CMS-Nursing-Home-Full-Deficiencies
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 mobility, transfer, dressing, toileting, and hygiene. The resident was on scheduled and as needed pain medication and had not had a fall during the seven day look back period. Resident received speech therapy, occupational therapy, and physical therapy. Observations, on 02/05/18 at 11:55 AM., revealed Resident#92 appeared clean, without any body odors, hair stubble noted on chin, and Foley catheter was draining to drainage bag on bedside. The bed rails properly fit the bed. The resident had a special needs call light (Blow call light) to accommodate resident due to paralysis and inability to use hands. Blow call light was within reach of the resident and he was observed using it with staff responding timely. Resident#92 did not want to be interviewed at the time the surveyor attempted an interview, and this surveyor told the resident the surveyor would come back the next day to talk to him. The next day when this surveyor went to interview Resident #92, the resident was no longer a resident at the facility, Resident #92 was transferred to live at another facility and was unavailable for interview On 02/06/18 at 11:25 AM, review of reportable events revealed a report concerning Resident #92, dated 12/26/17, where the Veterans Administration Medical Center (VAMC) notified the facility of an incident occurring that morning that was reported to all appropriate agencies. The incident reported to the facility, alleged upon EMS (emergency management service) ambulance arriving to take the resident to scheduled appointments, the resident was not cleaned up, had no breakfast, catheter needed emptied, and call light was not in reach. The report revealed, Per VA the resident stated his head hitting side rail on bed and he was yelling. Someone came and shut the door but did not provide care. The results of the facility's reportable investigation revealed the allegations were unsubstantiated due to lack of information provided by EMS. The facility requested an extension for five day follow up from 12/31/17 to 01/05/18, due to awaiting statements from EMS. Review of the facility's five day follow up report findings, revealed EMS arrived at approximately 7:00 AM on 12/26/17, and the NA (Nurse Aid) had not cleaned the resident up yet. The NA did clean the resident and emptied his catheter, after being told by a nurse to clean him up for his appointment after the EMS ambulance crew arrived to pick up the resident. Breakfast had not been served yet. The social worker (SW#68) noted that EMS had been contacted multiple times, requesting statements concerning the description of the incidence (the facility reported they did not receive EMS statements). Social worker SW#68's written investigation statement in response to these allegations, dated 12/27/17, stated the ambulance arrived closed to 7:00 AM for a 9:00 AM appointment, breakfast was not ready at the time, puffer call light attached to bed by maintenance and cannot come off the bed. EMS must have seen roommates call light. SW #68 did not substantiate these allegations. On 02/06/18 at 1:15 PM, an interview with Staff#5, responsible for logging resident's appointments, revealed the Veterans Administration Medical Center (VAMC) has a contract with an ambulance service (name of local ambulance service) to transport all residents that are veterans, to any of their appointments. The VAMC is responsible for setting up and paying transport for any appointment no matter where it is. When asked what the process was to assure residents get to their appointments, Staff#5 explained the contact person at the VAMC calls at least once a month, and goes over all appointments residents who are veterans have, where the appointments are, and tells me what time the ambulance is to pick up the resident. Staff#5 said she writes the resident's name, date and time of the appointment, and the time the ambulance is to pick up the resident on the appointment calendar book. Staff#5 said, then the charge nurse has the appointment calendar book and lets the nurse aides know when they need to have the residents cleaned up and ready to go. Review of the appointment calendar book for the month of (MONTH) (YEAR), with Staff#5, revealed Resident #92 had appointments four (4) different days in December. The appointments noted on 12/26/17, revealed Resident #92 had labs at 7:30 AM and an appointment at 9:00 AM at the VAMC Spinal Injury Clinic. Also, noted on the calendar was the time the ambulance was to pick up Resident #92, which was 7:00 AM on 12/26/17. Staff#5 said the VAMC always uses the same ambulance service for transports. When asked if the ambulance service ever is late or comes early, the receptionist replied, The ambulance service (the name of) is real good about being right on time. Staff#5 confirmed EMS ambulance was scheduled to arrive to pick Resident#92 up at 7:00 AM on 12/26/17. The facility investigation resulted in the allegations being unsubstantiated, however the investigation did not appear to be thorough. The facility's appointment calendar, clearly documented the ambulance was to pick the resident up at 7:00 AM to transport the resident for 7:30 AM labs, and that there was a second appointment at 9:00 AM. The facility's investigation Witness statements verified the ambulance arrived as scheduled and the resident was not cleaned up and ready to be transported. Resident #92 was cleaned and his catheter emptied, only after the NA was told by the nurse to clean him up for his appointment, after the ambulance crew arrived and waited. There was no evidence the resident needed to be fasting for his lab tests, nor any evidence that any breakfast had been offered to the resident, or any arrangements made to provide him a breakfast or snack. The resident did not get On 02/06/18 at 10:15 AM, after multiple failed attempts for observations and interview with Resident #92 due to not finding him in his room or elsewhere in the facility, an interview with the Administrator revealed Resident #92 was transferred to Veterans Administration Medical Center (VAMC) yesterday, 02/05/18. Administrator said this was a plan discharge that the resident had been on a waiting list to become a resident at the VAMC's facility, and an opening came available yesterday evening. Interview with the Coordinator of Health Information Management (HIMC Staff#73), on 02/07/16 at 10:00 AM, revealed Resident #92 had said he wanted to transfer to a facility closer to his ex-girlfriend so she could visit him. HIMC Staff#73 said the girlfriend told him there was one close to her that the Veterans Administration (VA) would pay for. HIMC Staff#73 said, the facility told him multiple times there was not one in that area the girlfriend was referring to, but he did not believe them, and would get upset about it each time. On 02/08/18 at 11:03 AM, an interview with VAMC Social Worker, VAMC SW#302 revealed she reported the situation because she is a mandatory reporter. VAMC SW#302 said, I was concerned for the resident because of his recent [DIAGNOSES REDACTED]. VAMC SW#302 said she reported to all the appropriate agencies, and spoke by phone to the facility's Director of Nursing (Nurse Executive Director) and SW #68 concerning these allegations on 12/26/17. VAMC SW#302 said she first saw the resident, on 12/26/17, after first being asked to see him, by the VAMC Nurse Practitioner (Family Nurse Practitioner Certification - FNPC), VAMC FNPC#304. VAMC SW#302 said, When I saw him (Resident #92) he was laying on a stretcher, unshaven, with a neck brace on. The resident was alert and oriented and was asking to go to another nursing home closer to his family. The resident said the nursing home he lived at did not beat him, but they don't take care of him. The ambulance crew reported the facility knew he was being picked up for a doctor's appointment, but he was not cleaned up. The ambulance crew said his call bell was across the room where he could not reach it. They had to ask someone to empty his catheter bag, and when it was emptied no one looked to see if anything else needed cleaned. He had not been given breakfast. The ambulance crew said he was upset because he wanted to be shaven and cleaned up before leaving for his appointment. Review of VAMC SW#302 Notes dated 12/26/17, revealed the ambulance crew reported, (Name of facility) knew we were picking him up for a doctor appointment today. When we arrived he was not cleaned up. His call bell was across the room where he could not reach it. He had no breakfast. We had to ask someone to empty his catheter bag. When staff emptied the bag they did not look under the covers to check to see if anything else needed taken care of. Further review of records (facility and VAMC records) revealed alternate placement was discussed with the resident several times. The resident had discussed moving to a nursing home closer to his family and girlfriend. When the resident discovered there was not another nursing home the Veterans Administration was contracted to pay for in the area close to his family and girlfriend, Resident #92 did not want to personally pay and choose to return to the facility. The Ombudsman was interviewed via phone, on 02/08/18 at 2:30 PM, for concerns regarding these allegations. Interview with Ombudsman revealed during her interview at the facility with Resident #92 and facility staff, on 01/03/18, the resident said he lied about his head being stuck in the bed rails, that he lied just because he was mad. The Ombudsman said Resident #92 bragged on the care he receives at the facility, appeared [MEDICATION NAME] pleased, and had no complaints against the facility. After record review, abuse and neglect policy review, staff interview, VAMC staff interview, and review of the facility's investigation record, the evidence revealed some of the allegations were substantiated. There is not enough evidence to substantiate the allegation the resident's special blow call light was not in reach of the resident. The resident denied, in front of multiple witnesses, his head was hitting the side rail on his bed, and someone shut the door without providing any care. The resident said he falsely made these accusations because he was mad. The facility did neglect to ensure Resident #92 was; cleaned up and shaven; catheter drainage bag was emptied; and resident was ready to be transported for medical appointments via ambulance, as was scheduled on the facility's appointment calendar book for 12/26/17 at 7:00 AM. The resident did not have breakfast, and the facility did not provide or make any arrangements for the resident to have breakfast or a snack on a day the resident was scheduled to be out of the facility for medical appointments. The catheter drainage bag was emptied by a nurse aid (NA) after the ambulance crew arrived and only after a nurse had to instruct the NA to clean up the resident. b) 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 December, and the resident was at the hospital on [DATE] until 12/04/17, on 12/11/17 until 12/13/17, and on 12/26/17 until 12/28/17, a total of six (6) days out of the facility (Note - It is possible the resident could have had or needed a bed bath on the days he went to the hospital and/or returned from the hospital. It is also possible an incontinent resident might need more than one bed bath per day). The resident received bed baths on fourteen days in December, on one day (12/05/17) he received two (2) baths. There was no evidence the resident refused any bed baths or refused being shaven. On 02/08/18 at 3:27 PM, interview with Nurse Aid (NA#40) revealed Resident #92 loved bed baths. NA#40 said, Resident #92 loved bed baths, they relaxed him and helped him sleep, he would take a two (2) hour nap after he got one. NA#40 denied ever knowing Resident #92 refusing a bed bath. Interview with NA#39, on 02/08/18 at 3:38 PM, revealed NA#39 stated, Resident #92 loved bed baths. I never knew of him refusing a bed bath. On 02/08/18 at 4:47 PM, an interview with two (2) Licensed Practical Nurse (LPN) LPN#44 and LPN#70 revealed the following information. When asked, as nurses, what their expectations of how often a totally dependent resident, incontinent of bowel should receive bed baths from nurse aides, both LPNs said at least daily, if not more depending on the resident's incontinence episodes. Both LPN#44 and LPN#70 said the nurse aides should have instruction on the resident's care plan and the Kardex for bathing and hygiene care. | 2020-09-01 |
| 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 for the use of the diathermy machine to be placed on his face, . Resolution to these concerns were completed by 09/27/17 with staff being educated to shave resident daily, Kardex being updated with the resident's preferences. A Kardex provides specific instructions, for the nursing assistants, concerning individualized care to be provided for a resident. Review of Resident #92's Kardex showed under the skin care focus instructions written as is ****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. On 02/08/18 11:03 a.m., an interview with VAMC SW#302 revealed she reported a situation concerning Resident #92 because she is a mandatory reporter and had notified the facility of the allegations. VAMC SW#302 said she first saw the resident, on 12/26/17, after being asked by the VAMC Nurse Practitioner (Family Nurse Practitioner Certification - FNPC), VAMC FNPC#304 to see the resident. VAMC SW#302 said, When I saw him (Resident #92) he was laying on a stretcher, unshaven, with a neck brace on. VAMC SW#302 described the resident was alert and oriented and the ambulance crew told VAMC SW#302, the facility knew he was being picked up for a doctor's appointment, but he was not cleaned up. The ambulance crew told VAMC SW#302 his call bell was across the room where he could not reach it. They had to ask someone to empty his catheter bag, and when it was emptied no one looked to see if anything else needed cleaned. He had not been given breakfast. The ambulance crew said he was upset because he wanted to be shaven and cleaned up before leaving for his appointment. | 2020-09-01 |
| 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 address the resident's current care needs related to the new [DIAGNOSES REDACTED]. On 02/07/18 at 12:50 PM, review of medical records revealed resident 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]. Review of VAMC physician progress notes [REDACTED]. Resident#92 returned to the facility with a soft cervical collar | 2020-09-01 |
| 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 December, and the resident was at the hospital on [DATE] until 12/04/17, on 12/11/17 until 12/13/17, and on 12/26/17 until 12/28/17, a total of six (6) days out of the facility (Note - It is possible the resident could have had or needed a bed bath on the days he went to the hospital and/or returned from the hospital. It is also possible an incontinent resident might need more than one bed bath per day). The resident received bed baths on fourteen days in December, on one day (12/05/17) he received two (2) baths. There was no evidence the resident refused any bed baths or refused being shaven. On 02/08/18 at 3:27 PM, interview with Nurse Aid (NA#40) revealed Resident #92 loved bed baths. NA#40 said, Resident #92 loved bed baths, they relaxed him and helped him sleep, he would take a two (2) hour nap after he got one. NA#40 denied ever knowing Resident #92 refusing a bed bath. Interview with NA#39, on 02/08/18 at 3:38 PM, revealed NA#39 stated, Resident #92 loved bed baths. I never knew of him refusing a bed bath. On 02/08/18 at 4:47 PM, an interview with two (2) Licensed Practical Nurse (LPN) LPN#44 and LPN#70 revealed the following information. When asked, as nurses, what their expectations of how often a totally dependent resident, incontinent of bowel should receive bed baths from nurse aides, both LPNs said at least daily, if not more depending on the resident's incontinence episodes. Both LPN#44 and LPN#70 said the nurse aides should have instruction on the resident's care plan and the Kardex for bathing and hygiene care. b) Grooming for appointments outside the facility On 02/06/18 at 11:25 AM, review of reportable events revealed a report concerning Resident #92, dated 12/26/17, where the Veterans Administration Medical Center (VAMC) notified the facility of an incident occurring that morning that was reported to all appropriate agencies. The incident reported to the facility, alleged upon EMS (emergency management service) ambulance arriving to take the resident to scheduled appointments, the resident was not cleaned up, had no breakfast, catheter needed emptied, and call light was not in reach. Review of the facility's investigation findings, revealed EMS arrived at approximately 7:00 AM on 12/26/17, and the NA (Nurse Aid) had not cleaned the resident up yet. The facility did not ensure Resident #92 was; cleaned up and shaven; catheter drainage bag was emptied; and resident was ready to be transported for medical appointments via ambulance, as was scheduled on the facility's appointment calendar book for 12/26/17 at 7:00 AM. The catheter drainage bag was emptied by a nurse aid (NA) after the ambulance crew arrived and only after a nurse had to instruct the NA to clean up the resident. Social worker SW#68's written investigation statement in response to the allegations, dated 12/27/17, stated the ambulance arrived closed to 7:00 AM for a 9:00 AM appointment ., however the facility's appointment calendar book for the month of (MONTH) (YEAR) showed Resident #92 had labs at 7:30 AM and an appointment at 9:00 AM at the VAMC Spinal Injury Clinic. Also, noted on the calendar was the time the ambulance was to pick up Resident #92, which was 7:00 AM on 12/26/17. On 02/06/18 at 1:15 PM, an interview with Staff#5, responsible for logging resident's appointments, revealed when a resident has an appointment Staff#5 writes the resident's name, date and time of the appointment, and the time the ambulance is to pick up the resident on the appointment calendar book. Staff#5 said, then the charge nurse has the appointment calendar book and lets the nurse aides know when they need to have the residents cleaned up and ready to go. Review of the appointment calendar book for the month of (MONTH) (YEAR), with Staff#5, revealed Resident #92 had labs at 7:30 AM and an appointment at 9:00 AM at the VAMC Spinal Injury Clinic. Staff#5 confirmed EMS ambulance was scheduled to arrive to pick Resident#92 up at 7:00 AM on 12/26/17. The facility's investigation Witness statements verified the ambulance arrived as scheduled and the resident was not cleaned up and ready to be transported. Resident #92 was cleaned and his catheter emptied, only after the NA was told by the nurse to clean him up for his appointment, after the ambulance crew arrived and waited. Review of VAMC SW#302 progress note, dated 12/26/17, revealed the ambulance crew reported, (Name of facility) knew we were picking him up for a doctor appointment today. When we arrived, he was not cleaned up . We had to ask someone to empty his catheter bag. When staff emptied the bag, they did not look under the covers to check to see if anything else needed taken care of. On 02/08/18 at 11:03 AM, an interview with VAMC Social Worker, VAMC SW#302 revealed she first saw the resident (Resident#92), on 12/26/17, after first being asked to see him by the VAMC Nurse Practitioner (Family Nurse Practitioner Certification - FNPC), VAMC FNPC#304. VAMC SW#302 said, When I saw him (Resident #92) he was laying on a stretcher, unshaven, with a neck brace on. VAMC SW#302 said, The ambulance crew reported the facility knew he was being picked up for a doctor's appointment, but he was not cleaned up . The ambulance crew said he was upset because he wanted to be shaven and cleaned up before leaving for his appointment. | 2020-09-01 |
