resident #94 had not received a tray. During an interview on 10/07/19 at 12:55 PM, Employee #199 was asked why another resident (Resident #104) had not received a tray. Employee #199 stated that the other resident (Resident #104) had been given a tray. During this interview, Employee #199 was asked if all residents now had their meals and trays delivered. Employee #199 stated that they had. The surveyor noted to Employee #199 that Resident #94 still had not received his tray. Employee #199 stated that she did not know that Resident #94 had not received a tray. Resident #94's tray was delivered on 10/07/19 at 1:02 PM. On 10/09/19 at 8:22 AM, an interview with the A… | 2020-09-01 |
| 145 | 145 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 578 | E | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that each resident's Physician order [REDACTED]. This failed practice had the potential to affect all residents residing at the facility. Resident identifiers: #125, #139, #9, #95, #108, and #137. Facility census: 182. Findings included: a) Resident #125 Review of Resident #125's medical records found a POST form completed and signed by the attending physician on [DATE]. No signature and/or verbal consent documented on the POST form. Interview with the Director of Nursing (DON) on [DATE] at 2:00 pm, confirmed there was no resident/family signature on the POST form dated [DATE]. b) Resident #139 Review of Resident #139's medical records found a POST form completed and signed by the attending physician and verbal consent given on [DATE]. The POST form was inaccurately marked to attempt resuscitation/CPR and comfort measures. Interview with the Director of Nursing (DON) on [DATE] at 2:00 pm, confirmed the POST form dated [DATE] was inaccurately noted the resident should have been marked Do Not Resuscitate/DNR. c) Resident #137 Review of Resident #137's physician's orders [REDACTED].N. (Registered Nurse) may pronounce death - (MONTH) have IV fluids for trial period no longer than 3 days - No feeding tube. Review of Resident #137's medical records revealed a Physician order [REDACTED]. During an interview on [DATE] at 2:57 PM, the Director of Nursing and the District DIrector of Clinical Services were informed Resident #137's most recent POST form did not correspond with the current physician's orders [REDACTED]. On [DATE] at 4:03 PM, the administrator was notified of the situation. During an interview on [DATE] at 3:00 PM, the Director of Nursing stated the order had been corrected. d) Resident #108 During a review of Resident #108's medical record on [DATE] at 9:34 AM Resident #108's physician orders [REDACTED].#108's preferences for intravenous (IV) fluids or a fe… | 2020-09-01 |
| 146 | 146 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 584 | D | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide a safe, sanitary, and homelike environment. Resident #9 had an order for [REDACTED]. Resident identifier: #9. Facility census: 182. Findings included: a) Resident #9 On 10/07/19 at 4:13 PM, during an observation of Resident #9's room, the fall mat located near the bathroom, was noted to have fluid underneath the entire length of the fall mat. Moreover, the fall mat located on the right side of Resident #9's bed had debris underneath the fall mat. The fall mat on the left side of Resident #9's bed had fluid underneath the fall mat, spanning the length of the mat. The floor underneath the fall mat was white, and discolored. On 10/07/19 at 4:15 PM, Employee #81, Unit Manger, entered Resident #9's room and observed the fluid underneath two fall mats and the debris underneath the third fall mat. Employee #81 stated that she would notify housekeeping. On 10/07/19 at 4:24 PM, the Director of Nursing (DON) and the District Director of Clinical Services were informed of the findings. On 10/09/19 at 2:06 PM, the findings were discussed with the Administrator and the DON and no further information was provided | 2020-09-01 |
| 147 | 147 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 605 | D | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure all residents were free from chemical restraint for purposes of discipline or staff convenience for 2 out of 35 sampled residents. This failed practice had the potential to affect a limited number of residents. Identified Resident identifiers: #161, and #9. Facility census 182. Findings included: a) Resident #161 During a review of medical records for Resident #161 on 10/08/19 at 12:30 PM, revealed his care plan had the following intervention: --Resident #161 receives antipsychotic medication-- [MEDICATION NAME]-- for refusal of care/mood changes. This was initiated on 03/20/18. During an interview on 10/10/19 at 9:45 AM, Director of Nursing agreed, he should not be given a medication for refusal of care, and that it was his right to refuse showering/bathing. b) Resident #9 Review of the medical record revealed a current order, dated 08/05/19 for [MEDICATION NAME] 200 mg given at bedtime for refusal of care related to [MEDICAL CONDITION] disorder, recurrent, and unspecified. Review of the care plan found the resident refuses to wear his identification bracelet. The care plan also noted that the resident would refuse incontinent care. The care plan referenced the use of an anti-anxiety medication and said the resident refused care related to anxiety but the specific care refused was not documented. On 10/10/19 at 11:26 AM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided to indicated what type of care the resident refused, prior to the survey conclusion. There was no evidence provided to verify the resident refused any type of care. | 2020-09-01 |
| 148 | 148 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 623 | D | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review and staff interview, the facility failed to notify the Ombudsman when Residents #94, #119, and #95 were transferred to a local hospital. This was true for two (2) of three (3) residents reviewed for hospital transfers and one (1) random opportunity for discovery. Resident identifiers: #94, #119, and #95. Facility census 182. Findings included: a) Resident #94 Record review on 10/07/19 at 8:19 PM, revealed the resident was discharged to the hospital on [DATE] at 11:13 AM, due to abnormal labs. b) Resident #119 Record review on 10/07/19 at 8:19 PM, revealed the resident was discharged to the hospital on [DATE] at 6:45 PM, due to abnormal and critical lab work. c) Resident #95 Record review on 10/08/19 at 9:04 AM, revealed the resident was discharged to the hospital on [DATE] at 7:25 PM, per resident and family request. d) Interviews On 10/08/19 at 1:20 PM, the Administrator stated the Social Worker completes the notifications to the Ombudsman regarding facility-initiated discharges. During an interview on 10/08/19 at 1:21 PM, Employee #126, Social Services Manager, stated the facility sends the discharge notifications to the Ombudsman every time a resident leaves the facility. Employee #126 was asked to provide the Ombudsman notification for Resident #94, #119, and #95 when each resident was transferred to a local hospital. Employee #126 stated that the facility does not notify the Ombudsman when a resident is discharged to the hospital. The facility only notifies the Ombudsman when the resident discharges to home or is transferred to another facility. On 10/09/19 at 8:22 AM, the findings were discussed with the Administrator and the Director of Nursing (DON). | 2020-09-01 |
| 149 | 149 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 625 | D | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review and staff interview, the facility failed to provide the resident/resident representative notice of the bed hold policy when Resident #95 was transferred to a local hospital. This was true for one (1) of three (3) residents reviewed for hospital transfers. Resident identifier: #95. Facility census 182. Findings include: a) Resident #95 During a medical record review, on 10/08/19, it was discovered that Resident #95 was transferred to a local hospital on [DATE] at 7:25 PM. There was no evidence the resident or the residents representative received a copy of the bed hold policy at the time of transfer. In addition there was no documentation in the medical record of contacting the resident / resident representative regarding the bed hold policy. During a record review on 10/08/19 at 1:47 PM, a copy of the bed hold notice could not be located on Resident #95's chart on the unit or in the thinned medical record. On 10/08/19 at 3:57 PM, the chart was given to the Director of Nursing (DON) for review to see if the bed hold notice could be located. The DON was unable to locate the bed hold notice. During an interview with the DON on 10/08/19 at 4:11 PM, the DON stated that she could not find the transfer form with the stamp that indicated that the notice of bed hold policy was provided upon discharge. The findings were discussed with the DON and Administrator on 10/09/19 at 8:22 AM and no further information was provided. | 2020-09-01 |
| 150 | 150 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 641 | D | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure accurately completed assessment for Resident #151 reflecting urinary catheterization for 1 of 35 sampled residents. This practice had the potential to affect a limited number of residents. Resident identifiers: R#151 Facility census: 181. Findings included: a) Resident #151 Review of records, on 10/08/19 at 12:28 PM, revealed Resident (R#151) was admitted on [DATE]. Review of the 5-day minimum data set (MDS) with an assessment reference date (ARD) 09/17/19 revealed the MDS was marked indicating an indwelling catheter and intermittent catheterization. Review of orders revealed an order Straight Cath resident if greater than 300 ml (milliliter) residual leave catheter in and follow up with provider . Physician was notified R#151 had 500 ml of output when catheter was initially inserted, an order was given to leave as an indwelling catheter. According to the National Library of Medicine, 'intermittent catheterization' is the insertion and removal of a catheter several times a day to empty the bladder. This type of catheterization is used to drain urine from a bladder that is not emptying adequately. Intermittent catheters are only used at certain times and they are removed right after the urine is drained. On 10/09/19 at 09:54 AM, an interview and review of records with Resident Care Management Director (RCMD#165) responsible for developing MDSs, revealed R#151's 5-day MDS was in error. RCMD#165 verified R#151's 5-day MDS should only have been marked indwelling catheter. Indwelling catheter due to when intermittent catheterization was first attempted the resident had 500 cc of urine drained and the catheter was not removed but remained indwelling and was attached to a closed drainage system as ordered. | 2020-09-01 |
| 151 | 151 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 657 | D | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to revise care plans regarding falls, behaviors, and Total [MEDICATION NAME] Nutrition (TPN). This was true for two (2) out of thirty-five (35) resident's care plans reviewed. This failed practice had the potential to affect a limited number of residents. Resident identifiers: R#116 and R#94. Facility census: 181. Findings included: a) Resident (R#116) 1. Falls Review of resident (R#116)'s recent annual minimum data set (MDS) with an assessment reference date (ARD) 09/06/19, on 10/08/19 at 03:53 PM, revealed the following. The resident's Brief Interview for Mental Status (BIMS) score is 3 indicating the resident has a severe cognitive impairment. The resident did not have any behaviors during the 7 day look back period. R#116 needs extensive assistance with all activities of daily living and has range of motion impairments on both sides of his upper and lower extremities. The resident has an indwelling catheter and is continent of bowels. Some pertinent [DIAGNOSES REDACTED]. The resident takes Antipsychotic medication daily. The resident has history of falls and currently participates in occupational therapy services. Review of records, on 10/08/19 at 04:23 PM, revealed the resident had an unwitnessed fall in the courtyard on 08/19/19. The resident fell out of his wheelchair bending forward to retrieve an item off the ground. The resident suffered an abrasion above the right eye on 08/19/19. Approximately a month later, on 09/12/19, the resident again fell out of wheelchair in courtyard reaching forward to pick something up off the ground, causing an abrasion to the back of his left hand's knuckle area. Both times the injured areas were appropriately cleaned and treated; vital signs and neuro checks were completed; and proper notifications were made. On 10/09/19 at 10:29 AM, an interview with Registered Nurse (RN#96) revealed at every morning meeting a post fall review from the da… | 2020-09-01 |
