cms_WV
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11,539 rows
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-02-09 | 600 | D | 1 | 0 | 3JZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review, abuse and neglect policy review, staff interview and local Veterans Administration Medical Center (VAMC) staff interview, the facility failed to provide necessary care and services to Resident #92 in preparation for scheduled appointments outside of the facility, of which the facility was aware of or should have been aware. The facility also failed to provide Resident #92 care and services in the care areas concerning baths and shaving. This was true for one (1) of six (6) sample residents dependent for care. This practice had the potential to affect more than a limited number of residents. Resident identifier: #92. Facility census: 107. Findings include: a) Scheduled appointments outside of the facility Resident #92 is a paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder. He is totally dependent for all care, is legally blind, and newly diagnosed with [REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve can produce numbness, paresthesia (pins and needles), and paralysis of the arms. Records show Resident #92's forearms, wrists, and hands were affected and symptomatic from the C5 compression. Review of medical records from VAMC physician progress notes [REDACTED]. C5 shows chronic cord compression possibly from an old trauma. Review of records on 02/05/18 at 2:55 PM revealed a significant change minimum data set (MDS) with an assessment reference date (ARD) 01/04/18. The resident had impaired vision (legally blind); had clear speech, was able to understand and make himself understood. The MDS revealed a Brief Interview for Mental Status (BIMS) with a score of fifteen (15) indicating the resident was cognitively intact. Resident #92 needed extensive assistance with eating and was dependent for all other activities of daily living (ADL) including bed … | 2020-09-01 |
| 2 | 2 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-02-09 | 656 | D | 1 | 0 | 3JZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and Center (VAMC) staff interviews, the facility did not implement interventions in Resident #92's care plan to meet the resident's preferences and address the resident's medical, physical, mental and psychosocial needs. This pertained to the care area of activities of daily living (ADL), concerning shaving Resident #92 daily. This was true for one (1) of three (3) care plans reviewed for resident's totally dependent for ADL care. This practice had the potential to affect more than a limited number of residents. Resident identifier: Resident #92. Census: 107. Findings include: a) Resident #92 Resident #92 is a legally blind paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder. The resident is incontinent of bowel and has a Foley catheter. He is totally dependent for all care, and was newly diagnosed with [REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve produces numbness, paresthesia (pins and needles), and paralysis of the arms. Records show both Resident #92's forearms, wrist, and hands were affected by and show symptoms of the C5 compression. Review of medical records from VAMC physician progress notes [REDACTED]. C5 shows chronic cord compression possibly from an old trauma. Observations, on 02/05/18 at 11:55 AM., revealed Resident #92 appeared clean, without any body odors, Foley catheter was draining to drainage bag on bedside. The resident was lying in his bed, eyes closed with hair stubble noted on resident's chin. The resident has a special needs call light (Blow call light) to accommodate resident due to paralysis and inability to use hands, and it was within reach of the resident. On 02/06/18 at 9:05 AM, review of grievance and concerns revealed on 09/12/17 the resident complained . he was not being shaven adequately to allow f… | 2020-09-01 |
| 3 | 3 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-02-09 | 657 | D | 1 | 0 | 3JZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility did not revise a care plan to meet the resident's medical, physical, mental and psychosocial needs. Resident #92's care plan was not revised with resident specific interventions to address the resident's newly diagnosed fractured neck. This was true for one (1) of three (3) care plans reviewed. This practice had the potential to affect more than a limited number of residents. Resident identifier: Resident #92. Facility census: 107. Findings include: a) Resident #92 Resident #92 is a legally blind paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder. The resident is incontinent of bowel and has a Foley catheter. He is totally dependent for all care, and was newly diagnosed with [REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve produces numbness, paresthesia (pins and needles), and paralysis of the arms. Records show both Resident #92's forearms, wrist, and hands were affected by and show symptoms of the C5 compression. Interview with the Minimum Data Set Registered Nurse (RN#49), on 02/07/18 at 11:55 AM, revealed the resident was found to have cord compression of his cervical spine and a fracture. RN#49 said this was found after the resident was admitted to the Veterans Administration Medical Center (VAMC), on 12/11/17, due to suddenly having problems with both his arms. RN#49 said the VAMC recommended the cervical collar. When asked where the physician's orders [REDACTED]. RN#49 requested the Coordinator Health Information Management, Staff#73, to try and locate the order. The Coordinator Health Information Management Staff#73, on 01/07/18 at 12:17 PM, agreed there should have been an order for [REDACTED]. Review of Resident#92's care plan with RN#49 revealed there were no resident specific interventions to ad… | 2020-09-01 |
| 4 | 4 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-02-09 | 677 | D | 1 | 0 | 3JZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review, facility staff interview and local Veterans Administration Medical Center (VAMC) staff interview, the facility failed to ensure Resident #92 received the care and services regarding an aspect of his life in the facility which was significant to the resident regarding bathing and shaving, and did not receive proper grooming when going to appointments outside the facility. This was true for one (1) of eleven (11) sample residents. This practice had the potential to affect more than a limited number of residents. Resident identifier: #92. Facility census: 107. Findings include: a) Baths and shaving On 02/06/18 at 9:05 AM, review of grievance and concerns revealed a grievance dated 09/12/17 revealing one of the issues was not being shaven adequately to allow for the use of the diathermy machine to be placed on his face. Resolution to the concerns were completed by 09/ 27/17 with staff being educated, Kardex being updated with the resident's preferences. The KARDEX provides specific instructions for the nursing assistants concerning individualized care to be provided for a resident. Review of Resident #92's Kardex showed it was important for resident to choose between a tub bath, shower, bed bath, or sponge bath, and under skin care it was noted as written ****Shave Resident daily****. Review of care plan, on 02/08/18 at 4:40 PM, revealed under the care area of self-care deficit an intervention to ****Shave Resident daily**** initiated 10/26/17. Resident #92 a legally blind paraplegic, totally dependent for all care, was to receive a shave and bed bath daily. The resident was incontinent of bowel and had a Foley catheter. Review of the ADL (activities of daily living) Record, on 02/07/18 at 4:00 PM, revealed during the month of (MONTH) (YEAR), Resident#92 had a minimum of twenty-five (25) opportunities to receive a bed bath and he only received fifteen (15) according to the ADL Record. There are thirty-one (31) days in … | 2020-09-01 |
| 5 | 5 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-02-09 | 684 | D | 1 | 0 | 3JZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to provide a resident with the necessary care and services to maintain the highest practicable level of well-being for one (1) of three (3) sample resident reviewed for neglect during a complaint investigation. The facility failed to obtain a physician's orders [REDACTED].#92, after being diagnosed with [REDACTED]. Resident identifier: #92. Facility census: 107. Findings include: a) Resident #92 On 02/05/18 at 12:48 PM, review of records revealed Resident #92, a legally blind paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder, totally dependent for all care, was admitted to the Veterans Administration Medical Center (VAMC) on 12/11/17 due to complaints of numbness of his arms, inability to raise his arms, and nausea. Resident returned to the facility on [DATE] with a new [DIAGNOSES REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve can produce numbness, paresthesia (pins and needles), and paralysis of the arms. Records show Resident #92's forearms, wrists, and hands were affected and symptomatic from the C5 compression. Review of medical records from VAMC physician progress notes [REDACTED]. C5 shows chronic cord compression possibly from an old trauma. Review of VAMC physician progress notes [REDACTED]. Resident#92 returned to the facility and with a soft cervical collar. Interview with the Minimum Data Set Registered Nurse (RN#49), on 02/07/18 at 11:55 AM, revealed the resident was found to have cord compression of his cervical spine and a fracture. RN#49 said this was found after the resident was admitted to the Veterans Administration Medical Center (VAMC), on 12/11/17, due to suddenly having problems with both his arms. RN#49 said the VAMC recommended the soft cervical collar. When asked where the physicia… | 2020-09-01 |
| 6 | 6 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 164 | D | 0 | 1 | ELSQ11 | Based on random observation and staff interview the facility failed to ensure the personal privacy and confidentiality of a resident's medication records. Resident identifier: #82. Facility census: 116. Findings include: a) Resident #82 On 05/18/17 at 6:30 a.m., Licensed Practical Nurse (LPN) #55 left Resident #82's medication record open in a way the information could be read by a person other than the nurse passing the medications. The LPN entered the resident's room and returned to the cart on at least two (2) occasions and continued to leave the medication information exposed. At 6:33 a.m. on 05/18/17, LPN #55 agreed the information was exposed. | 2020-09-01 |
| 7 | 7 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 241 | E | 0 | 1 | ELSQ11 | Based on observation and staff interview, the facility failed to maintain residents' dignity during the dining experience for seven (7) of twenty-seven (27) residents in the main dining room. A random observation revealed obviously soiled linens were not changed in a timely fashion for Resident #25. Facility census: 116. Resident identifiers: Resident #25, #124, #77, #71, #21, #49, #192 and #68. Findings include: a) Resident #25 During a random observation on 05/17/17 at 6:20 a.m., Nurse Aide (NA) #36 placed a sheet over Resident #25's blanket. Observation revealed a brown stain covering an area of approximately two feet by two feet (2 ft x 2 ft). The nurse aide looked at the area and verbalized, Oh, Lord. Another observation at 9:20 a.m., revealed Resident #25 sitting at the bedside eating his breakfast. The stained blanket was again visible from the doorway. Upon request, the Center Nurse Executive (CNE) completed an observation and interview. Resident #25, interviewed at 9:22 a.m., said he was sitting at his bedside the night before and had spilled his coffee, making a big mess. The resident said the accident occurred about 10:00 p.m. on 05/16/16. At 9:24 a.m., the CNE acknowledged the blanket should have been changed at the time of the spill, and as the resident sat at the bedside for breakfast, staff had additional opportunity to change the blanket. b) Residents #124, #77, #71, #21, #49, #192, and #68. A dining observation on 05/16/17 from 11:10 a.m. and 12:45 p.m., revealed Residents #124, #77, and #21 sat in the dining room and did not converse with other residents or staff during the pre-meal interim or during mealtime. Staff asked residents meal preferences, but did not converse in a social manner. Resident #71, sat at a table alone. She verbalized she had no friends, and felt lonely. At another table, Resident #21 did not have a tablemate. She looked around the room at other residents, but neither staff nor residents spoke to her throughout the course of the dining experience. Resident #77 and #125 requ… | 2020-09-01 |
| 8 | 8 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 253 | E | 1 | 1 | ELSQ11 | > Based on observation and staff interview, the facility failed to provide housekeeping and/or maintenance services necessary to maintain a comfortable and sanitary interior. This was evident for fifteen (15) of thirty-four (34) rooms observed during Stage I of the Quality Indicator Survey. Cosmetic imperfections or items in need of repair and/or cleaning in resident rooms included discolorations of the toilet bowl jets, debris noted on the floor for prolonged period of time, window sills and/or window blinds dirty/dusty in need of cleaning, a sliding curtain type bathroom door with a black-colored substance on the bottom portion, caulk missing around a toilet base, veneer missing from a bathroom door with the wood or particle board beneath it visible, cove base pulled away from the wall in a bathroom, the inside of a wall heating unit had a dirty vent with loose debris, and a piece of wallpaper not adhered to a wall. Affected rooms included room #101, #102, #103, #104, #105, #106, #111, #118, #126, #128, #129, #134, #141, #142, and #163. Facility census: 116. Findings include: a) Stage I findings During Stage I of the Quality Indicator Survey on 05/15/17 and on 05/16/17, thirty-four (34) resident rooms were observed. Of that number, fifteen (15) rooms were found with concerns related to maintenance and/or housekeeping issues. The identified rooms were toured with Housekeeping Manager (HM) #83 on 05/17/17 between 3:00 p.m. and 3:30 p.m., and with Maintenance Supervisor (MS) #88 between 3:30 p.m. and 3:45 p.m. Identified concerns were: - Room 101 The water jets in the toilet looked dirty. During a tour on 05/17/17, HM #83 said they had been using a type of acid-base cleanser to try to remove the discoloration as other products have not worked as well. A small piece of tissue lay on the floor at the head of the bed next to the window. Beneath that bed was what looked like a broken piece of hard, white colored vinyl. These objects were first observed on the floor on 05/16/17 at 11:14 a.m. On 05/17/17 at approximatel… | 2020-09-01 |
| 9 | 9 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 278 | D | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete an accurate quarterly minimum data set (MDS) assessment to reflect the resident's pain medication regimen. This was true for one (1) of thirty-two (32) residents reviewed. Resident identifier: #100. Facility census: 116. Findings include: a) Resident #100 Review of Resident #100's medical records revealed a physician's orders [REDACTED]. Record review revealed Resident #100 continued to receive this medication through the month of (MONTH) (YEAR). Review of a quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 05/05/17, revealed Resident #100 did not receive scheduled pain medication. On 06/01/17 at 5:46 p.m., the MDS coordinator, Registered Nurse (RN) #108, agreed the quarterly MDS with an ARD of 05/05/17 should have been coded to identify Resident #100 received scheduled pain medication. | 2020-09-01 |
| 10 | 10 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 279 | E | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, and family interview, the facility failed to develop a care plan for a resident with bruises and a skin tear (#92), failed to establish measurable objectives to monitor a resident's progress related to activities (#143) and range of motion (ROM) (#43), and failed to develop a care plan timely related to assessing a thrill and bruit for a resident with an arteriovenous graft (#45). Four (4) of thirty-two (32) residents on the sample were affected. Facility census: 116. Resident identifiers: #143, #92, #45, and #43. Findings include: a) Resident #143 The resident's medical record included a Brief Interview for Mental Status (BIMS) on which the resident scored ten (10), indicating moderate cognitive impairment. During a Stage 1 interview on 05/16/17 at 2:12 p.m., a family member verbalized Resident #143 liked to attend Church services. Resident #143, interviewed on 05/31/17 at 1:56 a.m., exhibited symptoms of confusion related to time, but with inquiry, verbalized she liked to go to church and wanted to go every Sunday. The resident expressed she did not care what denomination it was, just Christian. The care plan noted Resident #143 would indicate satisfaction in daily routine/activities as evidenced by verbalizing satisfaction, increase in affect during participation, increased focus and attention to activities of choice. The interventions included to assist, as needed, to activities of interest church, parties, socials, crafts, pets, music, and reading. During review of the resident's care plan with the administrator on 05/31/17 at 6:12 p.m., when asked how the facility measured increased affect, focus and attention, the administrator acknowledged the goal was not measurable, shook her head in a yes motion, and said, I get you. b) Resident #92 An observation on 5/16/17 at 1:08 p.m., revealed bluish red bruised from Resident #92's hand to upper arm. A bandage was present on t… | 2020-09-01 |
| 11 | 11 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 280 | D | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to review and/or revise care plans timely related to an arteriovenous (AV) graft (#159), restorative ambulation (#141), and an actual falls (#115). This practice affected three (3) of thirty-two (32) Stage 2 residents. Facility census: 116. Resident identifiers: #159, #141, and #115. Findings include: a) Resident #159 Medical record review revealed a physician's orders [REDACTED]. Upon inquiry, Health Information Management Coordinator (HIMC) #50, interviewed on 05/30/17 at 4:03 p.m., provided information noting the AV graft had been placed when the resident went to the hospital on [DATE] and returned to the facility on [DATE]. Further review of the medical record revealed the resident had discharge on 03/11/17 and re-entered the facility on 03/13/17. The care plan was not revised until after completion of the resident's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 04/11/17. The care plan noted a revision date of 04/17/17 to reflect Resident #159 had an arteriovenous graft. MDS Coordinator #108, interviewed on 05/24/17, verbalized it was the nursing staff's responsibility to update and/or revise the care plan with a change in condition. b) Resident #141 During a Stage 1 interview on 05/16/17 at 2:57 p.m., Resident #141 verbalized he was supposed to receive restorative therapy for ambulation, but had not received it for three (3) weeks. The resident voiced a concern that he lost strength and endurance when he did not walk with restorative. Medical record review revealed a current care plan with a goal to walk 150 feet two (2) times a day, six (6) days a week, initiated on 04/28/17. The intervention, dated 09/22/16, indicated Resident #141 would ambulate 200 feet twice a day, six (6) days a week. During an interview on 05/24/17 at 2:36 p.m., Nurse Aide (NA) #23 reviewed the restorative records and said Resident #141 walked… | 2020-09-01 |
| 12 | 12 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 282 | E | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, visitor/family interview, staff interview, observation, and policy review, the facility failed to ensure services were provided according to the resident's written plan of care for five (5) of thirty-two (32) Stage 2 residents. Residents #27 and #141 did not receive planned restorative services. Resident #143 did not participate in activities as identied on her care plan. Resident #163 did not receive treatments in accordance with the plan of care, and Resident #124 did not receive foods in accordance with her plan of care. Facility census: 116. Resident identifiers: Resident #27, #143, #141, #163 and #124. Findings include: a) Resident #27 A medical record review related to accidents revealed a physician's orders [REDACTED].#27 required limited assistance of one (1) person for ambulation, and utilized a walker and/or wheelchair. The assessment noted the resident was not steady, but able to stabilize without staff assistance. [DIAGNOSES REDACTED]. Further review of the medical record revealed a physician's orders [REDACTED]. - nursing to assist resident to ambulate 80 feet two (2) times a day with roll walker and gait belt using CGA (contact guard assist) six (6) days a week. Re-evaluate in 90 days and as needed. -Restorative nursing to assist with bilateral lower extremity (BLE) exercises using two pound (2 lb) weight-hip flexion, knee extension three (3) sets times ten (10) repetitions daily six (6) days a week. Re-evaluate in 90 days and as needed. The care plan indicated Resident #27 was at risk for falls and risk for bleeding related to anticoagulant therapy. It noted the resident demonstrated a deficit in ambulation related to (r/t) functional deterioration resolved on 04/01/17 and revised on 04/20/17. During an observation and interview with Resident #27 on 05/31/17 at 4:32 p.m., the resident voiced she stayed in her room most of the time, but walked to the bathroom. Upon inquiry, the visitor said she was a… | 2020-09-01 |