| 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 physician's orders [REDACTED].#49 after reviewing the record, said she could not find an order. RN#49 agreed a follow up for orders for the resident's current care needs due to the new [DIAGNOSES REDACTED].#49 requested the Coordinator Health Information Management, Staff#73, to try and locate a order for the soft cervical collar. The Coordinator Health Information Management Staff#73, on 01/07/18 at 12:17 PM, agreed there should have been an order for [REDACTED]. | 2020-09-01 |
| 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 | 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 required assistance to eat, but staff did not interact with the residents in a social manner. Residents #49 and#192 were seated at the same table. Resident #192 was served at 12:11 p.m., but Resident #49 did not receive his tray until 12:19 p.m. Staff began serving the long table nearest the kitchen at 12:02 p.m. At 12:08 p.m., Resident #68 verbalized in a crying tone, I can't (cannot) wait much longer. At that time, tablemates called out to the administrator who was standing nearby. The resident, with a frowned expression, informed her she had only ordered soup and did not understand why she had not received it. An observation and interview with the clinical nurse educator (CNE), toward the end of the meal, at about 12:30 p.m. on 05/16/17, agreed staff did not interact socially with residents who did not have a tablemate or who were not socializing with others. The CNE verbalized some residents were capable of socializing, but acknowledged staff should have interacted with them on a social level. | 2020-09-01 |
| 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 approximately 3:00 p.m., HM #83 removed the tissue from the floor and the broken piece of vinyl from beneath the bed. She said it was a broken piece off a coat hanger. - Room 102 On 05/17/17 during the afternoon tour, HM #83 agreed that the toilet bowl jets looked dirty, and the window blind was dusty and the window sill dirty. She said she thought perhaps some sheetrock fell on to the window sill. She said housekeeping staff would attend to those issues. - Room 103 During the afternoon tour on 05/17/17, HM #83 agreed the window blind was dusty and needed cleaned. There was a pile several inches thick of an unknown substance that resembled bird seed in the right lower corner of the window sill. HM #88 did not know the origin of that substance or what it was, but said they would clean it right away. - Room 104 On 05/17/17 during the afternoon tour, HM #83 agreed the window blinds were dusty and needed cleaned. Also, behind the bed by the window lay a silver hair barrette next to the cove base which was first observed on 05/16/17 at 11:32 a.m. About a foot away was a bunch of food particles that went up to the cove base behind the first bed by the door. The food particles were first observed on 05/16/17 at 11:32 a.m. HM #83 said she would speak to housekeeping staff about more thorough sweeping of the rooms. - Room 105 During the afternoon tour on 05/17/17, HM #83 agreed that the outside of the window sill was dirty and needed cleaned, and that the water jets in the toilet bowl looked dirty. - Room 106 On 05/17/17 during the afternoon tour, HM #83 agreed that the window blinds were dusty and needed cleaned, and that the water jets in the toilet bowl needed cleaned. - Room 111 Observations during Stage I of the survey on 05/15/17 at 3:24 p.m. noted the privacy curtain had some soiled areas. During the afternoon tour on 05/17/17, the privacy curtain was clean. - Room 118 During Stage I of the survey on 05/16/17 at 11:28 a.m., the privacy drape had areas where it was dirty. The privacy curtain was found to be clean on 05/17/17 during the afternoon tour. HM #83 agreed the window blinds were dusty and needed cleaned. - Room 126 On 05/17/17 during the afternoon tour, MS #88 agreed the sliding curtain type of bathroom door was soiled with a black mold-like substance on the bottom portion of the curtain. He said the curtain would have to be replaced as there was no way to adequately clean it. Also, during Stage I of the survey on 05/15/17 at 2:41 p.m., the floor was littered with two caps for gastrostomy tube syringes, a blue cap, and a lipstick tube cap. Those items were no longer present during the afternoon tour on 05/17/17. - Room 128 At approximately 3:30 p.m. on 05/17/17, MS #88 agreed the caulk on the front section of the commode base was missing. He said he would repair it right away. - Room 129 At approximately 3:35 p.m. on 05/17/17, MS #88 agreed some veneer was missing from the front of the bathroom door, which allowed the wood or particle board beneath to show through. He said he would repair this right away. - Room 134 At approximately 3:40 p.m. on 05/17/17, MS #88 agreed that a section of cove base or molding had pulled away from the wall on the left side of the wall behind the bathroom door. He said he would repair this right away. He also agreed that there was dirt in the corner behind the entrance room door where it had not been cleaned in that section. - Room 141 During the afternoon tour on 05/17/17 with HM #83, she agreed that the window sill was dirty and the blinds dusty. - Room 142 On 05/1717 during the afternoon tour, HM #83 agreed that the window blinds were dusty and needed cleaned. - Room 163 During the afternoon tour on 05/1717, MS #88 agreed the vent on the inside of the room's heating/cooling unit was dirty with loose debris. He said maintenance took care of the inside of the units, and he would make sure it was cleaned. Also, a small section of wallpaper inside the room near the floor in one area was not adhering to the wall and was loose. MS #88 said that would be corrected right away. b) During a pre-exit interview with the administrator on 06/01/17, at approximately 7:00 p.m., it was discussed that maintenance and housekeeping had toured on 05/17/17 and all the environmental findings were discussed during an afternoon tour between 3:00 p.m. and 3:45 p.m. with HM #83 and MS#88. The administrator acknowledged her awareness of the environmental tour on that date. | 2020-09-01 |
| 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 | 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 the left forearm, and the resident verbalized he had obtained a skin tear. During a wound care observation, on 05/23/17 at 11:40 a.m., the nurse removed a bandage from the resident's left great toe, revealing an open wound on the top of the toe. A physician's orders [REDACTED]. The care plan, reviewed on 05/24/17, revealed no evidence of bruising or of the toe wound. MDS Coordinator #108, interviewed at 2:01 p.m., voiced the nurses updated the care plans as new orders, concerns arose. She reviewed the care plan and verified a care plan was not developed related to the bruises or the skin tear on Resident #92's toe. c) Resident #45 Review of medical records revealed Resident #45 had an Arteriovenous Fistula (AV) for [MEDICAL TREATMENT] treatments. Review of the physician's orders [REDACTED]. The resident continued to have an AV fistula site at the time of the current survey beginning 05/15/17. Review of the resident's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no evidence the facility monitored the resident's AV fistula after 11/22/16 until a new order written on 05/02/17. On 05/24/17 at 4:21 p.m., Registered Nurse (RN) #126 stated the resident had had an AV fistula site for [MEDICAL TREATMENT] for at least three (3) years. Review of an article Caring for a patient's vascular access for [MEDICAL TREATMENT] in the 2010 Lippincott[NAME] & Wilkins medical surgery text book found it included a nurse should check the AV fistula site for patency at least every eight hours. On 05/24/17 at 3:18 p.m., the facility administrator agreed monitoring the bruit and thrill was not routinely completed, nor did the care plan include monitoring the AV fistula from 11/22/16 until 05/02/17. d) Resident #43 Review of the resident's medical record on 05/22/17 found the resident had [DIAGNOSES REDACTED]. The significant change minimum data set (MDS) with an assessment reference date (ARD) of 03/17/17, assessed contractures of the right upper extremity. Review of the care plan found it contained a focus where it identified her right side extremities were weaker than the left. The care plan identified that she had contractures of the right shoulder, elbow, wrist and hand; however, the care plan failed to provide individualized and measurable goals they wished to achieve related to the right upper extremity contractures. The care plan failed to provide individualized interventions to help prevent further loss of range of motion and/or other negative outcomes, related to the right upper extremity contractures. The care plan contained no directives for range of motion or for any splint/orthotic devices. During an interview on 05/22/17 at 4:01 p.m., Director of Rehabilitation Services #52, said (MONTH) (YEAR) was the last time occupational therapy (OT) had her on its case load. Their goals were for passive and active range of motion to the right upper extremities for three (3) sets of ten (10) repetitions daily to establish a contracture management program. Their goal was for her to work up to tolerate a right hand orthotic for four (4) hours per day. The final long term goal was to discharge her to the restorative program with 100% staff training for contracture management program. She said the director of nursing (DON) was the head of the restorative nursing department. In an interview on 05/22/17 at 4:22 p.m., the director of nursing (DON) said this resident used to have a Posey roll, and she used to have restorative nursing services for range of motion with restorative aides; however, she no longer received restorative services. She said she felt the regular nursing assistants on the units did enough range of motion during activities of daily living to make it count for range of motion. She said that the resident had a Posey roll for her right hand prior to a week-long hospital stay the first week in (MONTH) (YEAR), but it had not been re-ordered since the (MONTH) hospitalization . She said most likely restorative services order fell through the cracks and was not re-ordered upon her (MONTH) return to the facility. The DON provided a copy of the resident's care plan on 05/22/17 at 4:45 p.m. When asked to provide any evidence of care planned individualized and measurable goals and interventions related to contracture management, no further evidence was provided. Observation and interview with the resident on 05/23/17 at 9:41 a.m. found she could use her left hand and try to stretch out the fingers on her right hand. The little finger and the thumb of the right hand were not contracted. The three middle fingers on the right hand were contracted, and she could not stretch them out with her left hand. Those three fingers were bent downward, and then pointed back toward the wrist. She wore no splint device or palm protector when observed in Stage I of the Quality Indicator Survey. | 2020-09-01 |
| 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 150 feet two (2) times a day. Additionally, the physician's orders [REDACTED]. An interview with the director of nursing, immediately following the interview with NA #23, confirmed the care plan intervention had not been revised to reflect the physician's orders [REDACTED].> c) Resident #115 Medical record review on 05/30/17 found this resident, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. According to the medical record, she experienced actual falls on 04/30/17, 05/03/17, and 05/12/17. On the first and second occurrence she was found lying on the floor by the bed. On the latter occurrence, she slipped out of the wheelchair and onto the floor. Review of the current care plan found this resident was care planned as at risk for falls. The care plan was silent for any revisions showing the resident was not only at risk for falls, but that she had sustained actual falls since coming to the facility. In an interview with minimum data set (MDS) Registered Nurse #68 on 05/31/17 at 10:39 a.m., she reviewed the care plan and said they did not revise care plans to include the actual falls a resident experiences. When interviewed on 05/31/17 at 10:50 a.m., the administrator acknowledged that the care plan was not revised to include that she had sustained actual falls since admission to the facility. She said they typically update new interventions they may have added after a fall, but they do not revise the care plan to include either that the resident had sustained actual falls, or the dates of the falls. | 2020-09-01 |