| 152 | 152 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 684 | E | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, policy review, and medical record review, the facility failed to ensure each resident received medication as physicians orders; which includes the administration of medication timely for five (5) out of thirty-five (35) sampled residents. This failed practice had the potential to affect more than a limited number of residents residing at the facility. Resident identifiers: #139, #182, #130, #37 and #432. Facility census: 182. Findings included: a) Resident #139 Medical record review for Resident #139, revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident is unresponsive and requires a gastrostomy feeding tube for all nutritional needs and [MEDICAL CONDITION] in place secondary to [MEDICAL CONDITION]. Resident #139 is to receive nothing by mouth (po) secondary to dysphagia and aspiration. Further review of Resident #139's medical records found an order for [REDACTED]. Review of the Controlled Medication Utilization Record for 09/29/19 at 1:00 am through 10/01/19 at 5:00 pm, found Resident #139 received [MEDICATION NAME] 20 mg per 1ml; which equals 20 mgs by mouth (po) every hour. Resident #139 received fifty-one (51) doses of 20 mgs of [MEDICATION NAME] instead of the 4mgs and the resident received the [MEDICATION NAME] po instead of SL as ordered. Interview with attending physician on 10/09/19 at 5:00 pm revealed the [MEDICATION NAME] should be given SL not po and the dosage should be 20mg per 1 ml - give 0.25 ml which equals 4 mg every hour as needed for pain. Clarification orders noted by the attending physician to give SL not po due to aspiration. Interview on 10/10/19 at 10:00 am with the Director of Nursing (DON), found the resident received the wrong dosage of [MEDICATION NAME] on the above dates. Additionally, she confirmed the [MEDICATION NAME] was to be given SL but was documented it was administered po. Review of Resident #139's medical record found an order … | 2020-09-01 |
| 153 | 153 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 689 | D | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. This was true for 1 of 5 residents reviewed for care area of accidents. This practice had the potential to affect a limited number of residents. Resident identifiers: R#116. Facility census: 181 Findings included: a) Resident #116 Review of resident (R#116)'s recent annual minimum data set (MDS) with an assessment reference date (ARD) 09/06/19, on 10/08/19 at 03:53 PM, revealed the following. The resident's Brief Interview for Mental Status (BIMS) score is 3 indicating the resident has a severe cognitive impairment. R#116 needs extensive assistance with all activities of daily living and has range of motion impairments on both sides of his upper and lower extremities. The resident has an indwelling catheter and is continent of bowels. Some pertinent [DIAGNOSES REDACTED]. The resident takes Antipsychotic medication daily. The resident has history of falls and currently participates in occupational therapy services. Review of records, on 10/08/19 at 04:23 PM, revealed the resident had an unwitnessed fall in the courtyard on 08/19/19. The resident fell out of his wheelchair bending forward to retrieve an item off the ground. The resident suffered an abrasion above the right eye on 08/19/19. Approximately a month later, on 09/12/19, the resident again fell out of wheelchair in courtyard reaching forward to pick something up off the ground, causing an abrasion to the back of his left hand's knuckle area. On 10/09/19 at 10:29 AM, an interview with Registered Nurse (RN#96) revealed at every morning meeting a post fall review from the day before is completed. If a fall is unwitnessed or if the resident hits their head, then a physical therapy referral is made for an evaluation and neuro checks are done for 3 days after the fall. Records showed an interdisciplinary team (IDT) meeting note dated 8/20/… | 2020-09-01 |
| 154 | 154 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 698 | D | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Bsed on record review and staff interview, the facility failed to ensure the [MEDICAL TREATMENT] Communication Record post [MEDICAL TREATMENT] section was completed for Resident #151 each time he went to [MEDICAL TREATMENT]. The facility failed to follow up with the [MEDICAL TREATMENT] center regarding pre and post weights, and failed to follow the medication recommendations from the [MEDICAL TREATMENT] center. This practice had the potential to affect a limited number of residents. Resident identifiers: R#151. Facility census: 181 Findings included: a) Resident #151 Resident (R#151) was transferred and admitted to the facility on [DATE], after the resident had a failed kidney transplant. Some pertinent [DIAGNOSES REDACTED]. The resident was admitted to current [MEDICAL TREATMENT] services on 09/04/19. Interview with Licensed Practical Nurse (LPN#84), on 10/09/19 at 01:55 PM, revealed the facility maintains a communication record with the [MEDICAL TREATMENT] center in a [MEDICAL TREATMENT] communication book. The facility keeps forms in the book that requires pertinent information to be recorded by [MEDICAL TREATMENT] staff and facility nursing staff. Review of the resident's [MEDICAL TREATMENT] communications book with LPN#84 revealed the post [MEDICAL TREATMENT] section for R#151 was not completed by [MEDICAL TREATMENT] staff each time R#151 went to [MEDICAL TREATMENT]. The facility staff failed to follow up and obtain the pre and post weights from the [MEDICAL TREATMENT] center on 09/06/19, and post weights on 09/11/19. The facility staff failed to follow up or discontinue medications the [MEDICAL TREATMENT] center identified on 09/06/19 and requested the resident stop taking. ` The [MEDICAL TREATMENT] communication sheet dated 09/06/19 revealed no pre or post [MEDICAL TREATMENT] weights were recorded. In the 'Recommendation/Follow-up' section of the communication sheet dated 09/06/19 where orders from the [MEDICAL TREATMENT] center are wr… | 2020-09-01 |
| 155 | 155 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 711 | E | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the physician signed and dated all orders. This was random opportunity for discovery. This failed practice had the potential to affect more than a limited number of residents. Resident identifier: #94, #9, and #95. Facility census 182. Findings included: a) Resident #94 On 10/08/19 at 2:59 PM, during a review of the thinned medical record for a bed hold notification, the surveyor discovered several physician orders [REDACTED]. On 10/08/19 at 3:50 PM, Employee #73, Health Information Coordinator, confirmed that the physician orders [REDACTED].#73 was asked to copy all orders that were flagged. The following orders had not been signed by the physician: --03/21/19 16:02 - [MEDICATION NAME] HCI Tablet 20 MG Give 1 tablet by mouth every 8 hours for abdominal pain. discontinue --03/21/19 16:02 - [MEDICATION NAME] HCI Capsule 10 MG Give 1 capsule by mouth every 6 hours as needed for abdominal pain related to postsurgical malabsorption, not elsewhere classified --03/19/19 05:25 - Apply nourishing skin cream to bilateral lower extremities including feet, every shift for dry skin. discontinue --03/19/19 05:27 - Cleanse bilateral buttocks and coccyx with warm soapy water, rinse, pay dry, apply inzo barrier cream topically every shift for increased risk of skin breakdown and as needed. --03/19/19 05:27 - Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water, rinse, pat dry, apply [MEDICATION NAME] cream topically as needed AND every shift for increased risk of skin breakdown. discontinue --03/19/19 05:28 - Cleanse wound to sacrum with warm soapy water, rinse, pat dry, apply inzo barrier cream topically. Monitor skin surrounding area and report abnormalities to provider. Document in nurses notes if indicated, as needed for wound healing and every shift for wound healing. --03/19/19 05:30 - Cleanse wound to sacrum with warm soapy water, rinse, pat dry, apply thi… | 2020-09-01 |
| 156 | 156 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 726 | E | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to have nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Facility staff failed to ensure residents' advance directives contained in their Physician's Orders for Scope of Treatment (POST) forms were complete and/or accurately reflected in the physician's orders. Facility staff failed to ensure residents were free from chemical restraints. Facility staff failed to ensure physician's orders for medication parameters and medication dosages were followed. Facility staff failed to administer medications within the time period prescribed by the physician. Facility staff failed to provide [MEDICAL TREATMENT] services consistent with professional standards of practice. Facility staff failed to ensure residents were free from significant medication errors. Resident identifiers: 125, 139, 148, 9, 95, 108, 137, 161, 37, 130, 432, 182, 151. Facility census: 182. Findings included: a) Cross reference findings at F578 b) Cross reference findings at F605 c) Cross reference findings at F684 d) Cross reference findings at F698 e) Cross reference findings at F760 | 2020-09-01 |
| 157 | 157 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 756 | E | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the consultant pharmacist recognized medications were administered without the required blood pressure and/or heart rates prior to the administration of [MEDICATION NAME] for two (2) random opportunities for discovery. This failed practice had the potential to affect a limited number of residents residing at the facility. Resident identifiers: #139 and #182. Facility census: 182. Findings included: a) Resident #139 Review of Resident #139's medical record found an order for [REDACTED]. Order effective 08/15/19. Review of the August, (MONTH) and (MONTH) 2019, Medication Administration Record [REDACTED]. Review of the monthly medication regimen reviews found the consultant pharmacist completed a medication review on 08/24/19, 09/09/19 and 10/03/19 with no recognition the [MEDICATION NAME] was being administered without the required heart rate and blood pressure obtained prior to the administration of the medication. Interview with the DON on 10/10/19 at 10:00 am, confirmed the resident's blood pressure and heart rate was not taken and documented prior to the administration of the [MEDICATION NAME] and the consultant pharmacist had not recognized the medication was being administered without the required blood pressure and heart rate. b) Resident #182 Review of Resident #182's medical record found an order for [REDACTED]. Order effective 06/17/19. Review of the June, July, and (MONTH) 2019, Medication Administration Record [REDACTED]. Review of the monthly medication regimen reviews found the consultant pharmacist completed a medication review on 06/21/19, 07/17/19, and 08/22/19, with no recognition the [MEDICATION NAME] was being administered without the required heart rate obtained prior to the administration of the medication. Interview with the DON on 10/10/19 at 10:00 am, confirmed the resident's heart rate was not taken and documented prior to the administrat… | 2020-09-01 |
