cms_WV
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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 |
| 4634 | 4634 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-02-26 | 225 | D | 0 | 1 | 4CE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, family interview, and policy review, the facility failed to report and/or investigate allegations of neglect for one (1) of seven (7) residents reviewed for allegations of neglect. Staff failed to identify allegations of neglect, consequently, the facility failed to report and/or investigate allegations Resident #83 did not receive adequate and timely incontinence care. Resident identifier: #83. Facility census: 117. Findings include: a) Resident #83 During an interview with the resident's daughter, who was also the resident's medical power of attorney (MPOA), on 02/23/16 from 2:30 p.m. to 3:00 p.m., she related she had entered the facility on 02/09/16 at lunchtime. The MPOA said she changed her mother and, There was no sign of stool in her brief, but when I wiped her vagina, there was a ball of stool with a little bit of blood. She related she looked for Registered Nurse (RN) #34, but as she was at lunch, she spoke with Licensed Practical Nurse (LPN) #72, who said she would pass it on. Resident #83's daughter added that her mother was hosptalized on [DATE] related to a urinary tract infection [MEDICAL CONDITION] related to E-coli (Escherichia coli - an organism found in the colon). She said her mother returned to the facility on [DATE], at which time she spoke with the director of nursing (DON) and RN #34 regarding her concerns about her mother not being cleaned. She added that on 02/18/16, she entered the facility at 7:00 a.m. and her mother was at breakfast. The daughter related her mother returned to the room around 8:00 a.m. and when providing incontinence care, again wiped stool from the resident's vagina, but there was no stool in the resident's brief. She said the infection control nurse entered the room and she showed her the washcloth with the stool on it. On 02/24/16 at 8:15 a.m., review of complaints, grievance logs, and incidents reported to State agencies, found no evidence that t… | 2019-08-01 |
| 4635 | 4635 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-02-26 | 226 | E | 0 | 1 | 4CE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, family interview, and policy review, the facility failed to implement its abuse/neglect policies for one (1) of seven (7) residents reviewed for allegations of neglect. The facility staff failed to identify allegations of neglect and failed to report and/or investigate the allegations that Resident #83's medical power of attorney voiced relative to the resident not receiving adequate and timely incontinence care. Resident identifier: #83. Facility census: 117. Findings include: a) Resident #83 During an interview with the resident's daughter, who was also the resident's medical power of attorney (MPOA), on 02/23/16 from 2:30 p.m. to 3:00 p.m., she related she had entered the facility on 02/09/16 at lunchtime. The MPOA said she changed her mother and, There was no sign of stool in her brief, but when I wiped her vagina, there was a ball of stool with a little bit of blood. She related she looked for Registered Nurse (RN) #34, but as she was at lunch, she spoke with Licensed Practical Nurse (LPN) #72, who said she would pass it on. Resident #83's daughter added that her mother was hosptalized on [DATE] related to a urinary tract infection [MEDICAL CONDITION] related to E-coli (Escherichia coli - an organism found in the colon). She said her mother returned to the facility on [DATE], at which time she spoke with the director of nursing (DON) and RN #34 regarding her concerns about her mother not being cleaned. She added that on 02/18/16, she entered the facility at 7:00 a.m. and her mother was at breakfast. The daughter related her mother returned to the room around 8:00 a.m. and when providing incontinence care, again wiped stool from the resident's vagina, but there was no stool in the resident's brief. She said the infection control nurse entered the room and she showed her the washcloth with the stool on it. On 02/24/16 at 8:15 a.m., review of complaints, grievance logs, and incidents reported… | 2019-08-01 |
| 4636 | 4636 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-02-26 | 246 | D | 0 | 1 | 4CE211 | Based on a random observation, staff interview, and family interview, the facility failed to ensure reasonable accommodations of needs for Resident #83. The resident's call light was not within reach. Resident identifier: #83. Facility census: 117. Findings include: a) Resident #83 An interview with Confidential Interviewee (CI) #1, revealed Resident #83's call bell was sometimes placed out of reach. The interviewee related the resident sometimes rang the bell a lot and did not think the staff liked it. An interview with CI #2 revealed Resident #83 required assistance with all of her basic needs. CI #2 related the resident was able to ring her call bell and sometimes rang it about every fifteen to twenty (15-20) minutes. The interviewee related the resident sometimes stayed on the light, and staff had to keep going back in the room. Review of the resident's care plan on 02/24/16 at 8:30 a.m., revealed it included, Frequently on call light wanting care provided although care just provided The care plan also indicated the resident sometime threw it (the call bell) and/or other things on the floor. The Kardex, a brief care plan for nurse aides, instructed, Place call light within reach. On 02/24/16 at 10:44 a.m., Nurse Aide #97 performed incontinence care for Resident #83. Upon completion, the NA exited the room. The resident was positioned on her back and the call bell was attached to the upper portion of the side rail at the head of the bed on the resident's right side. Upon inquiry, Resident #83 related she was capable of ringing her call bell if desired. Upon request for a demonstration, the resident reached for the call bell with her right hand, but could not reach the call bell. She then rolled toward the right and tried to use her left hand, but still could not reach the call light. Upon request, Resident #83 demonstrated for NA #97 she was unable to reach the light. The resident's medical power of attorney was also present during the demonstration. An interview with the director of nursing, on 02/24/16 at ab… | 2019-08-01 |
| 4637 | 4637 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-02-26 | 272 | D | 0 | 1 | 4CE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to accurately complete a comprehensive assessment to reflect the active [DIAGNOSES REDACTED]. Resident identifiers: #115 and #60. Facility census: 117. Findings include: a) Resident #115 On 02/24/16 at 6:00 p.m., a review of Resident #115's current physician's orders [REDACTED]. A review of the resident's care plan on 02/25/16 at 12:12 p.m., found an intervention, with the revision date of 10/13/15, Receives Anti-depressant: Administer [MEDICATION NAME] ([MEDICATION NAME]). On 02/25/16 at 12:33 p.m., review of the resident's significant change minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/16/15, found Item I5800 depression (other than [MEDICAL CONDITION]) was not coded to identify the resident had an active [DIAGNOSES REDACTED]. In an interview on 02/25/16 1:07 p.m., Clinical Case Coordinator Registered Nurse (CCCRN) #70 stated, I reviewed the significant change MDS and the MDS should have been coded as the resident having either depression or dysthymic disorder either under I5800, or I1800 - other additional active diagnosis. b) Resident #60 A review of the medical record on 02/25/16 at 9:00 a.m., revealed the Significant Change MDS, with an ARD of 12/22/15, revealed Section I - Active Diagnoses, did not include gout as a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. [MEDICATION NAME] 100 milligrams (mg) once daily for gout since 11/30/15. During an interview on 02/25/16 at 9:33 a.m., the MDS Coordinator reported she did not complete Section I of the comprehensive MDS assessment accurately to include the [DIAGNOSES REDACTED]. | 2019-08-01 |
| 4638 | 4638 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-02-26 | 312 | D | 0 | 1 | 4CE211 | Based on observation, confidential interview, staff interview, medial record review, resident interview, and family interview, the facility failed to ensure one (1) of two (2) dependent residents reviewed for activities of daily living received the necessary care and services to maintain good oral hygiene. Resident identifier: #83. Facility census: 117. Findings include: a) Resident #83 A Stage 1 family interview on 03/23/16 at 2:43 p.m., revealed Resident #83 did not receive activities of daily living (ADL) assistance with oral care needed to maintain good oral hygiene. The family member related the resident had partial plates which were broken and missing one (1) tooth. The care plan, reviewed on 02/24/15, at approximately 8:30 a.m., indicated staff would assist Resident #83 with oral care daily. The Kardex, a care plan utilized by nurse aides, indicated the resident had likely dental cavities and partial dentures A confidential interview on 02/24/16, revealed Resident #83 only received oral care when she requested it. The interviewee was not aware of any dental concerns related to natural teeth or the resident's dentures, and was not aware the resident's partial denture was broken. An observation on 02/24/15 at 1:30 p.m., revealed thick stringy debris in the resident's mouth. Upon inquiry as to how often oral hygiene was provided by staff, the resident related it was not often and not daily. An interview with the director of nursing (DON) indicated oral care should be provided every day and as needed. . | 2019-08-01 |
| 4639 | 4639 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-02-26 | 315 | D | 0 | 1 | 4CE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and family interview, and competency record reviews, the facility failed to ensure two (2) of five (5) residents observed for incontinence care received appropriate treatment and services to prevent urinary tract infections. Improper techniques were utilized during incontinence care. Resident identifiers: #83 and #6. Facility census: 117. Findings include: a) Resident #83 An interview with the resident's daughter, who was also the resident's medical power of attorney (MPOA), on 02/23/16 from 2:30 p.m. to 3:00 p.m., she said she had found the resident had not received good incontinence care on several occasions. She had reported she had found the resident unclean to Registered Nurse (RN) #34 about two (2) weeks prior to Resident #83's hospitalization on [DATE]. She said on 02/09/16 at lunch time, she changed her mother and found, There was no sign of stool in her brief, but when I wiped the resident's vagina, there was a ball of stool with a little bit of blood. She related she had spoken with Licensed Practical Nurse (LPN) #72, who said she would pass it on. She further added, on 02/18/16 she entered the facility at 7:00 a.m. when her mother was at breakfast. The resident returned to her room around 8:00 a.m. and when providing incontinence care, the daughter again wiped stool from her vagina. She related the infection control nurse entered the room and she showed her the washcloth and took the brief home with her. During an observation and interview on 02/24/16 at 1:45 p.m., Resident #83 said she was wet and needed changed. The resident related staff had not asked her if she needed changed after lunch. Observation of the room continued until staff entered the room to perform care. At 3:33 p.m., Resident #83 was placed back in bed and incontinence care was provided by NA #97 and NA #73. The NA utilized washcloths, and did not apply peri-wash until an inquiry as to the product used … | 2019-08-01 |
| 4640 | 4640 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-02-26 | 441 | E | 0 | 1 | 4CE211 | Based on observation, staff interview, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to maintain an infection control program to prevent the transmission and spread of disease and infection to the extent possible. Staff handled soiled briefs and clean and soiled linens incorrectly, staff failed to utilize proper hand hygiene during management of impaired skin integrity and incontinence care. These findings had the potential to affect more than a limited number of residents. Resident identifiers: #83 and #6. Facility Census: 117. Findings include: a) Resident #83 1. An observation of incontinence care on 02/23/16 at 1:41 p.m., revealed the resident had a large loose bowel movement. After setting up supplies, the director of nursing (DON) removed the resident's brief and proceeded with incontinence care with the assistance of Licensed Practical Nurse (LPN) #72. Observation revealed excoriation and denuded areas on the resident's groin, inner thigh gluteal folds, and buttock areas. The areas were bright red in color, and the resident related they were painful. Additionally, an elongated area on the coccyx was open and contained a yellow slough-like substance. After cleansing Resident #83's buttocks with peri-wash, LPN #72 removed the soiled sheet and placed a clean sheet beneath the resident's buttocks and applied a clean brief. The LPN requested the Phytoplex nourishing skin cream from the DON. With soiled gloves and without performing hand hygiene, the DON picked up the lotion and placed it on LPN #72's soiled glove used to remove the bowel moment. The LPN proceeded to place the cream over all of Resident #83's wounds LPN #72 removed her gloves and washed her hands for a total count of nine (9) seconds. After the wash basin was rinsed, the DON removed her gloves, and with un-gloved hands placed the contaminated lotion container in the bath basin and placed the basin in the resident's closet. 2. During an observation on 02/24/16 at 10:44 a… | 2019-08-01 |