| 13 | 13 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 309 | E | 1 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, medical record review, observation, and policy review, the facility failed to ensure eight (8) of thirty-two (32) Stage 2 residents received care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being. The facility did not assess and monitor a resident's pain, did not ensure implementation of physician's orders [REDACTED].#163). Staff failed to properly position residents during meals and/or in bed (#76 and #101), did not ensure monitoring of residents receiving [MEDICAL TREATMENT] (#159 and #45), did not obtain neuro checks after a fall (#59), and did not follow physician's orders [REDACTED].#59). For Resident #100, the facility failed to monitor the resident's [MEDICATION NAME] as ordered and failed to provide physician ordered foods to Resident #124. Additionally, the facility failed to follow orders for restorative ambulation for and assessment of a pulse rate prior to administration of a medication. Additionally, the facility failed to follow physician's orders [REDACTED].#101, #104, #105, #107, #112, #116, #121, #124, #125, #150, #153, #16, #160, #187, #192, #195, #2, #20, #21, #26, #31, #37, #4, #45, #47, #49, #5, #59, #61, #64, #7, #76, #82, and #141). Facility census: 116. Findings include: a) Resident #163 1. Medical record review revealed a physician's orders [REDACTED]. Another order noted to cleanse an unstageable wound to the right second toe with wound cleanser and apply sure prep daily. Observation of wound care on 05/18/17 at 10:21 a.m., with Licensed Practical Nurse (LPN) #72, revealed the Stage 2 pressure ulcer present on the Resident #163's coccyx. When asked whether the unit charge nurses completed treatments, the LPN said she completed the treatments for the entire facility. The medical record and treatment administration records, reviewed for (MONTH) and (MONTH) (YEAR), revealed no evidence the treatment for [REDACTED]. No … | 2020-09-01 |
| 14 | 14 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 312 | D | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to provide necessary services to maintain good grooming for two (2) of thirty-two (32) sampled residents. Resident #117 had unshaven facial hair. Resident #76 had long unkempt hair, was unshaven, and wore the same clothing on successive days. Resident identifiers: #117 and #76. Facility census: 116. Findings include: a) Resident #117 Observation on 05/16/17 at 2:16 p.m. found this [AGE] year old resident had numerous long white hairs on her chin and lower jaw area. On 05/23/17, review of the most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) 04/13/17, found her Brief Interview for Mental Status (BIMS) score was three (3), indicating severe cognitive impairment. She required limited assistance with personal hygiene. Review of the resident's care plan found a focus statement identifying she was at risk for decreased ability to perform activities of daily living (ADL) functions due to generalized weakness, fluctuation in cognition/dementia with behaviors, and multiple other disease processes. Interventions included to provide assistance as needed, as the ADLs might fluctuate. Observation on 05/23/17 at 12:45 p.m. found she still had long white hairs on her chin and lower jaw area. When asked about the resident's chin whiskers, Nurse Aide (NA) #59 replied that just this morning he commented that the resident's beard was longer than his. He said he would shave her right away, and he did. During an interview on 05/23/17 at 4:20 p.m., the administrator said this resident's ADL abilities fluctuated due to her behaviors and dementia. No further information was provided about the resident's facial hair. b) Resident #76 A Stage 1 observation on 05/15/17 at 1:47 p.m., revealed Resident #76 was unshaven, and his hair was long, uncombed and unclean. Another observation on 05/16/17 at 8:30 a.m., revealed his beard grow… | 2020-09-01 |
| 15 | 15 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 315 | D | 0 | 1 | ELSQ11 | Based on a random observation and staff interview, the facility failed to provide care in a manner to prevent urinary tract infections. A staff member placed washcloths in the bathroom sink basin in preparation for incontinence care, creating a potential for introducing potential pathogens into the resident's urinary tract. This practice affected one (1) resident for whom incontinence care was observed. Facility census: 116. Resident identifier: #163. Findings include: a) Resident #163 During a wound care observation on 05/18/17 at 10:21 a.m., Licensed Practical Nurse unfastened the resident's brief revealing the resident had had an incontinence episode. Nurse Aide (NA) #102 obtained a stack of washcloths, placed them in the bathroom sink basin, and turned on the water. The NA wrung the washcloths and laid them on the left side of the sink near the faucet handle. NA #102 dried her hands, picked up the washcloths and gave them to Licensed Practical Nurse (LPN) #72 who utilized them to perform peri-care. | 2020-09-01 |
| 16 | 16 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 318 | D | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure one (1) of three (3) residents reviewed for range of motion received services to help prevent further decline. Resident #43 had contractures of the right hand, wrist, elbow, and shoulder, but had no range of motion or orthotics ordered to help prevent further decline or other negative outcomes. Resident identifier: #43. Facility census: 116. Findings include: a) Resident #43 Review of the resident's medical record on [DATE] found the resident's [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of [DATE], found she came to the facility with contractures of the right hand, wrist, elbow, and shoulder. Review of the most recent comprehensive assessment with an ARD of [DATE], found she was assessed with [REDACTED]. The facility assessed her as having received no therapy services, no restorative nursing services, and no hand or wrist splint/orthotic device during the look back period. Her Brief Interview for Mental Status (BIMS) score was eleven (11), indicating moderately impaired cognitive functioning. On [DATE] at 4:45 p.m., the administrator provided a copy of the resident's current care plan. Review of the care plan found a focus statement related to the right side extremities being weaker than the left, and contractures of the right shoulder, elbow, wrist, and hand. However, there was no goal related to what the facility hoped to achieve related to contracture maintenance, and no interventions on how the facility planned to ensure no worsening of the contractures, or no negative outcomes related to the contractures. During an interview on [DATE] at 4:01 p.m., Director of Rehabilitation Services #52 said this resident first began therapy services [DATE] through [DATE]. Their old record keeping was done on paper and they had transferred to electronic documentation sometime in (YEAR). She revi… | 2020-09-01 |
| 17 | 17 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 329 | D | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident remained free of unnecessary drugs. The physician ordered a reduction of Resident #9's [MEDICATION NAME] more than two (2) months after the pharmacist recommended the reduction. Two (2) days after the ordered reduction, the medication was increased without any evidence the increase was needed. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #9. Facility census: 116. Findings include: a) Resident #9 Review of a pharmacist's consultation report with a date of 02/09/17 revealed a recommendation to the physician to re-evaluate the continued use of [MEDICATION NAME] at the current dose of 0.5 mg (milligrams) at bedtime. The physician responded to this recommendation on 04/13/17, which was sixty-four (64) day after the initial recommendation. On 04/13/17 the physician ordered a reduction to 0.25 mg at bedtime for one (1) week and then discontinue the [MEDICATION NAME]. On 04/15/17 the physician discontinued [MEDICATION NAME] 0.25 mg at bedtime and restarted [MEDICATION NAME] 0.5 mg at bedtime. Review of the behavioral flow sheet for (MONTH) of (YEAR) did not reveal behaviors related to anxiety. Review of nursing notes between 04/13/17 and 04/15/17 did not reveal documentation of the resident experiencing anxiety. On 05/31/17 at 1:36 p.m., the director of nursing (DON) agreed the records did not reveal any indication of a need for increasing the [MEDICATION NAME]. | 2020-09-01 |
| 18 | 18 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 353 | E | 1 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, visitor interview, staff interview, medical record review, observation, and policy review, the facility failed to ensure sufficient staff to implement resident care plans and respond to residents' needs for thirty-four (34) of thirty-four (34) residents reviewed for restorative services (#101, #104, #105, #107, #112, #116, #121, #124, #125, #150, #153, #16, #160, #187, #192, #195, #2, #20, #21, #26, #31, #37, #4, #45, #47, #49, #5, #59, #61, #64, #7, #76, #82, and #141) and twelve (12) residents (#93, #125, #34, #43, #103, #126, #41, #121, #22, 104, 189, and #93) observed during the dining experience. Facility census: 116. Findings include: a) Resident #76 Medical record review found a minimum data set (MDS) with an assessment reference date (ARD) of 05/09/17 that identified Resident #76 required the extensive assistance of one (1) person for bed mobility. The MDS indicated the resident had impairment on both sides of his upper and lower extremities. The resident received hospice services for end of life care related to end stage [MEDICAL CONDITIONS]. Nurse Aide (NA) #135, interviewed on 05/23/17, verbalized Resident #76 had gotten weak and now staff did more for him than he did for himself. She said he was not eating at all. Licensed Practical Nurse (LPN) #62 concurred the resident had a recent decline. A Stage 1 observation on 05/15/17 at 2:14 p.m. found Resident #76 leaning to the right side without support to maintain an upright position. On 05/23/17 at 9:12 a.m., the resident was in bed lying on his back with the head of the bed elevated to about 45 degrees. The resident had slid down in bed. At 2:44 p.m., an observation revealed Resident #76 slid down in bed and was eating lunch. An unidentified NA was feeding the roommate and his brother and sister-in-law were standing at the bedside. Licensed Practical Nurse (LPN) #62 observed the resident and confirmed he was not positioned correctly and needed pulled u… | 2020-09-01 |
| 19 | 19 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 362 | E | 0 | 1 | ELSQ11 | Based on observation, staff interview, resident interview, and review of the dining schedule, the facility failed to ensure sufficient staffing to prepare and serve food in the scheduled timeframes. This practice affected twelve (12) residents served in their rooms during lunch dining. Facility census: 116. Resident identifiers: Residents #93, #125, #34, #43, #41, #121, #22 #104, #189, and #63 Findings include: a) Residents #93, #125, #34, #43, #41, #121, and #22 The dining schedule indicated lunch meals were served to areas as follows: -- fine dining 11:25 a.m. -- rehab (restorative) 11:30 a.m. -- south hall 12:10 p.m. -- south hall 12:15 p.m. -- east hall 12:20 p.m. -- east hall 12:30 p.m. -- north hall 12:35 p.m. -- north hall 12:40 b) During a random observation on 06/01/2017 12:50 p.m., a staff member announced by the overhead page Lunch is now being served on east hall. Within a few minutes the food cart was delivered and parked by the entrance near the main dining room. The time was 30 minutes later than noted on the schedule for the first cart. The dining schedule indicated the trays shoud have been served at 12:20 p.m. Observation revealed no resident on the hallway had a meal tray. c) At 12:55 p.m. on 06/01/17, observation of the South Hall revealed staff passing trays from the food cart on the hallway. The dining schedule indicated the floor trays were served at 12:10 p.m. NA#34 was heard informing Residents #93 and #125 they would be helped soon. Upon inquiry, the NA said ten (10) residents required assistance with meals and two (2) nurse aides passing trays. The dining schedule indicated the meal trays would be served at 12:10 p.m. - At 12:58 p.m., NA #2 passed a tray to Resident #34 and began to feed her. - At 12:58 p.m., Registered Nurse (RN) #126 and the interim CNE said they would assist. The CNE passed a tray to Resident #93 and fed her. - At 1:02 p.m., RN #126 passed a tray to Resident #125 - At 1:07 p.m., RN #108 passed a tray to Resident #121 - At 1:10 p.m., Resident #41 was asleep, her meal … | 2020-09-01 |
| 20 | 20 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 428 | D | 0 | 1 | ELSQ11 | Based on record review and staff interview, the facility failed to act upon a pharmacist's recommendation in a timely manner. This was true for two (2) of five (5) residents reviewed for unnecessary medications. The physician did not respond to a pharmacist's recommendation for Resident #9 for over two (2) months. For Resident #45, the resident continued to receive the medication Reglan nearly three (3) months after it should have been discontinued. Resident identifiers: #9 and #45. Facility census: 116. Findings include: a) Resident #9 Review of a pharmacist's consultation report dated 02/09/17 revealed a recommendation to the physician to re-evaluate the continued use of Clonazepam (a psychoactive medication) at the current dose of 0.5 mg (milligrams) at bedtime. The physician responded to this recommendation on 04/13/17, which was 64 days from the initial recommendation. On 05/31/17 at 1:36 p.m., the director of nursing (DON) agreed the physician's response to the pharmacist's recommendation was not timely. b) Resident #45 A pharmacist review dated 02/09/17 identified Resident #45 received Reglan 5 mg every 8 hours and was also taking Protonix 40 mg daily with both medications being for gastroesophageal reflux disease (GERD). The pharmacist's recommendation was to consider tapering the Reglan while continuing the Protonix. The physician accepted the recommendation with a modification of discontinuing the Reglan on 02/25/17. Review of the Medication Administration Record [REDACTED]. On 05/31/17 at 1:36 p.m., the DON agreed the resident continued to receive Reglan after the physician noted to discontinue the medication on 02/25/17. | 2020-09-01 |
| 21 | 21 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 431 | E | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the Centers for Disease Control (CDC) and Prevention guidelines, and review of manufacturer's guidelines, the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. A multi-dose vial of Purified Protein Derivative (PPD - a test to aid in the detection or [DIAGNOSES REDACTED]. This had the potential to negatively impact the safety and/or potency of the medication, and had the potential to affect any resident who might receive an injection from this vial. One (1) of two (2) medication storage room refrigerators contained a vial of PPD serum that was not labeled when initially opened. Facility census: 116. Findings include: a) East wing medication room refrigerator Observation of the East wing medication room refrigerator on 05/17/17 at 7:56 a.m., accompanied by Licensed Nurse (LN) #55, found an opened, partially used vial of Purified Protein Derivative (PPD) serum which contained no date indicating when it had first been opened. When full, the vial contained enough serum for ten (10) tests. The nurse said the vial should have been dated when it was first opened, so that staff could determine how long the vial had been in use. She said they should discard all opened vials of PPD after they were opened for thirty (30) days. She immediately discarded the opened vial of PPD. During an interview with the director of nursing on 05/17/17 at 5:00 p.m. she said the nurse informed her of the opened undated vial of PPD. She said their policy directed that all multi dose vials be dated initially when opened, and discarded in accordance with the manufacturer's guideline. The Centers for Disease Control and Prevention (CDC) guidelines include, If a multi-dose vial has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within twenty-eight (28) days unless the manufacturer specifies a different (shorter or longer) date for … | 2020-09-01 |
| 22 | 22 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 441 | E | 0 | 1 | ELSQ11 | Based on observations, staff interview, and policy review, the facility failed to maintain an effective infection control program to prevent the transmission of disease and infection to the extent possible. Staff failed to utilize proper hand hygiene, failed to utilize personal protective equipment (PPE) when required and/or dispose of PPE properly, and failed to handle medication properly. These practices affected nine (9) of the one hundred sixteen (116) residing in the facility and had the potential to affect additional residents. Facility census: 116. Resident identifiers: #25, #189, #127, #76, #104, #42, #31, #163, and #158. Findings include: a) Residents #25, #189, #127, #76, #104, and #42 During a lunch meal observation, Nurse Aide (NA) #75 touched items in the room of Resident #25, returned to the cart, poured a cup of coffee and placed it on top of the cart. The NA entered the room of Resident #189 who was in contact isolation for clostridium difficile (a highly contagious organism). The NA did not don personal protective equipment (PPE) prior to entering the room. Upon completion of the tray set-up, NA #75 washed her hands for a count of eight (8) seconds. The NA exited the room and poured coffee for Resident #68. Without performing hand hygiene, the NA passed trays to Resident #76 and assisted NA #135 with Resident #104. Upon completion, the NA washed her hands for a count of seven (7) seconds, then passed a tray to Resident #42. b) Resident #25 On 05/17/17 at 6:20 a.m., Nurse Aide (NA) #36 performed care for Resident #25. Upon completion, the NA bagged soiled items. With the same gloves the NA pulled up the resident's covers, picked up the bed remote from the floor and attached the call bell to the bed cover. c) Resident #163 During a wound care observation on 05/18/17 at 10:21 a.m., Nurse Aide (NA) #102 assisted Licensed Practical Nurse (LPN) #72 with wound care. The resident held Resident #163's hands. When the nurse unfastened the resident's brief, she found the resident had an incontinence episode… | 2020-09-01 |
| 23 | 23 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 514 | E | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to maintain complete and accurate medical records. For Resident #190, neurological assessments were incomplete. For Resident #163, documentation regarding treatments, response to pain medication, and a voiding diary were incomplete. For Resident #159, [MEDICAL TREATMENT] communication sheets and activities of daily living (ADLs) date were incomplete. ADL sheets were incomplete for Resident #76 and meal/snack percentages were not documented for Resident #143. This was true for five (5) of thirty-two (32) records reviewed. Resident identifiers: #190, #163, #159, #76, and #143. Facility census: 116. Findings include: a) Resident #190 Review of the resident's medical record on 05/30/17 found he sustained an unwitnessed fall in his room on 04/10/17 at 5:05 p.m. As a result of the fall, he incurred an abrasion and a skin tear to the back of his left arm between his elbow and shoulder. The facility initiated a neurological assessment flow sheet right away. On 04/11/17 at 4:30 p.m. and at 8:30 p.m., the flow sheet was silent for neurological assessments, vital signs, observations, or staff signatures. The assessment resumed on 04/12/17 at 12:30 a.m. On 05/30/2017 at 4:04 p.m., after reviewing the neurological assessment flow sheet, the director of nursing (DON) agreed there was incomplete documentation on 04/11/17 at 4:30 p.m. and at 8:30 p.m. with no documented refusals, and noted the night shift picked it back up as did the day shift, with no abnormalities noted. b) Resident #163 1. Review of the resident's medical record and treatment administration records for (MONTH) and (MONTH) (YEAR), found no evidence the treatment for [REDACTED]. No evidence was present to indicate the Stage 2 coccyx wound treatment was completed for seven (7) of forty (40) opportunities, on seven o'clock in the morning until three o'clock in the afternoon (7:00 a.m. - 3:00 p.m.) shift on the dates 05/14/17, 05… | 2020-09-01 |
| 24 | 24 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 558 | D | 0 | 1 | 8Y4111 | Based on observation, resident interview and staff interview, the facility failed to provide appropriate accommodation of needs regarding storage and accessibility of Resident #23's personal items. This was evident for one (1) randomly observed resident. Resident identifier: #23. Facility census: 111. Findings included: a) Resident #23 During initial screening process on 06/02/19 at 2:30 PM, Resident #23's dresser drawer was found to be in disrepair and not functionable. The front of the middle wooden dresser drawer was observed to be busted out, loosely hanging off the base of the drawer only to be attached by one nail in the left-hand corner. The broken drawer was hanging in such a way that it also blocked access to the bottom dresser drawer. On 06/02/19 at 2:33 PM, Resident #23 stated that she could not access her personal items in the middle or bottom dresser drawers due to the front of the middle drawer falling apart and hanging in the way. Resident stated, I told maintenance a while back, and he said he would have to go to into town and get some wood glue to fix the drawer, but he has never come back to fix it. The Resident also stated she had not been able to fully utilize her dresser for quite some time due to the broken dresser drawer. At 9:05 AM on 06/05/19 during an interview, the Administrator agreed the Resident's dresser drawer was in disrepair and inaccessible to Resident, and it needed repaired immediately. The facility's Administrator stated, I will get with our maintenance guy and have him get what ever supplies he will need to fix it today. | 2020-09-01 |
| 25 | 25 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 580 | D | 0 | 1 | 8Y4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview and policy review, the facility failed to promptly notify the physician when a resident experienced a change in condition. This was true of one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory). Resident (R#33) refused physician ordered wound dressing for multiple days without the physician being notified. This practice had the potential to effeect a limited number of residents. Resident identifier: R#33. Facility census: 111. Findings included: During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound drainage and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Pertinent [DIAGNOSES REDACTED]. The resident was admitted to the facility after having incision and drainage (I&D) of abscesses, which developed after having lower-back spinal surgery and after having a cholecystectomy. A cholecystectomy is the surgical procedure to remove a gallbladder. After gallbladder surgery the resident had a drainage tube at the surgical site, on his right upper abdomen, to prevent the build-up of bile, blood, and/or infection. The resident developed an abscess on his right side and another incision and drainage procedure was performed and a drainage tube was again placed to facilitate healing. On 04/04/19, after the drainage tube was removed a new order was given to clean surgical incision to right side with wound cleanser, pat dry, and apply dry dressing every day. Review of the treatment administration record (TAR) revealed daily wo… | 2020-09-01 |