| 158 | 158 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 757 | E | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary medications for three (3) random opportunities of discovery. This failed practice had the potential to affect more than a limited number of residents residing at the facility. Resident identifiers: #139, #182, and #151. Facility census: 182. Findings included: a) Resident #139 Review of Resident #139's medical record found an order for [REDACTED]. Order effective 08/15/19. Review of the August, (MONTH) and (MONTH) 2019, Medication Administration Record [REDACTED]. Interview with the DON on 10/10/19 at 10:00 am, confirmed the resident's blood pressure and heart rate was not taken and documented prior to the administration of the [MEDICATION NAME]. b) Resident #182 Review of Resident #182's medical record found an order for [REDACTED]. Order effective 06/17/19. Review of the June, July, and (MONTH) 2019, Medication Administration Record [REDACTED]. Interview with the DON on 10/10/19 at 10:00 am, confirmed the resident's heart rate was not taken and documented prior to the administration of the [MEDICATION NAME]. c) Resident (R#151) received Calcium Acetate after the [MEDICAL TREATMENT] Center wanted it to be discontinued. Resident (R#151) was transferred and admitted to the facility on [DATE], after the resident had a failed kidney transplant. Some pertinent [DIAGNOSES REDACTED]. The resident was admitted to current [MEDICAL TREATMENT] services on 09/04/19. Interview with Licensed Practical Nurse (LPN#84), on 10/09/19 at 01:55 PM, revealed the facility maintains a communication record with the [MEDICAL TREATMENT] center in a [MEDICAL TREATMENT] communication book. Review of the resident's [MEDICAL TREATMENT] communications book with LPN#84 revealed a [MEDICAL TREATMENT] center communication dated 09/06/19 for R#151 to stop taking Calcium Acetate. ` Review of orders revealed Calcium Acetate Capsule 667 mg (milligrams).… | 2020-09-01 |
| 159 | 159 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 758 | E | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents were free from unnecessary use of [MEDICAL CONDITION] medications. This was true for two (2) of five (5) reviewed for unnecessary medications. Resident identifiers: #161, and #9. Facility census: 182. Findings included: a) Resident #161 During a review of medical records for Resident #161 on 10/08/19 at 12:30 PM, revealed a statement on his Care Plan, it states, Resident #161 receives antipsychotic medication-- [MEDICATION NAME]-- for refusal of care/mood changes. This was initiated on 03/20/18. During an interview on 10/10/19 at 9:45 AM, Director of Nursing was asked about the care plan stating, that he was receiving this antipsychotic for refusal of care. She agreed, he should not be given a medication for refusal of care, and that it was his right to refuse showering/bathing. b) Resident #9 Review of the medical record revealed a current order, dated 08/05/19 for [MEDICATION NAME] tablet 200 mg at bedtime for refusal of care related to [MEDICAL CONDITION] disorder, recurrent, unspecified. A second order for [MEDICATION NAME] 100 mg, give 1 tablet in the morning for dementia related to dementia with Lewy Bodies was prescribed on 10/01/19. Review of the care plan found the resident refuses to wear his identification bracelet. The care plan also noted that the resident would refuse incontinent care. The care plan referenced the use of an anti-anxiety medication and said the resident refused care related to anxiety but the specific care refused was not documented. A review of Resident #9's [DIAGNOSES REDACTED]. On 10/10/19 at 11:26 AM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided to indicated what type of care the resident refused, prior to the survey conclusion. There was no evidence provided to verify the resident refused any type of care that would have caused him harm. There was no… | 2020-09-01 |
| 160 | 160 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 760 | D | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #139 was free from significant medication error. This failed practice had the potential to affect a limited number of residents residing at the facility. Resident identifier: #139. Facility census: 182. Findings included: a) Resident #139 Medical record review for Resident #139, revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident is unresponsive and requires a gastrostomy feeding tube for all nutritional needs and [MEDICAL CONDITION] in place secondary to [MEDICAL CONDITION]. Resident #139 is to receive nothing by mouth (po) secondary to dysphagia and aspiration. Further review of Resident #139's medical records found an order for [REDACTED]. Review of the Controlled Medication Utilization Record for 09/29/19 at 1:00 am through 10/01/19 at 5:00 pm, found Resident #139 received [MEDICATION NAME] 20 mg per 1ml; which equals 20 mgs by mouth (po) every hour. Resident #139 received fifty-one (51) doses of 20mgs of [MEDICATION NAME] instead of the 4mgs and the resident received the [MEDICATION NAME] po instead of SL as ordered. Interview with attending physician on 10/09/19 at 5:00 pm revealed the [MEDICATION NAME] should be given SL not po and the dosage should be 20mg per 1 ml - give 0.25 ml which equals 4 mg every hour as needed for pain. Clarification orders was noted by the attending physician to give SL not po due to aspiration. Interview on 10/10/19 at 10:00 am with the Director of Nursing (DON), found the resident received the wrong dosage of [MEDICATION NAME] on the above dates. Additionally, she confirmed the [MEDICATION NAME] was to be given SL but was documented it was administered po. | 2020-09-01 |
| 161 | 161 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 804 | E | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on confidential resident and family interviews, observation, record review, and staff interview the facility failed to provide food to residents that was palatable and attractive. This deficient practice was found during a random opportunity for discovery and affected more than an isolated number of residents. Facility census: 182. Findings included: a) Test Tray On 10/09/19 at 9:18 AM a regular diet test tray was requested for that day's lunch time meal from the facility's Dietary Manager (DM). On 10/09/19 at 11:44 AM the test tray was received and examined by surveyors. The food on the test tray was unattractive. The tray included a watery bowl of discolored tomato and onion slices. The tomato slices were dark and dull. The egg salad sandwich on the tray was so soggy that the buns could not be separated from the egg salad between them. A small bowl on the tray contained a mixture of pineapple chunks and marshmallows. The contents of the bowl were watery, and the marshmallows were actively disintegrating in the excess moisture and turning to mush. The facility's Administrator was advised of the above findings on 10/10/19 at 9:14 AM. No further information was provided prior to exit. b) Confidential Resident #A (CR #A) During the survey, in a interview the CR #A described the facility food as so-so and mediocre. c) Confidential Resident #B (CR #B) During the initial interview the CR #B stated, Most of the time the food around here is cold by the time you get it and not fit to eat. When asked if the foods that were supposed to be served hot was not hot but cold, the resident confirmed and said, That's exactly what I mean. How would you like to eat cold mashed potatoes and gravy? It's disgusting. d) Confidential Resident #C (CR #C) CR #C said, the food is always bad. CR #C stated they do not order pizza or fish but, they still serve it to them. CR #C stated one evening they were not served dinner, then they served fish and then they asked… | 2020-09-01 |
| 162 | 162 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 812 | E | 0 | 1 | RPKM11 | Based on observation, record review, and staff interview, the facility failed to maintain the kitchen and beverages distributed from the kitchen in a safe and sanitary manner. This deficient practice was found during a random opportunity for discovery and had the potential to affect more than an isolated number of residents. Facility census: 182. Findings included: a) Kitchen An initial tour of the facility's kitchen began on 10/07/19 at 10:53 AM. At 10:56 AM a square plastic container of lettuce in the reach-in cooler was found to have a use by date of 10/06/19. Also at 10:56 AM the reach-in cooler near the hand washing sink was found to have no temperature log. At 10:57 AM the facility's Dietary Manager (DM) confirmed that the lettuce had a use by date of 10/06/19. The DM then examined the lettuce closely and stated that it was still good. When asked for the facility's policy on what to do with a product that had passed its best by date, the facility's DM became silent and removed the lettuce from the cooler. At 10:58 AM the facility's DM confirmed there was no temperature log for the above-mentioned reach-in cooler. At 11:00 AM the dish machine temperature log was found to be blank on the following dates and times of the day during the month of (MONTH) 2019: breakfast, lunch, and dinner on 10/04/19, lunch and dinner on 10/05/19, and lunch and dinner on 10/06/19. Additionally, there was a large amount of scale running down the front of the machine. At 11:03 AM the facility's DM confirmed that the dish machine temperature log had not been filled out as it should have been. At 11:07 AM the facility's DM said that the large amount of scale running down the front of the dish machine was a constant problem. At 11:13 AM a 50 ounce can of chicken noodle soup with a large creased dent at the top seam was found in the dry storage area with food for resident service. At 11:14 AM the facility's DM confirmed that this severely damaged can should not have been in regular stock and then moved it to the damaged stock area of … | 2020-09-01 |
| 163 | 163 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 842 | E | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure medical records were complete and accurate for 1 of 35 residents in the survey sample. The physician's orders [REDACTED].#19 did not specify the specific supplement. Resident identifier: #19. Facility census: 182. a) Resident #19 Resident #19 had an order written [REDACTED]. The specific supplement was not identified in additional directives. Resident #19's Medication Administration Record [REDACTED]. During an interview on 10/10/19 at 8:28 AM, Licensed Practical Nurse (LPN) #185 stated she was pretty sure Resident #19 was receiving Juven as the commercial supplement. During an interview on 10/10/19 at 8:40 AM, the Director of Nursing (DoN) was informed the physician's orders [REDACTED].#19 did not specify the specific supplement. The DoN had no further information regarding the matter. No further information was provided through the completion of the survey. | 2020-09-01 |
| 164 | 164 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-10-10 | 867 | E | 0 | 1 | RPKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies. The facility had identified a deficient practice in the care area of advance directives, using medications as a chemical restaint for residents that refused care, failing to ensure all residents received medications that met the professional standard of practice, failing to ensure all orders were signed and dated by the physician, and failing to provide food that was palatable, attractive, to fit the needs of the residents, and their preferences. Has the potential to affect more than an isolated number of residents. Facility census 182. Findings included: a) Cross reference findings at F578 b) Cross reference findings at F605 c) Cross reference findings at F684 d) Cross reference findings at F711 e) Cross reference findings at F804 f) Interviews 1. During an interview on 10/10/19 at 11:52 AM, Director of Nursing (DoN) said, they did had audit in (MONTH) of 2019, and found no problems at that time. 2. Discussed the issues with the Post Forms with team and it was determined that the Post Forms was that was found to be incorrect the Post did not match the physician's orders [REDACTED]. Two (2) of the Post Forms were dated before the audit. 3. During an interview on 10/10/19 at 12:00 PM, Director of Nursing was asked about the orders not being signed and dated by the attending physician. DoN stated, that the physician was in transition for starting a new program for signing orders. 4. During an interview on 10/10/19 at 12:10 PM, DoN was asked the nurses not following perimeter on medication administration. DoN stated, that they were aware of the perimeters not being followed and did a Performance Improvement Procedure (PIP) in the Quality Assurance and Preformance Improvement (QAPI) meeting. She went on to say, they found the nurses had trouble using the sliding/scale… | 2020-09-01 |