| 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 at the facility about three (3) times a week, and was adamant that Resident #27 had not been walking in the hallway with restorative nursing. Restorative Nursing records, reviewed from 05/01/17 through 05/24/17 indicated Resident #27 only walked one (1) time a day on the days she received restorative ambulation. Additionally, no evidence was present to indicate the resident received restorative as ordered 05/10/17 through 05/24/17. No data was entered for the dates of 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, or 05/23/17. The restorative nursing for bilateral lower extremity exercises yielded no data for 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, and 05/23/17. Nurse Aide (NA) #37, interviewed on 05/23/17 at 12:48 p.m., verbalized only the restorative nurse aides walked with Resident#27 in the hallway for restorative care. NA #23, interviewed on 05/24/17 at 2:36 p.m., verified the residents did not receive restorative therapy if no data was present. The restorative/rehabilitative nursing program plan indicated the skilled functional area deficit was required because a potential for decline existed and to maintain the current level of function. Program instructions indicated therapy be completed six (6) days a week. The interim center nurse executive (CNE), interviewed on 05/24/17 at about 3:30 p.m., confirmed restorative care had not been provided as directed by the plan of care. b) Resident #143 A Stage 1 family interview, on 05/16/17 at 1:58 a.m., revealed Resident #143 preferred church activities. The family member said the resident liked to attend church services and went every Sunday morning. The minimum data set (MDS) with an assessment reference date (ARD) of 05/05/17 noted a brief interview for mental status (BIMS) score of ten (10) which indicated moderate cognitive impairment. The preferences for customary and activity section noted it was important for the resident to receive a snack between meals, music, reading, doing things with groups of people, participating in favorite activities, and participating in religious activities or practices. The recreation assessment noted the resident enjoyed small groups. The resident's care plan indicated Resident #143 enjoyed being in the dining room for lunch and socializing with staff. A nursing assessment dated [DATE] noted the resident watched television (TV) and attended church on occasion. The recreation assessment noted the resident seemed to enjoy games and religious activities. Observations on 05/15/17 at 1:46 p.m., 05/16/17 at 8:28 a.m., 05/31/17 at 10:04 a.m., revealed no evidence of participation in activities. Nurse Aide (NA) #73, interviewed on 05/31/17 at 10:23 a.m., said she was not sure what Resident #143 liked as she usually always worked on the south hallway. NA #100, interviewed at 10:24 a.m., said she had not really worked the hallway too long, and was not sure what the resident liked to do. The NA verbalized the resident did not come out of the room much and wanted staff to leave her alone. The (MONTH) (YEAR) recreation log indicated Resident #143 participated with socialization daily, attended a special event on one occasion (05/24/17), hydration cart two (2) of 28 opportunities,and participated with reminiscence daily. It noted she attended church on four (4) of seven (7) opportunities, Bible study two (2) of four (4) opportunities, and gospel music two (2) of five (5) opportunities. Recreation Assistant (RA) #34, interviewed on 05/31/17 at 1:33 p.m., said church services were usually in the morning and Bible study in the evenings. The RA reviewed the calendar and said the facility did have church services every Sunday morning and of four (4) opportunities, no evidence was present to indicate Resident #143 had been invited to two (2) of them. Upon inquiry, the RA said the floor staff were not provided information as to whom should attend each event. During an interview and observation on 05/31/17 at 1:56 p.m., Resident #143 was eating lunch in her room. She said she had lasagna for lunch (one small piece of pasta remained on her plate) and they put too much mayo (mayonnaise) on the salad. She exhibited confusion as to person and place, and talked about her mother. When asked what time she would like to get up she said around eight o'clock (8:00 a.m.). Upon inquiry as to what activities she liked, Resident #143 said she went to church every Sunday. The resident said she did not care what denomination it was, just Christian. On 05/31/17 from 4:37 p.m., until 4:59 p.m., during a dining observation, Resident #143 sat at a table with two (2) other residents. She was seated at the corner of the table, attempting to eat a sandwich with a spoon. The residents did not interact. RA #34, NA #116, RA #22, NA #79, Bookkeeper #20, and Activity Director/Guest Services #36 assisted in the dining room. No one conversed with the resident. RA #34 verbalized the social activity in which Resident #143 participated daily at 4:30 p.m., was the pre-meal activity. Upon inquiry, the recreation assistant verbalized Resident #143 would be included as having participated in the activity, even though no one socially interacted with the resident. The activity log and observations were reviewed with administrator on 05/31/17 at 6:12 p.m. She acknowledged the noted lack of participation related to the number of opportunities for things which were important to Resident #143. Additionally, she verbalized acknowledgement related to lack of socialization for the dining event and concurred the resident did not receive activities in accordance with the plan of care. c) 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. The medical record 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. Additionally, the physician's orders [REDACTED]. During an observation and interview with Resident #141, on 05/23/17 at 9:15 a.m. the resident said he had his bath and was waiting for the nurse to provide his pain relief therapy. He verbalized restorative would walk him after that. At 12:28 p.m., the resident said, No one has walked me yet. and at 2:30 p.m., the resident said he had not yet walked. The resident said he had walked three (3) times the previous week, but had not walked at all the three (3) weeks prior to that. Resident #141 expressed he felt like he was losing his strength. Another observation at 5:53 p.m. revealed the resident sleeping bed. Nurse Aide (NA) #34, interviewed at 12:48 p.m. on 05/23/17, said Resident #141 walked with restorative aides, but they get pulled to the floor a lot so it doesn't (does not) get done. The NA said the resident had no routine, just slept most of the day. The NA voiced the resident did not usually refuse to walk, but it took him a while because his legs shake. The NA reported it took about forty-five (45) minutes to an hour to walk him from his room to the doorway of the conference room and back, and that he usually took a break. The NA verbalized the resident walked on a good week four (4) times. An interview with Nurse Aide (NA) #23 on 05/24/17 at 2:36 p.m., reviewed the restorative records and said Resident #141 was supposed to walk 150 feet two (2) times a day. The NA verbalized restorative noted the shift and time of resident participation and/or refusal. The NA said if no entry was present then restorative did not ask the resident to ambulate. Upon request, the NA reviewed the (MONTH) (YEAR) and (MONTH) (YEAR) activity participation log and confirmed no evidence was present to indicate services had been offered on the dates of 05/01/17, 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/13/17, 05/14/17, 05/15/17, 05/16/17, 05/19/17, 05/21/17, 05/22/17, and 05/23/17. Additionally, no evidence was present to indicate it was offered twice on the dates of 05/17/17, 05/18/17, 05/20/17 and 05/24/17. The log noted Resident #141 had refused on the 3-11 shift on 05/03/17, 05/04/17 and 05/08/17, with no evidence it was offered during the 7-3 shift. The (MONTH) (YEAR) log indicated Resident #141 did not receive restorative ambulation services for the dates of 04/07/17, 04/09/17, 04/10/17, 04/13/17, 04/14/17, 04/15/17, 04/16/17, 04/18/17, 04/19/17, 04/21/17, 04/22/17, 04/25/17, 04/27/17 04/29/17 or 04/30/17. Additionally, NA #23 confirmed no evidence was present to indicate ambulation services had been offered twice daily on 04/08/17, 4/17/17, 04/23/17 and 04/28/17. Resident was out of facility for one (1) date and refused (R) for four (4) of twenty-three (23) opportunities. The interim Center Nurse Executive (CNE) interviewed on 05/24/17 at about 3:00 p.m., confirmed Resident #141 had not received restorative services as per the plan of care. d) Resident #163 A 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) # --- revealed the Stage 2 pressure ulcer present on the Resident #163's coccyx. Upon inquiry as to 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 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, 05/13/17, 05/12/17, 05/11/17, 04/15/17, 04/16/17 and 04/17/17. The CNE reviewed the medical record on 05/31/17 and confirmed omission of data. No evidence was present to indicate the facility had provided the wound care treatments as directed by the plan of care. e) Resident #124 The medical record was reviewed on 06/01/17. [DIAGNOSES REDACTED]. She weighed only 82 pounds on 05/26/17, as recorded on the computer weight records. Medications ordered included [MEDICATION NAME] fifteen (15) milligrams daily to help increase her appetite. Review of the current comprehensive care plan included interventions for weight maintenance or gain for this edentulous resident on pages twenty-one (21) and twenty-two (22) of the care plan. Interventions included eight (8) ounces of buttermilk with meals three (3) times per day at her request, and ice cream with lunch and dinner. She was observed eating her evening meal on 06/01/17 at 5:25 p.m. She had no buttermilk. Rather, dietary sent her a carton of skim milk. Dietary sent her a small bowl covered with cellophane wrap that looked like pudding. When asked if that was ice cream, the resident replied in the negative. When asked if she liked buttermilk with her meals, she replied in the affirmative. Nursing Assistant (NA) #11 was in the room at the time, assisting the resident's room-mate with her tray. NA #11 asked the resident if she would like some buttermilk, and the resident replied I sure would! NA #11 said she would also get her some ice cream from the dietary kitchen. An interview was conducted with the dietary director #89 on 06/01/17 at 5:50 p.m. Upon inquiry as to whether he received dietary orders for this resident to have eight (8) ounces of buttermilk with each meal, and ice cream with lunch and dinner, he slightly thumbed through some half sheets of dietary orders and diet changes he kept in a folder. He said he would have to check his file to see if he received an order for [REDACTED]. On 06/01/17 at 7:05 an interview was conducted with the director of nursing and the administrator. The administrator said the dietary director sent the buttermilk tonight after surveyor intervention. The administrator said the dietary director found he had ice cream, and sent ice cream to the resident this evening after we had discussed it. She agreed that the care plan directed this resident to receive eight (8) ounces of buttermilk with each meal, and ice cream daily with each lunch and dinner meal. | 2020-09-01 |
| 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 evidence was present to indicate the Stage 2 coccyx wound treatment was completed as ordered 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, 05/13/17, 05/12/17, 05/11/17, 04/15/17, 04/16/17 and 04/17/17. 2. Further review of the medical record revealed a new order for [MEDICATION NAME] sulfate 20 mg/ml, administer 0.75 ml sublingually (sl) every hour as needed and was clarified to administer 0.5 ml sl every hour as needed. Pain assessment records revealed no evidence the facility reassessed pain after administration of [MEDICATION NAME] sulfate on 05/18/17, 05/15/17 and 05/08/17, 04/23/17, 04/21/17, 04/18/17, 04/15/17 and 04/12/17. A pain presence monitoring tool was not present for (MONTH) (YEAR). The facility's pain management policy, reviewed on 05/23/17 at 9:00 a.m., required a pain evaluation be completed in the resident had a change in pain status. Residents receiving interventions for pain would be monitored for the effectiveness and side effects. On 05/22/17 at 2:57 p.m., the electronic medical record and paper medical record, reviewed with the CNE, confirmed no information was present to indicate the change in condition, or need for increased use of pain medication. The CNE agreed the change in the order was not a clarification and should have been discontinued, or noted as an error. The initial order indicated [MEDICATION NAME] sulfate 20 milligrams per milliliter (mg/ml) administer 0.75 ml sl every hour as needed and clarified to be administer 0.5 ml sl every hour as needed. 3. The bowel movement monitoring assessment indicated Resident #163 had no bowel movement on 05/01/17, 05/02/17 and received milk of magnesia (MOM) with no results noted until 05/04/17. No follow-up was noted on 05/03/17. No bowel movement was noted for 05/12/17, 05/13/17, 05/14/17, 05/15/17, 05/16/17, and 05/17/17. The action taken indicated MOM was administered on 05/14/17 with no results and no follow-up to ensure the resident had a bowel movement. Additionally, no information was present to indicate the facility had assessed and monitored the resident for complications. On 05/22/2017 at 4:15 p.m., Resident #163's medical record was reviewed with the interim CNE related to omission of data for bowel movements, not following physician's orders [REDACTED]. The CNE acknowledged the facility failed to assess/reassess Resident #163's pain and/or constipation per physician's orders [REDACTED]. The CNE reviewed the medical record on 05/31/17 and confirmed omission of data. No evidence was present to indicate the facility had provided the wound care treatments as directed by the plan of care. b) Resident #159 A 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 was in the hospital on [DATE] and the resident was readmitted 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. [MEDICAL TREATMENT] communication records, reviewed from 12/15/16 to present revealed incomplete records for fourteen (14) of fifteen (15) records reviewed. The communication record included a pre-[MEDICAL TREATMENT] assessment for a facility nurse to complete, a middle section for the [MEDICAL TREATMENT] center to complete, and a post-[MEDICAL TREATMENT] assessment for the facility to complete. Incomplete records included 05/23/17, 05/20/17, 05/18/17, 05/15/17, 05/12/17, 05/09/17, 05/06/17, 05/04/17, 05/02/17, 12/24/16, 12/22/17, 12/20/16,12/17/16, and 12/15/16. Records between 12/24/16 and 05/02/17 were absent from the [MEDICAL TREATMENT] records. On 06/12/17 at 6:17 p.m., an inquiry as to the facilit's responsibility related to the permacath and graft site, Registered Nurse (RN) #120 verbalized none, and said the [MEDICAL TREATMENT] site managed the line. Further inquiry related to the facility's responsibility for assessing and monitoring the site, RN #120 said the facility did not have a responsibility. Licensed Practical Nurse (LPN) #132 verbalized the facility was required to monitor the bruit and thrill of the graft site. RN #120 reviewed the [MEDICAL TREATMENT] communication records and confirmed they were incomplete. On 05/30/17 at 12:34 p.m., the communication records were reviewed with the interim Center Nurse Executive (CNE), who also confirmed the records were incomplete. The CNE said she did not know how laboratory results were communicated between [MEDICAL TREATMENT] and the facility. The nurse said she thought the [MEDICAL TREATMENT] center did send a report at times and would ask Health Information Management Coordinator (HIMC). The HIMC verbalized at 4:03 p.m., that no additional information was present in the medical record or thinned files. Additionally, HIMC said the graft had been placed on 02/08/17, but the facility did not have an order to monitor for thrill and bruit until 05/24/17. No evidence was present to indicate the bruit and thrill were monitored for the months of February, (MONTH) and (MONTH) (YEAR). c) Resident #101 A Stage 1 observation on 05/15/17 at 1:27 p.m., revealed Resident #101 in bed, leaning to the right side against the siderail. No support devices were in place to assist with maintaining an upright position. The bedsheets were tucked tightly over her toes holding the feet in plantar flexion position. On 06/01/17 at 11:19 a.m., a Stage 2 observation revealed the resident leaning against the side rail. The head of the bed was elevated between 45 and 90 degrees. Resident #101 verbalized she slid to the side, did not like lying that way, and would like to sit up. She had no positioning devices in place to maintain upright positioning. When asked if she could reposition herself, the resident reached back in an attempt to grab the siderail, but could not reach it. A Nurse Aide (NA) entered the room at that time and said she would assist the resident into a comfortable position. Physical Therapy Assistant (PTA) #52 and Physical Therapist #104, interviewed on 06/01/17 at 3:56 p.m., said Resident #101 was currently on the occupational therapy (OT) case load for wheelchair (w/c) positioning. Upon inquiry as to how the facility identified the need for therapy, the OT verbalized the resident was picked up on 05/23/17, during a routine screen by therapy. The OT said the resident had a spinal cord injury and was hoping for neuro-recovery and strength. The care plan indicated Resident #101 required assistive devices for bed mobility and limited to extensive assistance of one (1) person. The significant change minimum data set (MDS) with an assessment reference date (ARD) of 04/18/17 indicated Resident #101 required extensive assistance for bed mobility. d) Resident #76 The medical record review yielded a minimum data set (MDS) with an assessment reference date (ARD) of 05/09/17. It noted Resident #76 required extensive assistance of one (1) person for bed mobility. The MDS indicated the resident had impairment on both sides, 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., revealed 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 had slid down in his bed and was eating lunch. An unidentified NA was feeding the roommate and his brother and sister-in-law were standing at the bedside. Upon inquiry, LPN #62 confirmed he was not positioned correctly and needed pulled up in bed. She asked the NA to assist her to position him correctly to eat his meal. e) 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. review of the resident's medical record revealed [REDACTED]. Additionally, the physician's orders [REDACTED]. During an observation and interview with Resident #141 on 05/23/17 at 9:15 a.m. the resident said he had his bath and was waiting for the nurse to provide his pain relief therapy. He verbalized restorative would walk him after that. At 12:28 p.m., the resident said, No one has walked me yet. and at 2:30 p.m., the resident said he had not yet walked. The resident said he had walked three (3) times the previous week, but had not walked at all the three (3) weeks prior to that. Resident #141 expressed he felt like he was losing his strength. Another observation at 5:53 p.m. revealed the resident sleeping bed. Nurse Aide (NA) #37, interviewed at 12:48 p.m. on 05/23/17, said Resident #141 walked with restorative aides, but they get pulled to the floor a lot so it doesn't (does not) get done. The NA said the resident had no routine, just slept most of the day. The NA voiced the resident did not usually refuse to walk, but it took him a while because his legs shake. The NA reported it took about forty-five (45) minutes to an hour to walk him from his room to the doorway of the conference room and back, and that he usually took a break. The NA verbalized the resident walked on a good week four (4) times. During an interview with Nurse Aide (NA) #23 on 05/24/17 at 2:36 p.m., the NA reviewed the restorative records and said Resident #141 was supposed to walk 150 feet two (2) times a day. The NA verbalized restorative noted the shift and time of resident participation and/or refusal and if no entry was present, then restorative did not ask the resident to ambulate. Upon request, the NA reviewed the (MONTH) (YEAR) and (MONTH) (YEAR) activity participation log and confirmed no evidence was present to indicate services had been offered on the dates of 05/01/17, 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/13/17, 05/14/17, 05/15/17, 05/16/17, 05/19/17, 05/21/17, 05/22/17, and 05/23/17. Additionally, no evidence was present to indicate it was offered twice on the dates of 05/17/17, 05/18/17, 05/20/17, and 05/24/17. The log noted Resident #141 had refused on the 3-11 shift on 05/03/17, 05/04/17 and 05/08/17, with no evidence it was offered during the 7-3 shift. The (MONTH) (YEAR) log indicated Resident #141 did not receive restorative ambulation services for the dates of 04/07/17, 04/09/17, 04/10/17, 04/13/17, 04/14/17, 04/15/17, 04/16/17, 04/18/17, 04/19/17, 04/21/17, 04/22/17, 04/25/17, 04/27/17 04/29/17, or 04/30/17. Additionally, NA #23 confirmed no evidence was present to indicate ambulation services had been offered twice daily on 04/08/17, 4/17/17, 04/23/17, and 04/28/17. The resident was out of facility for one (1) date and refused for four (4) of twenty-three (23) opportunities. The interim Center Nurse Executive (CNE), interviewed on 05/24/17 at about 3:00 p.m., confirmed Resident #141 had not received restorative services as per the plan of care. f) Resident #27 Medical record review related to accidents revealed a physician's orders [REDACTED].