| 4740 | 4740 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 157 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to notify the responsible party, of an incapacitated resident, when the resident experienced a significant weight loss within thirty (30) days. This was true for one (1) of eleven (11) resident's reviewed during a complaint survey ending on 07/07/16. Resident identifier: #5. Facility census: 113. Findings include: a) Resident #5 Record review of the resident's weights at 7:30 a.m. on 07/07/16, found the following documented weights in the electronic medical record: --04/04/16 - 107 pounds --05/03/16 - 88.9 pounds --05/10/16 - 91.8 pounds --05/19/16 - 90.2 pounds --05/26/16 - 85 pounds --06/01/16 - 88.5 pounds --06/07/16 - 86.2 pounds --06/16/16 - 86.2 pounds --06/21/16 - 88.5 pounds --07/01/16 - 88.6 pounds The most recent nutritional assessment, completed on 04/27/16, by a registered dietician, revealed the following for Resident #5: --The resident's height was 63 inches and her weight was 107.0 pounds --The resident received a pureed diet with limitation of potassium rich foods. --A supplement previously initiated, but discontinued due to the resident's improved intake and weight gain. --The resident received a snack at 2:00 p.m. --The resident's previous weight loss and underweight body mass index was noted. --However, the resident's current weight at 107 pounds triggered as a significant gain. --The resident's body mass index noted as now within healthy limits, weight gain desirable --The resident noted as currently eating/drinking well with desirable weight gain. Review of the nursing notes found a, weight warning, note dated 05/06/16. The note indicated the resident had a continual and gradual weight loss despite the snacks and regular meals orders, and the assistance with eating. The noted indicated physician notification. Further record review found the physician had determined the resident lacked capacity to make medical decisions. The date the incapacity statement was… | 2019-07-01 |
| 4741 | 4741 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 280 | D | 1 | 0 | R67611 | > Based on record review and staff interview, the facility failed to revise the care plan for Resident #2 when the resident's therapeutic diet changed. This was true for one (1) of eleven (11) resident's whose care plans were reviewed during the complaint survey ending on 07/07/16. Resident identifier: #2. Facility census: 113. Findings include: a) Resident #2 Review of the resident medical record on 07/05/16 at 2:00 p.m. found a diet order, dated 05/25/16, for a dysphagia advanced diet with thin liquids. Review of the current care plan, updated on 06/13/16, revealed the problem as, Resident is at nutritional risk. The goals associated with this problem were: --Resident will have no signs or symptoms of dehydration and --Resident will maintain a stabilized weight with no significant changes. Interventions included: --Provide regular liberalized dysphagia puree diet with nectar thickened liquids as ordered with 8 ounces whole milk with meals. An interview with the dietary manager (DM), #67, at 4:15 p.m. on 07/05/16 verified the intervention on the care plan addressing nutritional status was incorrect. DM #67 stated the resident no longer received a liberalized dysphagia puree diet with nectar thickened liquids. He stated he diet was upgraded on 05/25/16, after an evaluation by the speech therapist. | 2019-07-01 |
| 4742 | 4742 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 309 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to consistently assess, monitor and attempt to manage or prevent Resident #7's pain. For Resident #1 the facility failed to follow the physician's orders [REDACTED]. This was true for two (2) of eleven (11) resident's medical records reviewed for quality of care during a complaint survey, ending on 07/07/16. Resident identifiers: #7 and #1. Facility census: 113. Findings include: a) Resident #7 Record review on 07/06/16 at 8:30 a.m. found a sixty-four (64) year old female resident admitted to the facility on [DATE]. The resident was discharged from a hospital, to the facility, for rehabilitation following total bilateral knees arthroplasty on 05/19/16. Other [DIAGNOSES REDACTED]. The facility's nursing notes, upon admission, indicated the resident was alert and oriented and able to voice her needs. Less than twenty-four (24) hours later, on 05/25/16, at 2:02 p.m., the resident was discharged to the hospital. Admitting medications included: [MEDICATION NAME]/[MEDICATION NAME] 5/325 to be administered every 4 hours, as needed, for pain. The hospital discharge summary noted the resident received her last dose of the pain medication at 3:00 p.m. on the day of discharge (05/24/16). Review of the nursing notes found the following documentation: --At 10:30 p.m. on 05/24/16, the resident was refusing to have CMP machine (continuous passive motion machine used for knee joint recovery) placed on at this time, currently waiting on pain medication from pharmacy. Pharmacy request for pain medication was faxed at 7:00 p.m. --A nursing note written at 6:59 a.m. on 05/25/16 revealed the resident resting in bed at this time. Upon putting resident on bed pan noted a small opened area to her right buttocks. Pain medication given as ordered due to the complaint of pain. Resident is complaining of some discomfort at this time but refuses pain medications said she feels different as of last dose giv… | 2019-07-01 |
| 4743 | 4743 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 325 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure two (2) of eleven (11) resident's records reviewed for the care area of nutritional status, maintained acceptable parameters of nutrition. For Resident #5, the facility failed to monitor the resident's significant weight loss (18 pounds in 30 days), and failed to ensure interventions implemented to address the resident's significant weight loss, remained in place. The facility failed to address Resident #9's (who is feed via a Percutaneous endoscopic gastrostomy (PEG) tube) 5 % weight loss and failed to monitor the resident's weight after admission for four (4) weeks to ensure further weight loss did not occur. Resident identifiers: #5 and #9. Facility census: 113. Findings include: a) Resident #5 Record review of the resident's weights at 7:30 a.m. on 07/07/16, found the following documented weights in the electronic medical record: --04/04/16-107 pounds --05/03/16 - 88.9 pounds --05/10/16 - 91.8 pounds --05/19/16 - 90.2 pounds --05/26/16 - 85 pounds --06/01/16 - 88.5 pounds --06/07/16 - 86.2 pounds --06/16/16 - 86.2 pounds --06/21/16 - 88.5 pounds --07/01/16 - 88.6 pounds The most recent nutritional assessment, completed on 04/27/16, by a registered dietician, revealed the following for Resident #5: --The resident's height was 63 inches and her weight was 107.0 pounds --The resident received a pureed diet with limitation of potassium rich foods. --A supplement previously initiated, but discontinued due to the resident's improved intake and weight gain. --The resident received a snack at 2:00 p.m. --The resident's previous weight loss and underweight body mass index was noted. --However, the resident's current weight at 107 pounds triggered as a significant gain. --The resident's body mass index noted as now within healthy limits, weight gain desirable --The resident noted as currently eating/drinking well with desirable weight gain. Review of the nursing notes found… | 2019-07-01 |
| 4744 | 4744 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 329 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility failed to ensure Resident #8's drug regimen was free from unnecessary medications. Resident #8 received excessive doses of an intravenous (IV) antibiotic. This was true for one (1) of 11 sampled residents. Resident Identifier: #8 Facility Census: 113. Findings include: a) Resident #8 A review of Resident #8's medical record at 1:30 p.m. on 07/06/16 found a physicians order dated 04/06/16 for [MEDICATION NAME] 3.375 milligrams IV every six (6) hours for 10 days. The resident was to receive a total of 40 doses of this medication. Review of the Medication Administration Record [REDACTED]. Resident #8 should have received her last dose of [MEDICATION NAME] on 4/16/16 at 6:00 p.m. however she received four doses on 04/17/16. She received a dose at 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m. on 04/17/16. She also received a dose at 12:00 a.m. on 04/18/16. These findings were reviewed with the Director of Nursing (DON) at 5:00 p.m. on 07/06/16 and with the Nursing Home Administrator (NHA) in the morning of 07/07/16. At 12:42 p.m. on 07/07/16 the NHA and DON both confirmed they had not additional information to provide in regards to these findings. | 2019-07-01 |
| 4745 | 4745 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 365 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to ensure the resident received the therapeutic diet ordered by the physician. This was true for one (1) of six (6) resident's whose meal service was observed during the complaint survey ending on 07/07/16. Resident identifier: #2. Facility census: 113. Findings include: a) Resident #2 Observation of the noon meal on 07/05/16 at 12:30 p.m. found Resident #2 eating the substitute meal, a(NAME)salad. The salad contained chunks of breaded chicken on a bed of lettuce. Review of the current physician's orders [REDACTED]. Interview with the speech therapist (PT) #98 at 2:10 p.m. on 07/05/16, revealed a dysphagia diet consists of serving soft vegetables, soft foods, with meats ground up. PT #98 stated a resident on this diet could have lettuce but should not have chunks of breaded chicken. At 3:21 p.m. on 07/05/16, the dietary manager (DM) #67 verified the resident's salad should have had ground chicken instead of the breaded chunks of chicken. DM #67 stated the resident was first served the regular meal which she did not want. The resident then requested the(NAME)salad which was the substitute meal. He said his staff probably did not know who the salad was for when requested by staff serving food in the dining room. | 2019-07-01 |
| 4746 | 4746 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 508 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility failed to obtain a chest x-ray ordered for Resident #9 by her attending physician. This was true for one (1) of eleven (11) sampled residents. Resident Identifier #9. Facility Census: 113. Findings Include: a) Resident #9 A review of Resident #9's medical record at 12:30 p.m. on 07/05/16 found a physician order [REDACTED]. Incentive spirometry 4 times daily. Repeat CXR (Chest X - Ray) after 4 (four) days. Further review of the record found the following nursing progress notes dated 12/19/16 (typed as written): . Now order to repeat chest x - ray post 4 days of PT left chest . Progress note date 12/21/15 noted, Resident resting in bed at this time. Resident was evaluated by respiratory therapy for incentive spirometry QID (four times a day) and chest PT daily. After initial treatment, resident had some coughing noted but no excretions emitted. Progress note dated 12/22/16 noted, Resident see (sic) by respiratory therapy today for chest pt and incentive spirometry. Resident has had some non productive coughing post incentive spirometry. Breath sounds are diminished in all fields. Respiratory therapy to continue for another two (2) days with follow up chest x-ray to be done on 12/26/15. Further review of the record found no evidence the x-ray ordered for 12/26/15 was ever obtained by the facility. The physician entered a progress note into Resident #9's record on 01/10/16 indicating there resident had completed Chest PT and needed a repeat chest x -ray. The repeat chest x-ray was again ordered on [DATE] and was obtained on 01/11/16. An interview with the Director of Nursing (DON) at 10:46 a.m. on 07/06/16 confirmed the x-ray which should have been obtained on 12/26/15 was not obtained as ordered by the physician. She stated, The next x-ray was not obtained until 01/11/16. She indicated, they must have missed getting it. | 2019-07-01 |
| 4747 | 4747 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 514 | D | 1 | 0 | R67611 | > Based on record review and staff interview the facility failed ensure complete documentation was in the medical record for meal consumption, snack intake and a neurological assessment. This was evident for four (4) of eleven (11) medical records reviewed. Resident Census was: 113. Findings include: a) Resident #1 On 07/07/16 at 2:25 p.m., a review of the medical record for this resident revealed the facility had not completed daily meal intake documentation. For the month of (MONTH) there were no intakes listed for breakfast on : 06/02, 06/14/16, 06/20/16, 06/26/16 and 06/28/16. There was no documentation of meal intakes at lunch on : 06/02/16, 06/08/16, 06/11/16, 06/14/16, 06/20/16, 06/26/16 and 06/28/16. Likewise, there was no intakes listed for dinner on : 06/07/16, 06/08/16, 06/09/16, 06/11/16, 06/12/16, 06/14/16, 06/16/16, and 06/26/16. Snack intakes were only shown to be given on 06/01/16, 06/02/16, 06/03/16, 06/15/16, 06/17/16, 06/18/16, 06/19/16, 06/22/16, 06/23/16, 06/24/16, 06/28/16 and 06/29/16. All the other days of the month were blank with no indication it was given and accepted or refused. b) Resident #3 Documentation of this medical record on 07/07/16 at 2:30 p.m. revealed no documentation for meal intake for the following occasions in (MONTH) (YEAR): --breakfast 06/11/16, 06/17/16, 06/18/16; --lunch: 06/11/16; and --dinner: 6/2/16, 6/6/16, 6/9/16, 6/12/16, 6/19/16, 6/24/16 and 6/26/16. c) Resident #4 A review of this resident's medical record on 07/07/16 at 2:40 p.m. indicated there was no documentation for meal intakes on the following occasions in (MONTH) (YEAR): --breakfast: 06/02/16, 06/11/16, 06/12/16, 06/14/16, 06/18/16, 06/19/16, 06/24/16, 06/25/16; --lunch: 06/02/16, 060/3/16, 06/11/16, 06/12/16, 06/14/16, 06/16/16, 06/18/16, 06/19/16, 06/24/16, 06/25/16; and --dinner: 06/02/16, 06/10/16, 06/12/16, 06/15/16, 06/17/16, 06/19/16, 06/20/16, and 06/25/16. All of these dates were verified with Employee #111 on 07/07/16 at 3:15 p.m. at which time she was given time to present any further evid… | 2019-07-01 |