| 26 | 26 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 584 | D | 0 | 1 | 8Y4111 | . Based on policy review, resident interview, staff interview and record review, the facility failed to ensure the resident has a right to a safe, clean, comfortable and homelike environment. Through a random opportunity for discovery, it was found Resident #23 had a busted up air conditioning unit that was in disrepair. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #23. Facility census: 111. Findings included: a) Resident #23 During initial screening process on 06/02/19 at 2:30 PM, Resident #23's dresser and HVAC (centralized heating ventilation and air conditioning system) unit in her room were found to be in disrepair and maintained in an unsafe manner. The front of the middle wooden dresser drawer was observed to be busted out, loosely hanging off the base of the drawer only to be attached by one nail in the left-hand corner. The Resident's HVAC unit in her room was found to be in poor condition with the plastic framing that enclosed the heating busted in several places, along the top and sides. The HVAC unit was loose and had came unattached from the right-hand side of the heating unit sliding down over the temperature control knob, causing the temperature control knob to be very difficult to turn. On 06/02/19 at 2:33 PM, Resident #23 stated that she could not access her dresser drawers due to the front of the middle drawer falling apart. Resident stated, I told maintenance a while back, and he said he would have to go to into town and get some wood glue to fix the drawer, but he has never come back to fix it. The Resident also stated she had not been able to fully utilize her dresser for quite some time due to the broken dresser drawer, and she was unable to adjust the heat on the HVAC unit due to the broken plastic frame, so she just left it on one setting (high heat) and had gotten used to hot temperature. At 9:05 AM on 06/05/19 during an interview, the Administrator agreed the Resident's dresser drawer was in disrepair and inaccessible to Resident, … | 2020-09-01 |
| 27 | 27 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 585 | D | 0 | 1 | 8Y4111 | Based on policy review, Resident interview, staff interview and record review the facility failed to make prompt efforts by the facility to resolve grievances the resident may have. This was true for two (2) of four (4) reviewed in the care area of personal property. Identified Resident's #115 and #82. The facility census was111. Findings included: a) Facility policy Facility Grievance/Concern Policy with a revision date of 03/01/18 stated: --The purpose for grievance /concern reporting is ensure that any patient/patient representative has the right to express a grievance/concern without fear of restraint, interference, coercion, discrimination, or reprisal in any form. --To assure prompt receipt and resolution of the grievance/concern. --Notify the person filling the grievance/concern of resolution within 72 hours. b) Resident #115 During an interview on 06/04/19 at 12:51 PM, Resident #115 stated, that while at the hospital her TV and google home was reported to be missing when she returned, but nothing has been done about it. A review of the Grievance/Concerns reports revealed that there was not a form filled out about the missing items. During an interview on 06/06/19 at 11:30 AM, Administrator was asked about a Grievance/Concern report on this missing TV and Google home. He stated that an employee that is no longer here spoke to Resident # 115, about her missing items, but for whatever reason there was not a form completed. During an interview on 06/10/19 at 9:11 AM, Administrator provided a completed Grievance/ Concern form, dated 06/06/19, he stated that he did look for Resident # 115 missing items and they could not be located. He stated, that the facility will have to replace them. b) Resident #82 During an interview on 06/03/19 at 1:45 PM, Resident #82 stated, that her red satin [NAME]et with a white strip has been missing for a while and that she did tell the Administrator, but nothing has been done. She went on to say, that some of the staff said, that they have looked for it, but all they did was put … | 2020-09-01 |
| 28 | 28 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 656 | D | 0 | 1 | 8Y4111 | Based on observation record review and staff interview, the facility failed to develop a care plan for discharge planning. This was true for one (1) of one (1) reviewed in for the care area of discharge planning. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #117. Facility Census: 111. Findings included: b) Resident #117 A review of the medical record on 06/05/19 for Resident #117 revealed the comprehensive care plan had not been developed to include discharge planning. In an interview on 06/05/19 at 3:22 PM, Social Services Specialist (SSS) #101 verified the care plan for Resident #117 was not developed to include discharge planning. | 2020-09-01 |
| 29 | 29 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 657 | D | 0 | 1 | 8Y4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise a care plan related to refusal of care and non-compliance. This was true of one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory). This practice had the potential to effect more than a limited number. Resident identifier: #33. Facility census: 111. Findings include: a) Resident #33 During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound draining and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Pertinent [DIAGNOSES REDACTED]. The resident was admitted to the facility after having incision and drainage (I&D) of abscesses, which developed after having lower-back spinal surgery and after having a cholecystectomy. A cholecystectomy is the surgical procedure to remove a gallbladder. After gallbladder surgery the resident had a drainage tube at the surgical site, on his right upper abdomen, to prevent the build-up of bile, blood, and/or infection. The resident developed an abscess on his right side and another incision and drainage procedure was performed and a drainage tube was again placed to facilitate healing. On 04/04/19, after the drainage tube was removed a new order was given to clean surgical incision to right side with wound cleanser, pat dry, and apply dry dressing every day. Review of the treatment administration record (TAR) revealed daily wound care treatment including a dry dressing was ordered and started on 04/04/19 and on 06/05/19 the wound nurse obtained an order to discontinue treatmen… | 2020-09-01 |
| 30 | 30 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 676 | D | 0 | 1 | 8Y4111 | Based on resident interview, staff interview, observation and record review, the facility failed to ensure care and services for the following activities of daily living; Hygiene, bathing, dressing, grooming, and oral care for Resident #33 and #78. This was true for two (2) of two (2) reviewed in the care area of ADLS. Also, the facility failed to provide a communication board for Resident #105. This was true for one (1) of one (1) in the care area of communication. Resident identifiers: #33 and #78. Facility census: 111. Findings included: a) Resident #33 During an interview on 06/03/19 at 10:56 AM, Resident #33 said, that it is hard to get the aides to help him with a shower, they seem to pass him to another aide, and they take a lot of smoke brakes. He stated, that he must give himself a bed bath. When asked how long it had been since his last shower, he stated, that he did not know only that it has been too long. A review of the of the ADL records revealed that Resident #33 is scheduled to get a shower on Wednesdays and Saturdays, and he had no showers or baths for the month of April, and one (1) shower in the month of May. There was 15 days between his last shower until the shower he received on 06/06/19. During an interview on 06/06/19 at 2:35 PM, Unit Manager #61 reviewed the ADL recorded and agreed that Resident #33 did not get his showers as scheduled and she stated, that she had already re-educated three of her staff members. b) Resident #78 During an interview on 06/03/19 at 12:14 PM, Resident #78 complained that it was hard to get a shower, and it had been ever since the one shower has been broken. He stated that the shower had been for down for months. He had below the shoulder length hair that appeared oily. A review of the ADL record revealed Resident #78 was scheduled to have showers on Tuesdays and Fridays. Review of ADL records revealed Resident # 78 in the month of (MONTH) he went 20 days without a shower or bath, and from (MONTH) 24th to (MONTH) the 6th that was 12 days without a shower or bat… | 2020-09-01 |
| 31 | 31 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 684 | D | 0 | 1 | 8Y4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, resident interview, and policy review, the facility failed to ensure and provide needed care and services in accordance with professional standards of practice for two residents reviewed during the annual LTCSP (Long Term Care Survey Process). This was true for one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory) who was not provided education on wound care and infection control. This was true for one (1) of five (5) sample residents reviewed for falls that was not provided neuro checks appropriately after a fall. This practice had the potential to affect a limited number. Resident identifier: R#33 and R#60. Facility census: 111. Findings included: a) R#33 During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound draining and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Some pertinent [DIAGNOSES REDACTED]. The resident was admitted to the facility after having incision and drainage (I&D) of abscesses, which developed after having lower-back spinal surgery and after having a cholecystectomy. A cholecystectomy is the surgical procedure to remove a gallbladder. After gallbladder surgery the resident had a drainage tube at the surgical site, on his right upper abdomen, to prevent the build-up of bile, blood, and/or infection. The resident developed an abscess on his right side and another incision and drainage procedure was performed and a drainage tube was again placed to facilitate healing. On 04/04/19, after the drainag… | 2020-09-01 |
| 32 | 32 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 689 | D | 0 | 1 | 8Y4111 | Based on observation, staff interview, and Policy review the facility failed to ensure an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This was a random opportunity for discovery with the potential to affect a limited number of residents. Resident identifier: #53. Facility census 111. Findings included: a) Resident #53 1. Policy review Facility Waste Management policy directed personnel to: --Discard contaminated sharps immediately be disposed in a sharp's container. --Not discard sharps in routine trash. 2. Observation During an interview on 06/04/19 at 9:40 AM, with the Resident #53's roommate, this surveyor observed Resident #53 in her wheelchair at the sink with the water running. Resident #53 then moved herself over to the window. Licensed Practical Nurse (LPN) #85 entered the room and asked if she could turn off the water. She turned off the water and picked up a blue razor from the sink and threw it in the trash can under the sink. Resident #53 wheeled herself to the sink and removed the razor from the trash can. With the razor on her lap she wheeled herself back in front of her window and began the shave her left leg. Upon closer observation it was noted that her left ankle was bleeding. 3. Interviews This surveyor asked a passing employee get a nurse and distracted the resident with conversation. LPN #85 returned to the room and looked at Resident #53's left. LPN #85 left the room to retrieve supplies to treat the cuts to Resident #53's legs. There were seven (7) cuts on her left leg from the razor. On 06/04/19 at 10:00 AM, LPN #85 and Nurse Unit Manager (NUM) #61 returned to the room with supplies to treat the wounds. LPN #85 was asked how it Resident #53 had access to a razor. She said she uses the razor for the hairs on her chin, but she does it for her. Resident # 53 stated, that she does not remember where she got the razor from. During an interview with Administrator… | 2020-09-01 |
| 33 | 33 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 690 | D | 0 | 1 | 8Y4111 | Based on observation, staff interview, and policy review the facility failed to ensure a resident's Foley Catheter drainage tubing was securely anchored. This was true of one (1) of three (3) sample residents reviewed for catheter care. This practice had the potential to effect more than a limited number. Resident identifier: R#68. Facility census: 111. Findings include: Observations of Licensed Practical Nurse (LPN#84) providing catheter care to Resident (R#68), on 06/05/19 at 04:13 PM, revealed the Foley catheter drainage tubing was not secured or anchored in anyway. LPN#84 first provided pressure ulcer wound care to R#68 for three (3) different areas on the resident's buttocks prior to providing catheter care. During the provision of care the resident was assisted to turn multiple times from side to side. The Foley catheter drainage tube was not secured to the resident's leg. Observations, during the repositioning of the resident to expose the areas being cared for, revealed strong tension, pulling, and stretching of the drainage tubing was occurring at times. The Foley catheter drainage tube's taut tension, pulling, and stretching had the potential to cause injury to the resident's urethra and urinary meatus. After LPN#84 stated she was finished doing catheter care, this surveyor asked what method the facility used to secure the Foley catheter drainage tube. LPN#84 then acknowledged the resident did not have an anchor device on and should have, and that she also forgot to anchor and secure the tubing when she did the catheter care. LPN#84 confirmed the catheter drainage tubing was supposed to be secured so it did not pull. Review of the facility's Catheter: Indwelling Urinary - Insertion policy revealed #25 stated Ensure the catheter tubing is secured with catheter tube holder or leg strap. Keep the drainage bag below the level of the patient's bladder and off the floor. | 2020-09-01 |
| 34 | 34 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 695 | D | 0 | 1 | 8Y4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to provide necessary respiratory care and services. This was true for one (1) of two (2) residents reviewed for respiratory services during the investigation phase of the survey process. It was observed R28 was not receiving her oxygen therapy at the prescribed flow rate. Resident identifier: #28. Facility census: 111. Findings included: a) Resident #28 A medical record review for Resident #28 on 06/04/19 revealed a physician's orders [REDACTED]. During an observation on 06/04/19 at 7:56 AM, it was discovered the oxygen concentrator for R28 was administering one and a half (1.5) liters of oxygen via nasal cannula and not the prescribed two (2) liters. Licensed Practical Nurse (LPN) #110 on 06/04/19 at 7:59 AM verified the oxygen concentrator for R28 was set on (1.5) liters and not the prescribed two (2) liters. | 2020-09-01 |
| 35 | 35 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 880 | E | 0 | 1 | 8Y4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and policy review, the facility failed to ensure and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infection to the extent possible. This was true for observations made in the laundry room regarding an inadequate negative air pressure. This was true for one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory) who had an exposed open draining wound. This was true of one (1) of three (3) sample residents reviewed for catheter care where a disposable contaminated wipe was placed back in the package with other uncontaminated disposable wipes. This was true for one (1) of four (4) sample residents reviewed for feeding tubes, who had a soiled feeding tube syringe laying out in the open not bagged. This was true for random observations made on two (2) separate occasions for a resident with a Foley catheter; one (1) observation revealed the Foley catheter drainage bag on the floor and one (1) observation revealed the Foley catheter drainage tubing on the floor. This practice had the potential to effect more than a limited number. Resident identifier: R#33, R#68, and R#23. Facility census: 111. Findings included: a) Laundry Room Inspection of the laundry room on 06/06/19 at 09:26 AM with the Environmental Services Director and the Director of Maintenance revealed the laundry room exhaust fan that provided the negative airflow in the dirty laundry room was not working properly. The Director of Maintenance after inspecting the exhaust fan said the exhaust fan was barely pulling air. The Environmental Services Director and the Director of Maintenance both acknowledged there was not adequate negative air flow in the dirty laundry room due to the poor performance of the exhaust fan. Both the Environmental Services Director and the Director of Maintenance confirmed the inadequate negative air … | 2020-09-01 |
| 36 | 36 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-07-19 | 684 | D | 0 | 1 | KVZF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and resident interview, the facility failed to provide appropriate treatment and care in accordance with physician orders [REDACTED]. This affected one (#160) of one sampled resident reviewed as a new admission. The facility census was 113. Findings included: Resident #160 was observed sitting up in bed on 07/16/18 at 10:15 AM. At the time of the observation, Resident #160 was interviewed. He stated he had not received his pain medication when he was admitted to the facility. Resident #160 also stated he did not get all his routine medications in a timely manner. He stated his sister brought in his medications from home and he took those. The medical record review for Resident #160 was completed on 07/19/18 at 5:30 PM. The census tab of the electronic record documented Resident #160 was admitted on [DATE] at 8:13 PM with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. The Medication Administration Record [REDACTED]. The documentation revealed Resident #160 did not receive the aspirin until one day after admission on 07/15/18 at 10:00 PM. The [MEDICATION NAME] was administered three days after admission on 07/18/18 at 6:00 AM. The [MEDICATION NAME] bisulfate was administered two days after admission on 07/16/18 at 9:00 AM. The [MEDICATION NAME] was administered four days after admission on 07/18/18 at 9:00 AM. the Tylenol administered two days after admission on 07/16/18 at 12:15 AM. Review of the weights and vitals summary on 07/19/18 at 5:30 PM revealed Resident #160 had vital signs documented approximately 5 hours after admission on 07/15/18 at 1:12 AM. The second set of vital signs was dated four days later at 07/18/18 at 7:32 PM. There was no documentation of any vital signs taken upon admission. An interview was conducted with the unit manager, Registered Nurse (RN) #23 on 07/18/18 at 6:10 PM. She stated according to the electronic record, Resident #160 was admitted on [DATE]… | 2020-09-01 |
| 37 | 37 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-07-19 | 801 | D | 0 | 1 | KVZF11 | Based on staff interviews, the facility failed to employ a full-time Dietary Manager that met the qualifications to manage the food and nutrition services. The facility census was 113. Findings included: On 07/18/18 at 5:00 PM, Food Service Director #121 was interviewed. Food Service Director #121 stated he was not a certified dietary manager. He stated he took the position of Food Service Director one week ago. He was not currently enrolled in a program for certification. Food Service Director #121 stated he was told he was going to be enrolled in the training program but did not know when. Food Service Director #121 verified he did not have any nutrition schooling or a college degree in nutrition. He verified he was not a certified food service manager and did not have a national certification for food service management and safety from a national certifying entity. On 07/19/18 at 1:27 PM, Regional Vice President #144 was interviewed. He verified Food Service Director #121 did not meet the qualifications for food service management and was not currently enrolled in a program for certification. | 2020-09-01 |
| 38 | 38 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-07-19 | 812 | E | 0 | 1 | KVZF11 | Based on observations, staff interview, review of cleaning logs and review of the facility policy, the facility failed to maintain the kitchen environment and equipment in a sanitary manner. This affected one of one kitchen. The facility census was 113. Findings included: On 07/17/18 at 10:57 AM, observations were made in the kitchen with Food Service Director #121. Observations revealed a build-up of food debris on the outside of the cabinet where the hot plate bases were stored. Additionally, a stainless table that holds the toaster had food debris build-up. The lower base cabinets under the prep sink on the back wall of the kitchen had food debris build up. The outside of a warming unit cabinet had a build-up of food debris and the windows around the prep area and prep sink had splatters that looked like food debris. Food Service Director #121 verified the food debris build-up on the hot plate holder cabinet, stainless table, lower base cabinets under the prep sink and the dirty windows. Immediately following the observations on 07/17/18 at approximately 11:00 AM, Food Service Director #121 provided the daily and weekly cleaning logs for (MONTH) (YEAR). The daily and weekly cleaning logs revealed daily and weekly cleaning tasks for the kitchen. The Cleaning Scheduled record revealed no documentation the equipment and work areas including the tables were cleaned by the evening cook assigned to do the task. On 07/11/18, the external plate warmer, bread warmer and work areas, including tables were not documented as being cleaned by the morning cook. On 07/11/18, the weekly cleaning of the base cabinets was not documented as being cleaned by the evening cook. Food Service Director #121 verified documentation of the cleaning was not complete and stated they (the staff) may have just wiped the areas with a rag and sanitizer but did not clean the areas thoroughly to remove the build-up of food debris. Food Service Director #121 was not sure if the cooks had followed the cleaning schedule due to the lack of documentat… | 2020-09-01 |