#27 required the 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 at the facility about three (3) times a week, and was adamant Resident #27 had not been walking in the hallway with restorative nursing. Restorative Nursing records, reviewed for the period from 05/01/17 through 05/24/17 indicated Resident #27 only walked one (1) time a day on the days she received restorative ambulation. Additionally, no evidence was present to indicate the resident received restorative as ordered from 05/10/17 through 05/24/17. No data was entered for the dates of 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, or 05/23/17. Review of the restorative nursing documentation for bilateral lower extremity exercises yielded no data for 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, and 05/23/17. Nurse Aide (NA) #37, interviewed on 05/23/17 at 12:48 p.m., verbalized only the restorative nurse aides walked with Resident#27 in the hallway for restorative care. NA #23, interviewed on 05/24/17 at 2:36 p.m., verified the residents did not receive restorative therapy if no data was present. The restorative/rehabilitative nursing program plan indicated the skilled functional area deficit was required because a potential for decline existed and to maintain the current level of function. Program instructions indicated therapy be completed six (6) days a week. The interim center nurse executive (CNE), interviewed on 05/24/17 at 3:30 p.m., confirmed restorative care had not been provided as directed by the plan of care. g) Residents #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, and #82. A complaint investigation was conducted simultaneously with a Quality Indicator Survey from 05/15/15 through 06/02/17 related to staffing concerns and a failure to provide care and services. During an interview with Nurse Aide (NA) #23 on 05/24/17 at 2:36 p.m., the NA reviewed the restorative records and verbalized restorative noted the shift and time of resident participation and/or refusal. The NA said if no entry was present then restorative did not ask the resident to participate. The restorative nursing record, reviewed for the dates of 05/01/17 through 05/14/17 indicated residents received nursing services per physician's orders [REDACTED].#141 and #27, as follows: - Resident #125: Restorative Nursing to assist resident to perform bilateral upper extremity active range of motion/passive range of motion (AROM/PROM) in all planes ten (10) repetitions (reps) for three (3) sets daily six (6) days a week. Re-evaluate in 90 days. Review of the (MONTH) (YEAR) restorative nursing record indicated Resident #125 did not receive restorative services for 12 of 20 opportunities. - Resident #116: Restorative Nursing to provide right upper extremity (RUE) AROM/PROM: fingers, wrist, and elbow- flexion extension, Right (R)-shoulder flexion ten (10) reps times three (3) sets daily as tolerated six (6) days a week. Re-evaluate on 06/22/17 and as needed (PRN). Also, restorative nursing to provide transfer training from w/c (wheelchair) to chair and chair to w/c four (4) times a day with gait belt and minimal assist six (6) times a week. Chair and w/c to be placed ten (10) feet apart. Re-evaluate on 07/09/17. The restorative nursing record indicated the resident did not receive restorative services for 12 of 24 opportunities: 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, 05/21/17 and 05/22/17. - Resident #45: Restorative staff to assist Resident to ambulate 100 feet two (2) times a day with roll walker, gait belt, and minimal assist with wheel chair (w/c) to follow per resident's tolerance six (6) days a week. Re-evaluate program on 07/09/17 and prn. No evidence was present to indicate the resident received services for fourteen (14) of 24 opportunities. - Resident #107: Restorative nursing to assist resident to perform left lower extremity (LLE) exercises - seated marches and long arc quads ten (10 sets times three (3) reps six (6) days a week, initiated on 04/13/17. Restorative nursing to assist Resident to perform five (5) sit-to-stand transitions using hallway rail outside of room with minimal assist and gait belt to stand up and contact guard assist (CGA) while standing (six 6) days a week. Re-evaluate in 90 days and as needed. No evidence was present to indicate services were offered for six (6) of twelve (12) opportunities. Restorative nursing to perform right upper extremity (RUE) PROM in all planes for ten (10) repetitions for two (2) sets daily as tolerated six (6) days a week and re-evaluate on 07/04/17 and PRN. Restorative staff to apply RUE hand roll splint following PROM for up to four (4) hours a day six (6) days a week. Inspect skin prior to application and after removal of hand splint. Re-evaluate on 07/04/17 and as needed. Restorative nursing to assist resident perform right lower extremity (RLE) PROM in all planes flexion/extension, and abduction/adduction. Ten (10) reps times two (2) sets daily as tolerated six (6) days a week. No evidence was present to indicate the resident received services as ordered between 05/06/17 and 05/24/17. - Resident #192 - Restorative nursing to assist resident perform LLE (left lower extremity) exercises while supine in bed - straight leg raises, heel slides, quad sets, abduction/adduction .three (3) reps times ten (10) sets daily six (6) days a week. Re-evaluate on 07/09/17 and PRN. Restorative nursing to assist resident to perform LUE (left upper extremity) exercises with stress ball .three (3) reps times ten (10) daily six (6) times a week. No evidence was present to indicate the facility provided services six (6) times a week including the dates of 05/02/17, 05/05/17, 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17, 05/23/17, and 05/24/17. - Resident #5: Restorative dining - resident to attend restorative dining six (6) days a week, lunch meal to increase nutritional intake. Revaluate on 06/10/17 and PRN. The restorative nursing record indicated restorative dining was not provided as ordered. Restorative nursing to assist with BLE (both lower extremities) therapeutic exercises while sitting .three (3) sets times ten (10) reps six (6) days a week. No evidence was present to indicate service were offered for the dates of 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/18/17, 05/19/17, 05/21/17 and 05/22/17. Additionally, the form indicated Resident #5 had refused on 05/03/17, 05/04/17, 05/16/17, and 05/17/17. - Resident #112: Restorative nursing to assist resident to ambulate 40 feet two (2) times with roll walker, CGA and w/c to follow six (6) days per week. Restorative nursing to assist resident to stand five (5) times daily for three (3) minutes each stand with CGA six (6) days per week. No evidence was present to indicate the facility attempted ambulation for the dates of 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17 or 05/24/17. - Resident #64: Restorative nursing to assist resident perform UE (upper extremity) exercises using yellow theraband .for ten (10) reps times two (2) sets daily six (6) days a week. No evidence of participation/refusal was noted for the dates of 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17 05/18/17, 05/19/17, 05/21/17 or 05/22/17. - Resident #121: Restorative nursing to assist with RUE active assistive range of motion (AAROM) .three (3) sets times ten (10) reps as tolerated by resident six (6) days a week. The resident refused on four (4) occasions with an additional thirteen (13) opportunities. Restorative to ambulate resident 150 feet twice daily .six (6) days a week. Omissions of opportunity included 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17, and 05/23/17. Additionally, no evidence was present to indicate services were offered twice daily as ordered for 24 of 24 opportunities. - Resident #16: Restorative nursing to provide LUE PROM in all planes one time a day Restorative staff to apply left resting hand splint following PROM - . Re-evaluate on 06/10/17. No evidence was present to indicate the splint was applied as ordered for or offered for the dates of 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, 05/21/17, or 05/22/17. - Resident #195: Restorative nursing to ambulate resident one (1) time daily 100 feet with roll-walker and CGA six (6) days a week, initiated on 05/13/17. Restorative nursing to transfer resident from bed to w/c or w/c to armchair with ten (10) feet separation between objects four (4) times a day .six (6) times a week. Review in 90 days. Restorative records indicated services were not offered/provided as ordered. - Resident #160: Restorative nursing to assist resident perform LUE PROM .re-evaluate on 07/23/17 and PRN. Restorative to apply LUE posey hand roll following PROM six (6) days a week. Restorative records indicated services were not provided per physician's orders [REDACTED]. - Resident #2: Restorative nursing to assist with BLE therapeutic exercises while sitting .using three (3) pound weights three (3) sets times ten (10) reps six (6) days a week - re-evaluate on 07/03/17. Restorative nursing to assist with trunk flexion .five (5) times a day six (6)days a week. Re-evaluate on 7/03/17 and PRN. The restorative nursing record was silent to services on 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/18/17, 05/19/17, 05/21/17, 05/23/17 and 05/24/17. - Resident #101: Restorative nursing to assist with BUE home theraband exercise program using yellow theraband .six (6) days a week. Re-evaluate on 07/19/17 and PRN; Restorative nursing to assist with BLE exercises .six (6) days a week. The restorative nursing record indicated the resident did not receive services as ordered. - Resident #104: Restorative nursing to provide gentle PROM to head/neck .then position with memory foam pillow Restorative nurse to provide BLE AAROM . six (6) times a week. Restorative to provide BUE PROM in all planes .six 96) times a week to prep for splinting of bilateral UE. Restorative nursing to apply BUE regular posey finger contracture rolls following PROM .six (6) days a week. Re-evaluate on 07/09/17 and PRN. No evidence was present to indicate the service was provided and/or offered on 05/06/17, 05/09/17, 05/10/17, 05/18/17, 05/19/17, or 05/21/17. - Resident #82: Restorative nursing to apply left resting hand splint following LUE PROM .six (6) days a week. Restorative nursing to assist with BLE therapeutic exercises .six (6) days a week Restorative records indicated services were not provided six (6) days a week. - Resident #105: Restorative staff to assist resident to stand 3 reps daily using roll walker and perform weight shifting up to one (1) minute then stand high marches for up to one (1) minute six (6) days a week. Restorative staff to assist resident to ambulate 50 feet to 300 feet daily with roll walker .assist with w/c to follow .six (6) days a week. Re-evaluate on 07/04/17. The restorative nursing record indicated services were not offered or provided as ordered for 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/15/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, and 05/21/17. - Resident #21: Restorative nursing to assist Resident perform five (5) sit-to-stand .six (6) days a week Restorative nursing to assist with BLE exercises while sedated .six (6) days per week. The restorative records indicated services were not provided and/or offered on 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, 05/23/7 or 05/24/17. The resident refused services on 05/03/17, 05/04/17, 05/16/17 and 05/17/17. - Resident #31: Restorative nursing to assist with BLE therapeutic exercises .six (6) days a week. Re-evaluate on 05/15/17. Restorative nursing to assist with BUE therapeutic theraband home exercise program .six (6) days a week. Re-evaluate on 05/15/17. No evidence was present to indicate services were provided and/or offered on the dates of 05/05/17, 05/06/17, 05/07/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/21/17, 05/23/17, or 05/24/17. - Resident #20: Restorative nursing to assist resident to perform BUE AROM .six (6) days a week. The restorative nursing log indicated staff did not offer/provide services on 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/21/17, or 05/23/17. Restorative nursing to assist BLE PROM .daily six (6) days a week, and Restorative nursing to apply lower extremity wedge for up to four (4) hours per day .six (6) days a week. Re-evaluate in 90 days. The log revealed no services were offered on 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17 05/14/17, 05/18/17, 05/19/17, 05/21/17 or 05/23/17. - Resident #47: Restorative nursing to provide BLE - ankles AAROM .six (6) days a week, and Restorative nursing to provide BUE AAROM ROM .six (6) days a week . Re-evaluate on 06/10/17 and PRN. The restorative log indicated the facility did not offer restorative services on 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, and 05/21/17. - Resident #153: Restorative nursing to assist resident to ambulate from room to Rehab Dining room, and then back to room .six (6) days a week Restorative dining: Resident to attend restorative dining six (6) days a week, lunch meal to increase safety and efficiency of swallowing function The restorative nursing records indicated restorative dining services were not provided as ordered, between 05/01/17 and 05/13/17. - Resident #61: Restorative staff to assist resident to ambulate from room to dining room and back daily with roll walker .six (6) days a week. Restorative nursing to provide transfer training from w/c to chair or chair to w/c with ten (10) feet separation .six (6) days a week. The restorative nursing record was silent for dates of 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, or 05/21/17. - Resident #7: Restorative nursing to assist resident perform BLE PROM .six (6) times a week Restorative nursing to assist resident perform BUE exercises using five (5) pound weight and red theraband .six (6) days a week, re-evaluate in 90 days. The restorative log indicated services were not provided six (6) days a week or offered and/or provided for thirteen (13) opportunities between 05/01/17 and 05/24/17. - Resident #4: Restorative dining lunch meal six (6) times a week .re-evaluate on 06/10/17. The log indicated services were not provided as ordered between 05/01/17 and 05/10/17. - Resident #150: Restorative to ambulate Resident 50-100 feet one (1) time daily .imitated on 05/05/17 - re-evaluate in 90 days and prn. The restorative record was silent for the dates of 05/06/17, 05/07/17, 05/08/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/15/17, 05/16/17, 05/19/17, 05/20/17, 05/21/17, and 05/24/17. - Resident #26: Restorative nursing to provide BUE PROM in all planes .six (6) days | 2020-09-01 |