| 165 | 165 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2017-06-20 | 223 | E | 1 | 0 | HCKF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of reported allegations, resident interview, staff interview, family interview, staffing records, policy review, and personnel record review; the facility failed to protect residents after an allegation of abuse for one (1) of five (5) allegations reviewed. This practice affected one (1) resident but had the potential to affect more than a limited number of residents. Resident identifier: Resident #1. Facility census: 55. Findings include: a) Resident #1 On 06/20/17 at 11:10 a.m., Assistant Administrator (AA) #11 was questioned as to whether the facility had any reportable allegations in the previous three (3) to six (6) months. The AA referred the question to Registered Nurse (RN) #71. Upon inquiry, the RN provided an allegation which she verbalized was being investigated. The immediate reporting form indicated Nurse Aide (NA) #79 had reported the allegation to the DON on 06//19/17, alleging NA #22 had used foul language/cursed at Resident #1 when the resident requested to be put back to bed after being toileted on the three o'clock to eleven o'clock (3:00 - 11:00) afternoon shift. Licensed Practical Nurse (LPN) #66, interviewed on 06/20/17 at about 10:30 a.m., had verbalized the facility completed annual training in-services, and had one scheduled for Wednesday, 06/21/17, related to abuse and neglect. The nurse said the LPN's role was to tell the director of nursing (DON) and the DON would do the rest. With further questioning, the LPN said the Charge Nurse would be notified on evenings and weekends, and that person would notify the appropriate entities. LPN #66 said if the alleged perpetrator was an employee, the person would not be allowed to work with the involved resident. NA#79, interviewed via telephone on 06/20/17 at 12:10 p.m. verbalized she usually worked day shift, but had worked over that day. The nurse aide said the resident was toileted on the bedside commode and when done was put in the wheelchair (w/c). The … | 2020-09-01 |
| 166 | 166 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2017-06-20 | 225 | D | 1 | 0 | HCKF11 | > Based on review of reported allegations, staff interview, family interview, and policy review, the facility failed to report timely and/or investigate an allegation of abuse for one (1) of five (5) allegations reviewed. Resident identifier: Resident #1. Facility census: 55. Findings include: a) Resident #1 On 06/20/17 at 11:10 a.m., Assistant Administrator (AA) #11 was questioned as to whether the facility had any reportable allegations in the previous three (3) to six (6) months. The AA referred the question to Registered Nurse (RN) #71. Upon inquiry, the RN provided an allegation which she verbalized was being investigated. The immediate reporting form indicated Nurse Aide (NA) #79 had reported the allegation to the DON on 06//19/17, alleging NA #22 had used foul language/cursed at Resident #1 when the resident requested to be put back to bed after being toileted on the three o'clock to eleven o'clock (3:00 - 11:00) afternoon shift. Licensed Practical Nurse (LPN) #66, interviewed on 06/20/17 at about 10:30 a.m., said the LPN's role was to tell the director of nursing (DON), and the DON would do the rest. With further questioning, the LPN said the Charge Nurse would be notified on evenings and weekends, and that person would notify the appropriate entities. NA#79, interviewed via telephone on 06/20/17 at 12:10 p.m. verbalized she usually worked dayshift, but had worked over that day. The nurse aide said the resident was toileted on the bedside commode and when done was put in the wheelchair (w/c). The NA said the resident asked what time dinner was served and was told about 5:30 p.m. NA#79 stated Resident #1 asked to be put back to bed because it was only 4:00 p.m. The nurse aide alleged NA#22 told the resident they were not playing these f-----g games and don't (do not) care what your daughter says. You are not being babied. NA#79 verbalized she notified LPN #63, who was passing medications. The LPN then ensured the resident was placed back in bed. NA #79 verbalized during the interview, that she went back in… | 2020-09-01 |
| 167 | 167 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2017-06-20 | 226 | E | 1 | 0 | HCKF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of reported allegations, resident interview, staff interview, family interview, staffing records, policy review, and personnel record review; the facility failed to implement policies and procedures after an allegation of abuse for one (1) of five (5) allegations reviewed. The facility failed to protect residents, and failed to report and/or investigate the allegation in a timely manner. This had the potential to affect more than an isolated number of residents. Resident identifier: Resident #1. Facility census: 55. Findings include: a) Resident #1 On 06/20/17 at 11:10 a.m., Assistant Administrator (AA) #11 was questioned as to whether the facility had any reportable allegations in the previous three (3) to six (6) months. The AA referred the question to Registered Nurse (RN) #71. Upon inquiry, the RN provided an allegation which she verbalized was being investigated. The immediate reporting form indicated Nurse Aide (NA) #79 had reported the allegation to the DON on 06//19/17, alleging NA #22 had used foul language/cursed at Resident #1 when the resident requested to be put back to bed after being toileted on the three o'clock to eleven o'clock (3:00 - 11:00) afternoon shift. Licensed Practical Nurse (LPN) #66, interviewed on 06/20/17 at about 10:30 a.m., had verbalized the facility completed annual training in-services, and had one scheduled for Wednesday, 06/21/17, related to abuse and neglect. The nurse said the LPN's role was to tell the director of nursing (DON) and the DON would do the rest. With further questioning, the LPN said the Charge Nurse would be notified on evenings and weekends, and that person would notify the appropriate entities. The LPN voiced she was unaware of any reportable allegations, other than six (6) to eight (8) months ago. LPN #66 said if the alleged perpetrator was an employee the person would not be allowed to work with the involved resident. NA#79, interviewed via telephone on 06/20/17 at 1… | 2020-09-01 |
| 168 | 168 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2019-06-26 | 584 | E | 1 | 0 | UZ4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview the facility failed to ensure a safe, comfortable, orderly, homelike environment. The screens in the windows of ten (10) out of thirty (30) resident rooms were either torn or not adequately secured snugly to the window. This had the potential to allow entrance of insects or flies into resident rooms. Rooms: 27, 29, 24, 21, 20, 18, 15, 13, 10, 9. Facility census: 53. Findings included: a) room [ROOM NUMBER] On 06/25/19 at 9:45 AM an inspection was made of room [ROOM NUMBER]. The first bed was stripped bare. A tag on the foot of the bed noted this bed was deep cleaned by housekeeping staff on 06/22/19. Resident #49 lay in the bed by the window. The large picture window in this room was closed. A screen was observed in the middle section of the picture window. When asked if she ever opened this window, she replied in the affirmative. The interim director of nursing (DON) unlocked the window and slid it toward the right. The screen had a tear in the lower left corner which was opened to about a two (2) inch by two (2) inch hole. This hole could allow entrance of an insect or a fly into the room if the window was to be opened. The interim DON said she did not know this window could be opened or ever was opened. She noted that the screen also did not fit tightly against the window pane and was loose. She said she would have maintenance make the necessary repairs to this window screen. When asked if a visitor or family member of either resident in this room could potentially have opened the window and let a fly into the room, she said she guessed that was possible. The interim DON informed the administrator of the window screen situation. The administrator then gave directives to the maintenance department to check all the windows in resident rooms for tears in screens or for ill-fitting screens. b) A tour of the facility to check the windows and screens of resident room was conducted on 06/25/19 from 12:30… | 2020-09-01 |
| 169 | 169 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2019-06-26 | 656 | D | 1 | 0 | UZ4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to develop person-centered, individualized care plan with measurable goals and appropriate interventions for one (1) of four (4) sampled residents. Resident identifier: #4. Facility census: 53. Findings included: a) Resident #4 The medical record was reviewed on 06/25/19 and continued through 06/26/19. Resident #4 was an elderly resident with [DIAGNOSES REDACTED]. On 04/24/19 a nurse's note conveyed that a venous stasis ulcer was beginning to open on the top of the right foot. Nursing notified the physician. The physician gave orders to cleanse the venous stasis ulcer to the top of the right foot with normal saline, pat dry, apply Silversorb gel to the wound bed, and cover with a dry dressing every day shift and as needed. A nurse's note dated 04/30/19 described the wound to the top of the right foot as full thickness tissue loss, 80% black tissue and 20% slough. The next nurse's note related to the stasis ulcer to the top of the right foot occurred on 05/18/19, when the physician gave new orders for [MEDICATION NAME] (antibiotic) 875 milligram (mg)/125 milligrams (mg) orally twice daily for seven (7) days for wound. A physician's hand-written progress note dated 05/18/19 assessed that the right foot has open area, and skin surrounding it has [DIAGNOSES REDACTED] and some purulent drainage. The diagnostic impression was [MEDICAL CONDITION] of the right foot. The plan was to administer [MEDICATION NAME] 875 mg. twice daily for a week. Review of the weekly wound observation tool dated 06/07/19 found the nurse described the stasis ulcer to the top of the right foot as 100% black, scab-like tissue with a small amount of serosanguinous drainage. The wound measured 75 millimeters long by 22 millimeters wide. A weekly wound observation tool dated 06/21/19 assessed that the stasis ulcer was 100% black, scab-like tissue with a small amount of serosanguinous drainage. Measurement… | 2020-09-01 |
| 170 | 170 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2019-07-10 | 656 | D | 0 | 1 | 5N8D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record reviews and staff interviews, the facility failed to develop a person-centered comprehensive care plan for two (2) of twenty one (21) care plans reviewed during the Long Term Care Survey Process (LTCSP). The care plan for R2 was not developed to address her end-of-life wishes and the care plan for R1 did not address the use of an arm sling. Resident identifiers: R1 and R2. Facility census: 53. Findings included: a) R2 During a medical record review on 07/10/19 revealed the care plan had not been developed to reflect R2's wishes for her end-of-life care. In an interview on 07/10/`19 at 9:35 AM with the Nursing Home Administrator verified, the care plan did not address the end-of-life wishes for R2. b) R1 During an interview and observation on 07/08/19 at 12:30 PM, R1 reported she was wearing an arm sling because she had broken her arm and dislocated her shoulder during a stay at another facility. Random observations during the survey revealed R #1's continued use of the right arm sling. Review of the medical record on 07/09/19, revealed an orthopedic note dated 07/18/18 with a [DIAGNOSES REDACTED]. The treatment included a right arm sling. The Occupational Therapy Discharge Note dated 07/30/2018 to 09/25/18, states under the section titled Equipment issued .pt (patient) continues to wear sling per her preference. The current care plan with a revision date of 07/09/19, is silent in regards to R1's continued use of the right arm sling. During an interview on 07/09/19 at 11:00 AM, Licensed Practical Nurse (LPN) #39 confirmed R1's care plan does not identify the arm fracture or address the sling she continues to wear for comfort. | 2020-09-01 |
| 171 | 171 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2019-07-10 | 657 | D | 0 | 1 | 5N8D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the comprehensive care plan had been revised to reflect the discontinued use of a diabetic medication for R45. This was found to be true for one (1) of twenty one (21) care plans reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: R45 Facility census: 53. Findings included: a) R45 During a medical record review on 07/09/19 revealed the care plan for R2 had not been revised to reflect the discontinuation of the diabetic medication [MEDICATION NAME]. In an interview on 07/09/19 at 2:11 PM with the Director of Nursing, verified the care plan for R45 had not been revised to indicate the diabetic medication [MEDICATION NAME] had been discontinued on 03/06/19. | 2020-09-01 |