| 39 | 39 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 157 | D | 0 | 1 | TKXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based resident, staff and physician interviews and clinical record review, the facility failed to notify the physician timely of a resident incident for one resident reviewed. The failed practice had the potential to affect an isolated number of residents. Resident identifiers: #260. Facility census 145. Findings include: a.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--[MEDICATION NAME] 5-325 milligrams (mg) every six (6) hours as needed for pain --Tylenol 325 mg, 2 tablets every four (4) hours as needed for mild pain. The 02/20/17 admission nursing assessment revealed the resident was not steady moving on and off the toilet and with surface to surface transfer, only able to stabilize with staff assistance. The clinical record was silent regarding any incident involving the resident on 02/22/17 or any administration of as needed pain medication. The record contained no notification of the physician of the incident. During an interview, on 02/23/17 at 12:45 p.m., Resident #260 stated she had an incident in the bathroom the previous evening. The resident stated the nurse aide was in a hurry and did not have the wheelchair close and when she went to get off the toilet. Resident #260 further said, I hit my right foot on the floor. It hurt me. I had to get pain medication for it. I had to have Tylenol and [MEDICATION NAME]. I didn't need it since my first day here. The resident stated her foot was still hurting now. During an interview, on 02/23/17 at 1:58 p.m., LPN #64 stated he was unaware Resident #260 had hurt her foot yesterday evening. LPN #64 stated he would immediately notify the physician about the incident. During an interview, on 02/23/17 at 2:52 p.m., the Director of Nursing (DON) stated she was unaware of the incident regard… | 2020-09-01 |
| 40 | 40 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 164 | E | 0 | 1 | TKXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain visual privacy during one (1) of three (3) dressing change observations for Resident #177. The facility failed to maintain privacy for medication packages for three (3) residents (Resident #38, #195 and #185). Resident identifiers: #177, #38, #195, and #185. Facility census 145. Findings include: a.) Resident #177 During a dressing change, on 02/23/17 at 12:00 p.m., Registered Nurse (RN) #137 and Licensed Practical Nurse (LPN) #64 entered the room to perform the dressing change. Resident #177 was in the bed by the window. The window blind was open and facing at street level a parking lot. RN #137 nor LPN #64 closed the window blind. RN #137 pulled the privacy curtain part of the way around the foot of the bed but leaving the mirror over the sink exposed to the resident's roommate. LPN #64 instructed Resident #177 to roll over onto her stomach. LPN #64 removed the dressing exposing a large stage IV pressure ulcer on the resident's coccyx. RN #137 was preparing the new dressing items. The resident's roommate face was seen in the mirror. The roommate had two (2) visiting family members. The roommate stated, you can pull the curtain, so she can have her privacy. LPN #64 then pulled the curtain completely to provide privacy from the mirror. During an interview, on 02/23/17 at 1:08 p.m., RN #137 stated she had thought about closing the window blind during the dressing change but just didn't do it. RN #137 stated she didn't realize the privacy curtain had not be pulled completely to provide privacy. During an interview, on 02/23/17 at 3:03 p.m., the Director of Nursing (DON) stated her expectation was all staff were to provide full visual privacy during dressing changes. b) A random observation of the 800 Hall on 02/23/17 at 8:15 a.m. revealed three (3) visible empty medication cards/packets in the trash can of the medication cart. The following medication cards contained th… | 2020-09-01 |
| 41 | 41 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 272 | D | 0 | 1 | TKXD11 | Based on staff interview, record review, resident interview, and observation, the facility failed to complete an accurate comprehensive assessment for one (1) of eighteen (18) sample residents. The dental status assessment of one (1) resident was inaccurate on the comprehensive minimum data set (MDS). Resident identifier: #33. Facility census: 145. Findings include: a) Resident #33 During the stage 1 observation and interview of Resident #33 conducted on 02/22/17 at 1:00 p.m., she said she had a broken front tooth and used to wear a partial denture. Her mouth had several teeth in various states of wear and decay, with missing teeth evident. During the medical record review performed on 02/28/17, there were dental consultation notes with the following information: --08/09/16 Exam: Generalized Decay; Generalized Periodontal Disease The attached treatment plan included options for replacing missing teeth, specifically dental implants and partial dentures. --08/30/16 Presents for exam and x ray with extractions Further interview with Resident #33 on 02/28/17 at 10:13 a.m. revealed she was looking into getting a new partial and was awaiting an appointment. On 02/28/17 at 12:30 p.m. a review of the most recent comprehensive (annual) MDS with an assessment reference date (ARD) of 09/24/16 found section L Oral/Dental Status with the following assessment: B. No natural teeth or tooth fragment(s) (edentulous). Registered Nurse Assessment Coordinator #102 was interviewed on 02/28/17 at 1:00 p.m. and said the oral assessment in section L was an error. She provided evidence that a correction was made to the MDS prior to the survey exit. | 2020-09-01 |
| 42 | 42 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 280 | D | 0 | 1 | TKXD11 | Based on resident interview, medical record review and staff interview, the facility failed to revise a care plan for one (1) of eighteen (18) stage 2 sample residents. The facility did not revise a Brief Interview for Mental Status (BIMS) score. Resident identifier: #12. Facility census 145. Findings include: a) Resident #12 Review of the most recent minimum data set (MDS) with an assessment reference date (ARD) of 12/02/16 revealed a BIMS score of fifteen (15) which indicates the resident is cognitively intact. The residents most recent care plan indicated a BIMS score of five (5) which indicates severely cognitive impaired. On 02/21/17 at 1:00 p.m., Resident #12 was able to answer stage one interview questions without difficulty. During interview on 02/28/17 at 3:45 p.m., registered nurse (RN) #17 stated the BIMS score on the care plan had not been updated from the residents admission and should have been updated to the current BIMS score of 15. | 2020-09-01 |
| 43 | 43 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 323 | D | 0 | 1 | TKXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record reviews and review of safety data sheets, the facility failed to prevent accidents by failing to use proper transfer technique for 1 of 1 residents reviewed for accidents, resulting in pain. (Resident #260.) The facility failed to prevent accident hazards by storing chemicals safely (Resident #177.)and storing medications safely. Census 145. The findings are: a.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--Norco 5-325 milligrams (mg) every six (6) hours as needed for pain --Tylenol 325 mg, 2 tablets every four (4) hours as needed for mild pain. The 02/20/17 admission nursing assessment revealed the resident was not steady moving on and off the toilet and with surface to surface transfer, only able to stabilize with staff assistance. The clinical record was silent regarding any incident involving the resident on 02/22/17 or any administration of as needed pain medication. The record contained no notification of the physician of the incident. During an interview, on 02/23/17 at 12:45 p.m., Resident #260 stated she had an incident in the bathroom the previous evening. The resident stated the nurse aide was in a hurry and did not have the wheelchair close and when she went to get off the toilet. Resident #260 further said, I hit my right foot on the floor. It hurt me. I had to get pain medication for it. I had to have Tylenol and Norco. I didn't need it since my first day here. The resident stated her foot was still hurting now. During an interview, on 02/23/17 at 1:58 p.m., LPN #64 stated he was unaware Resident #260 had hurt her foot yesterday evening. LPN #64 stated he would immediately notify the physician about the incident. During an interview, on 02/23/17 at 2:52 p.m., … | 2020-09-01 |
| 44 | 44 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 371 | E | 0 | 1 | TKXD11 | Based on observations, staff interview and review of FDA food code, the facility failed to serve foods in a sanitary manner. One (1) dietary aide was serving food with polished nails without wearing gloves and one dietary aide was wearing rings with stones on each hand while serving food. This has the potential to more than an isolated number of residents. Facility census: 145. Findings included: On 02/28/17 at 12:15 p.m., Dietary Aide (DA) #132 was plating resident food. DA #132 had polished finger nails and was not wearing gloves. DA #132 stated her nails were natural and were polished. Additionally, on 02/28/17 at 12:15 p.m., DA #26 was plating resident food on resident trays. DA #26 was wearing a diamond like ring on her left ring finger and a pearl like ring on her right ring finger. DA #26 stated she usually wore the rings when working in the kitchen. The Dietary Supervisor #125 instructed DA #26 to remove her rings. DA #26 removed her rings. The Dietary Supervisor instructed DA #132 to put on gloves, which she did. Review of the 2013 FDA Food Code Chapter 2 page 50 states: Unless wearing intact gloves in good repair, a FOOD EMPLOYEE may not wear fingernail polish or artificial fingernails when working with exposed FOOD. Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry including medical information jewelry on their arms and hands. | 2020-09-01 |
| 45 | 45 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 431 | E | 0 | 1 | TKXD11 | Based on observation and staff interview, the facility failed to properly store medications. The facility did not ensure resident's medications delivered from the pharmacy were put away in a inaccessible and locked area and did not ensure a medication cart on the 800 Hall was locked. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #15, #92, #184, and #187. Facility census: 145. Findings include: a) A random observation of the 200 Hall on 02/23/17 at 7:50 a.m. revealed medications on the counter of the nurses's station unattended and accessible to anyone from 7:50 a.m. to 8:00 a.m. The following Resident's medications were observed on the nurses's station counter: --Resident #15 - Ipratropium/Albuterol (3 packs). --Resident #92 - Phenytoin EX 100 mg (56 capsules). --Resident #184 - Clonidine HCL 0.1 mg (56 tablets). --Resident #187 - Celecoxib 200 mg (56 capsules). An interview with Licensed Practical Nurse (LPN) #64 on 02/23/17 at 8:00 a.m., revealed the night shift nurse must have left the medications at the nurse's station. The LPN stated his shift began at 7:00 a.m. The LPN stated the medications should have been locked upon acceptance from the pharmacy. b) A random observation of the 800 Hall on 02/23/17 at 8:05 a.m., revealed the medication cart was unlocked at the nurses station. The cart was unlocked, unattended, and out of sight of any staff from 8:05 a.m. until 8:12 a.m. The cart contained the medications for the 800 Hall residents. An interview with Registered Nurse-Nurse Manager (RN-NM) #21 on 02/23/17 at 8:12 a.m., revealed the medication cart should always be locked when not in sight of the nurse. | 2020-09-01 |
| 46 | 46 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 441 | D | 0 | 1 | TKXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to follow proper hand hygiene techniques during medication administration for one (1) of twenty six (26) opportunities observed. In addition, the facility failed to perform proper cleaning technique on reusable equipment during one (1) of three (3) dressing change observations. This failed practice affected an isolated number of residents who received medications administered by the facility and of those who had pressure ulcers. Resident identifiers: #126 and #177. Facility census: 145. Findings include: a) Resident #126 An observation of medication administration on 02/28/17 at 08:24 a.m., revealed Licensed Practical Nurse (LPN) #44 attempted to pop a [MEDICATION NAME] 25 milligram (mg) tablet out of the packaging into a medicine cup for Resident #126. The pill missed the cup and fell to the floor. LPN #44 picked up the pill with her bare hands and discarded it. She then popped out a second [MEDICATION NAME] 25 mg tablet into the medication cup and continued with her medication administration for Resident #126 without washing or sanitizing her hands. On 02/28/17 at 10:59 a.m. this matter was discussed with Employee #4, who was responsible for infection control. She agreed that it was an infection control issue. She provided the facility policy titled Handwashing/Hand Hygiene last revised (MONTH) (YEAR). This policy stated to use alcohol-based hand rub or soap and water Before preparing or handling medications. b.) Resident #177 During a dressing change, on 02/23/17 at 12:00 p.m., RN #137 removed scissors from her uniform pocket and cut kling soaked with acetic acid which LPN #64 was using to pack resident #177 coccyx stage IV wound. RN #137 did not clean the scissors prior to use. At the end of the dressing change procedure, RN #137 placed the scissors back into her uniform pocket without cleaning them when she left the room. During an interview, on 2/23/17 at 1:08… | 2020-09-01 |
| 47 | 47 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 514 | D | 0 | 1 | TKXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain a medical record that was complete and accurately for two (2) of eighteen (18) sample residents. Behavior monitoring and bowel pattern tracking was not consistently and/or accurately documented for one (1) resident and a second resident had incomplete medication administration records. Resident identifiers: #258 and #260. Facility census: 145. Findings include: a) Resident #258 1. Behavior sheets A medical record review for Resident #258 on 02/27/17 revealed she had physician's orders [REDACTED]. This medication was first administered on 02/03/17 at 8:00 p.m. She also had an order for [REDACTED]. Although the orders were initiated on 02/03/17, the Behavior/Intervention Monthly Flow Sheet were not documented until night shift of 02/04/17 for both [MEDICATION NAME] and [MEDICATION NAME]. In addition, there were multiple blanks holes on both sheets. The director of nursing (DON) was interviewed on 02/27/17 at 4:39 p.m. and she acknowledged the holes on the sheets were where nursing had not completed the forms. 2. Bowel patterns During the medical record review for Resident #258 on 02/27/17, there were several missing entries in the nurse aide documentation for Bowel Patterns. In addition, the documentation reflected no record of the resident having a bowel movement from night shift on 02/17/17 until evening shift on 02/23/17, as the nurse aides had documented 0 meaning No Bowel Movement. Nurse manager #21 was interviewed on 02/28/17 at 3:05 p.m. and she said that the documentation was inaccurate. She also agreed that the holes in the record resulted in the record being incomplete. c.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--[MEDICATION NAME] 5-325 milligram… | 2020-09-01 |
| 48 | 48 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 561 | D | 0 | 1 | X20F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promote one resident's right to make choices about aspects of their life. Specifically, the facility failed to provide a shower to resident #305 as requested. This failed practice had the potential to affect a limited number of residents. Resident identifier: #305. Facility census: 142. Findings included: a) Resident #305 According to the 5/18 physician's orders [REDACTED]. According to the admission progress note, dated 4/28/18, the resident was oriented to person, place, and time and was able to make her needs known. In an interview on 4/30/18 at 4:12 PM, Resident #305 said she had just admitted that past Saturday. She said the hospital never showered her so she really wanted a shower. She wanted to feel clean and thought she would feel much better after she received a shower. She said she had been asking for a shower since she admitted to the facilty. She asked her aide taking care of her that day if she could get a shower and the aide told her she would see what she could do. The resident was tearful during the interview. In an interview on 5/1/18 at 5:03 PM, Resident #305's hair was visibly wet and she was brushing it. She said she had just received a shower, her first since admission, and she felt much better. The resident's 5/18 physician's orders [REDACTED]. An order dated 4/28/18 directed Transfer assist of 2 with gait belt. An order dated 4/30/18 directed Cont (continue) with transfer assist of 2 and gait belt. Pt (patient) non-ambulatory on wing. Shower documentation and progress notes were reviewed on 5/2/18 at 4:50 PM. The shower records revealed an entry on 5/1/18 that documented not applicable, indicating a shower was not provided. Review of the progress notes revealed there was no documentation that a shower was given. The skilled progress note on 4/29/18 indicated the resident required assistance of two with transfers and bed mobility. In an interview o… | 2020-09-01 |
| 49 | 49 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 582 | E | 0 | 1 | X20F11 | Based on interview and record review, the facility failed to issue liability and appeal notices as required. Specifically, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) letter to Resident #253, issued the incorrect Center for Medicare and Medicaid Services (CMS) form letter to Resident #254 and issued an inaccurately completed SNFABN form letter and an altered NOMNC form letter to Resident #144. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #253, #254, and #144. Facility census: 142. Findings included: a) Review of guidelines Review of the current guidelines for the Centers for Medicare and Medicaid Services instructions for the SNFABN letters of notice, revised 1/18, revealed .Medicare requires SNFs (skilled nursing facilities) to issue the SNFABN (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage) to original Medicare, also called fee-for-service, beneficiaries, prior to providing care that Medicare usually covers . The SNFABN has the following 5 (five) sections for completion: Header, Body, Option Boxes, Additional Information, Signature and Date . SNFs must enter the first and last name of the beneficiary receiving the notice . There are 3 (three) options listed on the SNFABN with corresponding check boxes. The beneficiary must check only one option box . Review of the current guidelines for the CMS instructions for the NOMNC letter of notice revealed, .The NOMNC (Notice of Medicare Non-Coverage) must be delivered at least two calendar days before Medicare covered services end . The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice . b) Resident #253 Review of the clinical record for Resident #253 revealed no SNFABN letter was issued when Medicare benefits ended. c) Resident #254 Review of the clinical record for Resident #254 revealed the SNFABN letter was issued on 1/3… | 2020-09-01 |
| 50 | 50 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 657 | D | 0 | 1 | X20F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to include the resident in the care planning process. Specifically, the facility failed to keep one resident (#108) reviewed for Discharge informed of his progress towards discharge. This failed practice had the potential to affect a limited number of residents. Resident identifier: #108. Facility census: 142. Findings included: a) Facility policy The care planning policy, revised 09/2013, was reviewed on 5/3/18 at 9:15 AM. The policy indicated in pertinent part: .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan . Every effort will be made to schedule care plan meeting at the best time of the day for the resident and family .' b) Resident #108 Resident #108 admitted to the facility on [DATE] and discharged to the community on 4/30/18. According to admission physician's orders [REDACTED]. Review of the 3/22/18 Minimum Data Set (MDS) assessment on 5/2/18 at 11:35 AM. According to the MDS, the resident was cognitively intact with a brief interview of mental status score of 15 out of 15. The MDS assessed he required extensive assistance with all activities of daily living (ADLs). In an interview on 4/30/18 at 1:13 PM, the resident stated he was scheduled to be discharged around 3:00 PM that day. He complained that there was a lack of communication between the facility and himself. He stated he received therapy under his insurance and that staff never discussed his progress with him or discussed when discharge may occur. He said, all of a sudden they came and spoke with him and said they were discharging him in a couple days. He said he appealed the discharge and won, but he did not want to stay at the facility due to the lack of communication. He said they had a meeting with him when he first arrived back in March, but no other meetings since the… | 2020-09-01 |