| 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 growth remained unshaved. On 05/17/17 at 3:24 p.m., the resident's hair remained long and disheveled, but he had been shaved. The nurse said the hospice aide had provided care. An observation on 05/23/2017 at 9:09 a.m., found Resident #76 in bed awake, watching a game show on his roommate's television. The fingernails on his right hand had dark brown debris beneath them. His hair was uncombed, and he had not been shaved. When asked how often he would like to be shaved, he replied he would like shaved right now. The resident voiced he preferred to be shaved daily. At 11:56 a.m., the resident had been shaved, and his hair combed. Another observation at 2:25 p.m. revealed his nails had been clipped and cleaned. Nurse Aide (NA) #135, on 05/23/17 at 2:28 p.m., said the resident had gotten weak and now staff did most of his care. She verbalized the hospice aide had provided his care this date. The minimum data set (MDS) with an assessment reference date (ARD) of 05/15/15 indicated Resident #76 required extensive assistance with dressing, eating, toilet use and personal hygiene. The assessment 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]. The care plan, revised on 05/10/17, noted Resident #76 required assistance with activities of daily living (ADLs) with a goal to improve current level of ADL functions by next review. A hospice nurse aide (NA) provided care two (2) times a week. Licensed Practical Nurse (LPN) #62, interviewed on 05/24/17 at 1:26 p.m., said the resident was very noncompliant, but most of the time would let staff provide care if asked. She said the nurse would re-direct him if he refused for the nurse aides. An observation with the interim clinical nurse educator (CNE) on 05/24/17 at 4:10 p.m., revealed Resident #76 was still wearing the same clothing placed on him by the hospice NA on 05/23/17. During an observation on 06/01/17 at 11:27 a.m., Resident #76 was sitting in the dining room for lunch. His hair had been cut and he was clean shaven. The resident said he preferred his hair cut short. During a discussion with the CNE on 06/01/17 at 6:30 p.m., she said the facility was responsible to care for the resident on the days the hospice aide did not come to the facility. She voiced the resident had a decline, was dependent upon staff for care, and the resident should have been shaved by the facility nurse aides on the days a hospice staff member was not in the building. | 2020-09-01 |
| 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 | 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 reviewed the numerous times this resident had physical therapy (PT) and/or occupational therapy (OT) services in (YEAR) and found the following: - She was on PT and OT caseload [DATE] through [DATE]. - She received PT and OT services [DATE] through [DATE]. - She again received PT and OT services [DATE] through [DATE]. - She was on PT caseload [DATE] through [DATE]. Director of Rehabilitation Services #52 said she assumed the resident had a hospitalization in there somewhere. - She received OT services [DATE] through [DATE]. - She received PT and OT services [DATE] through [DATE]. Director of Rehabilitation Services #52 said they screened every patient in the facility at least every three (3) months at the time their quarterly assessments were due, and on patients after they sustained a fall. She said they also have a HEY program whereby they keep referral sheets at every nursing station. She said if any employee within the facility had a concern about a resident's functioning, they could communicate their concerns to therapy by utilizing the referral sheets. Director of Rehabilitation Services #52 said they screened this resident on [DATE] after she was readmitted to the facility following a psychiatric inpatient admission. They found that she was able to propel in a wheelchair around the facility and there was no change in functional transfers. Upon inquiry, she said the last time OT had her on case load was (MONTH) (YEAR). At that time, OT had goals for passive and active range of motion (ROM) to the right upper extremities, ten (10) repetitions for three (3) sets daily to establish a contracture management program. OT also had goals for her to tolerate a right hand orthotic for two (2) hours initially, with the goal to tolerate it long-term for four (4) hours. The final long-term OT goals were to discharge the resident to the restorative program with 100% staff training for the contracture management program. She said the director of nursing (DON) was the head of the restorative program. In an interview on [DATE] at 4:15 p.m., the DON said therapy did not say to pick her back up for restorative when they did her screening upon her return to the facility following that (MONTH) psychiatric hospitalization . Upon inquiry, she said this resident had not received restorative services since her return to the facility on or around [DATE]. On [DATE] at 4:22 p.m., during a joint interview with the DON and Director of Rehabilitation Services #52, the DON said the resident used to have a Posey roll. She said the resident also used to receive restorative services with the restorative aides. The DON said that formerly this resident had physician orders [REDACTED]. The DON said the old orders expired, and there were no new admission orders [REDACTED]. She said PT completed a screening upon her return to the facility from the hospital, and did not order restorative services or the Posey hand roll. She said that in all likelihood this may have fallen through the cracks. The DON said she felt that nursing assistants did enough range of motion during the activities of daily living to make it count for range of motion. The DON and Director of Rehabilitation Services #52 said they would check with therapy the next day to see if they want her picked back up again for restorative services. On [DATE], interviews with Nurse Aides (NA) #64 and #38, at 5:30 p.m. and at 5:35 p.m., respectively, revealed they were trained in nurse aide classes to exercise limbs of residents who had paralysis. NA #38 said she was assigned to provide care for this resident that day. She said she knew to exercise the affected limb. She said she has had no instructions to apply any type of splint, orthotic, carrot, or Posey roll to the affected hand. During an interview with the resident on [DATE] at 9:41 a.m., she demonstrated that she could use her left hand to try to stretch out the fingers on her right hand. The little finger and the thumb of the right hand were not contracted. The three (3) middles fingers on the right hand were contracted and she could not stretch them out. The three fingers were bent downward, and then pointed back toward the wrist. The fingernails that could be visualized were trim. There was no odor noted. During an another interview with Director of Rehabilitation Services #52 on [DATE] at 1:20 p.m., she said that OT looked at the resident and determined that she had not sustained any decline in functionality. She said they picked her back up on caseload. On [DATE] at 8:15 a.m., during an interview with OT #11, a box with a Posey hand splint inside was noted on her desk that had the resident's name written in black marker on the outside of the box. OT #11 said she assessed the resident yesterday and saw no decline in the functionality of the resident's right hand. She said the functionality of the resident's hand was the same as it was during the time she had most recently received therapy services. When asked what would happen if the resident did not wear the Posey hand splint, she said the palm of the resident's hand would become macerated, and her contracted fingertips could intrude into the palm. When asked if she would always need to wear a device of that type, she replied in the affirmative. She said the contracture would not correct itself at any time in the future, so it would be a lifetime need for the device. When asked whether the restorative service aides or the regular aides on the floor would apply the Posey when she was discharged from OT, she said only the restorative aides would apply it. She said the regular aides on the floor did not apply orthotics, and would not do so unless the policy changed sometime in the future to allow the aides to do so. She agreed that upon her return from the hospital in March, that she should have been picked up again for restorative and for the orthotic, and she was not. | 2020-09-01 |
| 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 | 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 up in bed. She asked the NA to assist her to position him correctly to eat his meal. 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. review of the resident's medical record revealed [REDACTED]. Additionally, the physician's orders [REDACTED]. During an observation and interview with Resident #141 on 05/23/17 at 9:15 a.m. the resident said he had his bath and was waiting for the nurse to provide his pain relief therapy. He verbalized restorative would walk him after that. At 12:28 p.m., the resident said, No one has walked me yet. and at 2:30 p.m., the resident said he had not yet walked. The resident said he had walked three (3) times the previous week, but had not walked at all the three (3) weeks prior to that. Resident #141 expressed he felt like he was losing his strength. Another observation at 5:53 p.m. revealed the resident sleeping bed. Nurse Aide (NA) #37, interviewed at 12:48 p.m. on 05/23/17, said Resident #141 walked with restorative aides, but they get pulled to the floor a lot so it doesn't (does not) get done. The NA said the resident had no routine, just slept most of the day. The NA voiced the resident did not usually refuse to walk, but it took him a while because his legs shake. The NA reported it took about forty-five (45) minutes to an hour to walk him from his room to the doorway of the conference room and back, and that he usually took a break. The NA verbalized the resident walked on a good week four (4) times. During an interview with Nurse Aide (NA) #23 on 05/24/17 at 2:36 p.m., the NA reviewed the restorative records and said Resident #141 was supposed to walk 150 feet two (2) times a day. The NA verbalized restorative noted the shift and time of resident participation and/or refusal and if no entry was present, then restorative did not ask the resident to ambulate. Upon request, the NA reviewed the (MONTH) (YEAR) and (MONTH) (YEAR) activity participation log and confirmed no evidence was present to indicate services had been offered on the dates of 05/01/17, 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/13/17, 05/14/17, 05/15/17, 05/16/17, 05/19/17, 05/21/17, 05/22/17, and 05/23/17. Additionally, no evidence was present to indicate it was offered twice on the dates of 05/17/17, 05/18/17, 05/20/17, and 05/24/17. The log noted Resident #141 had refused on the 3-11 shift on 05/03/17, 05/04/17 and 05/08/17, with no evidence it was offered during the 7-3 shift. The (MONTH) (YEAR) log indicated Resident #141 did not receive restorative ambulation services for the dates of 04/07/17, 04/09/17, 04/10/17, 04/13/17, 04/14/17, 04/15/17, 04/16/17, 04/18/17, 04/19/17, 04/21/17, 04/22/17, 04/25/17, 04/27/17 04/29/17, or 04/30/17. Additionally, NA #23 confirmed no evidence was present to indicate ambulation services had been offered twice daily on 04/08/17, 4/17/17, 04/23/17, and 04/28/17. The resident was out of facility for one (1) date and refused for four (4) of twenty-three (23) opportunities. The interim Center Nurse Executive (CNE), interviewed on 05/24/17 at about 3:00 p.m., confirmed Resident #141 had not received restorative services as per the plan of care. c) Resident #27 Medical record review related to accidents revealed a physician's orders [REDACTED].#27 required the 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 at the facility about three (3) times a week, and was adamant Resident #27 had not been walking in the hallway with restorative nursing. Restorative Nursing records, reviewed for the period from 05/01/17 through 05/24/17 indicated Resident #27 only walked one (1) time a day on the days she received restorative ambulation. Additionally, no evidence was present to indicate the resident received restorative as ordered from 05/10/17 through 05/24/17. No data was entered for the dates of 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, or 05/23/17. Review of the restorative nursing documentation for bilateral lower extremity exercises yielded no data for 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, and 05/23/17. Nurse Aide (NA) #37, interviewed on 05/23/17 at 12:48 p.m., verbalized only the restorative nurse aides walked with Resident#27 in the hallway for restorative care. NA #23, interviewed on 05/24/17 at 2:36 p.m., verified the residents did not receive restorative therapy if no data was present. The restorative/rehabilitative nursing program plan indicated the skilled functional area deficit was required because a potential for decline existed and to maintain the current level of function. Program instructions indicated therapy be completed six (6) days a week. The interim center nurse executive (CNE), interviewed on 05/24/17 at 3:30 p.m., confirmed restorative care had not been provided as directed by the plan of care. d) Residents #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, and #82. A complaint investigation was conducted simultaneously with a Quality Indicator Survey from 05/15/15 through 06/02/17 related to staffing concerns and a failure to provide care and services. During an interview with Nurse Aide (NA) #23 on 05/24/17 at 2:36 p.m., the NA reviewed the restorative records and verbalized restorative noted the shift and time of resident participation and/or refusal. The NA said if no entry was present then restorative did not ask the resident to participate. The restorative nursing record, reviewed for the dates of 05/01/17 through 05/14/17 indicated residents received nursing services per physician's orders [REDACTED].#141 and #27, as follows: - Resident #125: Restorative Nursing to assist resident to perform bilateral upper extremity active range of motion/passive range of motion (AROM/PROM) in all planes ten (10) repetitions (reps) for three (3) sets daily six (6) days a week. Re-evaluate in 90 days. Review of the (MONTH) (YEAR) restorative nursing record indicated Resident #125 did not receive restorative services for 12 of 20 opportunities. - Resident #116: Restorative Nursing to provide right upper extremity (RUE) AROM/PROM: fingers, wrist, and elbow- flexion extension, Right (R)-shoulder flexion ten (10) reps times three (3) sets daily as tolerated six (6) days a week. Re-evaluate on 06/22/17 and as needed (PRN). Also, restorative nursing to provide transfer training from w/c (wheelchair) to chair and chair to w/c four (4) times a day with gait belt and minimal assist six (6) times a week. Chair and w/c to be placed ten (10) feet apart. Re-evaluate on 07/09/17. The restorative nursing record indicated the resident did not receive restorative services for 12 of 24 opportunities: 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, 05/21/17 and 05/22/17. - Resident #45: Restorative staff to assist Resident to ambulate 100 feet two (2) times a day with roll walker, gait belt, and minimal assist with wheel chair (w/c) to follow per resident's tolerance six (6) days a week. Re-evaluate program on 07/09/17 and prn. No evidence was present to indicate the resident received services for fourteen (14) of 24 opportunities. - Resident #107: Restorative nursing to assist resident to perform left lower extremity (LLE) exercises - seated marches and long arc quads ten (10 sets times three (3) reps six (6) days a week, initiated on 04/13/17. Restorative nursing to assist Resident to perform five (5) sit-to-stand transitions using hallway rail outside of room with minimal assist and gait belt to stand up and contact guard assist (CGA) while standing (six 6) days a week. Re-evaluate in 90 days and as needed. No evidence was present to indicate services were offered for six (6) of twelve (12) opportunities. Restorative nursing to perform right upper extremity (RUE) PROM in all planes for ten (10) repetitions for two (2) sets daily as tolerated six (6) days a week and re-evaluate on 07/04/17 and PRN. Restorative staff to apply RUE hand roll splint following PROM for up to four (4) hours a day six (6) days a week. Inspect skin prior to application and after removal of hand splint. Re-evaluate on 07/04/17 and as needed. Restorative nursing to assist resident perform right lower extremity (RLE) PROM in all planes flexion/extension, and abduction/adduction. Ten (10) reps times two (2) sets daily as tolerated six (6) days a week. No evidence was present to indicate the resident received services as ordered between 05/06/17 and 05/24/17. - Resident #192 - Restorative nursing to assist resident perform LLE (left lower extremity) exercises while supine in bed - straight leg raises, heel slides, quad sets, abduction/adduction .three (3) reps times ten (10) sets daily six (6) days a week. Re-evaluate on 07/09/17 and PRN. Restorative nursing to assist resident to perform LUE (left upper extremity) exercises with stress ball .three (3) reps times ten (10) daily six (6) times a week. No evidence was present to indicate the facility provided services six (6) times a week including the dates of 05/02/17, 05/05/17, 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17, 05/23/17, and 05/24/17. - Resident #5: Restorative dining - resident to attend restorative dining six (6) days a week, lunch meal to increase nutritional intake. Revaluate on 06/10/17 and PRN. The restorative nursing record indicated restorative dining was not provided as ordered. Restorative nursing to assist with BLE (both lower extremities) therapeutic exercises while sitting .three (3) sets times ten (10) reps six (6) days a week. No evidence was present to indicate service were offered for the dates of 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/18/17, 05/19/17, 05/21/17 and 05/22/17. Additionally, the form indicated Resident #5 had refused on 05/03/17, 05/04/17, 05/16/17, and 05/17/17. - Resident #112: Restorative nursing to assist resident to ambulate 40 feet two (2) times with roll walker, CGA and