| 5691 | 5691 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 203 | D | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, the facility failed to notify the resident and/or the family in writing of: 1) the reason for the resident's discharge from the facility, 2) the effective date of transfer or discharge, 3) a statement that the resident had the right to appeal the action to the State, and 4) the name, address and telephone number of the State long term care ombudsman. This was evident for one (1) of three (3) residents reviewed for the care area of admission, transfer, and discharge. Resident #83 was transferred to a local hospital for exit seeking behaviors. The facility did not provide the resident or family member/legal representative the necessary documentation necessary at the time of the discharge. Resident identifier: #83. Facility census: 108. Findings include: a) Resident #83 The record review for Resident #83, on 01/28/15 at 1:30 p.m., revealed the facility discharged Resident #83 to a local hospital on [DATE] for exit seeking and combative behaviors. During Stage 1 of the Quality Indicator Survey (QIS), the facility provided a copy of information provided to residents upon transfer or discharge. The facility provided a form entitled, Notification of Transfer/Discharge. The form required the facility to complete the effective date of the transfer, the reason for the resident's discharge, a statement that the resident had the right to appeal the action to the State, and the name, address and telephone number of the State long term care ombudsman. At 2:30 p.m. on 01/28/15, the administrator was asked for a copy of the information provided to the Resident #83 and/or his family at the time of discharge. Review of the facility's policy, entitled, Discharge and Transfer found, All patients will receive a Notice of Transfer or Discharge and/or Discharge Transition Plan whenever a voluntary or involuntary transfer/discharge occurs . At 3:00 p.m. on 01/28/15 the medical record clerk, Employee… | 2018-08-01 |
| 5692 | 5692 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 224 | D | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure two (2) of three (3) residents reviewed for nutrition were free from neglect. Goods and services for the prevention of weight loss were not provided as ordered. Resident identifiers: #16 and #74. Facility census: #108. Findings include: a) Resident #16 Review of the weights and vital sign summary found the resident's most recent weight was 117.8 pounds on 01/20/15. The previous recorded weight was 131 pounds on 12/23/14. A nutritional assessment was completed on 11/04/14. The registered dietitian noted the resident had a 7.5% weight loss (a significant weight loss) in the past three (3) months. The dietitian ordered a house supplement and other interventions to address the resident's weight loss. During the survey, on 01/21/15, the resident was still receiving a house supplement, four (4) ounces, two (2) times a day at 10:00 a.m. and 2:00 p.m. At 2:50 p.m. on 01/21/15; the resident was sitting in her chair with a bedside table which contained two (2) cartons of the house supplement. Observation found the resident had not consumed any of the supplements. The paper cartons containing the supplements, were opened; however, the resident had no straw and no glass. Review of the Medication Administration Record [REDACTED]. At 2:57 on 01/21/15, the administrator and the director of nursing (DON) were asked to observe the supplement which was still on the resident's bedside table and to review the MAR. The DON confirmed the consumption of the supplement and the documentation on the MAR indicated [REDACTED] b) Resident #74 Review of the weights and vital sign summary found the resident weighed 165 pounds when admitted on [DATE]. Her last recorded weight was 140.9 pounds on 01/20/15. On 01/06/15, the physician ordered a house supplement, four (4) ounces two (2) times a day, at 10:00 a.m. and 2:00 p.m., for weight loss. At 12:53 p.m. on 01/22/1… | 2018-08-01 |
| 5693 | 5693 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 225 | F | 0 | 1 | WCKU11 | Based on staff interview and review of employee personnel files, the facility failed to conduct a thorough investigation into the criminal background of one (1) of five (5) employees hired within the past five (5) months. Employee #126 lived out of the state of West Virginia in the previous 5 years. The facility did not complete a fingerprint based criminal background check in the state in which the employee lived. This had the potential to affect all residents residing at the facility. Employee identifier: #126. Facility census: 108. Findings include: a) Employee #126 Review of the personnel files with Employee #27, identified as the bookkeeper, at 3:50 p.m. on 01/26/15 found Employee #126, a nurse aide, had lived in another state from 2007 to 2014. Employee #27 confirmed a criminal background check had not been completed in the other state. | 2018-08-01 |
| 5694 | 5694 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 241 | D | 0 | 1 | WCKU11 | Based on observation and staff interview, the facility failed to provide a dining experience with dignity for one (1) randomly observed resident receiving assistance with eating during a noontime meal. A nurse aide fed Resident #22 while standing beside the resident, rather than sitting down beside the resident and feeding her in a relaxed manner. Resident identifier: #22. Employee identifier: #11. Facility census: 108. Findings include: a) Resident #22 On 01/20/15 at 12:10 p.m., an observation of nurse aide (NA) #11 revealed the nurse aide in Resident #22's room feeding her. Resident #22 was seated in her reclining chair located near the foot of her bed. The NA was standing between the foot of the bed and Resident #22. The NA stood while feeding the resident for the duration of the meal. At 12:20 p.m. on 01/20/15, upon inquiry as to the way a resident should be fed, Employee #11 replied, I knew when I saw you, I should have been sitting down, but my hips hurt too bad to sit down. On 01/20/15 at 2:30 p.m., when made aware of the dining observation, the administrator agreed the NA should have been seated while feeding the resident. | 2018-08-01 |
| 5695 | 5695 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 242 | E | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, record reviews, review of shower schedules, and staff interviews, the facility failed to ensure two (2) of three (3) residents reviewed for the care area of choices were afforded the right to exercise autonomy regarding an important aspect of their lives. Both residents were not afforded the opportunity to receive their preference for two (2) showers a week. Resident identifiers: #132 and #75. Facility census: 108. Findings include: a) Resident #132 1. At 2:00 p.m. on 01/19/15, Resident #132 was asked if she was able to choose how many times a week she wanted to take a bath or shower. She replied, No I have had only had one (1) shower the entire time I have been here. She further indicated her daughter had called and talked to the staff about it the previous week, but it did not do any good because she had still not received a shower. When asked how many showers she would like to have in a week, Resident #132, stated, The two (2) I was scheduled for would be fine with me, but I do not even get those. Observations of Resident #132 made at this time revealed, her hair appeared to be unclean and oily. 2. A review Resident #132's medical record at 1:48 p.m. on 01/22/15, revealed Resident #132 was initially admitted to the facility on [DATE]. She remained in the facility until 10/08/14 when she was discharged to the hospital. Between 09/23/14 and 10/08/14, Resident #132 was scheduled to receive a shower on 09/25/14, 09/29/14, 10/02/14, and 10/06/14. A review of Resident #132's Activities of Daily Living (ADL) record for 09/23/14 through 10/08/14 revealed Resident #132 received a shower on 10/02/14 and did not receive her other three (3) scheduled showers. There were no documented shower refusals for Resident #132 during this time frame. 3. Resident #132 was readmitted from the hospital to the facility on [DATE]. She remained at the facility until 12/09/14 when she was discharged back to the hospital. Bet… | 2018-08-01 |
| 5696 | 5696 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 246 | D | 0 | 1 | WCKU11 | Based on observation and staff interview, the facility failed to provide a reasonable accommodation of individual needs for one (1) of forty (40) sampled residents observed during Stage 1 of the survey process. The call bell for a resident who was in bed, was lying on the floor out of reach under the bed. Resident identifier: #105. Facility census: 108. Findings include: a) Resident #105 An observation on 01/20/15 at 9:00 a.m., revealed the call bell for Resident #105 lying on the floor beneath the resident's bed. At 9:05 a.m. on 01/20/15, upon inquiry, Licensed Practical Nurse (LPN) #23, said the resident was able to make his needs known and to communicate well with the nurse aides. In an interview on 01/20/15 at 9:10 a.m., Nurse Aide (NA) #91 said Resident #105 was able to make his needs known, and was capable of using his call bell when he needed assistance. The NA was asked to observe the positioning of the call bell for Resident #105. The NA entered the resident's room, observed the call bell lying beneath the resident's bed, and promptly secured the call bell within the resident's reach. She verified the call bell should always be secured within reach of the resident. | 2018-08-01 |
| 5697 | 5697 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 272 | D | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, review of the Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument Manual, and staff interview, the facility failed to accurately complete comprehensive minimum data (MDS) assessments for three (3) of nineteen (19) residents whose MDSs were reviewed. The MDS for dental status was not accurate for Resident #137. The MDS in the area of skin conditions (pressure ulcers) was not accurate for Resident #75. The MDS was not accurate for Resident #132 in the area of medications. Resident identifiers: #137, #75, and #132. Facility census: 108. Findings include: a) Resident #137 Observation of the resident's oral cavity during an interview in Stage 1 of the Quality Indicator Survey (QIS), at 9:27 a.m. on 01/20/15, found he had discolored, broken, and missing teeth. When asked if he had problems with his teeth, the resident replied, Yes, my teeth are falling out just like an old horse. Review of the annual MDS with an assessment reference date (ARD) of 07/01/14 found Section (L), entitled oral/dental status, identified the resident as having no obvious cavity or broken natural teeth (L0200). At 4:45 p.m. on 01/20/15, the MDS coordinator, Employee #22, examined the resident's oral cavity. She confirmed the resident had discolored and missing teeth. Observation of the teeth on the bottom left revealed several teeth were black and broken at the gum line. She said she had not completed the oral exam herself, but relied on nursing documentation to complete the MDS. An annual nursing assessment completed on 07/01/14 revealed the nurse completing the assessment had checked the teeth located on the upper right, lower right, and lower left were all in poor condition. At 9:15 a.m. on 01/21/15, the director of nursing stated the annual MDS did not capture the resident's dental problems. The director of nursing said the facility would correct this MDS assessment. b) Resident #75 On 01/26/15 … | 2018-08-01 |
| 5698 | 5698 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 278 | D | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the health professional(s) who completed and certified the accuracy of portions of the minimum data set (MDS) assessments for two (2) of nineteen (19) sampled residents, failed to ensure all items in the sections were accurately coded. Section M of Resident #75's and Resident #124's assessments did not accurately reflect the residents' status regarding pressure ulcers. Resident identifiers: #75 and #124. Facility census: 108. Findings include: a) Resident #75 On 01/26/15 at 2:30, a review of Resident #75's admission nursing assessment dated [DATE], revealed the resident had an old surgical scar on the right knee. The quarterly minimum data set (MDS) assessment was reviewed on 01/26/13 at 1:00 p.m. Review of Section M of the minimum data set, with an assessment reference date (ARD) of 12/18/14, found Item M0100A was coded as the resident having a Stage I or greater pressure ulcer, a scar over a bony prominence, or a non-removable dressing/device. Item M0210 addressed the risk for pressure ulcers to develop. It was coded as the resident was not at risk of developing pressure ulcers. In an interview with the MDS Nurse #20, on 01/29/15 at 3:15 p.m., she said this resident did not have a Stage I or greater pressure ulcer, a scar over a bony prominence, or a non-removable dressing/device. She acknowledged the quarterly MDS was incorrectly coded. b) Resident #124 On 01/20/15 at 4:30 p.m., review of the resident's medical record revealed [REDACTED]. In Section M, Skin Conditions, Item M0300, addressing the current number of unhealed pressure ulcers at each stage, identified the resident had one (1) Stage II pressure ulcer. However, Item M0100, was not checked to indicate the resident had a Stage I or greater pressure ulcer. On 01/20/15 at 5:25 p.m., MDS Nurse #22, upon review of the resident's MDS assessment, verified Resident #124 had a Stage II pressure ulcer at the time the assessment had been completed,… | 2018-08-01 |
| 5699 | 5699 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 279 | D | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan to meet the assessed needs of three (3) of nineteen (19) residents whose care plans were reviewed in Stage 2 of the Quality Indicator Survey (QIS). Resident #93's care plan did not address the resident's activity goals, preferences or special needs related to activities. Resident #124 had an actual pressure ulcer, which was not addressed on her comprehensive care plan. Additionally, Resident #74's urinary incontinence status was not addressed on her comprehensive care plan. Resident identifiers: #93, #124, and #74. Facility census: 108. Findings include: a) Resident #93 A review of Resident #93's medical record on 01/28/15 at 9:25 a.m., revealed a recreation assessment dated [DATE]. This assessment indicated the following summary and goals for Resident #93 (typed as written), Resident is alert and able to voice needs with some confusion. Speech is clear. Vision impaired needs large print. Up in w/c (wheelchair) and transported by staff. She is friendly and likes to talk. Activities of interests are bingo, church, parties, and socials. Activities calendar provided and invited to attend activities. Material offered for self-directed activities. A review of Resident #93's care plan revealed no focus, goals or interventions pertaining to the resident's activities interests, need for large-print items, or her activity goals. The facility identified these activities of interest in the recreation assessment dated [DATE]. An interview with the Certified Activity Director (CAD) at 9:49 a.m. on 01/28/15, confirmed the care plan did not address Resident #93's activity goals, which the facility identified in the recreational assessment dated [DATE]. She stated she usually wrote a care plan for every resident, but must have missed Resident #93. b) Resident # 124 During a review of the care plan for Resident #124, on 01/21/15 at 8:20 a.m., a focus a… | 2018-08-01 |