| 51 | 51 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 689 | D | 1 | 1 | X20F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to provide adequate supervision in accordance with the resident's plan of care to prevent accidents. Specifically, two (2) residents reviewed for Accidents, the facility failed to follow aspiration precautions when each was allowed to use a straw despite physician's orders [REDACTED]. Resident identifiers: #93 and #8. Facility census: 142. Findings included: a) Resident #93 Review of the care plan, dated 3/5/18, revealed Resident #93 had nutritional risks based, in part, on a recent [DIAGNOSES REDACTED]. Review of the current Kardex (care directives provided for and used by Certified Nurse Aides - CNA) revealed Diet: ST (speech therapy) Orders: no straw protocol w/ liquids. The physician's orders [REDACTED]. Observation on 5/2/18 at 8:43 AM revealed CNA #110 place a breakfast tray in front of Resident #93. The CNA set up the resident's meal, including opening the resident's milk carton, placed it in front of him, and left. A straw was observed on the tray. Resident #93 picked up the straw, removed the paper wrap and placed it in the milk carton. He then began to drink using the straw. CNA #105 and #110 both passed by in the next few minutes, but did not intervene. There was no nurse on the unit during this observation. The meal card on the resident's tray did not identify the resident was not to have straws. In an interview on 5/2/18 at 8:52 AM CNA #110 stated she was not aware the resident was not supposed to have a straw. She said she did not think it was identified on the Kardex. At 9:01 AM CNA #105 stated she did not know Resident #93 was not supposed to have a straw. In an interview on 5/2/18 at 10:41 AM Nurses #3 and #82 explained there were three nurses splitting Unit 5 today. They explained there were extended periods of time they would each be on their other respective units, and so no nurse would be present on Unit 5. Both stated they were not aware Resident #9… | 2020-09-01 |
| 52 | 52 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 698 | D | 0 | 1 | X20F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate care with the [MEDICAL TREATMENT] Center for Resident #126, one of one residents reviewed for [MEDICAL TREATMENT]. The facility failed to ensure communication from the [MEDICAL TREATMENT] Center following the resident's treatment was reviewed and recorded. This failed practice had the potential to affect a limited number of residents. Resident identifier: #126. Facility census: 142. Findings included: a) Resident #126 Review of the resident's record revealed Resident #126 was admitted to the hospital 4/16-21/18. She readmitted to the facility 4/21/18. Review of physician's orders [REDACTED]. The record revealed the resident refused [MEDICAL TREATMENT] on 4/24/18, but went on 4/28/18 and 5/1/18. physician's orders [REDACTED]. Staff were directed, in the order, to put results in computer. Review of the electronic record revealed one weight for 4/28/18 and no weights for 5/1/18. In addition, a dietary progress note, dated 5/2/18 indicated .Current [MEDICAL TREATMENT] labs are unavailable to me here at this time. The [MEDICAL TREATMENT] labs were recommended to be obtained by our facility at today's morning/clinical meeting. In an interview on 5/2/18 at 1:34 PM, Licensed Nurse #82 was asked how the [MEDICAL TREATMENT] center and the facility communicate. She explained she did not work the floor very often, but had been pulled to do so that day. She stated they used to have a little form, with pre and post weights. Vital signs. She looked through the resident's record but was unable to locate any communication. In an interview on 5/2/18 at 1:37 PM, the Assistant Director of Nursing #88, stated We have a little form, with weights, treatment changes. Might be in her packet. Probably downstairs with (Receptionist). Let me go check. At 5/2/18 at 1:51 PM Staff #33 provided a blank copy of the [MEDICAL TREATMENT] Patient Data Sheet. It goes in the envelope and the van driver takes i… | 2020-09-01 |
| 53 | 53 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 725 | E | 1 | 1 | X20F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review the facility failed to ensure an adequate number of nurses and certified nursing assistants (CNAs) were present on a regular basis to provide care and supervision to residents. This resulted in extended call light response times, delays in meal delivery and assistance with eating, failure to follow care plans with regards to swallowing precautions, and extended periods of time where no staff were available on a unit. This failed practice had the potential to affect more than a limited number of residents. Facility census: 142. Findings included: a) Resident Council Review of Resident Council meeting minutes revealed residents voiced concern about staffing at the 3/6/18 meeting. Specifically, Extended call light response time was voiced. A resident discussed having had to wait 1.5 hours for her call light to be answered. (She needed a bed pan). The identified action was that the facility will reinforce to all staff that all employees are responsible for answering all call light. Additionally, residents voiced a concern regarding the Shortage of qualified nursing staff. The facility noted they would be offering another CNA class within the following months and that volunteers are continuously being sought. In addition, Coverage for extensive call-offs was voiced. Administration identified benefits being offered in an attempt to hire new staff. In a Resident Council meeting held as part of the survey process on 5/1/18 at 11:00 AM, residents voiced ongoing concerns about staffing. One resident stated her roommate recently waited an hour to be put to bed. She stated the staff working are very good, there just are not enough staff to meet needs timely. Resident #21 stated on night shift, she frequently waited 45 minutes to be placed on the bed pan and then another 45 minutes to be taken off the bedpan. Several other residents at the meeting reported waiting to be gotten out of bed in the morning, … | 2020-09-01 |
| 54 | 54 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 805 | E | 1 | 1 | X20F11 | > Based on observation, interview and record review, the facility failed to ensure food was prepared in a form to meet individual needs of the residents. Specifically, the facility failed to ensure proper pureed texture and failed to follow recipes for pureed food items for 12 residents that received a pureed texture out of 146 residents. This failed practice had the potential to affect more than a limited number of residents. Facility census: 142. Findings included: a) Facility policy The Progressive dysphagia diet: Puree policy, revised 01/2018, was provided by the Assistant Director of Nursing (ADON) #88 on 5/3/18 at 9:00 AM. The policy documented in pertinent part, .The diet uses slurried, blenderized, or pureed food that has a moist, pudding-like consistency without pulp or small food particles . Blenderized foods do not require chewing. They should have a pudding-like consistency without lumps (i.e., sour cream or mayonnaise thickness/moistness). All foods are appropriate if the consistency is pureed smooth without fibrous particles . b) Observations On 5/1/18 at 11:34 AM, Cook #119 was observed to remove two pans from the oven to take their temperatures. Cook #119 stated one was the mechanical texture pork and one was the pureed pork. The pureed pork was observed to have a similar texture as the mechanical pork. It appeared chunky. At 11:36 AM, the pureed cabbage was pulled out of the oven. The cabbage was observed to have visible chunks of cabbage in it. Staff began to plate meals for the lunch service at 11:54 AM, including pureed meals. The pork and cabbage were observed to be very chunky and the cabbage was watery. At 12:02 PM, the pureed pork and cabbage were taste tested . Neither of the puree food items had a smooth texture. Particles of meat and cabbage could be visualized and felt. On 5/2/18, the preparation of the pureed foods was observed from 10:08 AM to 10:30 AM. At 10:08 AM, Cook #119 was observed to place a third of the mixed vegetables in a 2.5 quart food processor. She processed the mixed … | 2020-09-01 |
| 55 | 55 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 812 | D | 0 | 1 | X20F11 | Based on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety in one of one kitchens. Specifically, the facility failed to ensure staff conducted proper hand hygiene and transported clean utensils in a sanitary manner. This failed practice had the potential to affect a limited number of residents. Facility census: 142. Findings included: a) Facility policy The Safety and Sanitation policy, revised 12/14/17, was provided by the Director of Nursing on 5/3/18 at 1:20 PM. The policy directed, in pertinent part: VII. Hand washing . 1. When to wash: i. After working with or cleaning dirty equipment or utensils . l. Between glove changes . q. Between any dirty to clean task . VII. Glove use . 1. Single use gloves: c. Wash hands thoroughly before and after wearing or changing gloves. Bacteria will build up under gloves and should be washed away after wearing gloves . 3. Cloth gloves: a. (MONTH) not be used in direct contact with food . b) Observations On 4/30/18 at 8:40 AM, during the initial tour, two trash cans were observed close to the handwashing sink. One trash can had a foot pedal that opened the top. The other trash can had a lid on top that had to be manually opened. Multiple observations were made on 5/1/18 from 11:10 AM to 12:25 PM. At 11:30 AM, Cook #119 was observed to mix cabbage and noodles togethers. During this process, the food mixture touched her oven mitt that was holding onto the pan. At 11:37 AM, Cook #119 was observed to gather the serving utensils to serve from the steam table. While transporting the utensils to the steam table, she held the ladle for the gravy up next to her chest, touching her shirt. Her shirt was visibly dirty with food debris. At 11:45 AM, Dietary Staff #89 was observed spreading butter on slices of bread, while wearing gloves. When she was finished with the butter, she covered it with plastic wrap and pulled a pen out of her shirt to write the date. Wearing the same glo… | 2020-09-01 |
| 56 | 56 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 842 | D | 0 | 1 | X20F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately transcribe, in the medical record, the correct amount of nutritional supplement ordered for one of five residents reviewed for nutritional weight loss. Resident identifier: #98. Facility census: 142. Findings included: a) Resident #98 The medical record was reviewed on 5/2/18 at 11:45 AM. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had verbal behaviors, received diuretics and had depression and anxiety. The Plan of Care dated 3/26/18 for Nutritional Status as evidenced by significant weight loss revealed the goal for the resident to consume appropriate amounts of food and fluids to maintain nutritional status. The plan of care revealed interventions to maintain weight through the next review that included the following: assist as needed to consume foods and/or supplements and fluids offered at and between meals, provide supplements per orders: Med Pass 2.0 (Dietary Supplement) 3 ounces, 4 times per day. On 5/2/18 at 1:54 PM the Medication Administration Records (MAR) for (MONTH) and (MONTH) (YEAR) were reviewed. The MARs for (MONTH) (YEAR) and up to 4/21/18 revealed the resident received Med Pass 2.0, 3 ounces, 4 times per day. On 4/21/18 at 11:30 AM, according to the MAR, the resident started receiving Med Pass 2.0, 2 ounces, 4 times per day. On 5/2/18 at 2:13 PM, a Dietary Communication form dated 4/20/18 by Registered Dietician (RD) #120 was reviewed. The dietary request directed: 1. Prosource Plus (Dietary Supplement) 1 ounce twice a day. 2. Please document the percentage of Med Pass 2.0 and magic cups that are already ordered in the MAR. The physician's orders [REDACTED]. The original order dated 12/10/15 directed Med Pass 2.0 before meals and at bedtime 3 ounces (4 times a day). A physician's orders [REDACTED]. On 5/3/18 at 11:52 AM the nutritional notes were reviewed. A nutritional note dated 5/3/18 indicated Please clarify th… | 2020-09-01 |
| 57 | 57 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 880 | D | 0 | 1 | X20F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain an infection prevention program designed to help prevent the development and transmission of diseases and infections. Specifically, the facility failed to keep Resident #301's [MEDICAL CONDITION] tubing off of the floor. This failed practice had the potential to affect a limited number of residents. Resident identifier: #301. Facility census: 142. Findings included: a) Resident #301 Resident #301 admitted to the facility on [DATE]. According to the 5/18 physician orders, [DIAGNOSES REDACTED]. The resident had orders for a [MEDICAL CONDITION]. Review of the 4/24/18 Minimum Data Set (MDS) assessment, on 5/2/18 at 9:05 AM revealed Resident #301 was in a vegetative state with no discernible consciousness. He required total care for all activities of daily living (ADL). He was identified as receiving [MEDICAL CONDITION] care, suctioning, and oxygen. Multiple observations were made of the resident throughout the day from 4/30/18 to 5/3/18. During each of these observations, the resident's [MEDICAL CONDITION] tubing was observed to be very long, with the tubing laying on the floor touching multiple objects next to the resident's bed. Specific observations included the following: On 4/30/18 at 10:57 AM, 5/1/18 at 4:51 PM, 5/2/18 at 12:01 PM, 5/2/18 at 4:58 PM and 5/3/18 at 8:49 AM, the resident's [MEDICAL CONDITION] tubing was observed laying on the floor touching multiple objects next to the resident's bed. On 5/2/18 from 7:53 AM to 8:11 AM, [MEDICAL CONDITION] care was observed to be given by Licensed Practical Nurse (LPN) #4. She suctioned the resident, cleaned around the [MEDICAL CONDITION], and changed the soiled gauze around the [MEDICAL CONDITION]. The [MEDICAL CONDITION] tubing was observed to be laying on the ground the entire time the treatment occurred. In an interview on 5/3/18 at 8:55 AM, LPN #4 observed the resident's [MEDICAL CONDITION] tubing. She acknowledged the tub… | 2020-09-01 |
| 58 | 58 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 550 | E | 0 | 1 | WJ7O11 | Based on observation and staff interview, the facility failed to treat each resident with respect and dignity, and failed to care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life. A nurse conducting medication administration did not knock or announce herself before entering Resident's rooms. This practice affected three (3) of four (4) residents observed during medication administration. Resident identifiers: #11, #71, and #101. Facility census: 140. Findings included: a) Observation An observation of Registered Nurse (RN) #5 during medication administration, on 08/05/19 at 08:05 AM, revealed the RN did not knock on the doors and announce herself before entering the rooms of Resident #11, #71, and #101. b) Interview An interview with RN #5, on 08/05/19 at 8:15 AM, revealed she usually knocks on the doors but forgot to because she was being observed and was nervous. | 2020-09-01 |
| 59 | 59 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 558 | D | 0 | 1 | WJ7O11 | Based on observation, record review, staff interview and policy review, the facility failed to provide reasonable accommodations to a resident. The facility failed to ensure resident's call light was within reach. This failed practice affected two (2) of 31 residents. Resident identifier: #130 and #111. Facility census: 140. Findings included: a) Resident #130 An observation, on 07/29/19 at 11:49 AM, revealed Resident #130's sheets and call light was laying on the floor by the foot of the bed. Resident #130 was in bed and unable to reach call light. An interview with Licensed Practical Nurse (LPN) #122, on 07/29/19 at 11:54 AM, confirmed call light was on floor and out of reach of Resident #130. LPN stated, I will go pick up her call light and change her sheets since hers are on the floor. A policy review Answering the Call Light with Revised date (MONTH) 2010. Policy stated, Step four (4) When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. b) Resident #111 An observation of the Resident, on 07/30/19 at 08:39 AM, revealed she was in bed. The call light was hanging off the side of the bed and was not within reach of the Resident. An interview with the Resident, on 07/30/19 at 8:40 AM, revealed she did not know where her call light was. An interview with Nurse Aide (NA) #100, on 07/30/19 at 8:45 AM, revealed all call lights should be within reach while residents are in bed. The NA placed the call light within reach. | 2020-09-01 |
| 60 | 60 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 584 | E | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to ensure comfortable and safe temperature levels for residents. The facility did not ensure the temperature range of 71 to 81 degrees Fahrenheit was maintained in the resident's Day/Dining Rooms. Three (3) Day/Dining Rooms tested higher than 81 degrees while being used by residents. The facility also failed to ensure a Broda Chair was not damaged and a wall in a resident's room was in good repair. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #62, #82, #21, #48, #110, & #115. Room identifiers: 100 Hall Day/Dining Room, 500 Hall Day/Dining Room, 600 Hall Day/Dining Room, 700 Hall Day/Dining Room, and the 800 Hall Day/Dining Room. Facility census: 140. Findings included: a) Temperature Observations An observation during the initial tour of the facility, on 07/29/19 at 11:15 AM, revealed the 100 Hall Day/Dining Room, 500 Hall Day/Dining Room, 600 Hall Day/Dining Room, 700 Hall Day/Dining Room, and 800 Hall Day/Dining Rooms all felt hot. There were no fans and the air conditioning units were only blowing warm air. These rooms are used as the main dining rooms for each hallway in the facility. An observation of the 600 Hall Day/Dining Room, on 07/29/19 at 12:55 PM, revealed the room felt hot. Resident #62 was attempting to eat her lunch and was visibly sweating. A room thermometer affixed to the wall read 83 Degrees Fahrenheit. No staff were present. There were no fans and the air conditioning units were only blowing warm air. An observation of the 800 Hall Day/Dining Room, on 07/29/19 at 1:15 PM, revealed Nurse Aide (NA) #100 was assisting two (2) residents with their lunch. The room felt hot. There were no fans and the air conditioning units were only blowing warm air. An observation of the 700 Hall Day/Dining Room, on 07/29/19 at 2:15 PM, revealed a room thermometer affixed to the wall read 82 Degrees Fa… | 2020-09-01 |
| 61 | 61 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 602 | D | 1 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure the resident's medications were not diverted to an unlicensed person for administration. A nurse gave [MEDICATION NAME] to a van driver to give to a resident while out of facility for an appointment. This is true for one (1) of two (2) complaint/concerns reviewed. Resident identifier: #239. Facility census: 140. a) Resident #239 Review of a complaint/concern with a date of 02/14/19 revealed a statement by registered nurse (RN) #94, explaining both she and the night nurse signed out, the pain medication, and placed the medication in a bag, and instructed the van driver to give the medication at 12:00 PM on this same date. The dosage is not revealed in the note. A grievance investigation form completed by risk manager RN #136 reveals, Resident left for at 7:15 AM for an appointment and medication was given to the van driver. According to Resident #239 she was given the medication, by the van driver, at approximately 8:30 AM. Resident #239's (MONTH) 2019 Medication Administration Record [REDACTED]. A new order with a start date of 02/13/19 is to give [MEDICATION NAME] 15 mg every four (4) hours as needed for pain. The first dose of this order was given on 02/13/19 at 7:54 PM. On 02/14/19 the MAR indicated [REDACTED]. Review of documentation concerning this matter found. 1. Van driver #63 was given the mediation by RN #94 who instructed the van driver to give to the resident at 12:00 PM. 2. A note written by the director of nursing reveals she spoke to van driver #63, who stated RN #94 gave him medication in a bag with instructions to give the medication to Resident #239 at 12:00 PM. This documentation is not signed by van driver #63. It is signed by the DON with a date of 02/15/19. 3. A note written by SS #111 in which Resident #239 stated she did not feel like it was not right for the van driver to give her [MEDICATION NAME]. 4. A note written by RN #136, with a date of… | 2020-09-01 |
| 62 | 62 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 609 | D | 1 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to identify and report an allegation of abuse/neglect related to a threat to discharge Resident #239, if she refused to go to an appointment and an allegation the nursing staff gave [MEDICATION NAME] to the van driver to dispense to Resident #239, while out of the facility. This is true for one (1) of two (2) complaint concerns reviewed. Resident identifier: #239. Facility census: 140. Findings included: Review of a complaint/concern with a date of 02/14/19 revealed Resident #239 reported to Social Services (SS) #111 on 02/14/19 a threat was made by facility staff that she would be discharged if she did not go to an appointment scheduled for this same day. She also reported the van driver was given [MEDICATION NAME] to dispense to her while on the trip. Further review found no evidence a Reportable was completed and sent to the Office of Health Facility Licensure and Certification (OHFLAC) concerning the allegations. On 07/31/19 at 4:00 PM the director of nursing expressed the incident was not reported to OHFLAC. On 08/05/19 at 3:58 PM the DON agreed sending medication with the van driver was inappropriate. | 2020-09-01 |
| 63 | 63 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 610 | D | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview the facility failed to thoroughly investigate an allegation of abuse/neglect related to a threat to discharge Resident #239, if she refused to go to an appointment and an allegation the nursing staff gave [MEDICATION NAME] to the van driver to dispense to Resident #239, while out of the facility. This is true for one (1) of two (2) complaint concerns reviewed. Resident identifier: #239. Facility census: 140. Findings included: a) Resident #239 Resident #239 filed a grievance with Social Services, (SS) #111, on 02/14/19 concerning a threat made by facility staff that she would be discharged if she did not go to an appointment scheduled for this same day. In addition, Resident #239 complained she did not believe the nursing staff should give [MEDICATION NAME] to the van driver to dispense to her, while out of the facility. On 02/14/19 the complaint/grievance form was signed by SS #111, and the risk manager registered nurse (RN), #136. The DON signed the resolution section of the complaint/grievance on 02/15/19 documenting the grievance was resolved and the complainant is satisfied. There no evidence the facility thoroughly investigated these allegations. On 02/25/19 RN #136, sent an e-mail to the DON an information statement regarding completing an investigation, by gathering witness statements and determining if Resident #239's rights were violated. On 07/31/19 at 4:00 PM the director of nursing expressed a thorough investigation did not occur related to the allegation of threatening to discharge Resident #239, and to medication being sent with the van driver. On 08/05/19 at 3:58 PM the DON agreed sending medication with the van driver was inappropriate. | 2020-09-01 |