w/c to follow six (6) days per week. Restorative nursing to assist resident to stand five (5) times daily for three (3) minutes each stand with CGA six (6) days per week. No evidence was present to indicate the facility attempted ambulation for the dates of 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17 or 05/24/17. - Resident #64: Restorative nursing to assist resident perform UE (upper extremity) exercises using yellow theraband .for ten (10) reps times two (2) sets daily six (6) days a week. No evidence of participation/refusal was noted for the dates of 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17 05/18/17, 05/19/17, 05/21/17 or 05/22/17. - Resident #121: Restorative nursing to assist with RUE active assistive range of motion (AAROM) .three (3) sets times ten (10) reps as tolerated by resident six (6) days a week. The resident refused on four (4) occasions with an additional thirteen (13) opportunities. Restorative to ambulate resident 150 feet twice daily .six (6) days a week. Omissions of opportunity included 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/21/17, 05/22/17, and 05/23/17. Additionally, no evidence was present to indicate services were offered twice daily as ordered for 24 of 24 opportunities. - Resident #16: Restorative nursing to provide LUE PROM in all planes one time a day Restorative staff to apply left resting hand splint following PROM - . Re-evaluate on 06/10/17. No evidence was present to indicate the splint was applied as ordered for or offered for the dates of 05/06/17, 05/09/17, 05/10/17, 05/11/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, 05/21/17, or 05/22/17. - Resident #195: Restorative nursing to ambulate resident one (1) time daily 100 feet with roll-walker and CGA six (6) days a week, initiated on 05/13/17. Restorative nursing to transfer resident from bed to w/c or w/c to armchair with ten (10) feet separation between objects four (4) times a day .six (6) times a week. Review in 90 days. Restorative records indicated services were not offered/provided as ordered. - Resident #160: Restorative nursing to assist resident perform LUE PROM .re-evaluate on 07/23/17 and PRN. Restorative to apply LUE posey hand roll following PROM six (6) days a week. Restorative records indicated services were not provided per physician's orders [REDACTED]. - Resident #2: Restorative nursing to assist with BLE therapeutic exercises while sitting .using three (3) pound weights three (3) sets times ten (10) reps six (6) days a week - re-evaluate on 07/03/17. Restorative nursing to assist with trunk flexion .five (5) times a day six (6)days a week. Re-evaluate on 7/03/17 and PRN. The restorative nursing record was silent to services on 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/18/17, 05/19/17, 05/21/17, 05/23/17 and 05/24/17. - Resident #101: Restorative nursing to assist with BUE home theraband exercise program using yellow theraband .six (6) days a week. Re-evaluate on 07/19/17 and PRN; Restorative nursing to assist with BLE exercises .six (6) days a week. The restorative nursing record indicated the resident did not receive services as ordered. - Resident #104: Restorative nursing to provide gentle PROM to head/neck .then position with memory foam pillow Restorative nurse to provide BLE AAROM . six (6) times a week. Restorative to provide BUE PROM in all planes .six 96) times a week to prep for splinting of bilateral UE. Restorative nursing to apply BUE regular posey finger contracture rolls following PROM .six (6) days a week. Re-evaluate on 07/09/17 and PRN. No evidence was present to indicate the service was provided and/or offered on 05/06/17, 05/09/17, 05/10/17, 05/18/17, 05/19/17, or 05/21/17. - Resident #82: Restorative nursing to apply left resting hand splint following LUE PROM .six (6) days a week. Restorative nursing to assist with BLE therapeutic exercises .six (6) days a week Restorative records indicated services were not provided six (6) days a week. - Resident #105: Restorative staff to assist resident to stand 3 reps daily using roll walker and perform weight shifting up to one (1) minute then stand high marches for up to one (1) minute six (6) days a week. Restorative staff to assist resident to ambulate 50 feet to 300 feet daily with roll walker .assist with w/c to follow .six (6) days a week. Re-evaluate on 07/04/17. The restorative nursing record indicated services were not offered or provided as ordered for 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/15/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, and 05/21/17. - Resident #21: Restorative nursing to assist Resident perform five (5) sit-to-stand .six (6) days a week Restorative nursing to assist with BLE exercises while sedated .six (6) days per week. The restorative records indicated services were not provided and/or offered on 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/15/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, 05/23/7 or 05/24/17. The resident refused services on 05/03/17, 05/04/17, 05/16/17 and 05/17/17. - Resident #31: Restorative nursing to assist with BLE therapeutic exercises .six (6) days a week. Re-evaluate on 05/15/17. Restorative nursing to assist with BUE therapeutic theraband home exercise program .six (6) days a week. Re-evaluate on 05/15/17. No evidence was present to indicate services were provided and/or offered on the dates of 05/05/17, 05/06/17, 05/07/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/21/17, 05/23/17, or 05/24/17. - Resident #20: Restorative nursing to assist resident to perform BUE AROM .six (6) days a week. The restorative nursing log indicated staff did not offer/provide services on 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/21/17, or 05/23/17. Restorative nursing to assist BLE PROM .daily six (6) days a week, and Restorative nursing to apply lower extremity wedge for up to four (4) hours per day .six (6) days a week. Re-evaluate in 90 days. The log revealed no services were offered on 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17 05/14/17, 05/18/17, 05/19/17, 05/21/17 or 05/23/17. - Resident #47: Restorative nursing to provide BLE - ankles AAROM .six (6) days a week, and Restorative nursing to provide BUE AAROM ROM .six (6) days a week . Re-evaluate on 06/10/17 and PRN. The restorative log indicated the facility did not offer restorative services on 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, and 05/21/17. - Resident #153: Restorative nursing to assist resident to ambulate from room to Rehab Dining room, and then back to room .six (6) days a week Restorative dining: Resident to attend restorative dining six (6) days a week, lunch meal to increase safety and efficiency of swallowing function The restorative nursing records indicated restorative dining services were not provided as ordered, between 05/01/17 and 05/13/17. - Resident #61: Restorative staff to assist resident to ambulate from room to dining room and back daily with roll walker .six (6) days a week. Restorative nursing to provide transfer training from w/c to chair or chair to w/c with ten (10) feet separation .six (6) days a week. The restorative nursing record was silent for dates of 05/06/17, 05/08/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, or 05/21/17. - Resident #7: Restorative nursing to assist resident perform BLE PROM .six (6) times a week Restorative nursing to assist resident perform BUE exercises using five (5) pound weight and red theraband .six (6) days a week, re-evaluate in 90 days. The restorative log indicated services were not provided six (6) days a week or offered and/or provided for thirteen (13) opportunities between 05/01/17 and 05/24/17. - Resident #4: Restorative dining lunch meal six (6) times a week .re-evaluate on 06/10/17. The log indicated services were not provided as ordered between 05/01/17 and 05/10/17. - Resident #150: Restorative to ambulate Resident 50-100 feet one (1) time daily .imitated on 05/05/17 - re-evaluate in 90 days and prn. The restorative record was silent for the dates of 05/06/17, 05/07/17, 05/08/17, 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/15/17, 05/16/17, 05/19/17, 05/20/17, 05/21/17, and 05/24/17. - Resident #26: Restorative nursing to provide BUE PROM in all planes .six (6) days a week; Restorative nursing to provide BLE PROM in all planes . re-evaluate in 90 days and PRN. The record indicated no services offered on 05/01/17, 05/02/17, 05/06/17, 05/09/17, 05/10/17, 05/12/17, 05/14/17, 05/16/17, 05/17/17, 05/18/17, 05/19/17, 05/20/17, or 05/21/17. - Resident #49: Restorative to ambulate resident two (2) times daily 50 feet with hemi-walker and CGA six (6) days a week, initiated on 05/13/17. The restorative log indicated the facility failed to offer services for eight (8) of twelve (12) days and for twenty (20) of thirty two opportunities. Restorative nursing to transfer resident from bed to w/c or w/c to armchair .six (6) times a week. Restorative was not offered for eight (8) of 12 opportunities. - Resident 124: Resident to attend restorative dining six (6) times a week, lunch meal The restorative log indicated the order was not completed as ordered from 05/01/13 through 05/24/17. - Resident #187: Restorative staff to assist resident to ambulate 150 feet twice a day with roll walker .six (6) days a week Restorative nursing to provide transfer training from w/c to chair .six (6) times a week. Services were not provided for thirteen (13) opportunities. e) Daily Staffing and Assignment sheets for 04/16/17 to 05/24/17, reviewed on 05/24/17 at 10:45 a.m., indicated restorative nursing was transferred from restorative services to nurse aide assignment services for all or part of a day on 05/19/17, 05/18/17, 05/17/17, 05/16/17, 05/08/17, 05/07/17, 05/04/17, 05/03/17, 05/02/17, 04/30/17, 04/28/17 (late), 04/27/17, 04/25/17, 04/24/17, 04/21/17, 04/19/17 04/18/17, 04/16/17. The assignment sheets also indicated only one (1) NA was assigned and/or performed restorative services on 05/24/17, 05/23/17, 05/22/17, 05/19/17, 05/21/17, 05/19/17, 05/17/17, 05/16/17, 05/15/17, 05/14/17, 05/12/17, 05/09/17, 05/08/17, 05/06/17, 05/05/17, 05/04/17, 05/03/17, 05/02/17, 04/30/17, 04/28/17, 04/23/17, 04/22/17, 04/21/17, 04/17/17, and 04/16/17. f) The interim Center Nurse Executive (CNE) interviewed on 05/24/17 at about 3:00 p.m., confirmed residents had not received restorative services as per physician's orders [REDACTED]. New orders, dated 05/25/17 to 05/26/17 to discontinue and/or reduce restorative services to four (4) days a week included 27 of 27 residents reviewed: Resident #27, #61, #26, #150, #49, #141, #187, #195, #160, #101, #105, #21, #31, #20, #47, #153, #61, #125, #45, #107, #192, #5, #112, #84, #121, and #16. The administrator, at 6:40 p.m. on 06/01/17, requested to share the facility's quality assurance action plan. The administrator verbalized a staffing concern had been identified on 03/24/17 and a plan initiated that date to address concerns related to restorative services. The administrator said the facility was reviewing the services monthly to determine if the plan was working and if not, would revise it again. The administrator said that on 05/25/17 the program was reviewed and revised to reduce restorative care to four (4) days a week, as that was manageable for the facility and what residents were routinely receiving and required. g) Residents #93, #125, #34, #43, #103, #126, #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 During a random observation, on 06/01/2017 12:50 p.m., an overhead page announced, Lunch is now being served on east hall. Within a few minutes the food cart was delivered and parked by entrance near the main dining room. The time was 30 minutes later than noted on the schedule for the first cart. 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. NA #34 informed Resident #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 were 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 tray on the table in front of her. A small fly/gnat was crawling on her sandwich. The resident had not eaten her meal. - Resident #64 was asleep with her tray uneaten - At 1:14 p.m. Resident #22 had not eaten. At this time NA #34 entered the room and encouraged the resident to eat. - At 1:15 p.m., NA #103 tried to awaken Resident #43, but the resident was not responding. NA #2 talked loudly to the resident and rubbed her chest in circular motions with his hand. The resident barely opened her eyes for a second and went back to sleep. - At 1:19 p.m. LPN #94 walked by the room of Resident #41 and #103, but did not stop or try to awaken the residents who had not started eating their meals. h) Residents #104, #189, and #63 Observation of the North Hall meal tray service at 1:20 p.m., revealed staff passing meal trays - At 1:26 p.m. meal tray served to Resident #104 who was fed by NA #41. - At 1:27 p.m. - trays passed to Resident #189 and #63 by Health Information Management Coordinator (HIMC) #50 During an interview with Resident #92 on 05/16/17 at 10:28 a.m., the resident voiced meal services were often late 30 to 60 minutes. i) During an interview with the interim CNE, on 06/01/17 at about 2:15 p.m., an inquiry was made as to who the facility addressed staffing concerns. The CNE verbalized the restorative nursing staff was pulled to the floor. She further added that staff in other disciplines, who were also nurse aides, were sometimes pulled to the floor. Additionally, the CNE verbalized staff from sister facilities would help. With inquiry as to how staff functions during the evening meals and on weekends when administrative staff is not in the facility to assist, the CNE verbalized the weekend manager assisted. Discussion included that four (4) administrative staff assisted on two (2) hallways during the lunch meal observation on 06/01/17. | 2020-09-01 |
| 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 tray on the table in front of her. A small fly/gnat was crawling on her sandwich. The resident had not eaten her meal. - Resident #64 was asleep with her tray uneaten - At 1:14 p.m., Resident #22 had not eaten. At this time NA #34 entered the room and encouraged the resident to eat. - At 1:15 p.m., NA #103 tried to awaken Resident #43, but the resident was not responding. NA #2 talked loudly to the resident and rubbed her chest in circular motions with his hand. The resident barely opened her eyes for a second and went back to sleep. - At 1:19 p.m., LPN #94 walked by the room of Resident #41 and #107, but did not stop or try to awaken the residents who had not started eating their meals. The resident response list on the South Hall, dated 06/01/17 at 2:52 p.m., identified Resident #93, Resident #67, and Resident #77 were totally dependent for eating. Those who required extensive assistance included Residents #125, #107, #117,#129, #34, #18, #5, and #9. d) Residents #104, #189 and #63 Observation of the North Hall meal tray service at 1:20 p.m., revealed staff passing meal trays - At 1:26 p.m. - meal tray served to Resident #104 who was fed by NA #41. - At 1:27 p.m. - trays passed to Resident #189 and #63 by Health Information Management Coordinator (HIMC) #50 e) During an interview with Resident #92 on 05/16/17 at 10:28 a.m., the resident voiced meal services were often late, 30 to 60 minutes. f) During an interview with the interim Center Nurse Executive on 06/01/17 at 2:15 p.m., when asked to whom the facility addressed staffing concerns, the CNE said the restorative nursing staff were pulled to the floor. She further added that staff in other disciplines, who were also nurse aides, were sometimes pulled to the floor. Additionally, the CNE verbalized staff from sister facilities would help. When asked how staff functioned during the evening meals and on weekends when administrative staff were not in the facility to assist, the CNE said the weekend manager assisted. ( Four (4) administrative staff assisted on two (2) hallways during the lunch meal observation on 06/01/17.) | 2020-09-01 |
| 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 | 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 that opened vial. The Aplisol PPD manufacturer's guidelines includes, Vials in use for more than thirty (30) days should be discarded due to possible oxidation and degradation which may affect potency. | 2020-09-01 |