| 5700 | 5700 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 280 | D | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to re-evaluate and revise the comprehensive care plans for two (2) of nineteen (19) residents whose care plans were reviewed, when the residents' status changed. Resident #74's care plan was not revised when her activity preferences changed. Resident #122's care plan was not revised when her pain medication was discontinued. Resident identifiers: #74 and #122. Facility census: 108. Findings include: a) Resident #74 Review of the resident's medical record found the resident came to the facility on [DATE]. A recreational assessment, completed on 11/11/14, listed the resident's religion as Methodist. According to the assessment, it was very important for the resident to participate in religious services. An activities care plan, developed on 11/17/14, identified a problem of, Resident would benefit from opportunities to make decisions/choices related for self-directed or group involvement in meaningful activities. Prefers to remain in room at this time. The goal associated with this problem was, Resident will plan and choose to engage in preferred group activities enjoys bingo and church or in room self-directed activities through next review. On 12/22/14, the facility created a new recreational assessment for this resident. The assessment listed the resident's religion as Christian. The assessment also indicated the resident did not consider it important to attend religions services. The facility did not revise the current care plan when the resident no longer expressed an interest in attending church services. In an interview at 2:00 p.m. on 01/21/15, the activity director, Employee #38, confirmed she had interviewed the resident on 12/22/14 and the resident had stated it was not important at all for her to participate in religious activities. b) Resident #122 A review of Resident #122's care plan at 10:14 a.m. on 01/28/15, revealed a focus of (typed as written), PAIN: Res… | 2018-08-01 |
| 5701 | 5701 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 282 | E | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, and staff interview, the facility failed to implement the interventions established in care plans for four (4) of nineteen (19) residents whose care plans were reviewed in Stage 2 of the survey. Resident #75 and Resident #132 did not receive showers as directed by the care plan. Resident #54 did not have her vital signs taken before and after her [MEDICAL TREATMENT] treatments as directed by the care plan. Resident #137 did not have interventions implemented in accordance with his care plan when the resident refused care. Resident identifiers: #75, #54, #137, and #132. Facility census: 108. Findings include: a) Resident #75 During Stage 1 of the Quality Indicator Survey, at 1:47 p.m. on 01/19/15, the resident was asked, Do you choose how many times a week you take a bath or shower? The resident replied, They don't tell me when I am getting a shower. I am supposed to get two (2) a week, but I don't know when they are scheduled. Medical record review revealed Resident # 75 was scheduled to receive showers twice a week on Tuesdays and Friday on the 7-3 shift. Review of the care plan identified the resident had a self-care deficit related to cognitive impairment, muscle weakness, visual impairment, and shortness of breath at times. The goal regarding this was for the resident to continue to participate in activities of daily living (ADLs), continue to be independent to supervision only with ADL functions and to have a neat, clean well groomed appearance, be appropriately dressed, be odor free, and needs met daily. An intervention was, Baths and showers per schedule and when necessary (PRN). Skin checks, shower, shampoo hair, nail care and lotion PRN. Review of the medical record for (MONTH) 2014, found the resident did not receive showers on six (6) of nine (9) scheduled days as directed by the care plan. Review of the (MONTH) (YEAR) documentation found the resident did not receive a shower… | 2018-08-01 |
| 5702 | 5702 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 309 | E | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility policy, and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of [MEDICAL TREATMENT] during Stage 2 of the Quality Indicator Survey (QIS) received care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment. The facility failed to ensure Resident #54, who received [MEDICAL TREATMENT], was assessed at the nursing facility before and after [MEDICAL TREATMENT]. In addition, the facility failed to correlate the resident's care with the [MEDICAL TREATMENT] center and failed to follow facility policy for care of a resident receiving [MEDICAL TREATMENT]. Resident identifier: #54. Facility Census: 108. Findings include: a) Resident #54 Medical record review found the resident was receiving [MEDICAL TREATMENT] via an arteriovenous (AV) fistula in the left arm three (3) days a week, on Tuesdays, Thursdays and Saturdays, at an offsite [MEDICAL TREATMENT] center. The resident had resided at the facility since 07/28/14 and had been receiving [MEDICAL TREATMENT] since admission.The medical record contained copies of a [MEDICAL TREATMENT] communication record, shared by the facility and the [MEDICAL TREATMENT] center. The facility was to complete the top half of the form, which included the resident's vital signs before the resident left the facility for [MEDICAL TREATMENT], an examination of the shunt site, the time of the resident's last meal, medication given prior to [MEDICAL TREATMENT], the resident's general condition, and special instructions. The [MEDICAL TREATMENT] center was to complete the bottom half of the form which also included obtaining vital signs, lab work done, medications given, intake and output, monitoring the shunt site for location, the condition of the dressing, ports, pain and any other pertinent information.Neither the facility, no… | 2018-08-01 |
| 5703 | 5703 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 312 | E | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, and staff interview, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) without staff assistance, received the necessary care and services to maintain good grooming and personal hygiene. Resident #132 was only provided a shower and/or offered a shower on multiple occasions. On occasion, she refused when offered, but asked to be showered the following morning. There was no evidence that upon these refusals the facility staff offered and/or provided a shower the following morning. One (1) of five (5) residents reviewed for Activities of Daily Living, Cleanliness and Grooming were affected. Resident Identifier: #132. Facility Census: 108. Findings Include: a) Resident #132 1. At 2:00 p.m. on 01/19/15 Resident #132 was asked if she was given the opportunity to choose how many times a week she took a bath or shower, she replied, No I have only had one (1) shower the entire time I have been here. She further indicated her daughter had called and talked to the staff about it last week, but it did not do any good because she has still not received a shower. Observations of Resident #132 made at this time noted her hair was unclean and oily. 2. A review Resident #132's medical record at 1:48 p.m. on 01/22/15 revealed Resident #132 was initially admitted to the facility on [DATE]. She remained in the facility until 10/08/14 when she was discharged to the hospital. Between 09/23/14 and 10/08/14 Resident #132 was scheduled to receive a shower on 09/25/14, 09/29/14, 10/02/14 and 10/06/14. A review of Resident #132's Activities of Daily Living (ADL) record for 09/23/14 through 10/08/14 revealed Resident #132 was only showered on 10/02/14 and did not receive her other three (3) scheduled showers. There were no documented shower refusals for Resident #132 during this time frame. Further record review found an Admission Minimum Data Set (MDS) with an a… | 2018-08-01 |
| 5704 | 5704 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 315 | E | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interview, the facility failed to ensure a resident, who had a decline in bladder functioning shortly after admission to the facility, received a thorough assessment to determine if any services could be provided to restore or improve bladder functioning. The facility completed a three-day voiding diary but did not identify the type of incontinence present and did not determine if the resident could benefit from a toileting program to restore or improve the resident's urinary incontinence. This was true for one (1) of three (3) residents reviewed for the care area of urinary incontinence during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #74. Facility census: 108. Findings include: a) Resident #74 Resident #74 was admitted to the facility on [DATE]. Review of admission minimum data set (MDS) with an assessment reference date (ARD) of 11/11/14, found Section H - Urinary Incontinence, Item H0300 identified the resident as being frequently incontinent of urine (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). A significant change MDS with an ARD of 12/23/14 indicated the resident was always incontinent of urine (no episodes of continent voiding) in Item H0300. A three-day Bowel and Bladder Continence Evaluation was completed from 6:00 p.m. on 12/16/14 through 5:00 p.m. on 12/19/14. The evaluation was to be completed by checking the following: - The type of incontinence: functional, mixed, overflow, stress, transient, and urge. - The type of program and state reason for choice: A restorative program with bladder re-training or prompted voiding, or scheduled voiding, or check and change. - The last step required documentation of interventions on the resident's care plan and nursing assistant care card as applicable. This information had not been completed on the evaluation. The facility failed to identify the type of inco… | 2018-08-01 |
| 5705 | 5705 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 323 | E | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, record review, and staff interview, the facility failed to provide a resident environment, in which the facility had control over, that was as free from accident hazards as possible. Resident #132 had multiple falls while a resident at the facility. Resident #132 often self-ambulated in her room with assistance from her walker. The facility put in place a fall mat at her bedside, which caused Resident #132 to experience a fall. This was true for one (1) of three (3) residents reviewed for the care area of accidents during Stage 2 of the Quality Indicator Survey. Resident identifier: #132. Facility census: 108. a) Resident #132 An observation of Resident #132 at 2:00 p.m. on 01/19/15, revealed a Band-Aid just above her left eye. When asked what had happened to her forehead, Resident #132 stated, I got up to go to the bathroom and they had one of them rugs down and it caused me to fall and hit my head. She further stated, They took it out of here after I fell because it caused me to fall. Review of facility records at 4:00 p.m. on 01/20/15, revealed an incident/accident report for Resident #132 dated 01/15/15. The circumstances of the event were described as follows, Resident was witnessed falling in front of sink. Resident was ambulating with walker without assistance to restroom and fell . Resident hit head on floor causing a superficial laceration above the left eye . The incident/accident report also indicated the immediate actions taken to the safeguard the resident were (typed as written), Skin and Pain evaluation first aid applied to laceration above left eye. DC (discontinue) fall mats, encourage resident to ask for assistance and use call light. A review of Resident #132's medical record at 4:20 p.m. on 01/20/15, revealed a physician's orders [REDACTED].#132's bed. A review of Resident #132's activities of daily living record for the dates of 12/30/14 through 01/15/15 revealed resident was inde… | 2018-08-01 |
| 5706 | 5706 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 329 | E | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary medications. One (1) resident (#54) identified through random opportunity for discovery, and one (1) of ten (10) residents reviewed for unnecessary medications, were affected. Resident #54, did not have a dosage reduction of [MEDICATION NAME] ([MEDICAL CONDITION] medication) as recommended by the nephrologist when the resident was discharged from the hospital. The facility physician did not provide a clinical rationale as to why the medication was not reduced. Resident #120, reviewed for unnecessary medications received [MEDICATION NAME] after the medication had been discontinued by the physician. Resident identifiers: #54 and #120. Facility census: 108. Findings include: a) Resident #54 Medical record review for Resident #54 on 01/26/15 at 11:00 a.m., revealed a hospital discharge summary in which the nephrologist recommended decreasing the [MEDICATION NAME] to 30 milligrams (mg) until 01/10/15. Further medical record review revealed an order from the facility physician for [MEDICATION NAME] 75 mg everyday on 01/07/15. The order was for one (1) tablet of [MEDICATION NAME] to be given daily until 01/10/15. The medical record did not contain a clinical rationale from the resident's attending physician at the facility regarding why the dose of [MEDICATION NAME] was not reduced as recommended by the nephrologist upon the resident's discharge from the hospital. On 01/26/15 at 2:00 p.m., the director of nursing verified there was no clinical rationale provided by the facility's attending physician for not reducing the [MEDICATION NAME] as recommended by the nephrologist when the resident was discharged from the hospital on [DATE]. b) Resident #120 On 11/21/14, the pharmacist reviewed the resident's drug regimen and recommended the medication, [MEDICATION NAME] 20 milligrams (mg) be discontinued because the medica… | 2018-08-01 |