| 172 | 172 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2019-07-10 | 684 | D | 0 | 1 | 5N8D11 | Based on observation, medical record review and staff interview, the facility failed to ensure R52 received treatment and care in accordance with professional standards of practice. During a random observation it was discovered the oxygen concentrator was delivering air flow to R52 at a rate of four (4) liters and not the prescribed two (2)-three (3) liters. This was true for one (1) of two (2) residents reviewed for Respiratory Care Services during the Long Term Care Survey Process (LTCSP). Resident identifier: R52. Facility census: 53. Findings included: a) R52 During an observation on 07/09/19 at 3:50 PM for R52, it was discovered the oxygen concentrator was delivering air flow to R52 at a rate of four (4) liters and not the ordered 2-3 liters via nasal cannula for shortness of breath. In an interview on 07/09/19 at 3:55 PM with E60 Licensed Practical Nurse (LPN) verified the oxygen concentrator for R52 was providing an air flow of four (4) liters and not the ordered two (2)-three (3) liters. | 2020-09-01 |
| 173 | 173 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2019-07-10 | 689 | D | 0 | 1 | 5N8D11 | Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. A bottle of shampoo/body wash was accessible to residents in the unsecured community bathroom. This practice had the potential to affect more than a limited number of residents. Facility census: 53. Findings include:d a) Observations During initial tour observation of the middle of the facility hallway by activities room on 07/08/19 at 10:35 AM, discovered the community bathroom door open and unlocked. An eye wash station is located inside the bathroom and a 12 ounce bottle of Soothe and Cool Shampoo and Body Wash was found sitting in the basin of the eye wash station. The label stated, External use only. Avoid contact with eyes. b) Interview Immediately following the observation, Employee #69 walked into the open door of the bathroom and removed the bottle of the shampoo/body wash from the basin of the eye wash station. Upon inquiry she stated, No this bottle does not belong in the bath area or the eye wash station. Employee #69 agreed it is an accident hazard due to being accessible to residents. | 2020-09-01 |
| 174 | 174 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2019-07-10 | 695 | D | 0 | 1 | 5N8D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to provide respiratory care services, consistent with professional standards of practice. This was true for one (1) of two (2) residents reviewed for respiratory services. During an observation it was discovered R52 was receiving her oxygen air flow at four 4 litters and not the ordered two (2)-three (3) liters. Resident identifier: R52. Facility census: 53. Findings included: a) R52 During a medical record review on 07/09/19, revealed the physician's orders [REDACTED]. An observation on 07/09/19 at 3:50 PM, it was discovered the oxygen concentrator for R52 had an air flow set on four (4) liters. An observation by E60, licensed practical nurse (LPN) verified the oxygen concentrator for R52 was providing an air flow of four (4) liters and not the ordered two (2) to three (3) liters as per orders. | 2020-09-01 |
| 175 | 175 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2019-07-10 | 755 | E | 0 | 1 | 5N8D11 | Based on record review and staff interview, the facility failed to maintain complete and accurate drug records to ensure an account of all controlled medications (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence). This practice has the potential to affect all residents residing in the facility. Facility census: 53. Findings included: a) At 3:07 PM on 07/09/19, a review of the medication carts with Licensed Practical Nurse (LPN) #60 and LPN #76, revealed incomplete controlled substance medication count sheets on one (1) of two (2) med carts. LPN #76 reported the off going and the on coming nurses count the controlled medications together and then sign the Controlled Substances Shift Count form. LPN #60 confirmed the narcotic count sheet was incomplete on 07/04/19, 07/06/19 and 07/07/19. The Controlled Substance Shift Count form states at the top: Federal Drug Standards require accountability for all controlled substances. The count must be verified at the time there is a change of responsibility for the drugs from one nurse to another. Two (2) licensed nurses, oncoming and off going, will count the controlled drugs together and signed to verify the accuracy of the count. Any discrepancy, without exception, must immediately be reported to the Director of Nursing or Designee . The controlled substance shift count form for (MONTH) 2019, lacks numbers identifying the current medication counts on 07/04/19 day shift and 07/07/19 evening shift. In addition, the signature section is blank for Nurse II on 07/06/19 and 07/07/19 and blank for Nurse I on 07/07/19. | 2020-09-01 |
| 176 | 176 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2019-07-10 | 756 | F | 0 | 1 | 5N8D11 | Based on policy review and staff interview, the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that include time frames for physician notification and response of drug irregularities. This practice has the potential to affect all residents. Facility census: 53. Findings included: a) On 07/09/19 at 2:00 PM, review of the facility policy titled Medication Regimen Review with an implemented date of 12/06/18 and reviewed/revised date of 03/19/19, states the following (typed as written): 5. The pharmacist shall communicate any irregularities to the facility in the following ways: a. Verbal communication to the attending physician, Director of Nursing (DON), and/or staff of any urgent needs. b. Written communication to the attending physician, the facility's Medical Director, and the Director of Nursing. 6. Written Communications from the pharmacist shall become a permanent part of the resident's medical record. 7. Timelines and responsibilities for the Medication Regimen Review: a. The consultant pharmacist shall schedule at least one monthly visit to the facility, and shall allow for sufficient time to complete all required activities. b. The pharmacist shall communicate any recommendations and identified irregularities via written communication within 10 working days of the review. c. If the pharmacist should identify an irregularity that requires urgent action to protect a resident, the DON or designee is informed verbally. d. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. After review of the facility policy titled Medication Regimen Review on 07/09/19 at 2:30 PM, the DON and the Administrator agreed the facility policy does not contain time frames for physician notification and response of drug irregularities. The Administrator and DON explained the procedure is for the pharmacist to notify the physician by written communication. Both agree the policy should include time frames f… | 2020-09-01 |
| 177 | 177 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2019-07-10 | 761 | F | 0 | 1 | 5N8D11 | Based on observation, record review and staff interview, the facility failed to monitor the temperature of the medication refrigerator daily. This was true for one (1) of one (1) medication refrigerators and has the potential to affect all residents residing in the facility. Facility census: 53. Findings included: a) On 07/09/19 at 3:00 PM, a review of the medication room with Licensed Practical Nurse (LPN) #76, revealed the medication refrigerator temperature was not documented daily. The Refrigerator Temperature Log for (MONTH) 2019, was blank on 07/02/19 and 07/04/19. During this observation, LPN #76 confirmed the temperature log for the medication refrigerator was incomplete. LPN #76 reported the facility policy is the 3-11 nurse checks the temperature and documents the findings. | 2020-09-01 |
| 178 | 178 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2019-07-10 | 812 | F | 0 | 1 | 5N8D11 | Based on observation and staff interview, the facility failed to ensure foods were stored under sanitary conditions after opening. During the kitchen tour it was discovered foods were not dated after opening. These food items were not stored in accordance with professional standards for food service safety. This had the potential to affect all residents receiving their nutrition from the kitchen. Facility census: 53. Findings included: a) Kitchen tour During the kitchen tour on 07/08/19 at 11:24 AM, it was discovered whipped cream, swiss cheese slices, bottled chocolate sauce and mustard were not dated after opening. These food items were not stored in accordance with professional standards for food service safety. In an interview on 07/08/19 at 11:35 AM the dietary manager (DM) verified the whipped cream, swiss cheese slices, chocolate sauce, and mustard were not dated after opening and the foods were not stored under proper food service safety. | 2020-09-01 |
| 179 | 179 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2019-07-10 | 842 | D | 0 | 1 | 5N8D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure care and treatment was being provided in accordance with professional standards. This was true for two (2) of twenty- one (21) residents physician's orders [REDACTED]. R14 was not receiving oxygen therapy and still had an order for [REDACTED]. Facility census: 53. Findings include a) R14 During a medical record review on 07/10/19 revealed physician's orders [REDACTED]. In an interview with the Director of Nursing (DON) on 07/10/19 at 8:28 AM, verified the order for oxygen therapy should have been discontinued for R14 since she was no longer receiving oxygen. b) R52 During a medical record review on 07/09/19, revealed the physician's orders [REDACTED]. This order was not specific as to the correct amount of oxygen air flow R52 was to receive. In an interview with the Director of Nursing (DON) on 07/10/19 at 8:28 AM, verified the order for R52 was non-specific as to the correct amount of oxygen 2-3L she was to receive. For staff having to decide what air flow to provide 2-3L would be a decision outside their scope of practice. | 2020-09-01 |
| 180 | 180 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2019-07-10 | 880 | F | 0 | 1 | 5N8D11 | Based on observation 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 laundry room lacked separation between the soiled and clean laundry/linen area and no identified negative air flow. In addition a cracked and worn computer mouse pad in use located on a medication cart. This has the potential to affect all residents in the facility. Facility census: 53. Findings included: a) Laundry Room On 07/09/19 at 8:30 AM during a tour of the laundry room in the presence of Employee #56 and #47, discovered no separation between the soiled and clean linen, also lacking identified negative air flow. The washers and dryers are located in the same room within close proximity. While standing in the middle of the room could feel air flow descending from ceiling. Employee #56 and #47 explained the laundry room has been like that except last year the facility made the room across the hall with the laundry chute the soiled room. Employee #56 explained the procedure for collecting the soiled linen. The soiled linen is retrieved from the cart under the laundry chute, sorted then covered with a sheet and transported across the hall to the laundry room to place in the washers. At 8:45 AM on 07/09/19, the Administrator and the Assistant Administrator #69 stated, We thought we had fixed the laundry issue when our plan of correction was accepted. We moved the soiled laundry to the other room and sort it there before taking it across the hall. I now understand what you are saying that it is still soiled linen coming into a clean room Upon inquiry about separation between soiled and clean linen with washers and dryers being in the same room, the Administrator stated, We will brainstorm how to separate the washers and dryers. Whether by putting up a wall with negative air flow. Maybe move the washers to the room with the… | 2020-09-01 |