| 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. The NA removed her gloves and without performing hand hygiene exited the room. Upon return, the NA went to the bathroom and donned gloves. Upon completion of care, the NA removed her gloves and exited the room without utilizing hand hygiene. During care, Resident #163 pulled the barrier on the nightstand and a plastic bag with wound care supplies fell to the floor. Upon completion of wound care, LPN #72 removed her gloves and used hand sanitizer. The LPN picked up the plastic bag from the floor which contained gloves and four by four gauze pads. She placed the tube of cream utilized for wound care and the wound care cleanser in the bag. LPN #72 picked up the bag in her right hand and the garbage bag with her left hand and exited the room. She stopped at the treatment cart, placed the bag on top of the cart without first cleansing it, then placed it in the drawer, laying it across the top of other opened bags which contained other residents' supplies, still without cleansing the bag. d) Resident #31 A random observation on 06/01/17 at 4:24 p.m., revealed an isolation cart stationed outside of Resident #31's door. A small trash can, located on the right side of the resident's bed, near the foot of the bed, contained a yellow isolation gown protruding over the top of the garbage can. An isolation mask was located on the floor bedside the bed. Upon request, Licensed Practical Nurse (LPN) #60, completed an observation and said, Not cool. The nurse said the gown should be in a covered container and asked AD #36 to obtain one. The resident was identified as having shingles. e) Housekeeping During a random observation on 05/23/17 from 11:59 a.m. until 12:24 p.m., a bucket of mop water was noted spilled in the hallway at the room of Resident #50. Housekeeping (HSK) #133 and physical therapy assistant (PTA) cleaned the spill using towels to wipe up the contents. They did not wear PPE. Upon completion, HSK #133 wiped her hands down the sides of her uniform pants, as if to further dry them. f) During an interview on 05/30/17 at 2:58 p.m., Registered Nurse (RN) #6, the infection control coordinator, said the facility's policy required staff wash hands for a minimum of twenty (20) seconds. The nurse said the washcloths utilized for peri care should not have been placed in the sink basin, and PPE was required prior to entering the room of the resident in isolation. The RN identified Resident #189's infection as clostridium difficile, which required stringent hand hygiene. The nurse verbalized LPN #72 should have sanitized the bag she picked up from Resident #163's floor, prior to placing it back in the cart, but would have obtained a new bag herself. g) The hand hygiene policy with a revision date of 11/28/16, required staff perform hand hygiene before patient care, before an aseptic (clean) procedure, after any contact with blood or other body fluids even if gloves were worn, after patient care, and after contact with the patient's environment. The policy noted staff might decontaminate with alcohol based rub or wash hands with soap and rub vigorously for 20 seconds, covering all surfaces of hands and fingers. h) Resident #158 During medication administration observations on 05/16/17 at 8:16 a.m. Licensed Practical Nurse (LPN) #132 obtained a box from the drawer of her medication cart which contained Breo Elipta (an inhaler). She carried the box into Resident #158's room, and set the box directly onto the resident's bedside stand. She removed the inhaler and handed it to the resident to use. After the resident finished with the inhaler, LPN #132 placed the inhaler back into its box. She then placed the box directly onto the countertop of the resident's sink while she washed her hands. She then placed the box back into the drawer of the medication cart. During an interview with the director of nursing on 05/17/16 at 5:15 p.m., the risk of possibly transmitting pathogens by not maintaining a barrier between clean objects (medication box) and resident furnishings during the medication pass was discussed. She agreed, and said she would educate the nurse. | 2020-09-01 |
| 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, 05/13/17, 05/12/17, 05/11/17, 04/15/17, 04/16/17, and 04/17/17. 2. Further review of the medical record revealed a new order for [MEDICATION NAME] sulfate 20 mg/ml (milligrams per milliliter) administer 0.75 ml sublingually (sl) every hour as needed and was clarified to administer 0.5 ml sl every hour as needed. Pain assessment records revealed no evidence the facility reassessed pain after administration of [MEDICATION NAME] sulfate on 05/18/17, 05/15/17 and 05/08/17, 04/23/17, 04/21/17, 04/18/17, 04/15/17, and 04/12/17. A pain presence monitoring tool was not present for (MONTH) (YEAR). 3. The three (3) day incontinence management diary, dated 04/12/17 through 04/15/17, revealed no data for 9 of 36 opportunities including 7:00 a.m. to 9:00 a.m., 9:00 a.m. to 11:00 a.m., 11:00 a.m. to 1:00 p.m., and 1:00 p.m. to 3:00 p.m. on 04/14/17 and 04/15/17, and 11:00 p.m. to 1:00 a.m. on 04/12/17. c) Resident #159 1. [MEDICAL TREATMENT] communication records, reviewed for the period from 12/15/16 to present, revealed incomplete records for fourteen (14) of fifteen (15) records reviewed. The communication record included a pre-[MEDICAL TREATMENT] assessment for the facility nurse to complete, a middle section for the [MEDICAL TREATMENT] center to complete, and a post-[MEDICAL TREATMENT] assessment for the facility to complete. Incomplete records were found for 05/23/17, 05/20/17, 05/18/17, 05/15/17, 05/12/17, 05/09/17, 05/06/17, 05/04/17, 05/02/17, 12/24/16, 12/22/17, 12/20/16,12/17/16, and 12/15/16. Records between 12/24/16 and 05/02/17 were absent from the [MEDICAL TREATMENT] records. On 06/12/17 at 6:17 p.m., when asked what the facility's responsibility related to the permacath and graft site were, Registered Nurse (RN) #120 verbalized none, and said the [MEDICAL TREATMENT] site managed the line. Further inquiry related to the facility's responsibility for assessing and monitoring the site, RN #120 said the facility did not have a responsibility. Licensed Practical Nurse (LPN) #132 verbalized the facility was required to monitor the bruit and thrill of the graft site. RN #120 reviewed the [MEDICAL TREATMENT] communication records and confirmed they were incomplete. On 05/30/17 at 12:34 p.m., the communication records were reviewed with the interim Center Nurse Executive (CNE), who also confirmed the records were incomplete. The CNE said she did not know how laboratory results were communicated between [MEDICAL TREATMENT] and the facility. The nurse said she thought the [MEDICAL TREATMENT] center did send a report at times and would ask Health Information Management Coordinator (HIMC). The HIMC verbalized at 4:03 p.m., that no additional information was present in the medical record or thinned files. Additionally, HIMC said the graft had been placed on 02/08/17, but the facility did not have an order to monitor for thrill and bruit until 05/24/17. No evidence was present to indicate the bruit and thrill were monitored for the months of February, March, and (MONTH) (YEAR). 2. Activity of daily living records reviewed for (MONTH) (YEAR) revealed omissions of data for meal percentages for 05/30/17, 05/29/17, 05/27/17, 05/26/16, 05/08/17, and 05/06/17. Omissions related to snacks included 05/31/17, 05/30/17, 05/29/17, 05/27/17, 05/26/17, 05/24/17, 05/16/17, 05/09/16, 05/08/16, 05/06/17, and 05/04/17. The interim CNE reviewed the medical record on 06/01/17 and confirmed the record was not complete. d) Resident #76 05/30/17 at 10:24:05 p.m., review of the resident's activities of daily living (ADL) records found incomplete data for bed mobility, transfers, eating, toilet, walking, locomotion, dressing, personal hygiene, bathing, meals, bladder, and bowel for dates 05/07/17, 05/08/17, 05/11/17, 05/12/17, 05/17/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, and 05/24/17. e) Resident #143 Review of the resident's medical record related to nutrition revealed omissions of data for meal percentages and bedtime snacks. The (MONTH) (YEAR) activity of daily living records noted omissions of data for 18 of 93 opportunities for meals on 05/31/17, 05/30/17, 05/26/17, 05/22/17, 05/21/17, 05/20/17, 05/13/17, 05/02/17, and 05/01/17. Snack data omissions included 6 of 31 opportunities for snacks on 05/30/17, 05/29/17, 05/26/17, 05/25/17, 05/05/17, and 05/02/17. | 2020-09-01 |
| 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 | 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 wound care treatment including a dry dressing was ordered and started on 04/04/19. The wound care and dry dressing was applied daily from 04/04/19 until 04/10/19 when it was documented refused and applied again daily on 04/11/19 until 04/14/19 when it was documented as refused. The wound care treatment and dry dressing was applied daily again on 04/15/19 until 04/18/19 when it was documented refused. The wound care treatment and dry dressing was applied on 04/19/19, 04/20/19, 04/21/19, 04/24/19, 04/27/19, and 04/28/19. On 04/22/19, 04/23/19, 04/25/19, 04/29/19, and 04/30/19 it was documented refused, and on 04/26/19 there was no documentation either way as to refusal or provision of wound care treatment and the dry dressing, the TAR entry was blank. In the month of (MONTH) 2019 the resident had twenty seven (27) opportunities to have wound care treatment and a dressing applied daily and had the ordered treatment randomly eighteen (18) times. There was no wound care treatment provided at all during the month of May. According to the TAR, R#33 refused wound care treatment and daily dressings twenty-nine (29) days in the month of May, and two (2) days there was no documentation either way as to refusal or application of wound care or the dry dressing, the TAR was blank on those two days. According to the TAR, R#33 refused treatment on (MONTH) first, second, third, and fourth; and on 06/05/19 the wound nurse obtained an order to discontinue treatment due to refusals. From the time of the order until the order was discontinued there were sixty-two (62) opportunities to provide daily wound care treatment as ordered and it was documented treatment was provided as ordered on only eighteen (18) days, and three (3) days there was no documentation either way as to refusal or provision. There was no documented evidence the physician was notified of the resident's refusals until 06/05/19, when the order was discontinued. An interview with the wound nurse, Licensed Practical Nurse (LPN#84), on 06/10/19 at 11:44 AM, revealed LPN#84 said she kept trying to get R#33 to allow her to provide the wound treatment but he always refused. LPN#84 said the resident would let her clean and measure the wound weekly but not provide treatment and place a dry dressing on it daily as it was ordered. This surveyor requested evidence or documentation showing the resident refused wound care treatment, the physician was notified about the refusals of treatment, and R#33 was provided education concerning the importance of wound care and infection control. LPN#84 asked the nurse unit manager (LPN#61), to help review R#33's medical records for any of the requested documentation, while she finished the interview with this surveyor. LPN#84 said she was aware there was still some occasional drainage from the wound site. LPN#84 agreed the physician should have been notified concerning the resident's refusal of daily wound care and dressings. LPN#84 said she thought she contacted the physician sometime during the middle of (MONTH) and told the physician about the resident's refusal of treatment, however she said she did not document the conversation as she should have. When asked what instructions the physician gave her, LPN#84 said, I was to keep encouraging the resident to allow dressing changes. LPN#84 was asked by this surveyor if any other nursing staff tried to get the resident to comply with the ordered wound care treatment, such as the Center Nurse Executive (CNE), formerly known as the Director of Nursing or the Nurse Practitioner (NP). A Nurse Practitioner works in the facility three to four days a week and was available to see the resident. The wound nurse said she did not speak with the CNE or the NP or any other staff concerning R#33's refusals of wound care treatment. LPN#84 said she did not ask anyone else to see or speak to the resident to see if they might get R#33 to comply with the wound care treatment and/or to educate the resident on the importance of proper wound care and/or to ensure the resident understood. After review of the resident's medical records the nurse unit manager (LPN#61) stated she could find no documentation concerning refusal or non-compliance with the wound care treatment. LPN#61 said there was documentation concerning refusing care and non-compliance in other areas, but nothing concerning wound care. The facility was unable to provide any documentation or evidence that patient education was provided to the resident or any documentation that showed the physician was notified of the resident's refusals of wound care treatment. On 06/10/19 at 01:10 PM, interview with the resident revealed the wound still has some occasional drainage, but not as much as it did. When asked if anyone had explained to him the importance of wound care and applying a dry dressing to cover and catch any drainage the resident stated no one at the facility had talked to him about infections or the proper way to care for the wound. R#33 said he did not want a dressing on it now. R#33 said, I had training myself and if I wanted a dressing I'd ask for it, but it doesn't need one. When asked where he had training and what kind of training he had, the resident did not answer but informed this surveyor he was done talking about it. Review of Refusal of Treatment policy, on 06/10/19 at 03:55 PM, revealed if the patient refuses treatment staff will determine what the patient is refusing and why. Staff will try to address the patient's concerns and consult his/her supervisor. Notify physician of the refusal of treatment. Staff will determine and document what the patient is refusing; assess the reasons for refusal; advise patient of consequences of refusal; and offer alternative treatments. Document discussions with the patient/health care decision maker, physician, and other involved persons. The wound nurse did not follow the facility's policy on Refusal of Treatment. Review of care plan, on 06/10/19 at 11:23 AM, revealed a focus area related to the potential for further skin breakdown due to history of abscess to right side s/p (status [REDACTED]. An intervention added to this focus area on 06/05/19 by the wound nurse LPN#84 was Resident frequently refuses to come back from room from outside smoking for treatments to be completed A revision noted to the focus area potential for further skin breakdown on 06/06/19 now includes Resident noncompliant with wound treatments at times. The care plan was not revised timely to address resident's noncompliance with wound care treatments. The care plan was not revised to reflect any interventions addressing non-compliance and refusal of care in other areas that LPN#61 confirmed was documented in the resident's medical record. An interview with the Center Nurse Executive (CNE), on 06/10/19 at 2:30 PM, confirmed staff should have notified the physician sooner than 06/05/19, more than forty days after the resident consistently refused wound care treatment. The physician should have been notified when the resident continued refusing wound care treatment, so that the physician could order an alternative treatment if they chose to. The CNE confirmed R#33's care plan should have been revised with interventions concerning refusal of treatment and non-compliance prior to 06/05/19, due to R#33 medical record revealed non-compliance and refusal of care in other areas other than wound treatment. | 2020-09-01 |
| 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, and it needed repaired immediately. The facility's Administrator stated, I will get with our maintenance guy and have him get whatever supplies he will need to fix it today. In regard to the broken plastic framing around the HVAC unit, the Administrator stated, I will have our maintenance guy go to storage right now and see if we have another HVAC unit that we can use to replace this immediately, this is not acceptable. | 2020-09-01 |
| 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 things in her closet that does not belong to her. During an interview on 06/06/19 at 11:15 AM, Administrator asked Resident #82 about her missing [NAME]et. He said to her that he thought they had found and returned her red [NAME]et. Resident #82 applied to him, that they put a man's tan [NAME]et in her closet, and that was not hers and it is not even red. Administrator looked though her closet with her consent and presents, no red satin [NAME]et was found. On 06/10/19 at 9:11 AM, Administrator provided a Grievance/ Concern form dated; 06/06/19 concerning the red [NAME]et. It stated, that a search for the [NAME]et was done, the item was not located and will be replaced with a like item. | 2020-09-01 |