| 5707 | 5707 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 406 | D | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide specialized rehabilitative services (physical therapy) for Resident #74 after the physician ordered the therapy services. This was true for one (1) of three (3) residents reviewed for the care area of rehabilitation. Resident identifier: #74. Facility census: 108. Findings include: a) Resident #74 Review of the medical record found the resident went out for a consult with a general surgeon on 01/06/15. This physician had handwritten on the consult report, Needs Physical Therapy. Upon return to the facility, the resident's attending physician also wrote an order on 01/06/15 for the resident to have physical therapy. Further review of the medical record found a nurse's note, written on 01/06/15 at 10:31 a.m., .Return from appointment with (name of the surgeon) physical therapy needed, physical therapy aware of request On the morning of 01/26/15, the director of the therapy department, Employee #46, a speech therapist, was asked when the resident was last evaluated for physical therapy. Employee #46 stated physical therapy discharged the resident from their services on 12/24/14 for refusing to participate. When asked if the therapy department had evaluated the resident since that time, she replied, No. When asked about the physician's orders [REDACTED]. The director of nursing (DON) was interviewed at 4:23 p.m. on 01/26/15. She said nursing had done their part and written an order for [REDACTED]. | 2018-08-01 |
| 5708 | 5708 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 411 | D | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, observation, and staff interview, the facility failed to obtain dental services for one (1) of three (3) residents reviewed for the dental care area during Stage 2 of the Quality Indicator Survey. The facility staff had knowledge the resident's lower dentures were broken and subsequently became lost on or before 12/30/14, but failed to make the necessary arrangements for the resident's identified dental needs. Resident identifier: #132. Facility census: 108. Findings Include: a) Resident #132 An interview with Resident #132 at 2:08 p.m. on 01/19/15, found she was having difficulty chewing some foods because her lower dentures were missing. She stated she had her teeth from (MONTH) 2014 until her most recent readmission to the facility a few weeks ago (12/30/14). She stated while she was out to the hospital the facility staff moved her things from one room to another, and her lower dentures were lost. When asked if she had told anyone at the facility her teeth were missing, she stated, Yes I told everyone the nurse aides, the nurses, and the big boss. She indicated the facility staff told her they looked for them, but were unable to locate her dentures. When asked if anyone had offered to make her a dental appointment to see about getting a new set of dentures she replied, No one has offered to do anything to help get them replaced. At 11:07 a.m. on 01/22/15, the Director of Nursing (DON) performed an oral assessment on Resident #132. The note written by the DON relating to this oral assessment contained the following text (typed as written): .Resident and family member confirmed that bottom set of dentures was later brought into the facility however was broken and glued to fit and then was dropped by the resident and re-broken and was misplaced before they could be glued for resident to wear again The DON indicated in this progress note the facility would consult Resident #132's preferred dentist fo… | 2018-08-01 |
| 5709 | 5709 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 441 | E | 0 | 1 | WCKU11 | Based on observation and staff interview, the facility did not maintain an infection control program which prevented, to the extent possible, the development and transmission of disease and infection. This was true for ten (10) residents who received a snack/supplement on East wing on 01/22/15. Resident #81 took the snacks and supplements out of a cooler. A staff member assisted the resident in finding his snack/supplement, then placed the snacks back into the cooler. The staff member failed to return the snack/supplements to the kitchen after they were contaminated, and they were later distributed to ten (10) separate residents. Resident identifiers: #81, #8, #147, #16, #137, #9, #74, #53, #171, #176, and #32. Facility census: 108. Findings include: a) Snack/Supplement Pass Observation An observation at 10:13 a.m. on 01/22/15 revealed Resident #81 was taking snacks and supplements out of the East wing cooler. Registered Nurse (RN) #107 (East wing unit manager) was asked if Resident #81 should be going through the snack/supplement cooler, she stated, No. RN #107 approached Resident #81 and helped him find his supplement and put the remainder of the snacks/supplements back into the cooler. At 10:22 a.m. on 01/22/15, nurse aide (NA) #71 began passing the snacks/supplements contained in the cooler. She passed a snack/supplement to Resident #8, Resident #147, Resident #16, Resident #137, Resident #9, and Resident #74. RN #107 approached NA #71, while she was passing snacks, and stated, Mr. (Resident #81's last name) was helping himself to those (referring to the snack/supplements). NA #6 also passed snacks/supplements from the cooler to Resident #53, Resident #171, and Resident #176. NA #123 also passed a supplement to Resident #32 from the cooler. An interview with the Director of Nursing at 12:30 p.m. on 01/22/15 confirmed RN #71 should have returned the snacks/supplements to the kitchen for new snacks/supplements after Resident #81 went through the cooler. She indicated the staff should not have distributed the sn… | 2018-08-01 |
| 5710 | 5710 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 514 | D | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for one (1) of nineteen (19) medical records reviewed during Stage 2 of the Quality Indicator Survey. Resident #93's admission nursing and nutritional assessments contained an inaccurate weight. Additionally, a nursing assessment did not accurately represent Resident #93's bowel and bladder continence status. Resident identifier: #93. Facility census: 108. Findings include: a) Resident #93 1. A review of Resident #93's medical record on 01/27/15 at 9:17 a.m., revealed a nursing admission assessment dated [DATE], which indicated Resident #93 weighed 164.6 pounds. Resident #93's medical record also contained a nutrition assessment dated [DATE]. This nutrition assessment indicated the resident's weight was 164.6 pounds. Further review of Resident #93's medical record found a nursing progress note dated 12/31/14, which contained the following text (typed as written), Resident admitted to the facility with DX (diagnosis) of adult FTT (failure to thrive) and nutritional mairasmus (marasmus - a form of severe malnutrition characterized by energy deficiency) with entered into PCC (the facility's computer program) incorrectly re-weight of 99.2 (pounds) in wheelchair. Review of Resident #93's weight record indicated the weight of 164.6 pounds, which was obtained on admission was struck out by the director of nursing (DON) on 12/31/14 when a re-weight of 99.2 pounds was obtained and entered into the resident's weight record. An interview with the DON at 4:00 p.m. on 01/27/14 confirmed the weight of 164.6, recorded on the nursing admission assessment and the nutrition assessment was inaccurate. She indicated the resident only weighed 99.2 pounds on 12/31/14 and there was no way she lost that much weight in one (1) week. She indicated whoever completed her admission entered the wrong weight into the medical record. 2. A review of Resident #93… | 2018-08-01 |
| 7077 | 7077 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2014-08-08 | 157 | D | 1 | 0 | 16RF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and interview with a resident's guardian, the facility failed to promptly notify the resident's legal representative of a change in the resident's condition for one (1) of seven (7) residents reviewed. The legal representative was not notified when Resident #115 was transferred to the hospital. Resident identifier: #115. Facility census: 113. Findings include: a) Resident #115 Review of the electronic medical record, on 08/07/14 at 8:07 a.m., revealed a nurse's note indicating Resident #115 was transferred to the hospital by ambulance on 10/24/13 for complaints of increased weakness. The minimum data set (MDS) with an assessment reference date (ARD) of 10/24/13, indicated an unplanned discharge to an acute hospital. Further review of the medical record revealed a psychiatric review, indicating the resident lacked capacity to make medical decisions. Additionally, the resident was appointed a legal guardian, who would make medical decisions on her behalf, until 11/16/13. During an interview, on 08/07/14 at 8:15 a.m., the legal guardian indicated she was not notified of the change in condition, or transfer to the hospital. Further review of the medical record, revealed no evidence the facility attempted to notify the resident's legal guardian. An interview with the director of nurses (DON) on 08/07/14 at 10:30 a.m., revealed the facility required staff to notify the medical power of attorney, guardian . of a change in condition. She indicated staff would enter a notation on the physician's orders [REDACTED]. She reviewed the medical record and confirmed no evidence was present to indicate the facility attempted to notify the legal guardian. | 2017-08-01 |
| 7078 | 7078 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2014-08-08 | 314 | G | 1 | 0 | 16RF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and medical record review, the facility failed to ensure that a resident having pressure sores received necessary treatment and services to prevent new sores from developing for one (1) of three (3) residents reviewed with pressure ulcers. A resident developed a Stage III pressure ulcer before staff identified skin impairment. Resident identifier: #68. Facility census: 113. Findings include: a) Resident #68 An electronic medical record review, on 08/08/14 at 9:00 a.m., revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission assessment noted pressure ulcers (PU) on his upper mid back. Review of physician's orders [REDACTED]. They indicated a Stage II PU on his left lower back and a Stage III PU on his left hip. The Stage III pressure ulcer, in-house acquired, measuring 1.5 centimeters (cm) x 1.5 cm x 0.5 cm with 1 cm undermining/tunneling at 12:00 (12:00 indicates the anatomical position of the undermining/tunneling). Review of the pressure ulcer logs revealed the tissue around the wound was inflamed and the wound had purulent drainage. According to the resident's admission minimum data set assessment (MDS), with an assessment reference date of 05/16/14, the resident scored 15 on his Brief Interview for Mental Status (BIMS) indicating he was cognitively intact. His [DIAGNOSES REDACTED]. According to the assessment, the resident was at risk for developing pressure ulcers and was also noted to have existing pressure ulcers. During an interview with Resident #68, on 08/08/14 at 10:00 a.m., he related he had been in the facility a few months related to a neck injury. The resident said he could move his extremities, but could not feel them. The resident said he was aware of the pressure ulcers, but related he could not feel them due to the paralysis. He indicated he was unable to determine whether he had a skin impairment. An interview with Employe… | 2017-08-01 |
| 7154 | 7154 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 248 | D | 0 | 1 | XYYM11 | Based on observation, family interview, record review, and staff interview, the facility failed to provide an activity program according to a resident's identified interests and needs for one (1) of three (3) sampled residents. The facility did not ensure Resident #107 was consistently invited/reminded to attend group activities. Resident identifier: #107. Census: 111. Findings include: a) Resident #107 Observations, during Stage 1 of the Quality Indicator Survey (QIS), on 09/09/13, and during the morning hours of 09/10/13, found the resident was in his room. He did not come out of his room to attend activities. During an interview with Resident #107's family, on 09/09/13 at 3:07 p.m., a family member voiced a concern the resident had not been reminded/invited to attend group activities. On 09/13/13, review of the resident's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 04/27/13, found under Item F0500 E., the resident was assessed as liking to attend group activities. Review of the resident's activity/recreation assessment, on 09/13/13 at 3:15 p.m., found Resident #107 was assessed as liking large group activities. The resident's care plan was reviewed on 09/13/13 at 3:20 p.m. One (1) of the interventions was for the resident to be provided reminders of activities and to be invited to attend activities. Review of the activity attendance sheet, on 09/1313 at 3:30 p.m., revealed the resident had not been consistently invited/reminded to attend group activities. An interview was conducted on 09/11/13 at 10:15 a.m. with Employee #108, the activities director (AD). When asked, Does the staff remind/invite the resident to attend group activities?, she replied, We have no documentation that the resident was consistently invited/reminded and assisted to attend group activities. She further stated, The resident has not attended group activities due to behaviors. When asked, Does the resident have any documented behaviors during activities?, she confirmed there was no evidence Resident #107… | 2017-07-01 |