| 64 | 64 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 623 | D | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the Ombudsman of resident transfers to an acute care setting. This was found for two (2) of two (2) residents reviewed for hospitalization s. Resident identifiers: #133 and #130. Facility census: 140. Findings included: a) Resident #133 Review of the medical record on 07/31/19, revealed Resident (R) #133 was admitted to the facility on [DATE] and discharged to the hospital after a fall on 05/29/19. The medical record is silent in regard to the Ombudsman being notified of the unplanned transfer and admission to the hospital. During an interview on 07/31/19 at 1:20 PM, social workers (SW) #134 and #111, acknowledged the Ombudsman was not notified. SW #134 stated, We just started notifying the Ombudsman on 07/01/19, after the new Administrator identified the issue. b) Resident #130 During a medical record review on 07/31/19 at 1:19 PM, found no evidence of a bed hold or ombudsman notification for hospitalization s on 04/28/19, 05/31/19 and 06/30/19. Employee #111 and Employee #134 reported on 07/31/19 at 1:20 PM, the facility just started notifying the ombudsman on 7/1/19. On 07/31/19 at 1:30 PM, Employee #40 and Employee #147 explained she (Resident #130) is on Medicaid so it is automatically a twelve (12) day bed hold. Upon further inquiry Employee #40 stated, We just heard that we need to notify the ombudsman for hospitalization s. Employee #40 and Employee #147 verified the medical record did not contain any notification for hospitalization s on 04/28/19, 05/31/19 and 06/30/19. | 2020-09-01 |
| 65 | 65 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 625 | D | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide the resident and/or family with a copy of the Bed-Hold notification on admission and/or at the time of transfer. This was found for one (1) of two (2) residents reviewed for hospitalization . Resident identifier: #133. Facility census: 140. Findings included: a) Review of the medical record on 07/31/19, revealed Resident (R) #133 was admitted to the facility on [DATE] and discharged to the hospital after a fall on 05/29/19. The medical record is silent regarding the resident and/or Medical Power of Attorney receiving information related to the facility's bed-hold policy on admission or at the time of the unplanned transfer to the hospital. Social Worker (SW) #111 reported the business office staff review the bed-hold policy with the resident and/or family on admission. SW #111 reviewed the electronic medical record and confirmed it lacked any information related to this policy. At 11:42 AM on 07/31/19, the Business office Manager (BOM) acknowledged she reviews the bed-hold policy with the resident and/or family on admission and a signed copy is placed in the medical record. The BOM reported the nurse is to complete a second bed-hold notification when the resident is transferred to the hospital. On 07/31/19 at 12:30 PM, SW #134, verified R#133's medical record lacks any information indicating the bed-hold policy was reviewed and/or given to the resident and/or family during admission or at the time of the hospital transfer. | 2020-09-01 |
| 66 | 66 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 640 | D | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to transmit a resident assessment within 14 days after completion. This was true for one (1) of 31 residents reviewed. Resident identifier: #1. Facility census: 140. Findings included: a) Review of the medical record on 07/31/19, revealed Resident (R) #1 was admitted to the facility on [DATE] and discharged to home 02/26/19. The status section of the electronic minimum data set (MDS) assessment for the five (5) day admission assessment dated [DATE], the 14-day assessment dated [DATE] and the discharge return not anticipated assessment dated [DATE], all state assessment was never added to batch. The status section of R #1's MDS assessments was reviewed by corporate consultant (CC) #152 and Registered Nurse Assessment Coordinator (RNAC) #33, during an interview on 07/31/19 at 3:45 PM. CC#152 acknowledged the status was marked incorrectly and the discharge assessment was never submitted. CC #152 corrected the discharge assessment and submitted it during this interview. | 2020-09-01 |
| 67 | 67 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 641 | D | 0 | 1 | WJ7O11 | Based on record review, staff interview and Minimum Data Set (MDS) Resident Assessment Instrument (RAI) version 3.0 manual, the facility failed to ensure the accuracy of a MDS for a resident receiving Hospice services. This practice was found for one (1) of one (1) residents reviewed for Hospice services. Resident identifier: #130. Facility census: 140. Findings included: a) Resident #130 On 07/31/19 at 11:45 AM, review of the medical record revealed Resident #130 was admitted to Hospice services on 07/19/19. Review of the significant change MDS with assessment reference date (ARD) of 07/21/19 discovered the following: Section J, titled Health Conditions, J1400 Prognosis, coded as: NO. MDS RAI version 3.0 manual coding instructions for J1400 Prognosis (typed as written): . --Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. After review of the significant change MDS with ARD of 07/21/19 on 07/31/19 at 11:55, Employee #152 stated, Yes, the manual states it should be coded yes because the resident is on Hospice. But the coordinator was waiting on physician documentation. Yes, if you follow the manual which they are supposed to, it is coded wrong. | 2020-09-01 |
| 68 | 68 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 656 | D | 0 | 1 | WJ7O11 | Based on record review, hospice contract review and staff interview, the facility failed to implement and/or develop a comprehensive person-centered care plan. A resident's call light was not within reach as directed by their care plan and a resident receiving hospice services did not have a care plan that included a detailed description of the services being provided. These practices affected two (2) of thirty-one (31) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #111 and #130. Facility census: 140. Findings included: a) Resident #111 An observation of the Resident, on 07/30/19 at 08:39 AM, revealed she was in bed. The call light was hanging off the side of the bed and was not within reach of the Resident. An interview with the Resident, on 07/30/19 at 8:40 AM, revealed she did not know where her call light was. An interview with Nurse Aide (NA) #100, on 07/30/19 at 8:45 AM, revealed all call lights should be within reach while residents are in bed. The NA placed the call light within reach. A review of the Resident's Care Plan, on 07/30/19 at 10:15 AM, revealed the focus History of falls with the intervention keep call light within reach. The Care Plan was initiated on 3/31/2017. b) Resident #130 On 07/31/19 at 11:45 AM, review of the medical record revealed Resident #130 was admitted to Hospice services on 07/19/19. Review of the care plan revealed an intervention created on 07/19/19 stating (typed as written): . Hospice staff to visit to provide care, assistance and/or evaluation . The care plan lacked a goal related to Hospice care and/or services. After review of the care plan on 07/31/19 at 12:35 PM, the Director of Nursing (DON) agreed the care plan was not individualized with measurable goals and interventions. She further agreed the care plan did not specify what Hospice staff would visit and when the visits would occur. | 2020-09-01 |
| 69 | 69 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 657 | D | 0 | 1 | WJ7O11 | Based on resident interview, record review and staff interview the facility failed to ensure a resident was invited to a care plan meeting. The facility failed to ensure a resident had the right to participate in choosing treatment options and was given the opportunity to participate in the development, review and revision of the care plan. The failed practice affected one (1) of 31 residents. Resident identifier: Resident #7. Facility census: 140. Findings included: a) Resident #7 A resident interview, on 07/29/19 at 1:00 PM, Resident #7 revealed questions about medication orders and administration. Resident #7 stated, I have tried to ask the nurses and doctors about my meds but they are always too busy, I would like to know what medications I am taking and why I need to take them. A record review, on 07/31/19 at 10:00 AM, revealed a social service note dated for 07/24/19 that stated, SW talked with brother (name of brother), MPOA, and updated him on IDT review. He is not interested in having a quarterly review meeting. He visits regularly and is aware of (resident's name) condition and daily routine. (Resident's name) continues attending activities of choice and interacts well with other residents. He is aware to contact SW with questions/concerns. A second social service note found dated for 05/24/18, stated, SW talked with brother (brother;s name) by phone and updated him on IDT review of treatment plan and asked if he would like to schedule a meeting. (Brother's name) visits regularly and is aware of (resident's name) condition and daily routine. He was not interested in having a meeting. (Resident's name) attends activities of choice and interacts well with staff, residents and visitors. He is well adjusted to long term care and aware to contact SW with questions/concerns. Further record review, on 07/31/19, revealed Resident #7 has a current Brief Interview for Mental Status (BIMS) of 15. An interview with Social Worker (SW) #134, on 07/31/19 at 11:08 AM, revealed no documentation that Resident # 7 was eve… | 2020-09-01 |
| 70 | 70 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 679 | E | 1 | 1 | WJ7O11 | > Based on resident interviews, staff interviews, van specifications and family interview, the facility failed to implement an on-going resident centered activities program that meets resident preferences. This has the potential to effect more than a limited number. Resident identifiers: #82, #48, #21. Facility census: 140. Findings included: a) Resident #82 An interview with Resident #82, on 07/29/19 at 11:40 PM, revealed, the activities can be very juvenile at times. Resident #82 stated one activity was to finger paint. As an adult I will finger paint with my grandchildren maybe but for an adult activity? Resident #82 revealed finger painting made her feel belittled and degraded. b) Resident #48 A family interview with Resident #48's husband, on 07/29/19 at 12:42 PM, revealed Resident #48 enjoyed being around other residents even though no one can understand what is said by her. Resident #48's husband stated, A couple of weeks ago they had a movie night and when I found out Resident #82 was not invited and sat out in the hall looking in at the movie I raised a fit about that. Resident #48's husband stated, the residents had nothing in the building to stay occupied so I bought the 30 puzzles for residents laying here in the day room for them to have something to do. c) Resident #21 An interview with Resident #21, on 07/29/19 at 2:10 PM, revealed, the activities provided by the facility is not always enjoyable when other residents disrupt the group. Resident #21 stated, they have two vans for transportation and usually only one driver so this does not allow everyone to go to activities when off site. On 07/29/19 at 3:00 PM during Resident Council meeting, residents voiced concerns about activity programs often starting late, and the inability for the facility to transport groups of people out in the community. They explained the vans are not available due to all the medical appointments. Thirteen (13) of sixteen (16) residents in the Resident Council meeting would like to go out in the community for meals, and ev… | 2020-09-01 |
| 71 | 71 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 684 | D | 1 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, Hospice service contract and staff interview, the facility failed to ensure prescribed Hospice services were provided to a resident in accordance with professional standards of practice. This practice was found for one (1) of one (1) Hospice resident reviewed during the survey. In addition the facility failed to ensure staff followed physician orders [REDACTED]. This practice was found for one (1) of thirty-one (31) residents reviewed during the survey. Resident identifiers: #130 and #233. Facility census: 140. Findings include: a) Resident #130 On 07/31/19 at 11:45 AM, review of the medical record revealed Resident #130 was admitted to Hospice services on 07/19/19 for a terminal health condition. Continued review of the medical record found no evidence of documentation of further Hospice care visits following her admission to Hospice services. Review of the Hospice care plan created on admission was silent for the identification of services to be provided. After reviewing the medical record on 07/31/19 at 12:35 PM, the Director of Nursing (DON) was unable to locate documentation of Hospice visits following Resident #130's initial admission to Hospice services. The DON stated, I am sure that they have been here to visit, but there is nothing to prove it. I agree their care plan does not even tell who is going to visit and when. Review of the facility agreement/contract with the contracted Hospice services provided by the DON revealed the following (typed as written): .III Services provided by Hospice: .C. Hospice shall develop the Plan of care to be provided to the Home specifying information pertinent to the resident's treatment. The Plan will be updated bi-weekly by the hospice team . M. Documentation of all visits by Hospice staff shall be placed on the Home chart at the time of the visit . b) Resident #233 Review of medical records for Resident #233, found an order with a start date of 07/26/19 to give Me… | 2020-09-01 |
| 72 | 72 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 689 | D | 0 | 1 | WJ7O11 | Based on observation and staff interview, the facility failed to provide an environment free of accident hazards over which it had control. The facility failed to secure hot liquids from resident's access. The 700 Hall Nourishment Room contained a coffee maker that was left unattended and brewing with hot coffee in the pitcher. The room, which is located on the resident hallway, had no door and was accessible to anyone. There was a resident observed seated in a wheelchair at the entrance of the Nourishment Room. No staff was in sight of the Nourishment Room at the time of the observation. The coffee inside the pitcher was tested to be 184.6 degrees Fahrenheit by the facility's Maintenance Director. An observation of the first floor lobby, on 07/29/19 at 4:30 PM, revealed three (3) male residents sitting in the lobby. Resident #121 was observed independently pouring a cup of coffee from a coffee maker that was on a counter in the lobby. The coffee maker, which was unsupervised at the time of the observation, had coffee readily available. The coffee was then poured into a cup and tested at 161 degrees Fahrenheit. The facility also failed to secure chemicals and sharp objects and to keep resident area floor's dry. All the deficient practices had the potential to affect more than a limited number of residents residing in the facility. Room identifiers: 700 Hall Nourishment Room, First Floor Lobby, 600 Hall Soiled Utility Room, and 100 Hall Shower Room. Facility census: 140. Findings included: a) 700 Hall Nourishment Room An observation of the 700 Hall Nourishment Room, on 07/29/19 at 11:30 AM, revealed a coffee maker noted to be brewing with six (6) ounces of coffee in the pot. The coffee was situated on the countertop approximately three (3) inches from the edge of the counter. There was no separation or door to the Nourishment Room from the resident hallway. Residents were observed walking by as well as one resident seated in a wheelchair at the entrance of the Nourishment Room. An interview with Licensed Practical… | 2020-09-01 |
| 73 | 73 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 692 | D | 0 | 1 | WJ7O11 | Based on family interview, record review, staff interview, the facility failed to ensure a resident maintained an acceptable parameter of nutritional status. A resident who was admitted under weight, was not weighed after a decline in status. This is true for one (1) of nine (9) residents reviewed for nutrition. Resident identifier: #126. Facility census: 140. Findings included: a) Resident #126 On 07/29/19 at 12:25 PM Resident #126's wife expressed she did not think the facility was weighting her husband, she requested his weight be obtained, and she is concerned about how very thin he is. Review of medical records found the admit weight on 06/21/19 to be one-hundred and thirteen (113) pounds. Additional weights on 07/07/19, 07/05/19, remained at (113) pounds. On 07/12/19 the residents weight was one-hundred and twelve (112) pounds. On 07/31/19 the surveyor requested the facility weight the resident. The residents weight was one-hundred and seven (107) pounds which represents a five (5) percent weight loss between 07/12/19 and 07/31/19. Observation of the resident during the survey found the resident to appear very weak, and with very low energy. The facility followed the weight admission orders [REDACTED]. | 2020-09-01 |
| 74 | 74 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 741 | D | 1 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility to failed to provide competent staffing for the care and services delivered to maintain resident safety and attain the highest practicable physical mental and psychosocial well-being of each resident. The facility failed to thoroughly investigate an allegation of neglect related to threatening a resident with discharge and an incident in which a nurse gave [MEDICATION NAME] to a van driver to give to a resident while out of the facility. This is true for one (1) of two (2) compliant/concerns reviewed. Resident #239. Facility census. 140. Findings included: a) Resident #239 Review of medical records revealed a physician order [REDACTED]. The first dose of this order was given on 02/13/19 at 7:54 PM. The previous order with a start date of 01/23/19 was [MEDICATION NAME] 15 mg every six (6) hours as needed for pain. Review of a complaint/concern with a date of 02/14/19 revealed a statement by registered nurse (RN) #94, explaining both she and the night nurse signed out, the pain medication, and placed the medication in a bag, and instructed the van driver to give the medication at 12:00 PM on this same date. The dosage is not revealed in the note. A grievance investigation form completed by risk manager RN #136 reveals, Resident left for at 7:15 AM for an appointment and medication was given to the van driver by nursing staff. According to Resident #239 she was given the medication, by the van driver, at approximately 8:30 AM. Review of documentation concerning this matter found. 1. Van driver #63 was given the mediation by RN #94 who instructed the van driver to give to the resident at 12:00 PM. 2. A note written by the director of nursing reveals she spoke to van driver #63, who stated RN #94 gave him medication in a bag with instructions to give the medication to Resident #239 at 12:00 PM. This documentation is not signed by van driver #63. It is signed by the DON with a date of 02/15/… | 2020-09-01 |
| 75 | 75 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 755 | E | 1 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to safely provide pharmaceutical services including administering drugs to meet the needs of resident. The facility failed to utilize only persons authorized by state or local, regulations to administer medication to a resident. A nurse gave medication to a van driver to give to a resident while out of the facility. This is true for one (1) of two (2) complaint/concerns reviewed. Resident identifier: #239. Facility census: 140. Findings included: a) Resident #239 Review of complaint concerns found a note written by social services #111 in which Resident #239 stated she did not feel like it was right for the van driver to give her [MEDICATION NAME] (a highly additive medication). A complaint/concern with date of 02/14/19 includes a statement by register nurse (RN) #94 explaining she and the night nurse signed out, the pain mediation, and placed it in a bag, and instructed the van driver to give the medication at 12:00 PM on this same date. On 02/15/19 a note by the director nursing (DON) reveals, van driver #63 confirmed he was given medication by nursing staff to give to Resident #239 while out of the facility for a medical appointment. On 02/14/19 risk manager RN #136 documented [MEDICATION NAME] was sent with the van driver #63 and the van driver gave it to the resident at approximately 8:30 AM, and this dose of medication was not on the Medication Administration Record [REDACTED] On 0805/19 at 3:58 PM the DON agreed sending medication with the van driver was inappropriate. b) Incomplete Narcotic Counts On 07/31/19 at 4:31 PM, a review of the Controlled Substance Forms on the 200 hall with Licensed Practical Nurse (LPN) #143 revealed nurses failed to initial the sheets at the change of shift after controlled medications were counted. LPN #143, confirmed medication counts are to be completed between two (2) nurses at the change of shift and both nurses are to initial the forms… | 2020-09-01 |
| 76 | 76 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 756 | F | 0 | 1 | WJ7O11 | 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, but are not limited to, time frames for the different steps in the monthly medication regimen review (MRR) process. This practice has the potential to affect all residents. Facility census: 140. Findings included: a) The facility policy titled Consultant Pharmacist Reports with an effective date of (MONTH) 23, 2019, states the Consultant Pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. --Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication review. In the event of a problem requiring the immediate attention of the prescriber, the responsible prescriber or physician's designee is contacted by the consultant pharmacist or the facility, and the prescriber response is documented on the consultant pharmacist review record or elsewhere in the resident's medical record. --Recommendations are acted upon and documented by the facility staff and/or the prescriber in non-urgent cases within 30 days. If the prescriber does not respond to the recommendations directed to him/her, the Director of Nursing (DON) and/or the consultant pharmacist, may contact the Medical Director. The policy lacked specific time frames for facility notification including Physician notification and response time for urgent and non-urgent recommendations. After review of the facility MRR policy on 07/31/19 at 3:25 PM, the Director of Nursing (DON) verified the policy did not contain detailed specific time frames for facility notification including Physician notification and response time for urgent and non-urgent recommendations. She stated, the pharmacist is here monthly, does notify us in writing and there has not been a problem. | 2020-09-01 |