| 181 | 181 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2018-09-27 | 550 | D | 0 | 1 | DL7D11 | Based on random observation, staff interviews and policy review, the facility failed to promote care for residents in a manner that maintained or enhanced dignity. The staff entered a resident's room without knocking, identifying themselves, or obtaining permission. This practice had the potential to affect a minimal number of residents. Resident identifiers: #24 and #31. Facility census 52. Findings included: a) Resident #24 and #31 During an observation of a resident room, on 09/24/18 at 11:30 AM, revealed Nurse Aide (NA) #40 walked into the room without knocking, identifying themselves, and asking for permission to enter Resident #24 and #31's room. NA #40 walked over to Resident #24's bed and stated, It is time to go to the bathroom. NA #40, turned around and left the room. A few minutes later NA#40 returned to room with NA #17 without knocking, identifying themselves, and asking for permission to enter Resident #24 and #31's room. The NA's walked over to Resident #24's bed. NA #17 went around to the far side of the bed. NA #40 was on the opposite side of the bed closest to the Resident in the A - bed and the door. NA#40 reached up and pulled down Resident #24's bed covers exposing the resident in an adult brief to her roommate with the door to the resident's room wide open for anyone to view inside. In an interview on 09/24/18 at 11:32 AM, NA #40 and #17, revealed the NA's forgot to knock on the residents door, identifying themselves and ask for permission prior to enter the room. The NA's also agreed they should have closed the entrance door to the room and pulled the curtain between the residents prior to pulling down Resident #24's bed covers. An interview on 09/24/18 at 12:00 PM, with the Assistant Administrator #13, she was informed of the observation above and she stated, I will address this matter. A review of the facility policy, on 09/27/18 at 2:00 PM, titled Promoting/Maintaining Resident Dignity with a revision date of 08/30/18, stated, Maintain Privacy. Staff shall knock on doors and properly ann… | 2020-09-01 |
| 182 | 182 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2018-09-27 | 583 | D | 0 | 1 | DL7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observation, staff interview and policy review, the facility failed to provide privacy for a resident during personal care. Staff failed to pull the curtain while performing personal care and close the door to the resident room. This practice had the potential to affect a minimal number of residents. Resident identifier: #24. Facility census 52. Findings included: a) Resident #24 During an observation of room [ROOM NUMBER], on 09/24/18 at 11:30 AM revealed Nurse Aide (NA) #40, walked into the room without knocking, identifying themselves, and asking for permission to enter Resident #24 and #31's room. NA #40 walked over to Resident #24's bed, in which she resides in the b bed, and stated, It is time to go to the bathroom. NA #40, turned around and left the room. A few minutes later NA#40 returned to room with NA #17 without knocking, identifying themselves, and asking for permission to enter Resident #24 and #31's room. The NA's walked over to Resident #24's bed. NA #17 went around to the far side of the bed. NA #40 was on the opposite side of the bed closes to the Resident in the A - bed and the door. NA#40 reached up and pulled down Resident #24's bed covers exposing the resident in an adult brief to her roommate with the door to the resident's room wide open for anyone to view inside. In an interview on 09/24/18 at 11:32 AM, NA #40 and #17, revealed the NA's forgot to knock on the residents door, identifying themselves and ask for permission prior to enter the room. The NA's also agreed they should have closed the entrance door to the room and pulled the curtain between the residents prior to pulling down Resident #24's bed covers. An interview on 09/24/18 at 12:00 PM, with the Assistant Administrator #13, she was informed of the observation above and she stated, I will address this matter. A review of the facility policy, on 09/27/18 at 2:10 PM, titled Resident Right to Privacy During Care with a revision date of 08/30/18,… | 2020-09-01 |
| 183 | 183 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2018-09-27 | 761 | D | 0 | 1 | DL7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure all multi-dose vials of insulin were dated when initially opened for used and needle-punctured. According to manufacturer's guidelines, [MEDICATION NAME]left in a multi-dose vial beyond twenty-eight (28) days of opening must be discarded. By not dating the multi-dose vial when initially opened, nursing staff had no way of knowing when to discard the vial. This practice had the potential to negatively impact the safety and/or potency of the insulin. This was evident for one (1) of ten (10) opened and used multi-dose vials of insulin observed. Resident identifier: #26. Facility census: 52. Findings include: a) Resident #26 Opened and used (needle punctured) multi-dose vials of insulin were observed on 09/27/18 at 10:53 AM. An opened and needle punctured vial of [MEDICATION NAME]for this resident contained no date to indicate when it had initially been opened for use. The label on the vial indicated pharmacy filled that prescription on 09/13/18. Licensed nurse employee #25 (E#25) was present at this time. She said staff should have dated this vial when initially opened to ensure that staff disposed of the vial twenty-eight (28) days after it was first opened for use. She said the [MEDICATION NAME]is used as sliding scale coverage for this resident's blood glucose checks per the glucometer. On 09/27/18 at 11:10 AM the director of nursing (DON) provided a copy of their policy titled Labeling of Medications and Biologicals with revision date of 08/30/18. Page two (2) and item number eight (8) of this policy stated All opened or accessed vials should be discarded within twenty-eight (28) days unless the manufacturer specified a different (shorter or longer) date for that opened vial. An interview was conducted with the administrator and assistant administrator on 09/27/18 at 1:15 PM. No further information was provided prior to exit. | 2020-09-01 |
| 184 | 184 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2018-09-27 | 842 | D | 0 | 1 | DL7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , medical record review, and staff interview, the facility failed to ensure accurate medical transcription and documentation of a physician's orders [REDACTED]. A nurse wrote a physician's orders [REDACTED]. This order was transcribed onto the medication administration record at 2% strength. Nurses documented twelve (12) times they administered a 2% strength dose. However, pharmacy provided this prescription at 0.5% strength. Per a nursing drug handbook information, this ophthalmic ointment is only available at 0.5% strength. This was evident for one (1) of four (4) residents observed during medication pass out of thirty-four (34) medication administration observations. Resident identifier: #50. Facility census: 52. Findings included: a) Resident #50 During a medication administration observation on 09/26/18 at 9:10 AM, licensed nurse employee #26 (E#26) administered [MEDICATION NAME] 0.5% ophthalmic ointment to this resident's right eye. Observation of the electronic medical record found directive to administer [MEDICATION NAME] 2% ointment to the right eye. Review of the hard copy medical record revealed a hand-written physician's verbal order which was written by a nurse on 09/18/18 at 3:00 PM. This order directed to instill [MEDICATION NAME] ointment 2% topically to the right eye twice daily for seven (7) days related to irritation, redness, swelling. Review of the facility's Nursing (YEAR) drug handbook which was located at the nurses' station, found that [MEDICATION NAME] ophthalmic ointment is only available at the 0.5% strength. An interview was conducted with the assistant administrator on 09/26/18 at 9:15 AM regarding this scenario. She said this was a transcription error. The medication administration record (MAR) was reviewed on 09/26/18. The MAR contained a typed order to administer [MEDICATION NAME] ointment 2% to the right eye topically twice daily for seven (7) days. Nursing staff initialed on the electron… | 2020-09-01 |
| 185 | 185 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2018-09-27 | 865 | E | 0 | 1 | DL7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility's quality assurance and performance improvement program (QAPI) / quality assessment and assurance (QAA) committee failed to identify and implement corrective action for quality deficiencies for which they should have been aware of to improve the lives of the residents. The facility failed to ensure that 10 out of 13 residents either received the appropriate pneumococcal immunization, or did not receive the pneumococcal immunization due to medical contraindication or refusal. These practices had the potential to affect more than a limited number of residents at the facility. Resident Identifiers: #26, #35, #42, #201, #24, #5, #101, #15, #4, #16, #17, #2, #30. Facility census: 52. Findings included: a) Staff interview at 11:13 on 09/26/18 with Licensed Practical Nurse (LPN) #70 revealed the facility did not routinely offer or administer the 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13). The PVC13 is not readily available within the facility. LPN #70 also stated they only administer the PVC13 vaccine if it is specifically ordered by the physician, and the vaccine is not a standing order upon admission. b) Review of facility policy for Pneumococcal Vaccine state under Policy Explanation and Compliance Guidelines each resident will be offered a pneumococcal immunization unless it is medially contraindicated, or the resident has already been immunized, and prior to immunization the resident or resident's representative will have the opportunity to refuse. The policy also state the type of pneumococcal vaccine, 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13) or 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME] 23) offered will depend upon the recipient's age and suitability to pneumonia, in accordance with current Centers for Disease Control (CDC) guidelines and recommendations. Explanation of the facility's complian… | 2020-09-01 |
| 186 | 186 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2018-09-27 | 880 | E | 0 | 1 | DL7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview the facility failed to maintain an effective infection control program designed to provide a safe and sanitary environment to help prevent the development of and transmission of communicable disease to the extent possible. A nursing assistant provided care to Resident #101 who was in contact precautions, without donning a gown or gloves. Licensed nurses cleaned the facility's two (2) resident shared glucometers improperly using 70% ethyl alcohol. One facility staff member was observed utilizing an improper hand-washing technique. The facility also failed to handle, store, and/or process linens in a satisfactory manner to prevent infection. These practices had the potential to affect more than a limited number of residents. Resident identifier: #101. Facility census: 52. Findings included: a) Resident #101 Observation on 09/24/18 at lunch time found nursing assistant employee #32 (E#32) entered the room of Resident #101 to deliver his lunch tray. A sign on the door conveyed that he was in contact precautions. An isolation cart sat outside his door in the hallway. E#32 did not don an isolation gown or gloves. She touched his bed linens with her bare hands. She touched his overbed tray with her bare hands. She picked up the bed control with her bare heads and raised the head of his bed. She helped him become positioned comfortably, and removed the brown plastic lid which covered the hot foods on his plate. At 12:19 PM E#32 walked down the hallway to the dining room where she passed this brown plastic plate cover through the kitchen window, where she placed it on top of other plate covers. She then used hand sanitizer and left the dining room. Review of the medical record on 09/25/18 found a physicians order dated 09/21/18 for contact isolation due to [MEDICAL CONDITION] resistant [DIAGNOSES REDACTED] aureus (MRSA) of the right foot wound. An interview was conducted with infection control r… | 2020-09-01 |