| 7155 | 7155 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 272 | D | 0 | 1 | XYYM11 | Based on medical record review and staff interview, the facility failed to complete an accurate minimum data set (MDS) assessment for one (1) of thirty-one (31) Stage 2 sample residents. Resident #174's assessment was not coded accurately regarding urinary continence. Resident identifier: #174. Census: 111. Findings include: a) Resident #174 Review of the resident's significant change MDS assessment, with an assessment reference date (ARD) of 07/01/13, on 09/11/13 at 11:00 a.m., found assessment item H0300 was coded to identify the resident as always incontinent Further review of the medical record, on 09/11/13 at 11:20 a.m., found copies of the Resident Functional Performance Record, completed daily by the nursing assistants, which reflected the resident was continent of bladder functioning during the look back period, 06/25/13 through 07/01/13, the time frame for which the MDS was completed. Employee #63, a registered nurse MDS manager, was interviewed on 09/11/13 at 12:55 p.m. Employee #63 compared the information from the Resident Functional Performance Record to the 07/01/13 MDS and stated, It would appear the resident was continent. She stated she did not complete the MDS and she would send Employee #55, who had completed the MDS, to speak with the surveyor. At 1:28 p.m. on 09/11/13, Employee #55, a registered nurse MDS manager, stated she was responsible for completion of the resident's 07/01/13 MDS. Employee #55 verified the look back period for the 07/01/13 MDS was 06/25/13 through 07/01/13. She looked at the Resident Functional Performance Record completed by the nursing assistants and stated, I made a mistake, she was continent of bladder. I will complete a corrected MDS and submit it. She provided a copy of her MDS collective data used to complete the 07/01/13 MDS. She stated, I knew she was continent when I completed the MDS, I just made a mistake. On 09/11/13 at 2:00 p.m., the administrator stated the facility did not have a policy pertaining to the completion of the MDS. She stated the facility jus… | 2017-07-01 |
| 7156 | 7156 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 278 | D | 0 | 1 | XYYM11 | Based on medical record review and staff interview, the individual completing and certifying the accuracy of the minimum data set (MDS) assessment for one (1) of thirty-one (31) sample residents failed to ensure the assessment was coded accurately. Resident #174's assessment did not accurately reflect the resident's urinary continence status. Resident identifiers: #174. Census: 111. Findings include: a) Resident #174 Review of the resident's significant change MDS assessment, with an ARD of 07/01/13, on 09/11/13 at 11:00 a.m., found assessment item H0300 was coded to identify the resident as always incontinent Further review of the medical record, on 09/11/13 at 11:20 a.m., found copies of the Resident Functional Performance Record, completed daily by the nursing assistants, which reflected the resident was continent of bladder functioning during the look back period, 06/25/13 through 07/01/13, the time frame in which the MDS was completed. Employee #63, a registered nurse MDS manager, was interviewed on 09/11/13 at 12:55 p.m. Employee #63 compared the information from the Resident Functional Performance Record to the 07/01/13 MDS and stated, It would appear the resident was continent. She stated she did not complete the MDS and she would send Employee #55, who had completed the MDS, to speak with the surveyor. At 1:28 p.m. on 09/11/13, Employee #55, a registered nurse MDS manager, stated she was responsible for completion of the resident's 07/01/13 MDS. Employee #55 verified the look back period for the 07/01/13 MDS was 06/25/13 through 07/01/13. She looked at the Resident Functional Performance Record completed by the nursing assistants and stated, I made a mistake, she was continent of bladder. I will complete a corrected MDS and submit it. She provided a copy of her MDS collective data used to complete the 07/01/13 MDS. She stated, I knew she was continent when I completed the MDS, I just made a mistake. On 09/11/13 at 2:00 p.m. the administrator stated the facility did not have a policy pertaining to the com… | 2017-07-01 |
| 7157 | 7157 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 280 | D | 0 | 1 | XYYM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the care plan for one (1) of thirty-one (31) residents reviewed during Stage 2 of the survey. The physician ordered the discontinuation of a resident's anti-anxiety medication. A subsequent revision of the resident's care plan contained focus statements and interventions related to the use of the anti-anxiety medication. Resident Identifier: #88. Facility Census: 111. Findings Include: a) Resident #88 The resident's medical record was reviewed at 2:34 p.m. on 09/10/2013. This review revealed a physician's orders [REDACTED]. The resident's care plan was reviewed. The care plan had revision dates of 09/06/13 and 09/07/13. The post-revision care plan included a focus statement of Potential for decline in mood and cognition related to [DIAGNOSES REDACTED]. An additional focus on the care plan was, Chronic/Progressive decline characterized by: deficit in memory, judgement, decision making and thought process related to dementia/Alzheimer Disease. Receiving anti-anxiety medication for dementia, and anti-depressant (being used for appetite stimulant). The resident's care plan also contained the following intervention related to the resident's ineffective coping skills, Administer medications as ordered for dementia and anxiety. The care plan also indicated the facility should monitor for side effects of the anti-anxiety medication. Employee #1, Director of Nursing (DON), was interviewed at 8:21 a.m. on 09/11/13. She confirmed the resident's anti-anxiety medication was discontinued and the resident was not receiving any other anti-anxiety medication at that time. The DON confirmed Resident #88's care plan contained focus statements and interventions which indicated the resident was still receiving an anti-anxiety medication. She confirmed the revision date of the care plan was after the date the resident's anti-anxiety medication was discontinued and the care plan should have b… | 2017-07-01 |
| 7158 | 7158 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 282 | D | 0 | 1 | XYYM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to implement a comprehensive care plan for one (1) of thirty-one (31) Stage 2 sample residents. Resident #105's care plan included interventions related to monitoring the resident's [MEDICAL TREATMENT] site. Review of the resident's medical record found no evidence the facility implemented the care plan to assess the resident's [MEDICAL TREATMENT] site as identified in the care plan. Resident identifier: #105. Facility census: 111. Findings include: a) Resident #105 Review of this resident's medical record identified this resident received [MEDICAL TREATMENT] services outside of the facility. Review of the resident's care plan found a plan had been established to observe the Tessio site (the [MEDICAL TREATMENT]) for signs and symptoms of infection. Review of the treatment record for Resident #105 found no evidence the interventions to assess the Tessio site had been implemented. An interview conducted with Employee #1 (director of nursing), on 09/10/13, at 3:30 p.m., confirmed the facility failed to implement the interventions to assess the resident's Tessio site. . | 2017-07-01 |
| 7159 | 7159 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 309 | D | 0 | 1 | XYYM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and medical record review, the facility failed to ensure one (1) of thirty-one (31) Stage 2 sample residents was provided care and services as ordered by the physician. The facility failed to implement the resident's physician's orders [REDACTED]. Resident identifier: #139. Facility census: 111. Findings include: a) Resident #139 During Stage 1 of the quality indicator survey (QIS), Employee #18, the unit manager on south wing (the unit where Resident #139 resided) was interviewed at 1:03 p.m. on 09/09/13. When asked the question from the QIS, Does the resident receive a nutritional supplement, defined as a prescribed high protein high calorie nutritional supplement between or with meals (there must be documentation in the medical record), Employee #18 stated, Yes, then showed the current Medication Administration Record [REDACTED]. Resident #139 was interviewed during Stage 1 of the QIS at 2:11 p.m. on 09/09/13. When asked about the food, the resident stated, I gained 2 or 3 pounds when I got a milkshake, but they don't send it anymore. Haven't had one for 2 or 3 weeks. The resident explained he had lost weight and he felt he needed the milkshake, to gain some more weight. According to the resident, he liked the milkshakes and he needed them. Upon conclusion of the interview with the resident, at 2:30 p.m. on 09/09/13, Employee #3, a nursing assistant, was outside the resident's door passing the 2:00 p.m. snacks. Upon inquiry regarding Resident #139's supplement, Employee #3 stated the resident only had a cookie on the snack cart. She stated, He used to get a milkshake, but he hasn't had one for a while now. Employee #3 then gave the cookie to Resident #139. The director of nursing (DON) appeared during the interview with Employee #3 and stated she would go get a milkshake for the resident. At 3:00 p.m. on 09/09/13, observation revealed the resident had consumed 100% of the milkshake… | 2017-07-01 |
| 7160 | 7160 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 329 | D | 0 | 1 | XYYM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure one (1) of five (5) a residents who triggered the care area of unnecessary medications during Stage 2 of the quality indicator survey (QIS) was free from unnecessary medications. The resident was receiving [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The facility failed to identify the specific behaviors exhibited by the resident for which the medication was prescribed. Failure to identify the specific behaviors also affected the facility's ability to monitor the actual benefit of the medication. Resident identifier: #30. Facility census: 111. Findings include: a) Resident #30 Medical record review found the resident was receiving the anti-anxiety medication, [MEDICATION NAME] 0.5 milligrams (mg) two (2) times a day for a [DIAGNOSES REDACTED]. Review of the facility's psychopharmacological drug monthly flow records, for 06/06/13 through 09/10/13, found the specific behaviors exhibited by the resident for the use of [MEDICATION NAME] were not described. Each of the monthly flow records listed only anxious as the behavior exhibited by the resident. The director of nursing (DON), on 09/10/13 at 4:04 p.m., was asked how nursing staff were monitoring the resident to determine if the [MEDICATION NAME] was effective. The DON stated she had just provided an in-service on this particular subject two (2) weeks ago. She stated the September 2013 flow record should identify the specific behaviors exhibited by the resident which warranted the use of [MEDICATION NAME]. When the DON provided a copy of the monthly flow record for September, she stated, I can't believe they did this, they know anxious is not a behavior. During the interview, the DON also acknowledged there were no behaviors documented on the behavior monitoring sheets. She also confirmed the behavior monitoring sheets did not describe any specific behaviors for the use of [MEDICATION NAME]. Review of the nurses… | 2017-07-01 |
| 7161 | 7161 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 505 | D | 0 | 1 | XYYM11 | Based on medical record review and staff interview, the facility failed to ensure the physician was notified of all laboratory results in a timely manner for one (1) of five (5) Stage 2 sample residents reviewed for laboratory results. Resident identifier: #21. Facility census: 111. Findings include: a) Resident # 21 Review of medical records, on 09/11/13 at 1:00 p.m., found laboratory tests (Basic Metabolic Panel (BMP) and Complete Blood Count (CBC)) had been ordered and obtained for Resident #21 on 09/09/13. The attending physician was called the results of the CBC on 09/09/13. No verification could be located to indicate the results of the BMP had been called to the physician. An interview with Employee #1, the director of nursing (DON), on 09/11/13 at 3:10 p.m., confirmed the attending physician was not notified of the results of the BMP. The DON said both of the tests were ordered STAT (immediately). The facility received the results of the CBC, but not the BMP. The DON said it was the facility's responsibility to call the lab if results were not provided. She confirmed the facility failed to ensure the receipt of the BMP results and notify the physician. | 2017-07-01 |
| 7162 | 7162 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-09-16 | 514 | E | 0 | 1 | XYYM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure medical records were complete, accurately documented, readily accessible, and/or systematically organized for five (5) of thirty-one (31) Stage 2 sample residents, and one (1) resident identified through a random opportunity for observation. Resident #67's physician's order did not contain the amount of eye drops to be administered. Resident #139 was not receiving a house supplement as ordered; however, staff documented the consumption of a snack on the record as the house supplement consumption. Resident #37's admission nursing assessment and skin integrity reports had conflicting measurements and location of pressure ulcers documented. Resident #184's hospice order was not placed on the monthly orders. Nursing staff continued to document on the medication record after a medication was discontinued for Resident #88. Medication administration records for Resident #150 were found in Resident #88's medical records. Resident identifiers: #67, #37, #139, #184, #88, and #150. Facility census: 111. Findings include: a) Resident #67 Review of medical records, on 09/12/13 at 9:00 a.m., revealed a physician's order for [MEDICATION NAME] 0.5% eye drops solution, twice a day; left eye. An interview was conducted with Employee #45, licensed practical nurse, (LPN) on 09/12/13 at 9:26 a.m. When asked how she determined how many eye drops to instill in the left eye, she said, The order should contain how many drops to instill. At that time, she confirmed the resident's order did not contain how many eye drops to instill in the left eye. b) Resident #37 Review of the resident's medical records, on 09/11/13 at 10:00 a.m., revealed the admission nursing assessment and skin integrity reports had conflicting measurements and locations regarding the resident's pressure ulcers. The admission nursing assessment indicated the resident had a pressure ulcer on the left hip and coccyx. Both were … | 2017-07-01 |