| 77 | 77 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 761 | E | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure drugs and biological's used in the facility were stored and labeled in accordance with currently accepted professional principles. Multiple opened medications stored in the 100, 200, and 300 Hall Medication Carts were unlabeled and undated. This practice had the potential to affect more than a limited number of residents. Facility census: 140. Findings include: a) 100 Hall Medication Cart An observation of the 100 Hall Medication Cart, on 08/05/19 at 8:26 AM, revealed the following items: --One (1) bottle of opened and undated Fiber Caps. --Two (2) bottles of opened and undated Senna tablets. --One (1) bottle of opened and undated [MEDICATION NAME] tablets. --One (1) unidentified white pill was at the bottom of the medication cart. --One (1) package of opened and undated [MEDICATION NAME] Sodium tablet. An interview with Registered Nurse (RN) #5, on 08/05/19 at 8:30 AM, revealed all medications should be dated when opened. b) 200 Hall Medication Cart An observation of the 200 Hall Medication Cart, on 08/05/19 at 8:38 AM, revealed the following items: --One (1) package of Gas-X with an expiration of 03/2014. --One (1) package of [MEDICATION NAME] with an expiration of (YEAR). --One (1) opened package of [MEDICATION NAME] Suppositories with no open date. An interview with Licensed Practical Nurse (LPN) #113, on 08/05/19 at 8:40 AM, revealed she was not sure why the medications had not been dated or thrown away. c) 300 Hall Medication Cart An observation of the 300 Hall Medication Cart, on 08/05/19 at 8:52 AM, revealed the following items: --One (1) weekly pill [MEDICATION NAME] with three unidentified (3) pills in each of the seven (7) daily spots. There was no name on the [MEDICATION NAME]. --One (1) bottle of opened and undated Sodium [MEDICATION NAME]. --One (1) pack of opened and undated Sore Throat [MEDICATION NAME]. --Two (2) bottles of opened and undated Cough Suppre… | 2020-09-01 |
| 78 | 78 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 802 | E | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review and temperature logs review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of nutritional services. The facility failed to provide staff that exhibited competent skills sets in hygiene and food preparation. The failed practice had the potential to affected more than an unlimited number of residents. Facility census: 140. Findings included: a) Kitchen An observation, on 07/30/19 at 11:13 AM, revealed Dietary Cook (DC) #93 washed and dried hands with a paper towel. DC #93 preceded to a trash can and used hand to lift the lid and throw away the paper towel. An immediate interview with Dietary Supervisor (DS) #142 revealed no concern with hand washing practice. DS #142 stated DC was supposed to use the trash can around the corner with the foot pedal. DS #142 immediately took the trash can with manual lid out of the kitchen area. An observation, on 07/30/19 at 11:40 AM, revealed DS #142's hand washing practice. DS #142 washed hands, turned the water facet off with her washed hands and then manually used the lever on the paper towel dispenser with washed hands. DC #93 was observed next and also washed hands, turned the water facet off with her washed hands and then manually used the lever on the paper towel dispenser with washed hands. An immediate interview with DS #142, stated, I have always done it this way. DS #142 stated, If I wash my hands and am not allowed to touch the handles of the sink how am I supposed to turn the sink off? An observation, on 07/30/19 at 11:41 AM, revealed DC #53 transferring hot metal containers with a dirty towel. DC #53 placed towels on a soiled countertop and used towels to transfer metal containers of food from the oven to countertop. DC #53 was observed holding the metal containers by the top inside of the metal container with the dirty towels. An immediate interview with DS #142 confi… | 2020-09-01 |
| 79 | 79 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 804 | E | 0 | 1 | WJ7O11 | Based on observation, resident interview, test tray results and staff interview, the facility failed to serve food that is palpable, attractive, at safe temperatures, and with accuracy related to each residents tray card. This is true for 13 tray cards reviewed for the long term care survey process. This practice has the potential to effect more than a limited number. Resident identifiers: #181, #27, #94, #126, #49, #36, #238, #108, #231, #102, #119, #21, and #383. Facility census: 140. Findings included: a) The following tray cards with issues of accuracy include: 1. Resident #181 Resident: #181's noon meal on 07/30/19 had two (2) percent(%) milk. The tray card called for whole milk. 2. Resident #27 Resident #27's breakfast meal on 07/30/19 had french toast, dipped in eggs. The tray card reveals NO EGGS. 3. Resident #94 Resident #94's noon meal, on 07/30/19 did not include, a roll, and whole milk as listed on tray card. During interview at 1:45 PM, licensed nurse (LPN) #19, explained she did not think the resident would drink whole milk. 4. Resident #126 Resident #126's breakfast meal on 07/30/19 had 2% milk did not have syrup. The tray card reveals whole milk and syrup. 5. Resident #49 Resident #49's breakfast meal on 07/30/19; the tray card reveals resident to receive a renal diet. The resident did not receive juice as listed on the tray card. The resident prefers some kind of juice. She explained she could not receive orange juice because of being on a renal diet but was not offered an alternative juice. 6. Resident #36 The tray also included a banana which is high in potassium. Resident #36 explained her breakfast tray usually has a banana which is high in potassium. Potassium should be limited on a renal diet Resident #36's breakfast meal on 07/30/19, included french toast which appeared soggy. The resident did not eat and explained the french toast was soggy. 7. Resident #238 Resident #238's breakfast tray on 07/30/19 had 2% milk. The tray card lists whole milk. Resident #238 explained she request coffee b… | 2020-09-01 |
| 80 | 80 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 809 | E | 0 | 1 | WJ7O11 | Based on observation, resident interview, staff interview, record review and policy review, the facility failed to ensure no more than 14 hours elapsed between evening meals and breakfast. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #90 and #111. Hall identifier: 500 Hall. Facility census: 140. Findings included: a) Observations An observation of the 500 Hall, on 07/30/19 at 8:00 AM, revealed that breakfast trays had not been delivered to the floor or served yet. Further observation of the 500 Hall, on 07/30/19 at 8:30 AM, revealed that breakfast trays had not been brought to the floor or served yet. An observation of the 500 Hall, on 07/30/19 at 8:50 AM, revealed the trays were brought to the floor and the staff began to distribute them. b) Interviews An interview with Resident #90, on 07/30/19 at 7:30 AM, revealed she was hungry and sick of always waiting on breakfast. The Resident stated breakfast is not usually served on the 500 Hall until around 9:00 AM. The Resident stated her evening meal the day before was delivered at 5:45 PM. An interview with Resident #111, on 07/30/19 at 8:00 AM, revealed the meals are always late on the 500 Hall. An interview with Nurse Aide (NA) #104, on 07/30/19 at 8:40 AM, revealed the breakfast trays had not yet arrived. The NA stated they are always late on this hall. The NA stated this is the last hall to get trays in the whole building. The NA stated the trays usually come between 8:30 AM and 9:00 AM. The NA stated this is a daily thing. An interview with the Dietary Supervisor (DS), on 07/30/19 at 12:45 PM, revealed the 500 Hall is the last hall to receive trays. The DS stated breakfast should be served by 8:00 AM to all floors but that is only on a perfect day. c) Policy Review A review of the facility policy titled Meal Service with an effective date of 05-16-16. was conducted on 07/31/19. The policy stated Not more than 14 hours will elapse between the serving of the evening meal and the breakfast meal. The polic… | 2020-09-01 |
| 81 | 81 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 812 | E | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, test tray and review of temperature logs, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility failed to label and date food items in the walk-in refrigerator, freezer and dry storage area. The facility failed to prepare food in a safe and sanitary manner. The failed practice had the potential to affect more than unlimited number of residents. Facility census: 140. Findings included: a) Kitchen initial tour During the initial tour of the kitchen accompanied by the Dietary Supervisor (DS) #142, on 07/29/19 at 11:00 AM, revealed several food items not labeled or dated. The list of food items found were: --A metal container full of individual packets for salad dressing were found in the walk-in refrigerator dated 04/08/19. --Two (2) medium sized frozen cheese pizzas were found in the refrigerator with no date. --One (1) Full box of Baker Source garlic bread found in the freezer with box lid open and ice on garlic bread. Garlic bread appeared to be freezer burnt. --Two (2) brown bags of tri patties hash browns found in the freezer unlabeled and not dated. --Four (4) bags of Rice Crispies, two (2) pound bags, found in dry storage area not dated. --Five (5) bags of Corn Flakes, two (2) pound bags, found in dry storage area not dated. --Two (2) Pork Roast Gravy Mix, 11.3 ounces' packets, found in dry storage area not dated. An immediate interview with DS #142, on 07/29/19, acknowledged all items were not dated or labeled. DS #142 had dietary staff date and label items as items were found. b) Kitchen follow-up visit During the follow up visit in the kitchen, on 07/30/19, revealed several observations and interviews. The findings included multiple issues related to preparation of food in a safe and sanitary manner. An observation, on 07/30/19 at 11:13 AM, revealed Dietary Cook (DC) #93 washed and dried hands… | 2020-09-01 |
| 82 | 82 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 849 | D | 0 | 1 | WJ7O11 | Based on medical record review, Hospice service contract and staff interview, the facility failed to ensure in accordance with the agreement/contract prescribed Hospice services were provided to a resident. This practice was found for one (1) of one (1) Hospice resident reviewed during the survey. Resident identifier: #130. Facility census: 140. Findings included: a) Resident #130 On 07/31/19 at 11:45 AM, review of the medical record revealed Resident #130 was admitted to Hospice services on 07/19/19 for a terminal health condition. Continued review of the medical record found no evidence of documentation of further Hospice care visits following her admission to Hospice services. Review of the Hospice care plan created on admission was silent for the identification of services to be provided. Review of the facility agreement/contract with the contracted Hospice services provided by the Director of Nursing (DON) revealed the following (typed as written): --Hospice shall develop the Plan of care to be provided to the Home specifying information pertinent to the resident's treatment. The Plan will be updated bi-weekly by the hospice team . --Documentation of all visits by Hospice staff shall be placed on the Home chart at the time of the visit . After reviewing the medical record on 07/31/19 at 12:35 PM, the DON was unable to locate documentation of Hospice visits following Resident #130's initial admission to Hospice services. The DON stated, I am sure that they have been here to visit, but there is nothing to prove it. I agree their care plan does not even tell who is going to visit and when. In addition the DON agreed the Hospice services company did not adhere to their contract regarding the care plan and documentation. | 2020-09-01 |
| 83 | 83 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 867 | E | 0 | 1 | WJ7O11 | Based on facility record review, staff interview, and review of deficient practices identified during the survey, the facility failed to maintain an effective Quality Assurance Committee to develop and implement appropriate plans to correct identified quality deficiencies and coordinate the facility's required implementation of all regulatory changes. No attempts were made to correct nurses' failure to sign off narcotic counts at shift change after the pharmacist identified the concern. This has the potential to affect all residents residing in the facility. Facility census: 140. Findings include: a) On 07/31/19 at 4:31 PM, a review of the Controlled Substance Forms on the 200 hall with Licensed Practical Nurse (LPN) #143 revealed nurses failed to initial the sheets at the change of shift after controlled medications were counted. LPN #143, confirmed medication counts are to be completed between two (2) nurses at the change of shift and both nurses are to initial the forms. Further review at this time found incomplete Controlled Substance Forms on both medication carts on the 200 and 300 hall and the single cart located on the 100 hall. The Assistant Director of Nursing (ADON) acknowledged the Controlled Substance Forms were incomplete during an interview on 07/31/19 at 4:32 PM. On 08/05/19 at 9:52 AM, a review of the pharmacist's Controlled Substance Audit dated 02/08/19 with the ADON revealed the pharmacist identified missing signatures during a random audit of the change of shift count forms. On 08/05/19 at 3:17 PM, a review of the Quality Assurance & Performance Improvement Plan 2019 presented with the Quality Assurance & Performance Improvement (QAPI) policy revealed the facility did not address the incomplete controlled substance forms. An interview was conducted with the Administrator, the person in charge of Quality Assurance #136 and Corporate Consultant (CC) #154 on 08/05/19 at 3:30 PM. The Administrator and CC #154 confirmed they were unaware of results of the pharmacist's 02/08/19 findings of missing … | 2020-09-01 |
| 84 | 84 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 880 | F | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy and procedure review, the facility failed to maintain an effective infection control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. Observation of pressure ulcer dressing changes revealed no use of a barrier, soiled dressing placed on an overbed table next to water pitcher and drinking glasses and failure to change gloves when going from the buttocks area to the residents back. During medication administration, residents medication was placed on the resident's overbed table without any type of barrier. In addition, the laundry room lacked separation between the clean and soiled areas to prevent cross contamination and failed to change contaminated gloves while changing a resident's tube feeding. Three (3) breakfast trays were found in the Nutrition room [ROOM NUMBER] hall after the lunch meal had been returned to the kitchen. One of the breakfast tray was from a resident who was on isolation precautions. This practice has the potential to affect more than a limited number of residents. Resident identifiers: #116, #76, #115, #101, #98. Facility census: 140. Findings included: a) Resident #116 On 07/30/19 at 10:22 AM observation of pressure ulcers dressing change with Licensed Practical Nurse (LPN) #1 revealed clean dressings were placed on the residents bed. b) Resident #76 On 07/31/19 at 10:52 AM observation of pressure ulcer dressing change by LPN #1 revealed there was no barrier placed on the overbed table or was the overbed bed cleaned prior to opening pressure ulcer dressings. The soiled dressing was placed on the overbed table next to the Resident #76 water pitcher and drinking cups. In addition, obtained marking pen from pocket, dated the dressing, and placed the pen back into pocket with contaminated gloves. c) Resident #115 Observation of a pressure ulcer dressing on 07/31/19 at 11:37 AM with LPN… | 2020-09-01 |
| 85 | 85 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 925 | E | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain an effective pest control program so that the facility is free of pests. The facility failed to maintain a kitchen area that was free from bugs. The failed practice had the potential to affect an more than a limited number of residents. Facility census: 140. Findings included: a) Kitchen An observation, on 07/30/19 at 1:48 PM, revealed a brown shelled bug with antennas crawling on the kitchen wall above the steam tables. An immediate interview with Dietitian occurred and bug was pointed out to Dietitian. The Dietitian stated, Oh that stinks. The bug was not obtained off the wall and then disappeared to wander the kitchen. An observation on 07/30/19 at 4:11 PM, revealed approximately 12 gnats flying in the kitchen area. An interview with DC #126, on 07/30/19 at 4:13 PM, revealed the facility had a history of [REDACTED].#126 stated the bugs are coming in through the floor drain. | 2020-09-01 |
| 86 | 86 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 947 | D | 0 | 1 | WJ7O11 | Based on employee records and staff interview the facility failed to ensure continuing competence of nurse aides (CNA) included dementia management and abuse prevention training. Two (2) CNA's lacked dementia care and one (1) CNA lacked abuse prevention training as required. The failed practice affected two (2) of five (5) CNA's employed by the facility. Employee identifiers: #1 and #4. Facility census: 140. Findings included: a) Employee #1 An employee record review, on 08/06/19 at 8:39 AM, of CNA's in-service trainings was conducted. Employee #1 lacked training in the areas of Dementia Management and Abuse Prevention courses as required. An interview with ADoN, on 08/06/19 at 8:39 AM, revealed no other documentation availability for Employees #1 regarding in-service completion. ADoN stated, that is all the information for training we could find. b) Employee #4 An employee record review, on 08/06/19 at 8:39 AM, of CNA's in-service trainings was conducted. Employee #4 lacked training in the area of Dementia Management as required. An interview with ADoN, on 08/06/19 at 8:39 AM, revealed no other documentation availability for Employees #4 regarding in-service completion. ADoN stated, that is all the information for training we could find. | 2020-09-01 |
| 87 | 87 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-12-18 | 583 | E | 1 | 0 | 0M5911 | > Based on observation and staff interview, the facility failed to protect the personal privacy of residents including personal and medical information. Documents containing personal and medical information for multiple residents were left unattended on a medication cart and in a staff bathroom. Personal identifiers including residents' names, date of births, social security numbers, phone numbers, addresses, medications, diagnoses, and other health information were accessible. This was a random observation. This practice affected eight (8) residents. Resident identifiers: #11, #12, #13, #14, #15, #16, #17, and #18. Facility census: 144. Findings include: a) Medication Cart A random observation on 12/18/17 at 9:45 a.m., on the 800 Wing, revealed Resident #11's Pre-Admission Screening form was left on a medication cart uncovered and unattended. The Pre-Admission Screening form contained the following personal information: --Resident's name --Resident's address --Resident's phone number --Resident's Social Security Number --Resident's date of birth --Resident's Medicare Number An interview with Licensed Practical Nurse (LPN) #2, on 12/18/17 at 9:50 a.m., revealed the Pre-Admission Screening form should have never been left on top of the medication cart unattended. b) Staff Bathroom A random observation on 12/18/17 at 10:10 a.m., on the 500 Wing, revealed a bin of folders in the staff bathroom. The bin containing information for Resident #12, #13, #14, #15, #16, #17, and #18 was readily accessible for anyone using the restroom. The folders within the bin contained multiple Minimum Data Set assessments, Care Plan Team Meeting Summaries, and admission records. These documents contained: --Resident's names --Resident's Social Security Numbers --Resident's date of births --Resident's diagnoses --Resident's treatment and medical information An interview with LPN #2, on 12/18/17 at 10:15 a.m., revealed the the bin of folders had been in the bathroom for a while. The LPN stated he was not sure why medical information was b… | 2020-09-01 |
| 88 | 88 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-12-18 | 689 | E | 1 | 0 | 0M5911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. Chemical substances, shaving razors, skin treatments, needles, and a knife, were unsecured and accessible to residents on the 500, 600, and 800 Wings. This practice had the potential to affect more than a limited number of residents. Facility census: 144. Findings include: a) 500 Wing A tour of the 500 Wing, on 12/18/17 at 9:50 a.m., revealed the Shower Room door was open. The room contained the following items: --Five (5) containers of Medspa Shave Cream with the warning Keep out of reach of children. --One (1) container of Medline Shampoo & Body Wash with the warning Caution-Keep out of reach of children-Avoid contact with eyes. --One (1) container of [MEDICATION NAME] Maltodextrin Powder Dressing. b) 600 Wing A tour of the 600 Wing, on 12/18/17 at 10:15 a.m., revealed the Nutrition Room was open for access by anyone. On the top shelf in the unlocked cabinet was a knife with approximately an 8 inch blade. An interview with Licensed Practical Nurse (LPN) #1, on 12/18/17 at 10:20 a.m., revealed she had no idea why the knife was in the cabinet. The LPN stated she would ensure the knife was taken away immediately. c) 800 Wing A tour of the 800 Wing, on 12/18/17 at 10:25 a.m., revealed one (1) container of [MEDICATION NAME] Solution 4%-Antiseptic/Antimicrobial Skin Cleanser was on the counter of the nurses station unattended. The container had the warning Keep out of reach of children-If swallowed get medical help or contact a Poison Control Center right away. Further touring of the 800 Wing, on 12/18/17 at 10:30 a.m., revealed the Examining Room had a key in the door and was accessible to anyone. The room contained the following items: --Seven (7) containers of Medspa Shave Cream with the warning Keep out of reach of children. --Seven (7) containers of Medline Shampoo & Body Wash with the warn… | 2020-09-01 |