| 187 | 187 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2018-09-27 | 883 | E | 0 | 1 | DL7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, policy review and documentation review, the facility failed to ensure 10 out of 13 sample residents were given opportunity to receive, refuse, or to have contraindication determined for the appropriate pneumococcal vaccination to be administered. Resident identifiers: #26, #35, #42, #201, #24, #5, #101, #15, #4, #16, #17, #2, #30. Facility census: 52. Findings included: a) Staff interview at 11:13 on 09/26/18 with Licensed Practical Nurse (LPN) #70 revealed the facility did not routinely offer or administer the 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13). The PVC13 is not readily available within the facility. LPN #70 also stated they only administer the PVC13 vaccine if it is specifically ordered by the physician, and the vaccine is not a standing order upon admission. b) Review of facility policy for Pneumococcal Vaccine state under Policy Explanation and Compliance Guidelines each resident will be offered a pneumococcal immunization unless it is medially contraindicated, or the resident has already been immunized, and prior to immunization the resident or resident's representative will have the opportunity to refuse. The policy also state the type of pneumococcal vaccine, 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13) or 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME] 23) offered will depend upon the recipient's age and suitability to pneumonia, in accordance with current Centers for Disease Control (CDC) guidelines and recommendations. Explanation of the facility's compliance guidelines indicate the residents medical record must include documentation that indicates the resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. c) Centers for Disease Control (CDC) guideline for Pneumococcal Vaccine Timing for adults [AGE] years or older state for those who have not received any pneumococcal vaccines, or t… | 2020-09-01 |
| 188 | 188 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2017-10-18 | 323 | E | 0 | 1 | XKNG11 | Based on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Observations during Stage 1 of the Quality Indicator Survey (QIS) found a Soiled Utility closet on Wing one (1) was unlocked with chemicals stored on a shelf, and the Clean Room, which contained biologicals. This had the potential to affect more than an isolated number of residents. Facility census: 55 Findings include: a) Observations of Wing one (1) On 10/16/17 at 10:51 a.m., during an observation on Wing one (1), it was discovered the Soiled Utility closet was unlocked. In the Soiled Utility closet there was one (1) gallon container of Pinesol and one (1) gallon of Lysol mixtures on a shelf. The unlocked door allowed any wandering resident access to this closet with the potential to ingest these hazardous chemicals. During an interview with Employee #80, licensed practical nurse (LPN) on 10/16/17 at 10:52 a.m., verified the Soiled Utility closet was always unlocked, she did agree these chemicals should not be stored in an unlocked area accessible to wandering residents. b) Clean Utility Room A random observation on 10/17/17 at 8:00 a.m. discovered an unlocked room with a plaque on the door stating, clean utility with no lock on the door or door knob. The room contained various supplies which included a drawer containing numerous packets of INZO Barrier Cream with 5% dimethicone (uses include: temporarily protects - and helps relieve chapped or cracked skin - minor cuts), written on the packets was Warning which stated (typed as written): Keep this and all drugs out of reach of children for external use only. Avoid contact with eyes. When accompanied by Licensed Practical Nurse (LPN) #22 to the clean utility room on 10/17/17 at 8:05 a.m., she verified and agreed the door is unlocked with no means of locking the room. She stated, The door has never been locked, commenting the room contains clean supplies which include as Foley catheter insertion… | 2020-09-01 |
| 189 | 189 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2017-10-18 | 371 | E | 0 | 1 | XKNG11 | Based on observation and staff interview the facility failed to store food items under sanitary conditions. Bottles of thickened liquids were found not dated when opened. This practice has the potential to affect more than limited number of residents. Census: 55. Findings include: a) During the initial tour of the dietary department at 10:45 a.m. on 10/16/17 with the certified dietary manager, the following issue was revealed: plastic bottles containing thickened liquids such as prune juice, apple juice and water were found opened but not dated. This would not allow the dietary staff to determine how long the product had been opened and the chance for contamination to be greater. | 2020-09-01 |
| 190 | 190 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2017-10-18 | 431 | E | 0 | 1 | XKNG11 | Based on observation and staff interview, the facility failed to ensure it provided permanently affixed compartments for storage of controlled medications and other drugs subject to abuse (Fentanyl, Norco, Morphine Sulfate, Oxycontin, Roxicodone, and Percocet). This was found in one (1) of one (1) medication storage room. This practice has the potential to affect more than an isolated number. Resident census: 55. Findings include: a) An observation of the metal cabinet in the medication storage room on 10/17/15 at 2:20 p.m., with Registered Nurse (RN) #79, revealed an unsecured clear white plastic box sealed with a zip tie and labeled: Attention All Nurses DEA (Drug Enforcement Administration) STOP Controlled Substance. The box contained the following: --5 Acetaminophen / Codeine (Tylenol #3) --5 Alprazolam (Xanax) 0.25 milligrams (mg) --3 Clonazepam (Klonopin) 0.5 mg --3 Diphenoxylate Atropine (Lomotil) 2.5 mg --2 Fentanyl (Duragesic) 25 mg patch --2 Fentanyl (Duragesic) 50 mg patch --6 Hydrocodone/Apap (Norco) 5/325 mg --6 Hydrocodone/Apap (Norco) 7.5/325 mg --6 Hydrocodone/Apap (Norco) 10/325 mg --5 Lorazepam (Ativan) 0.5 mg --5 Morphine Sulfate ER (extended release) (MS Contin) 15 mg --2 30 milliliter (ml) bottles Morphine Sulfate (Roxanol) 20 mg/ml --3 Oxycodone SR (sustained release) (Oxycontin) 10 mg --5 Oxycodone IR (immediate release) (Roxicodone) 5 mg --6 Oxycodone/Apap (Percocet) 5/325 mg --3 Phenobarbital (Phenobarb) 32.4 mg --3 Tramadol (Ultram) 50 mg --3 Zolpidem (Ambien) 5 mg This clear white plastic container was not secured to the metal cabinet and was demonstrated to be easily removed. RN #79, confirmed the clear white box containing controlled substances was not secured to the cabinet and could be removed easily. During an interview on 10/17/17 at 2:35 p.m., the Director of Nursing (DON) agreed the drug box was not secured to the cabinet. She reported the pharmacist routinely checks the drug box and never informed the facility that the box needed to be permanently affixed to the cabinet. | 2020-09-01 |
| 191 | 191 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2017-10-18 | 441 | E | 0 | 1 | XKNG11 | Based on observation, policy review and staff interview, the facility failed to maintain an effective infection control program to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. Breaches in infection control practices were observed during medication administration for Resident #7 and Resident #18 and during a random observation of the clean utility room involving a soiled laundry chute. This practice has the potential to affect more than an isolated number of residents residing in the facility. Resident identifiers: #7 and #18. Facility census: 55. Findings include: a) Resident #7 After a medication administration pass observation for Resident #7 on 10/17/17 at 8:04 a.m. Licensed Practical Nurse (LPN) #80 performed hand hygiene with soap and water for fourteen (14) seconds then proceeded to turn off the faucet with the same paper towel used to dry her hands. b) Resident #18 After a medication administration pass observation for Resident #18 on 10/17/17 at 8:17 a.m. LPN #80 performed hand hygiene with soap and water for seventeen (17) seconds then proceeded to turn off the faucet with the same paper towel used to dry her hands. Immediately following the observations LPN #80 stated, I thought I washed my hands for 20 seconds but maybe I did it too quickly. She agreed and verified that the same paper towel used to dry her hands was used to turn off the water faucet. Reported I didn't know I was supposed to get a clean dry paper towel but it makes sense that it would be wet and cause contamination from the faucet. Our hand-washing policy is to wash our hands for twenty (20) seconds). Review of the facility hand-washing policy provided by the Director of Nursing (DON) on 10/17/17 at 8:55 a.m. with titles from Centers for Medicare & Medicaid Services (CMS) and World Health Organization (WHO) with a date of 2009 stated the following (typed as written): .Rub hands and forearms briskly for 20 seconds . The (YEAR) hand hygiene recommendations from the Centers… | 2020-09-01 |
| 192 | 192 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2019-04-11 | 578 | D | 0 | 1 | M7ZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure all elements of the advance directive were completed for three (3) of 14 residents reviewed during the long-term care survey process. Facility identifiers: #1, #6, #27. Facility census: 39. Findings included: a) Resident #1 Review of Resident #1's West Virginia Physician order [REDACTED]. No length of time had been entered into the space provided on the form. During an interview on 04/09/19 at 1:30 PM, Social Worker #4 agreed Resident #1's POST form did not specify the length of time for the IV fluids trial period. On 4/9/2019 at 2:25 PM, a progress note was written which stated, This DSS (Director of Social Services) and administrator spoke with resident's HCS (Health Care Surrogate) (name of health care surrogate) this date regarding resident's POST form. This DSS asked for clarification of a defined trial period of IV fluids and HCS stated that 1 month would be ideal. This DSS and administrator assured HCS that this would be written in and if the HCS would ever like to change it this can be done. No concerns noted at this time. Will continue to monitor and report any new changes. b) Resident #6 Review of Resident #6's West Virginia Physician order [REDACTED]. The defined trial period was not stated. The POST form did not include an area on the form to indicate the defined trial period. The POST form was dated 05/15/2006 and had been reviewed on 09/26/17 according to the form. During an interview on 04/09/19 at 1:30 PM, Social Worker #4 agreed Resident #6's POST form did not specify the defined trial period for IV fluids or feeding tube. Social Worker #4 stated this POST form was an old form. She stated Resident #4's Health Care Surrogate would be contacted to clarify the interventions and complete a new form. On 04/11/19 at 9:46 AM, Social Worker #4 stated an updated POST form had been completed for Resident #6. c) Resident #27 Review of Resident #27's medical record… | 2020-09-01 |
| 193 | 193 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2019-04-11 | 584 | D | 0 | 1 | M7ZP11 | Based on observation, resident interview, and staff interview , the facility failed to provide a safe clean home like environment to the extent possible. A random observation of a dependent resident's bedside phone revealed the phone to be grossly dirty and in need of cleaning and sanitizing. This practice had the potential to affect more than limited number of residents. Resident identifier: #17. Facility census: 39. Findings included: a) Resident #17 Observation of Resident#17's bedside telephone, on 04/10/19 at 9:20 AM, revealed a lot of built up crusty dirt and debris inside the phone cradle, where the ear piece of the phone rested when not in use. Inspection of the earpiece revealed some dried debris coating the outer surface of the earpiece that would lay against the resident's ear when she spoke on the phone. This surveyor asked the resident, When was the last time the phone had been cleaned? The resident replied, I don't remember when it was ever cleaned. This surveyor pointing at the phone, asked the resident if she talked on that phone. The resident replied, Oh yes, I talked to my daughter all the time. On 04/10/19 at 9:23 AM, this Surveyor went into the hallway and asked nurse aide (NA#13) to step into resident 17's room. NA#13 was asked to pick up the resident's phone and look at the cradle. The nurse aide picks up the phone and looking at the cradle gasped, Oh! I will get housekeeping to clean this immediately. | 2020-09-01 |