| 7340 | 7340 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2014-05-29 | 164 | D | 1 | 0 | MSKF11 | Based on observation, review of facility policy and procedure, and staff interview, the facility failed to provide personal privacy for a resident during an observation of a pressure ulcer on the resident's coccyx. When observing Resident #59 ' s pressure ulcer, the nursing staff did not close the blinds to the window in the resident ' s room or pull the privacy curtains completely around the resident's bed. This was true for one (1) of five (5) residents whose pressure ulcers were observed. Resident identifier: #59. Facility census: 117. Findings include: a) Resident #59 On 05/29/14 at 11:10 a.m., during an observation of Resident #59's Stage II pressure ulcer located on the coccyx, Employee #43, a registered nurse (RN), did not close the blinds to an outside window. A parking lot was located outside the window where random observations revealed people walked down the sidewalk to their cars. In addition, the privacy curtain was pulled the length of Resident #59's bed, but was not pulled around the foot of the bed. Two (2) visitors and a roommate were also in the room during the observation. A review of the facility ' s policy and procedure titled Wound Dressings: Aseptic, on 05/29/14 at 1:45 p.m., revealed Section 7. included, Explain the procedure and provide privacy. The nursing home administrator (NHA) and the director of nursing (DON) were present during this policy and procedure review. When asked whether she agreed there was a problem with providing privacy during the observation of Resident #59's pressure ulcer, the NHA smiled and shrugged her shoulders. | 2017-05-01 |
| 7341 | 7341 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2014-05-29 | 280 | D | 1 | 0 | MSKF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the care plan for a resident was revised to reflect the nothing by mouth (NPO) status when the resident was receiving nourishment by tube feeding. This was true for one (1) of three (3) sample residents reviewed with tube feedings. Resident identifier: #5. Facility census: 117. Findings include: a) Resident #5 On 05/28/14 at 2:26 p.m., a review of Resident #5 ' s care plan revealed an intervention, dated 05/20/14, of Encourage increased fluid intake. An intervention, dated 05/21/14, was to Offer fluids frequently, encourage to drink all fluids offered on trays. Water pitcher in reach at bedside. A review of the current physician's orders [REDACTED]. On 05/28/14 at 3:30 p.m., an interview with the nursing home administrator (NHA) revealed she had been made aware of this care plan issue by her staff and had implemented an audit of all resident care plans who were receiving tube feedings to ensure there were no other issues with the care plans. | 2017-05-01 |
| 7342 | 7342 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2014-05-29 | 441 | E | 1 | 0 | MSKF11 | Based on observation, facility policy and procedure review, review of the Center for Medicare and Medicaid Services (CMS) State Operations Manual (SOM) handwashing procedure, review of the Centers for Disease Control handwashing recommendations, and staff interview, the facility failed to ensure staff employed proper handwashing techniques, and practiced aseptic dressing procedure to prevent cross contamination and the spread of infection. Nursing staff members (Employees #43 and 82) were observed using paper towels to turn off the water faucet, then dry their hands with the contaminated paper towels for. During a pressure ulcer dressing change on Resident #23, the nurse placed a bag directly on the resident ' s bed and returned the bag to the treatment cart used for all residents, thereby potentially cross contaminating all dressing bags in the treatment cart. A nurse placed a clean dressing and a hydrogel container on Resident #23 ' s over-bed table without benefit of a barrier to prevent contamination of the dressing materials. These practices had the potential to affect more than a limited number of residents. Resident identifiers: Resident #6, #5, #59, and #23. Facility census: 117. Findings include: a) Resident #6 On 05/29/14 at 11:00 a.m., Employee #82, a nurse, was observed washing her hands, turning off the water faucet with paper towels and then drying her hands with the contaminated paper towels after providing care to the resident. b) Resident #5 On 05/29/14 at 11:06 a.m., Employee #82, a nurse, was observed washing her hands, turning off the water faucet with paper towels and then drying her hands with the contaminated paper towels after providing care to the resident. c) Resident #59 On 05/29/14 at 11:10 a.m., two (2) nurses (Employee #82 and #43) were observed washing their hands, turning off the water faucet with paper towels, and then drying their hands with the contaminated paper towels after providing care to this resident. When brought to the attention of Employee #82, she agreed she had not f… | 2017-05-01 |
| 8181 | 8181 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-08-01 | 279 | D | 1 | 0 | HEN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan reflective of an accurate assessment of the resident. The resident had a deep tissue injury (DTI) to his buttocks. According to the care plan, a contributing factor related to the development of the DTI was incontinence; however, the resident had a suprapubic catheter and a [MEDICAL CONDITION]. This was true for one (1) of four (4) residents whose care plan was reviewed during the complaint investigation. Resident identifier: #82. Facility census: 111. Findings include: a) Resident #82 Medical record review, on 07/30/13, found a care plan for the DTI, initiated on 07/29/13. The care plan addressed a problem of DTI to left buttocks surrounded by incontinence associated [MEDICAL CONDITION] (IAD) related to immobility and incontinence. Further review of the medical record found the resident had a suprapubic catheter and a [MEDICAL CONDITION] before the development of the DTI. At 5:00 p.m. on 07/30/13, the director of nursing verified the care plan was not correct. She stated incontinence was not a contributing factor in the development of the DTI as the resident had a suprapubic catheter and a [MEDICAL CONDITION] before the development of the DTI. | 2016-07-01 |
| 8182 | 8182 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-08-01 | 282 | D | 1 | 0 | HEN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure licensed nursing staff followed the facility's written care plan for Resident #116 related to the maintenance of a Foley catheter. This was true for one (1) of seven (7) residents whose care plans were reviewed during the complaint survey. Resident identifier: #116. Facility census: 111. Findings include: a) Resident #116 Resident #116 was noted to have an indwelling Foley catheter due to [MEDICAL CONDITION] and hypertrophy of the prostate with urinary obstruction. Review of care plan, on 07/30/13 at 11:00 a.m., found an intervention for the nursing staff to Empty catheter drainage bag every shift and record. Review of medical records, on 07/30/13 at 12:00 p.m., found the staff did not consistently record the amount emptied from the catheter bag as directed by the written care plan. In interviews with Employee #56, a licensed practical nurse (LPN), and Employee #47, a registered nurse (RN), on 07/30/13 at 12:30 p.m., both confirmed the catheter bags were emptied every shift and the urine outputs were not recorded routinely. Occasionally the licensed nurse did record the output in the nurses' notes. In an interview conducted on 07/30/13 at 1:30 p.m., Employee #1, the director of nursing, (DON) confirmed the staff did empty catheter bags every shift, but did not record the resident's output every shift as directed in the resident's written care plan. | 2016-07-01 |
| 8183 | 8183 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-08-01 | 309 | D | 1 | 0 | HEN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure consistent assessment, monitoring, and evaluation of a resident who had an indwelling Foley catheter. This practice affected one (1) of five (5) residents reviewed during the complaint survey who had an indwelling Foley catheter. Resident identifier: #116. Facility census: 111. Findings include: a) Resident #116 Review of medical records, on 08/01/13 at 11:30 a.m., noted this resident had been admitted to the facility on [DATE]. The resident had an indwelling Foley catheter due to [MEDICAL CONDITION] and hypertrophy of the prostate with urinary obstruction. Review of nurses' notes found a note written by Employee #66, a licensed practical nurse (LPN), on 07/15/13 at 2:45 p.m. The nurse noted (typed as written), Foley cath changed due to leaking. 24 french 30 cc balloon placed without difficulty. Redness to right and left groin area noted, treatment ordered. The next nurse's note concerning the Foley catheter was written on 07/20/13 at 12:00 p.m. The nurse noted Foley cath to BSD (bedside drainage) intact, no leaking, sediment urine noted. The next nurse's note concerning the Foley was dated 07/25/13 at 10:30 p.m. The nurse documented Foley patent to BSD (bedside drainage) with approx. 300 cc of urine, dark yellow. During an interview with Employee #1, the director of nursing (DON), on 08/01/13 at 1:00 p.m., it was confirmed from review of nurses' notes, the licensed staff had not consistently assessed, monitored, and evaluated the Foley catheter and the nature and amount of the resident's urinary output. | 2016-07-01 |
| 8184 | 8184 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-08-01 | 441 | D | 1 | 0 | HEN111 | Based on observation, medical record review, and staff interview, the facility failed to maintain proper care of a resident's catheter to prevent the spread of infection. Observation found the resident's catheter drainage bag was lying on the floor. This was true for one (1) of four (4) observations of residents with catheters. Resident identifier: #82. Facility census: 111. Findings include: a) Resident #82 During the initial tour of the facility, on 07/30/13, the resident was in bed at 9:45 a.m. on 07/30/13. His catheter drainage bag was lying on the floor beside the bed. Employee #46, the assistant director of nursing (ADON) was in the hallway outside the resident's room at 9:45 a.m. on 07/30/13. She was asked to witness the observation. She entered the room and stated, I will get a new bag and change it because of infection control issues. She verified the catheter bag should not be lying on the floor. At 5:00 p.m. on 07/30/13, the director of nursing (DON) was made aware of the above situation. She stated the resident could have knocked the catheter onto the floor by moving around in bed. Further review of the resident's care plan found a problem, initiated on 07/29/13, related to the resident's deep tissue injury, which stated the resident was immobile. Review of the resident's most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/27/13, found Item G0110, (activities of daily living assistance - bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture,) reflected the resident required the extensive assistance of two (2) staff persons to complete the activity of moving while in bed. . | 2016-07-01 |
| 8185 | 8185 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-08-01 | 514 | D | 1 | 0 | HEN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of facility policy and procedure, the facility failed to ensure a permanent entry in the resident's medical record was not changed after being recorded. This was true for one (1) of seven (7) medical records reviewed during the complaint survey. Resident identifier: #82. Facility census: 111. Findings include: a) Resident #82 Review of the resident's current care plan, located on the medical record, on 07/30/13 at 10:15 a.m. found a handwritten entry to the care plan, Deep tissue injury (DTI) to left buttocks surrounded by IAD (incontinence related [MEDICAL CONDITION]) related to immobility and incontinence, this entry was dated 07/29/13. On 07/30/13 at 10:30 a.m. the unit manager, Employee #47, was asked to make a copy of the resident's care plan. When she returned with the care plan, the original problem was no longer on the care plan. A new care plan problem had been written and dated 07/29/13, Deep tissue injury to left buttocks surrounded by MASD (moisture associated [MEDICAL CONDITION]) related to immobility. The surveyor found Employee #47 and Employee #34, a registered nurse, at the nurses station at 10:35 a.m. on 07/30/13. The surveyor spoke to both employees and asked who had changed the original care plan. Employee #34 stated she had re-written the care plan because it was incorrect. Employee #34 stated she saw the resident's DTI could not be due to incontinence because the resident had a catheter and a [MEDICAL CONDITION]. During the discussion with Employees #47 and #34, the director of nursing (DON) came to the nurses' station. The DON told Employee #34 she should have, yellowed out the problem and corrected it on the original copy. Employee #34 was asked for the original copy of the care plan and she said she could not find it. The DON found the original copy of the care plan in the trash can, torn into pieces. The DON stated she would tape the care plan t… | 2016-07-01 |
| 8633 | 8633 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-03-28 | 371 | E | 0 | 1 | 8VU011 | Based on observation, staff interview, and the facility's Dented Can Policy, the facility failed to ensure proper food storage to prevent possible foodborne illness. This had the potential to affect more than a limited number of residents. Facility census: 109. Findings include: a) On 03/26/13 at 8:50 a.m., during an observation of the kitchen food pantry, a dented #10 can of beef stew was discovered on the shelf. The facility failed to dispose of the dented can of beef stew to eliminate a possible food safety risk. An interview was conducted on 03/26/13 at 8:51 a.m. with Employee #154, the Regional Dietary Manager. She stated the dented #10 can of beef stew should have been pulled from the rack and agreed there was a possibility the dent was severe enough to represent a health issue. On 03/26/13 at 9:17 a.m., Employee #154, the Regional Dietary Manager presented the facility's Dented Can Policy. This policy indicated cans with serious defects or severe dents could compromise the integrity of the can, allowing the contents unsafe for consumption. However, the policy did not provide instructions about what was to be done with a dented can. | 2016-04-01 |