| 89 | 89 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-03-13 | 580 | D | 1 | 0 | 6GC411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, and policy and procedure review, the facility failed to promptly notify a resident's physician and responsible party when there was an accident involving injury, a significant change in the resident's condition including a need to alter treatment significantly for one (1) of five (5) residents reviewed. The facility failed to immediately notify a resident's representative when there were new orders involving care and treatment upon return from the hospital. Resident identifier:: R1 The findings included: a) Resident #1 (R1) Record review on 3/11/19, noted R1 had sustained a fall on 01/26/19, at 12:10, resulting in a laceration to the face. R1 was taken to the hospital for care and further treatment. R1 was released back to the nursing facility on 01/26/19, with the following change in orders: --[MEDICATION NAME] Suspension Reconstituted 250 milligrams {mg} / 5 milliliters {ml}. Give 10 ml by mouth four times a day for periorbital laceration status [REDACTED]. --Neuro checks per facility policy times 72 hours --Therapy to evaluate wheelchair status [REDACTED].>Further review of the medical record on 3/12/19, revealed no evidence the resident's responsible party had been notified of the orders upon return from the hospital. A review of the policy and procedure, Changes in Resident Condition, revision date, (MONTH) (YEAR), noted under Guideline 2. prompt notification is required when there is a need to alter treatment significantly. An interview with the Director of Nursing (DON), on 03/12/19, at 01:26 PM, revealed there was no documentation of the medical power of attorney (MPOA) for R1 being notified of the new orders for Cepahalexin suspension , the neuro checks or therapy evaluation when R1 had returned from the hospital. The DON further stated I did not see where the MPOA was notified and agreed notification was not done in accordance with facility policy. | 2020-09-01 |
| 90 | 90 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-03-13 | 656 | D | 1 | 0 | 6GC411 | > Based on observation, record review, resident interview, and staff interview, the facility failed to ensure the implementation of individualized care plan interventions related to high fall risks. Call lights were not within reach for residents as directed by their care plans. This practice affected two (2) of five (5) residents reviewed for high fall risks. Resident identifiers: #3 and #4. Facility census. 182. Findings include: a) Resident #3 An observation of the Resident, on 03/12/19 at 10:05 AM, revealed the Resident was in bed. The Resident's call light was under the bed and out of reach of the resident. An interview with Licensed Practical Nurse (LPN) #100, on 03/12/19 at 10:10 AM, revealed the Resident's call light should be within reach at all times. The LPN placed the Resident's call light on the bed within reach of the Resident. A review of the Care Plan was conducted on 03/12/19 at 11:15 AM. The Care Plan dated 01/21/19 with a focus of Actual fall and continues to be at risk for falls with the intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. b) Resident #4 An observation of the Resident, on 03/12/19 at 10:30 AM, revealed the Resident was up in his wheelchair in his room watching television. The Resident's call light was under the opposite side of the bed where he was sitting and out of reach of the resident. An interview with the Resident, on 03/12/19 at 10:32 AM, revealed the Resident did not know where his call light was. The Resident stated I do not see it anywhere. An interview with Nurse Aide (NA) #101, on 03/12/19 at 10:35 AM, revealed the Resident does not need his call light near him because he is more mobile than most other residents. A review of the Care Plan was conducted on 03/12/19 at 11:30 AM. The Care Plan dated 02/25/19 with a focus of Actual fall and continues to be at risk for falls with the intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance a… | 2020-09-01 |
| 91 | 91 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-03-13 | 689 | D | 1 | 0 | 6GC411 | > Based on observation, record review, resident interview, and staff interview, the facility failed to provide an environment free from accident hazards over which it had control. Call lights were not within reach for high fall risk residents as directed by their care plans. This practice affected two (2) of five (5) residents reviewed for high fall risks. Resident identifiers: #3 and #4. Facility census. 182. Findings included: a) Resident #3 An observation of the Resident, on 03/12/19 at 10:05 AM, revealed the Resident was in bed. The Resident's call light was under the bed and out of reach of the resident. An interview with Licensed Practical Nurse (LPN) #100, on 03/12/19 at 10:10 AM, revealed the Resident's call light should be within reach at all times. The LPN placed the Resident's call light on the bed within reach of the Resident. A review of the Care Plan was conducted on 03/12/19 at 11:15 AM. The Care Plan dated 01/21/19 with a focus of Actual fall and continues to be at risk for falls with the intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. b) Resident #4 An observation of the Resident, on 03/12/19 at 10:30 AM, revealed the Resident was up in his wheelchair in his room watching television. The Resident's call light was under the opposite side of the bed where he was sitting and out of reach of the resident. An interview with the Resident, on 03/12/19 at 10:32 AM, revealed the Resident did not know where his call light was. The Resident stated I do not see it anywhere. An interview with Nurse Aide (NA) #101, on 03/12/19 at 10:35 AM, revealed the Resident does not need his call light near him because he is more mobile than most other residents. A review of the Care Plan was conducted on 03/12/19 at 11:30 AM. The Care Plan dated 02/25/19 with a focus of Actual fall and continues to be at risk for falls with the intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as n… | 2020-09-01 |
| 92 | 92 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 550 | E | 1 | 0 | R6BQ11 | > Based on observation, staff interview, and policy review, the facility failed to ensure residents were treated with dignity and respect. A staff member was yelling at a resident during care and a catheter bag was not covered . This practice affected two (2) of eleven (11) residents observed. Resident identifiers: #4 and #8. Facility census: 178. Findings included: a) Resident #8 A random observation by two surveyors on the A Hall on the 4th floor, on 04/17/18 at 7:40 AM, revealed Nurse Aide (NA) #22 was getting Resident #8 dressed in the Resident's room. NA #22 was heard yelling loudly and forcibly Jesus, what the hell are you doing to Resident #8. NA #4 was also present in the room. When both NAs exited the room NA #22 stated Oh my God, there is state. An interview with NA #22, on 04/17/18 at 7:42 AM, revealed the NA was helping Resident #8 get dressed. The NA stated the resident must be dizzy because she would not cooperate like usual. The NA stated she laid the Resident back down due to her functioning level at the time of care. An observation of the Resident, on 04/17/18 at 7:45 AM, revealed the Resident was lying in bed. The Resident was unable to answer yes and no questions. An interview with the Administrator, on 04/17/18 at 7:50 AM, revealed that any abusive behavior is not tolerated and the situation would be investigated immediately. An interview with the District Director of Clinical Services (DDCS), on 04/17/18 at 9:30 AM, revealed both NA #22 and #8 were suspended and a full investigation had begun. The DDCS stated all residents in the facility were immediately being interviewed and checked for abuse. The DDCS stated the behavior of CNA #22 was absolutely abuse and was highly unacceptable. The DDCS stated any kind of abuse would never be acceptable or tolerated at any of my facilities. A review of the facility policy titled OP 00 Abuse & Neglect Prohibition, with a revision date of (MONTH) (YEAR), was conducted on 04/18/18 at 9:45 AM. The policy stated Each resident has the right to be free from ab… | 2020-09-01 |
| 93 | 93 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 558 | D | 1 | 0 | R6BQ11 | > Based on observation, resident interview, and staff interview, the facility failed to provide services with reasonable accommodation for residents. A resident's over the bed light cord was not long enough to be easily reached and a resident could not access his bathroom due to the door being locked. This practice affected two (2) of eleven (11) residents observed. Resident identifiers: #10 and #11. Facility census: 178. Findings included: a) Resident #10 An observation of the Resident, on 04/16/18 at 11:10 AM, revealed the Resident's over the bed light cord was approximately 6 inches long. An interview with the District Director of Clinical Services (DDCS), on 04/16/18 at 11:15 AM, revealed the Resident could not easily reach the over the bed light cord without having to get up out of bed. b) Resident #11 An observation of the Resident's room, on 04/16/18 at 11:25 AM, revealed the Resident's bathroom door was locked. The bathroom was not occupied at the time of the observation. An interview Resident #11, on 04/16/18 at 11:27 AM, revealed the door to the bathroom is locked almost daily. The Resident stated he has to go to room next door to enter his bathroom. The Resident stated whoever uses the bathroom in that room keeps the door locked preventing him from getting in. An interview with the DDCS, on 04/16/18 at 11:30 AM, revealed she had no idea Resident #11 was being locked out of his bathroom. The DDCS stated she would take care of the issue. | 2020-09-01 |
| 94 | 94 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 583 | E | 1 | 0 | R6BQ11 | > Based on observation and staff interview, the facility failed to protect the personal privacy of residents including medical and health information. A medication re-order sheet was left unattended on medication cart in the hallway. Personal identifiers including residents' names, medications, and other health information were viewable by any person in the hall. This was a random observation. This practice affected five (5) residents. Resident identifiers: #20, #21, #22, #23, #24, and #25. Facility census: 178. Findings included: a) Medication Re-Order Sheet A random observation of the 3rd Floor B-Hall, on 04/16/18 at 11:45 AM, revealed a medication re-order sheet was left on top of the medication cart. The medication re-order sheet contained the following: -Resident #20-Resident's name, room number, medication, and dosage -Resident #21-Resident's name, room number, medication, and dosage -Resident #22-Resident's name, room number, medication, and dosage -Resident #23-Resident's name, room number, medication, and dosage -Resident #24-Resident's name, room number, medication, and dosage -Resident #25-Resident's name, room number, medication, and dosage An interview with Licensed Practical Nurse (LPN) #10, on 04/16/18 at 11:48 AM, revealed the LPN should not have left the medication re-order sheet unattended on the medication cart. The LPN stated she usually turns the paper over or takes it with her when away from the cart so that no patient information can be seen by others. | 2020-09-01 |
| 95 | 95 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 584 | E | 1 | 0 | R6BQ11 | > Based on observation and staff interview, the facility failed to ensure a safe, clean, comfortable and homelike environment for 3 of 11 sampled residents. The facility failed to ensure the resident's room was in good repair, clean and /or homelike. Resident identifiers: #8, #3 and #4. Facility census: 178. Findings included: An observation on 04/17/18 at 10:30 AM, revealed a lack of personal items noted in Resident #8's room. An interview with the District Director of Clinical Services, on 04/17/18, at 12:20 PM, verified it was uncertain why Resident #8 did not have personal effects making the room homelike. It was further stated, staff would assess resident's preferences and assist the resident to make the room homelike. An observation of Resident #3's room, on 04/16/18 at 11:05 AM, revealed a plastic glove laying under a chair. An additional observation, on 04/17/18, at 7:30 AM, revealed a plastic glove laying under the same chair and debri on the floor, in the area close to the door. c) Resident #4 An observation of Resident #4, on 04/16/18 at 11:05 AM, revealed paint missing along with paint chips hanging from the ceiling above the bed. An interview with the District Director of Clinical Services (DDCS), on 04/16/18 at 11:10 AM, revealed the ceiling would be taken care of immediately. | 2020-09-01 |
| 96 | 96 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 600 | E | 1 | 0 | R6BQ11 | > Based on observation, staff interview, and policy review, the facility failed to ensure residents were free from verbal abuse and mistreatment. A staff member was yelling at a resident during care. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #8. Facility census: 178. Findings included: a) Resident #8 A random observation by two surveyors on the A Hall on the 4th floor, on 04/17/18 at 7:40 AM, revealed Nurse Aide (NA) #22 was getting Resident #8 dressed in the Resident's room. NA #22 was heard yelling loudly and forcibly Jesus, what the hell are you doing at Resident #8. NA #4 was also present in the room. When both NAs exited the room NA #22 stated Oh my God, there is state. An immediate interview with NA #22, on 04/17/18 at 7:41 AM, revealed the NA was helping Resident #8 get dressed. The NA stated the resident must be dizzy because she would not cooperate like usual. The NA stated she laid the Resident back down due to her functioning level at the time of care. An observation of the Resident, on 04/17/18 at 7:43 AM, revealed the Resident was lying in bed. The Resident was unable to answer yes and no questions. An interview with the Administrator, on 04/17/18 at 7:50 AM, revealed that any abusive behavior is not tolerated and the situation would be investigated immediately. An interview with the District Director of Clinical Services (DDCS), on 04/17/18 at 9:30 AM, revealed both NA #22 and #8 were suspended and a full investigation had begun. The DDCS stated all residents in the facility were immediately being interviewed and checked for abuse. The DDCS stated NA #22 works all over the facility. The DDCS stated the behavior of NA #22 was absolutely abuse and was highly unacceptable. The DDCS stated abuse would never be acceptable or tolerated at any of my facilities. A review of the facility policy titled OP 00 Abuse & Neglect Prohibition, with a revision date of (MONTH) (YEAR), was conducted on 04/17/18 at 9:45 AM. The policy stated Each resident ha… | 2020-09-01 |
| 97 | 97 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 684 | E | 1 | 0 | R6BQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to ensure that 5 of 11 sampled residents received care and treatment in accordance to the comprehensive assessment and plan of care. Heels were not floated for Resident #1, Resident #2, and Resident #4. Fall mats were not provided for Resident #7, and Resident #9. Resident identifiers: #1. #2, #4, #7 and #9. Facility census: 178. Findings included: a) Resident #2 A review of the medical record for Resident #2 revealed a physician's orders [REDACTED]. An observation made of Resident #2, while in bed, on 04/16/18, at 11:45 AM, revealed the resident's right sock was off her foot, laying on the floor, and her right heel was positoined directly on the bed. Both heels were not being floated in accordance with physician's orders [REDACTED]. An interview with the District Director of Clinical Services, on 04/17/18, at 12:15 PM, verified understanding of following physician orders [REDACTED]. b) Resident #1 A review of the medical for Resident #1, on 04/16/18, revealed a physician's orders [REDACTED]. An observation made of Resident #1, while in bed, on 04/17/18, at 07:20 AM, revealed the resident's heels were not floated in accordance with physician's orders [REDACTED]. An interview with the District Director of Clinical Services, on 04/17/18, at 12:15 PM, verified understanding of following physician orders [REDACTED]. c) Resident #7 An observation of Resident #7 on 04/17/18 at 7:20 AM, revealed a bruised area on the right side of the resident's face. A review of the medical record for Resident #7, on 04/17/18, revealed Resident #7 had sustained a fall on 04/16/18 at 10:44 AM. The facility implemented the Fall Protocol related to the fall occurrence. Resident was to have a fall mat to right side of bed. An observation made, 04/17/18 at 09:25 AM, revealed no fall mat present beside Resident #7's bed. On 04/17/18, at 09:40 AM, an interview with Staff #4 verified there was n… | 2020-09-01 |
| 98 | 98 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 880 | E | 1 | 0 | R6BQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and record review, the facility failed to carry out proper infection control practices. A resident's sheets and bed had multiple areas stained with blood, a staff member failed to ensure contact isolation procedures were utilized, and several resident's oxygen tubing was on the floor and not dated. This practice affected six (6) of eleven (11) residents observed. Resident identifier: #1, #2, #5, #7, #10, and #11. Facility census: 178. Findings include: a) Resident #10 An observation of Resident #10, on 04/16/18 at 11:00 AM, revealed the Resident was lying in bed. At the time of the observation the Resident's sheets and bed railings had multiple areas that were stained with blood. An interview with Certified Nursing Assistant (CNA) #50, on 04/16/18 at 11:00 AM, revealed the Resident must have scratched an open area and got blood on her bed and sheets. The CNA stated she would ensure the sheets were changed and the bed cleaned immediately. b) Resident #5 An observation of Resident #5, on 04/16/18 at 11:20 AM, revealed the Resident was lying in bed. The Resident was on contact isolation. CNA #1, entered the resident's room, pulled up her covers, and exited the room. The CNA did not wash her hands before or after touching the resident's covers nor use gloves. The CNA did not use any isolation equipment that was provided at the Resident's door. An interview with CNA #1, on 04/16/18 at 11:24 AM, revealed the Resident is on contact isolation. The CNA stated as long as she did not touch the resident then she did not have to wear any gloves or isolation precautions while in the room. An review of the Resident's physician orders, on 04/16/18 at 11:35 AM, revealed an order for [REDACTED]. A review of the facility policy titled Standard and Transmission-Based Precautions-Contact Precautions, with a revision date of 02/2018, was conducted on 04/16/18 at 11:45 AM. The policy stated for someone on Contact Precautions… | 2020-09-01 |
| 99 | 99 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 924 | E | 1 | 0 | R6BQ11 | > Based on observation and staff interview, the facility failed to ensure handrails were securely and firmly affixed to the walls. Several handrails throughout the facility were coming undone and were loose. This practice had the potential to affect more than a limited number of residents. Handrail identifiers: WV Building-A Hall, WV Building-B Hall, and WV Building C-Hall. Facility Census: 178. Findings included: a) Handrails A random observation of the WV Building A-Hall, B-Hall, and C-Hall, on 04/17/18 at 8:45 AM, revealed multiple loose handrails. The handrails were coming loose on the ends causing them not to be securely and firmly attached to the walls. An interview with the District Director of Clinical Services (DDCS), on 04/17/18 at 9:40 AM, revealed she was not aware of the handrails coming undone but would ensure they were looked at immediately. The DDCS stated the handrails should be secure. | 2020-09-01 |
| 100 | 100 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-08-23 | 679 | D | 0 | 1 | TKSO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, observations and review of policy and procedure for activities, the facility failed to invite and provide activities of interests for two of three residents reviewed for activities. Resident identifiers: #74 and #80. Facility census: 176. Findings included: a) Resident #74 1. Resident #74's medical record was reviewed on 08/22/18 at 09:46 AM. The resident was admitted on [DATE]. The Admission Minimum Data Set (MDS) assessment Section I revealed the resident had [DIAGNOSES REDACTED]. Section G0110, required extensive assistance of two with transfers. Section F0500, Interview for Activity Preferences, responses from the resident were reviewed and revealed that is was very important to have books, newspaper or magazines to read, music, news, group activities, favorite activities, religion and fresh air. The resident's activities care plan, dated 05/15/18, was reviewed on 08/22/18 at 10:18 AM. The care plan revealed the resident had an anticipated short stay and had interventions that included the following: ensure that the activities the resident attend are compatible with known interests, invite the resident to activities, provide a program of activities that is of interest, provide activity calendars, review resident activation needs, staff will informally visit on a regular basis to ensure leisure needs are being met, the resident needs assistance/escort to activity functions, attending church services, when resident chooses not to participate in organized activities, the resident prefers to spend time in room listening to music or reading. Observations were made of the resident on 08/20/18 at 03:35 PM of the resident in bed and awake. The television that was in front of the bed was not on. On 08/21/18 at 12:12 PM the resident was observed lying in bed asleep. On 08/22/18 at 08:57 AM the resident was observed in bed and had just finished breakfast, at 10:58 AM the resident was asleep in bed. On 08/23/… | 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 );