| 194 | 194 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2019-04-11 | 641 | D | 0 | 1 | M7ZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, facility failed to accurately complete the Minimum Data Set (MDS) to reflect Resident #19's urinary continence status. This was true for one (1) of fourteen (14) sampled residents. Resident identifiers: #19. Facility census: 39. Findings included: a) Resident #19 Review of Resident #19's medical records, found the resident was admitted on [DATE]. [DIAGNOSES REDACTED]. Neuromuscular dysfunction of bladder is a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition. Review of Resident #19's admission MDS assessment with an assessment reference date (ARD) of 03/01/19, which found section H - Bladder and Bowel indicates the resident has an indwelling Foley catheter. Under Section H 0300 urinary incontinence the MDS was coded 3, to indicate the resident is always incontinent (no episodes of incontinence). Review of the Resident Assessment Instrument (RAI) the appropriate answer is Code 9, not rated: if during the 7-day look-back period the resident had an indwelling bladder catheter, condom catheter, ostomy, or no urine output (e.g., is on chronic [MEDICAL TREATMENT] with no urine output) for the entire 7 days. Interview with the Director of Nursing (DON) on 04/10/19 at 12:15 p.m., after review of the admission MDS with ARD of 03/01/19, she confirmed the MDS was coded in error. She confirmed the answer should have been 9 not 3. She confirmed the admission MDS with ARD of 03/01/19 was inaccurate. | 2020-09-01 |
| 195 | 195 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2019-04-11 | 656 | D | 0 | 1 | M7ZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, resident interview, and staff interview, the facility failed to develop a care plan to include the contact information of a resident's Hospice service provider; and implement care plan interventions related to oxygen therapy, positioning, and skin integrity. This was true for three (3) of fourteen (14) resident care plans reviewed during the annual long-term care survey process. This practice had the potential to affect more than a limited number of residents. Resident identifier: #2, #17, and #1. Facility census: 39. Findings included: a) Resident #2 (R#2) Review of records revealed R#2 was admitted to Hospice services on 07/09/18 and was admitted to the facility on [DATE]. Review of R#2's care plan, on 04/10/19 at 2:54 PM, revealed the Hospice 24-hour contact information was not included in the care plan. An interview, on 04/10/19 at 3:50 PM with the MDS nurse responsible for developing resident care plans, confirmed R#2 care plan was developed without including the Hospice 24-hour contact information. The MDS nurse said the resident already had Hospice services when she came to the facility, and the Hospice 24-hour contact information should have been included when the facility first developed the resident's care plan. The MDS nurse stated she would update the care plan now with the Hospice 24-hour contact information. b) Resident #17 (R#17) Review of the resident's quarterly minimum data set (MDS) with an assessment reference date (ARD) 02/18/19, on 04/10/19 at 09:46 AM, revealed the resident has clear speech, makes them self-understood and understands. The resident's Brief Interview for Mental Status (BIMS) score was twelve (12) indicating the resident is moderately impaired. R#17 did not exhibit any behaviors. The resident is totally dependent with bed mobility, meaning full staff performance every time. The resident needs supervision with eating and is totally dependent with all other activ… | 2020-09-01 |
| 196 | 196 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2019-04-11 | 684 | D | 0 | 1 | M7ZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure Resident #4 received treatment and care with professional standards of practice and the comprehensive person-centered care plan. This was true for one (1) of fourteen (14) residents reviewed. Resident identifier: #4. Facility census: 39. Findings included: a) Resident #4 Review of medical records for Resident #4 found a physician's orders [REDACTED]. oxygen saturation level below 92% (percent) and Check oxygen saturation (SPO2) every shift. Review of the Medication Administration Records (MAR) for 01/01/19 through 04/09/19 found the MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 04/10/19 at 1:15 p.m., found the staff had failed to document the results of the SPO2 % as the physician order [REDACTED]. She confirmed the nurses were not following the physician's orders [REDACTED].> | 2020-09-01 |
| 197 | 197 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2019-04-11 | 842 | D | 0 | 1 | M7ZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record for three (3) of 14 residents reviewed during the long-term care survey process. The facility failed to document wound care on Resident #1's Treatment Administration Record. The facility failed to ensure Resident #27's tube feeding order contained all required elements. The facility failed to ensure Resident #10's [DIAGNOSES REDACTED]. Resident identifiers: #1, #27, #10. Facility census: 39. Findings included: a) Resident #1 Resident #1 had an order for [REDACTED]. Sure Site is a transparent dressing used to protect a wound while it heals. On 04/11/19 at 10:30 AM, Assistant Director of Nursing (ADoN) #23 was observed changing Resident #1's coccyx Sure Site dressing because the dressing was soiled with stool. The Sure Site dressing removed had a date of 04/10/19 on it. Resident #1's Treatment Administration Record did not include the order to change the resident's coccyx dressing every seven (7) days and as needed. Resident #1's progress notes contained notations that the Sure Site dressing was clean, dry, and intact, but did not contain information regarding when the dressing was changed. During an interview on 04/11/19 at 1:01 PM, the Director of Nursing agreed Resident #1's coccyx dressing change was not included on the resident's Treatment Administration Record. She stated the resident's coccyx dressing was changed frequently because the resident was incontinent of stool, soiling the dressing. During an interview on 04/11/19 at 1:56 PM, the Administrator was informed Resident #1's coccyx dressing change was not included on the resident's Treatment Administration Record. She had no further information regarding the matter. No information was provided through the completion of the survey. b) Resident #27 Resident #27 had the following tube feeding order: [MEDICATION NAME] 1.2 Cal Liquid (Nutritional Supplements). Give 240 … | 2020-09-01 |
| 198 | 198 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2019-04-11 | 880 | D | 0 | 1 | M7ZP11 | Based on observation, resident interview, and staff interview , the facility failed to implement an ongoing infection prevention and control program (IPCP) to help prevent, recognize, and control the onset, cross-contamination, and spread of infection to the extent possible. A random observation of two nurse aides tidying a dependent resident's bed revealed a breach in infection control principles when a nurse aide held the used bed linens against her uniform. This practice had the potential to affect more than limited number of residents. Resident identifier: #17. Facility census: 39. Findings included: a) Resident #17 Observations, on 04/10/19 at 5:22 PM, revealed Nurse Aide (NA#25) and Nurse Aide (NA#40) in Resident (R#17)'s room. The resident was lying in the bed, NA #25 was straightening the bed linens, and NA#40 was standing at the left side foot of the resident's bed with her arms full of a large amount of wadded up blankets against the uniform of her upper body. Interview with the nurse aides confirmed the blankets NA#40 was holding had just came off the resident's bed. NA #25 said she was straightening the bed and piled the blankets in NA#40's arms to get them out of her way as she was fixing the bed. Both NA #25 and NA#40 confirmed and acknowledged holding used bed linens against their uniform was a breach in infection control principles they were taught in their nurse aide training. According to the Centers for Medicare & Medicaid Services (CMS) laundry includes resident's personal clothing, linens (i.e. sheets, blankets, pillows), towels . CMS Guidance for handling laundry includes, The facility staff should handle all used laundry as potentially contaminated and use standard precautions. CMS Guidance states one of the practices facilities should use, is; Staff should handle soiled textiles/linens with minimum agitation to avoid the contamination of air, surfaces, and persons. Guidance from CMS also states, The facility practices must include how staff will handle and transport the laundry with approp… | 2020-09-01 |
| 199 | 199 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2017-04-19 | 157 | E | 0 | 1 | HZCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, responsible party interview, and resident interview, the facility failed to notify the responsible party/resident of changes in the residents medications and treatments for three (3) of four (4) residents reviewed for the care area of notification of change during Stage 2 of the Quality Indicator Survey (QIS). This was true for Resident #49, #44 and #8. Resident Identifiers: #49, #44 and #8. Facility Census: 39. Findings Include: a) Resident #49 A review of Resident #49's medical record, at 8:58 a.m. on 04/18/17, found Resident #49 was declared incapacitated by her attending physician on 12/29/16. Also contained in the record was the residents appointment of a Power of Attorney (POA) which was completed on 01/28/11. This POA included medical decision making power. Further review of the record found the following physician orders: --Order dated 01/18/17 for Vitamin D level every 12 months --Order dated 03/24/17 got Physical Therapy five (5) times a week for two (2) weeks --Order dated 03/30/17 for [MEDICATION NAME] 20 milligrams one time a day, KCL 10 meq one time a day, and Basic Metabolic Panel in one week due to pedal [MEDICAL CONDITION] The medical record contained no evidence the POA was notified of these medication/treatment changes. An interview with the Director of Nursing, at 9:57 a.m. on 04/19/17, confirmed the medical record contained no evidence Resident #49's POA was notified of the medication/treatment orders. b) Resident #44. Record review found the resident was admitted to the facility on [DATE]. During Stage 1 of the Quality Indicator Survey (QIS), on 04/17/17 at 12:21 p.m., the resident said she is not included in changes about her medication and care at the facility. She said, They tell my daughter, I guess. They must think I am senile. Review of the resident's most recent annual, minimum data set (MDS) with an assessment reference date (ARD) of 03/13/17, found the resident's brief in… | 2020-09-01 |
| 200 | 200 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2017-04-19 | 242 | D | 0 | 1 | HZCX11 | Based on medical record review, resident interview and staff interview, the facility failed to ensure a resident received his desired two (2) showers per week for two (2) of the most recent six (6) weeks. This was evident for one (1) of four (4) residents reviewed for choices. Resident identifier: #18. Facility census: 39. Findings include: a) Resident #18 During an interview with Resident #18, on 04/17/17 at 11:59 a.m., he said he would prefer to have showers three (3) times per week. He stated his belief that staff is aware of this desire, but too busy to honor his choice for three (3) showers per week. He said he does not always get even two (2) per week. Review of the significant change minimum data set (MDS) with assessment reference date (ARD) of 03/03/17, found his brief interview of mental assessment (BIMS) score was fourteen (14) out of a possible score of fifteen (15). A BIMS score of fourteen (14) indicates intact cognition. According to this assessment, the resident required extensive assistance for personal hygiene, and required physical help in part of the bathing activity. Review of the shower records, on 04/18/17 at 9:56 a.m., found this resident was scheduled for two (2) showers per week, on Tuesdays and Fridays. Further review found that of the past six (6) weeks, were two (2) weeks where he received only one (1) shower per week. There was no evidence found that he had refused showers, or that he was out of the facility those weeks. The week of 03/12/17 through 03/18/17, he received only one (1) shower, on 03/17/17. The week of 03/26/17 through 04/01/17, he received only one (1) shower, on 03/31/17. An interview was conducted with licensed practical nurse (LPN) #40, on 04/18/17 at 10:12 a.m. She said she was unaware this resident wanted three (3) showers per week. She said if a resident requested changes in his shower schedule, she tells the assistant director of nursing (ADON) #76, who would then make changes in the shower schedule. An interview was then conducted with nurse #76 on 04/18/17 at … | 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 );