| 8752 | 8752 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-03-13 | 152 | D | 1 | 0 | MS9D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that for residents who had been determined to lack the capacity to make informed medical decisions, a legal surrogate was designated in accordance with State law to exercise the resident's rights to the extent provided by the law. This was found for two (2) of four (4) residents whose records were reviewed. Resident identifiers: #116 and #117. Facility census: 115. Findings include: a) Resident #116 The medical record of Resident #116 was reviewed on 3/11/13 at 3:40 p.m. Resident #116 was admitted to the facility on [DATE], and discharged on [DATE]. He was seventy (70) years old. His [DIAGNOSES REDACTED]. He was determined by a physician to lack the capacity to make informed healthcare decisions on 02/27/13. He was admitted to the facility for skilled therapy services designed to strengthen him, and improve his ability to assist with activities of daily living (ADLs) to allow him to return home with his son and daughter-in-law. There was an indication in the admission paperwork that a health care surrogate (HCS) had been appointed. Further review found a form entitled West Virginia Health Care Surrogate Designation, which had been faxed to the facility on [DATE] from the admitting hospital. The form indicated the resident's sister had consented over the telephone to act as the resident's HCS on 02/18/13. The cause of Resident #116's incapacity to make his own decisions was not completed. The expected duration of his incapacity to make his own decisions was not completed. The person that the physician intended to appoint as HCS was not named. There was a signature in the space marked attending physician, but the signature was not dated. During an interview, on 03/13/13 at 8:45 a.m., the administrator, Employee #38, stated that a new health care surrogate appointment form containing all the information required by the West Virginia Health Care Decisions Act ?16-30-1 shoul… | 2016-03-01 |
| 8753 | 8753 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-03-13 | 203 | D | 1 | 0 | MS9D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview the facility failed, before a discharge, to notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge in writing and in a language and manner they understood, the reason for transfer or discharge; the effective date of transfer or discharge; the location to which the resident was being transferred or discharged ; a statement the resident had the right to appeal the action to the State; and the name, address and telephone number of the State long term care ombudsman. This was found for two (2) of four (4) residents whose records were reviewed. Facility census: 115 Findings include: a) Resident #116 The medical record of Resident #116 was reviewed on 03/11/13 at 3:40 p.m. Resident #116 was admitted to the facility on [DATE], and discharged on [DATE]. Resident #116 was discharged back to his son's home on 3/10/13. Discharge planning was appropriate, but there was no evidence the health care surrogate (HCS) received any written notice of discharge and applicable appeal rights. This information was specifically requested from administrator on 03/13/13 at 8:45 a.m., but could not be located by the time of exit. b) Resident #117 The medical record of resident #117 was begun on 03/11/3 at 3:00 p.m. and continued on 03/12/13 at 8:59 a.m. Resident #117 was admitted following hospitalization for a fall resulting in a head injury. The hospital discharged him to the facility on [DATE]. He was subsequently discharged to an adult care home on 11/08/12. The administrator, Employee #38, was interviewed on 03/12/13 at 3:47 p.m. She was not able to provide any supporting documentation to show that Resident #117's sister, who the facility considered the legally appointed health care surrogate (HCS), was notified in writing of his discharge and thereby given her appeal rights and contact information. | 2016-03-01 |
| 8754 | 8754 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-03-13 | 204 | D | 1 | 0 | MS9D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, staff interview, interview of the owner of a receiving facility, and family interview, the facility failed to provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility to a legally unlicensed adult care home. This was found for one (1) of four (4) records reviewed. Facility census: 115. Findings include: a) Resident #117 The medical record of Resident #117, was begun on 03/11/3 at 3:00 p.m. and continued on 3/12/13 at 8:59 a.m. This fifty-nine (59) year old man, was admitted to the facility on [DATE], and discharged on [DATE]. His [DIAGNOSES REDACTED]. Resident #117 was admitted following hospitalization for a fall resulting in a head injury. The hospital discharged him to the facility on [DATE]. Upon admission to the nursing home, his comprehensive assessment (MDS) of 03/13/12, under section G0110, G0120, and G0300 documented his ability as: Bed Mobility coded: 0,0 indicating 'independent with no help from staff Transfer ability coded: 2,2 indicating 'limited assistance of one staff Walking in room coded: 3,3 indicating 'extensive assistance of two or more staff Walk in corridor coded: 8,8 indicating 'did not occur Locomotion on unit coded: 3,2 indicating 'extensive assistance of one staff Locomotion off unit coded: 3,2 indicating 'extensive assistance of one staff Dressing coded: 3,2 indicating 'extensive assistance of one staff Eating coded: 0,1 indicating 'independent with set up help only Toileting coded: indicating 'limited assistance of one staff Personal Hygiene coded: 0,1 indicating 'set up help only Bathing coded: 3,2 indicating 'extensive assistance of one staff Balance sitting to standing coded: 2 indicating 'not steady, only able to stabilize with staff assistance Balance Walking coded: 2 indicating 'not steady, only able to stabilize with staff assistance Turning around coded: 8 indicating 'activity did not occur Moving on/off toilet c… | 2016-03-01 |
| 9763 | 9763 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-09-26 | 329 | D | 1 | 0 | FJI611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure residents who received antianxiety and/or hypnotic medications received the smallest effective dose for the shortest period of time. A resident received anti-anxiety medication for nearly a year, at a dose higher than that recommended for the elderly. Another resident received a hypnotic medication for sleep for a prolonged period of time. The medication used was one which was typically used only for short-term management of [MEDICAL CONDITION]. Additionally, there was no evidence of non-pharmacological interventions to alleviate the symptoms for either resident. Resident identifiers: #145 and #93. Facility census: 109. a) Resident #145 Review of the medical record revealed this [AGE] year old resident with dementia was admitted to the facility on [DATE]. She was ordered [MEDICATION NAME] (an anti-anxiety medication) one (1) milligram (mg.) twice daily for anxiety on 09/21/11. Approximately two (2) weeks later, the dosage was increased to one (1) mg. three (3) times daily, where it has since remained. Review of manufacturer's recommendations, found that the total daily dose threshold for anxiolytic medication, [MEDICATION NAME], is up to two (2) mg. daily in divided doses for geriatric patients. On 07/03/12 a gradual dose reduction (GDR) was recommended by the consultant pharmacist. The pharmacist recommended a reduction in the [MEDICATION NAME] dosage to 0.5 mg. three (3) times daily. The physician declined to decrease the dose, and gave no rationale for this decision on the pharmacy consultation report form. Review of a physician's progress note, dated 07/03/12, found the physician's assessment of tremor, nervous, and the plan to continue the [MEDICATION NAME] and observe. Review of the behavior monthly flow sheets for June, July, and August 2012, revealed [MEDICATION NAME] was used for the [DIAGNOSES REDACTED]. Further review revealed this form was only sporadicall… | 2015-09-01 |
| 9819 | 9819 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 225 | E | 1 | 0 | L6DT11 | . Based on review of the facility's concern/complaint files, review of the reportable allegations in the facility's abuse/neglect files, and staff interviews, the facility failed to ensure all allegations of neglect and abuse were reported and/or investigated. Additionally, the facility failed to report the results of an investigation of an allegation of neglect within five (5) working days of an incident. The unreported allegations included: soiled clothing, bed linens, and furnishings, failure to provide mouth care, failure to provide a breathing treatment, bruising of unknown origin, failure to answer call lights, staff eating a resident's food, and failure to provide pain medication. The follow-up which was not reported was a complaint related to a failure to check blood sugar levels. Resident identifiers: #119, #5, #71, #116, #117, and #60. Facility census: 115. Findings include: a) Resident #119 The social worker (Employee #9) provided the past three (3) months of reportable allegations of abuse/neglect on 04/02/12, at approximately 11:00 a.m. The reportable allegations revealed an allegation involving Resident #119 which was reported on 12/27/11. The family's concern was regarding the facility's failure to check blood sugar levels. The facility did not have a five (5) day follow up which summarized the results of the investigation of this allegation of neglect. . . b) Resident #5 Review of complaint files revealed a complaint, dated 02/23/12, in which Resident #5's family alleged the resident vomited on 02/22/12 at 6 p.m., and still had vomit on her shirt and handrail on 02/23/12 at 10:45 a.m. The family also stated the resident had not received mouth care. The facility failed to report this allegation. During an interview with Employee #9 on 04/03/12, at approximately 3:45 p.m., she stated, "The last director of nursing took care of this, and I can find no other information on it." c) Resident #60 Within the complaint files was a complaint, dated 01/26/12, regarding this resident. A staff member from the … | 2015-08-01 |
| 9820 | 9820 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 243 | E | 1 | 0 | L6DT11 | . Based on review of family council meeting minutes, resident council meeting minutes, and staff interview, the facility failed to act upon the issues identified by the family council and the resident council. There was no evidence the concerns brought to the attention of the facility, by either group, were seriously considered and/or addressed. This practice had the potential to affect more than an isolated number of residents. Facility census 115. Findings include: a) Resident Council On 01/04/12, the resident council completed a grievance report stating scheduling was inappropriate. The facility's resolution to the concern was, "We schedule staff to census and state requirements of 2.25. Facility attempts to replace call-ins immediately. Running ads for new hires. Offering vacant shifts for bonus." The complaint was made by the resident council on 01/04/12, but was not addressed to the resident council on 02/14/12. b) Family Council Review of the minutes of a family council meeting, held on 03/20/12, revealed family members made various complaints: - Residents were not gotten out of bed - The facility's staffing level was inadequate - Resident rooms were not clean - Water and ice was not passed - Water and ice was out of residents' reach - Water was not given to those who needed help drinking - Incontinent residents were not changed in a timely manner - Call lights were not answered in a timely manner - Staff members passed call lights and did not answer them "stating not their residents." - Lotion was not applied to residents - Residents were not being walked - Medications were passed late - Catheter bags were hung incorrectly There was no evidence the facility gave serious consideration to any of the concerns expressed by the members of the family council. There was nothing to suggest the facility acted upon, or made any attempts to investigate the concerns expressed by the family council. Had the facility listened to the concerns, evaluated the concerns, and/or sought additional information, some of the con… | 2015-08-01 |
| 9821 | 9821 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 272 | D | 1 | 0 | L6DT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, facility policy review, and staff interview, the facility failed to ensure a stage I pressure ulcer was assessed for one (1) of four (4) residents. The resident developed a stage I pressure ulcer which was not assessed according to the facility's policy on wound management. Resident identifier: #84. Facility census: 115. Findings include: a) Resident #84 On 04/02/12, review of the medical record for Resident #84 revealed an [AGE] year old paraplegic male. According to the medical record, he developed a stage I pressure ulcer on 03/20/12. The wound, measuring 3.5 cm in width, was identified by a local surgeon to whom the facility referred the resident due to multiple vascular ulcers to the bilateral lower extremities. The surgeon ordered a derma float air mattress, on 03/21/12, to promote wound healing. The order, dated 03/21/12, stated, "(physician name) ordered HILL ROM AIR MATTRESS FOR STAGE I ULCERS ON BUTTOCKS." The facility provided the resident with the air mattress. The assistant director of nursing (Employee #65) provided a copy of the facility's wound management policy on 04/03/12 at 9:40 a.m. The policy, dated January 2008, stated "Weekly Wound Rounds: The team makes rounds weekly to evaluate wound treatment and other care interventions. The licensed nurse evaluates the pressure ulcer and documents pressure ulcer healing using the pressure ulcer documentation form. If a pressure ulcer fails to show progress toward healing within 2-4 weeks the team reevaluates the treatment plan to determine whether to modify the current interventions. Individual nurses should not alter the treatment plan without input from the interdisciplinary team and the physician." The medical record contained non pressure and skin condition reporting forms for non pressure related areas on the resident's coccyx. As of 04/03/12, the last documentation on this form was dated 03/07/12. At that time the area on the coccyx was red, … | 2015-08-01 |
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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 );