| 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 | 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 treatment due to resident refusing treatment. From the time of the order until the order was discontinued there were sixty-two (62) opportunities to provide daily wound care treatment and it was documented treatment was provided randomly only in the month of April. R#33 received wound care treatment eighteen (18) days due to resident refusing care on the other days, and three (3) times out of the sixty-two (62) opportunities to provide daily wound care treatment there was no documentation either way as to refusal or provision. An interview with the wound nurse, Licensed Practical Nurse (LPN#84), on 06/10/19 at 11:44 AM, revealed LPN#84 said she kept trying to get R#33 to allow her to provide the wound treatment but he always refused. LPN#84 said the resident would let her clean and measure the wound weekly but not provide treatment and place a dry dressing on it daily as it was ordered. This surveyor requested evidence or documentation showing the resident refused wound care treatment. LPN#84 asked the nurse unit manager (LPN#61), to help review R#33's medical records for the requested documentation, while she finished the interview with this surveyor. LPN#84 said she was aware there was still some occasional drainage from the wound site. LPN#84 agreed the physician should have been notified concerning the resident's refusal of daily wound care and dressings. LPN#84 said she thought she contacted the physician sometime during the middle of (MONTH) and told the physician about the resident's refusal of treatment, however she said she did not document the conversation as she should have. When asked what instructions the physician gave her, LPN#84 said, I was to keep encouraging the resident to allow dressing changes. After review of the resident's medical records the nurse unit manager (LPN#61) stated she could find no documentation concerning refusal or non-compliance with the wound care treatment. LPN#61 said there was documentation concerning refusing care and non-compliance in other areas, but nothing concerning wound care. The facility was unable to provide any documentation or evidence that patient education was provided to the resident or any documentation that showed the physician was notified of the resident's refusals of wound care treatment. Review of care plan, on 06/10/19 at 11:23 AM, revealed a focus area related to the potential for further skin breakdown due to history of abscess to right side s/p (status [REDACTED]. An intervention added to this focus area on 06/05/19 by the wound nurse LPN#84 was Resident frequently refuses to come back from room from outside smoking for treatments to be completed A revision noted to the focus area potential for further skin breakdown on 06/06/19 now includes Resident noncompliant with wound treatments at times. The care plan was not revised timely to address resident's ongoing noncompliance with daily wound care treatments. The care plan was not revised to reflect any interventions addressing non-compliance and refusal of care in other areas that LPN#61 confirmed was documented in the resident's medical record. An interview with the Center Nurse Executive (CNE), on 06/10/19 at 2:30 PM, confirmed staff should have notified the physician sooner than 06/05/19, more than forty days after the resident consistently refused wound care treatment. The physician should have been notified when the resident continued refusing daily wound care treatment, so that the physician could order an alternative treatment if they chose to. The CNE confirmed R#33's care plan should have been revised with interventions concerning refusal of treatment and non-compliance prior to 06/05/19, due to the ongoing refusal of daily wound care treatment. The CNE also confirmed based on R#33 medical record showing non-compliance and refusal of care in other areas the care plan should have been revised to address refusal of care in those areas as well. | 2020-09-01 |
| 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 bath. During an interview on 06/06/19 at 2:35 PM, Unit Manager #61 reviewed the ADL records and agreed that Resident # 78 did not get his showers as scheduled and she stated, that she had already re-educated three of her staff. c) R105 During an observation with R105 on 06/04/19 at 9:14 AM it was discovered the word/letter board she used as a communication system was found in very poor condition, with food particles, water stains and frayed edges. The regulation requires any communication devices used by residents to be in good repair. In an interview with E84, Licensed Practical Nurse (LPN) on 06/05/19 at 8:44 AM, verified the communication board was in very poor repair and needed to be replaced. | 2020-09-01 |
| 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 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 treatment due to resident refusing treatment. From the time of the order until the order was discontinued there were sixty-two (62) opportunities to provide daily wound care treatment and it was documented treatment was provided randomly only in the month of April. R#33 received wound care treatment eighteen (18) days due to resident refusing care on the other days, and three (3) times out of the sixty-two (62) opportunities to provide daily wound care treatment there was no documentation either way as to refusal or provision. An interview with the wound nurse, Licensed Practical Nurse (LPN#84), on 06/10/19 at 11:44 AM, revealed LPN#84 said she kept trying to get R#33 to allow her to provide the wound treatment but he always refused. LPN#84 said the resident would let her clean and measure the wound weekly but not provide treatment and place a dry dressing on it daily as it was ordered. This surveyor requested evidence or documentation showing the resident refused wound care treatment, the physician was notified about the refusals of treatment, and R#33 was provided education concerning the importance of wound care and infection control. LPN#84 asked the nurse unit manager (LPN#61), to help review R#33's medical records for any of the requested documentation, while she finished the interview with this surveyor. LPN#84 said she did not document notifying the physician about the refusal of treatment or any education concerning wound care or infection control. LPN#84 said she was aware there was still some occasional minimal drainage from the wound site. LPN#84 said she thought she contacted the physician sometime during the middle of (MONTH) and told the physician about the resident's refusal of treatment, however she said she did not document the conversation as she should have. When asked what instructions the physician gave her, LPN#84 said, I was to keep encouraging the resident to allow dressing changes. LPN#84 was asked by this surveyor if any other nursing staff tried to get the resident to comply with the ordered wound care treatment, such as the Center Nurse Executive (CNE), formerly known as the Director of Nursing or the Nurse Practitioner (NP). A Nurse Practitioner works in the facility three to four days a week and was available to see the resident. The wound nurse said she did not speak with the CNE or the NP or any other staff concerning R#33's refusals of wound care treatment. LPN#84 said she did not ask anyone else to see or speak to the resident to see if they might get R#33 to comply with the wound care treatment and/or to educate the resident on the importance of proper wound care and/or to ensure the resident understood. After review of the resident's medical records the nurse unit manager (LPN#61) stated she could find no documentation concerning refusal or non-compliance with the wound care treatment or any documentation or evidence that patient education was provided to the resident concerning wound care, disease processes, or infection control. On 06/10/19 at 01:10 PM, interview with the resident revealed the wound still has some occasional drainage, but not as much as it did. When asked if anyone had explained to him the importance of wound care and applying a dry dressing to cover and catch any drainage; the resident stated no one at the facility had talked to him about infections or the proper way to care for the wound. Review of Refusal of Treatment policy, on 06/10/19 at 03:55 PM, revealed if the patient refuses treatment staff will determine what the patient is refusing and why. Staff will try to address the patient's concerns and consult his/her supervisor. Staff will determine and document what the patient is refusing; assess the reasons for refusal; advise patient of consequences of refusal; and offer alternative treatments. Document discussions with the patient/health care decision maker, physician, and other involved persons. The wound nurse did not follow the facility's policy on Refusal of Treatment, particularly advising or educating the resident of consequences of refusal. An interview with the Center Nurse Executive (CNE), on 06/10/19 at 2:30 PM, confirmed the resident should have been provided education by staff regarding wound care, infection control, and disease processes that influence healing, and was not. b) Resident #60 On 06/10/19 at 09:55 AM, medical record review revealed Resident #60 had endured an un-witnessed fall on 05/22/19 at 3:00 PM while transferring from wheelchair to bed. Licensed Practical Nurse (LPN) #110 documented that the Resident stated (typed as written), I hit head but not hurting. At that time, LPN #110 implemented neurological assessments (screening tool used post fall for monitoring and detection of head injury) with a start time of 3:00 PM. The neurological assessments were completed for the following dates and time: --05/22/19 at 3:00 PM --05/22/19 at 3:30 PM --05/22/19 at 4:00 PM --05/22/19 at 4:30 PM --05/22/19 at 5:30 PM --05/22/19 at 6:30 PM --05/22/19 at 7:30 PM --05/22/19 at 8:30 PM --05/23/19 at 12:30 AM --05/23/19 at 4:30 AM The neurological assessment flow sheet was found to be incomplete with no data in all the following categories: level of consciousness, pupil response, hand grasps, movement of extremities, and pain response for nine (9) of the ten (10) assessments completed. The first neurological assessment completed on 05/22/19 at 3:00 PM was the only neurological assessment found to be completed in its entirety. Review of the facility's Neurological policy on 06/10/19 at 11:20 AM revealed the following guidelines for completion of neuroglial assessments (after an unwitnessed fall) to be done at the following frequency: --Every 30 Minutes x 2 hours, then --Every 1 hour x four hours, then --Every four hours x 24 hours. Further review of the neurological assessment sheet revealed the neurological assessments were discontinued without completion for the frequency as indicated. The last neurological assessment was completed on 05/23/19 at 4:30 AM, for a total of ten (10) assessments. In order to complete the neurological assessments for the correct number of times as indicated in the facility's Neurological policy, fourteen (14) assessments should have been done with an end time and date of 05/23/19 at 8:30 PM. During an interview on 06/10/19 at 11:28 AM the Director of Nursing (DON) agreed that the neurological assessments for the Resident was not completed correctly. The DON stated the expectation is for nursing staff to complete all information on the Neurological Assessment Flow sheet, and nothing should ever be left blank. The DON also stated, Yes we stopped the neurological assessments too soon, we did not complete the 24-hour frequency. At 1:10 PM on 06/10/19 during an interview, LPN #110 verified the portion of the Neurological Assessment Flow Sheet that she completed, and agreed the assessments were not completed correctly and should not have been left blank for level of consciousness, pupil response, motor response, and pain response. LPN #110 stated, It just gets so busy around here, and it's hard to get everything done because it's so hectic, I should have done better. | 2020-09-01 |
| 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 on 06/06/19 at 11:30 AM, was asked where the razors where kept. He stated they were stored in the clean utility room that had a coded lock on the door, inside the room they were stored in a drawer. He stated, that he does not understand how Resident #53 got a razor. During an interview on 06/10/19 at 10:00 AM, Director of Nursing (DoN) stated, that she has removed all razors from the utility rooms and put them in the medication rooms that are locked and only the nurses have access to and the NA have to sign the razors out and back in with a nurse for disposal. She agreed this was an avoidable accident. | 2020-09-01 |
| 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 | 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 | 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 flow in the dirty laundry room created an infection control issue. The Director of Maintenance said he would immediately have the fan fixed. b) R#33 - an open draining wound 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 has a history of having abscesses that have needed to be treated with incision and drainage (I&D) procedures. The resident last abscess was on his right side and 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 treatment due to resident refusing treatment. From the time of the order until the order was discontinued there were sixty-two (62) opportunities to provide daily wound care treatment and it was documented treatment was provided randomly only in the month of April. R#33 received wound care treatment eighteen (18) days due to resident refusing care on the other days, and three (3) times out of the sixty-two (62) opportunities to provide daily wound care treatment there was no documentation either way as to refusal or provision. An interview with the wound nurse, Licensed Practical Nurse (LPN#84), on 06/10/19 at 11:44 AM, revealed LPN#84 said she kept trying to get R#33 to allow her to provide the wound treatment but he always refused. LPN#84 said the resident would let her clean and measure the wound weekly but not provide treatment and place a dry dressing on it daily as it was ordered. This surveyor requested evidence or documentation showing the resident refused wound care treatment, the physician was notified about the refusals of treatment, and R#33 was provided education concerning the importance of wound care and infection control. The facility was unable to provide any documentation or evidence that patient education was provided to the resident or any documentation that showed the physician was notified of the resident's refusals of wound care treatment untill 06/05/19. LPN#84 said she was aware there was still some occasional drainage from the wound site. LPN#84 agreed the physician should have been notified concerning the resident's refusal of daily wound care and dressings and that the open wound was a breech of infection control principals. On 06/10/19 at 01:10 PM, interview with the resident revealed the wound still has some occasional drainage, but not as much as it did. When asked if anyone had explained to him the importance of wound care and applying a dry dressing to cover and catch any drainage the resident stated no one at the facility had talked to him about infections or the proper way to care for the wound. An interview with the Center Nurse Executive (CNE), on 06/10/19 at 2:30 PM, confirmed staff should have notified the physician sooner than 06/05/19, more than forty days after the resident consistently refused wound care treatment. The physician should have been notified when the resident continued refusing wound care treatment, so that the physician could order an alternative treatment if they chose to. The CNE confirmed an open draining wound is an infection control issue. c) R#68 disposable wipes Observations of Licensed Practical Nurse (LPN#84) providing peri-care (washing the genitals and anal area) and catheter care to Resident (R#68), on 06/05/19 at 04:13 PM, revealed a breech in infection control principals. LPN#84 used packaged disposable wipes to provide the peri-care and to clean around the catheter drainage tube inserted in the resident's urethra. When the LPN finished providing peri-care she took her soiled gloved hand that was contaminated from providing peri-care and pushed a clean unused disposable wipe back into the package, thus contaminating the package of disposable wipes. LPN#84 acknowledge this was a breach in infection control principles. d) Resident #23 On 06/05/19 at 10:50 AM observation was made of a 60 milliliter (ml) syringe in Resident's room lying on her bedside table. The syringe was open to air, placed on top of a pile of papers beside a used tissue. The syringe appeared to be soiled with light brown crusty residue inside the syringe and along the tip. Liscensed Practical Nurse (LPN) #110 verified that syringe belonged to Resident #23, and it had been used for bolus tube feedings. LPN #110 agreed the syringe was not stored properly and discarded syringe into the trash. The syringe did not have any information written on it to indicate the time/date it was initiated for use. Review of facility's Enteral Feeding policy revealed instructions to label and date syringe, store in plastic bag or appropriate container, and the syringe can be used for 24 hours. During an interview on 06/05/19 at 12:30 PM the Director of Nursing (DON) agreed the syringe was maintained in an unsanitary manner. The DON stated, The syringe was improperly stored and should have been dated. Moving forward better measures will be taken. e) R68 On 06/03/18 at 2:01 PM during a random opportunity for discovery a catheter bag belonging to R68 was found on the floor under her bed. During an observation on 06/03/19 at 2:03 PM with E114 assistant center nurse executive (ACNE) verified the catheter bag was on the floor and not securely attached to R68's bed. On 06/04/19 at 12:42 PM during a random opportunity for discovery the catheter tubing was dragging on the floor under R68's wheel chair. During an observation on 06/04/19 at 12:44 PM with E27 nursing assistant (NA) verified the drainage tubing was dragging on the floor and not securely attached under R68's wheelchair. A review of the policy for Care of Indwelling Urinary Catheter revised on 02/01/19 states, Secure catheter tubing to keep the drainage bag .off the floor. | 2020-09-01 |
| 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] at 8:13 PM. She verified the progress notes did not indicate the date and time Resident #160 was admitted . RN #23 verified Resident #160 did not receive his medications as ordered by the physician according to the Medication Administration Record [REDACTED]. An interview with RN #23 on 07/19/18 at 10:45 AM revealed the expectation of the facility was newly admitted residents received their medications within 24 hours. An interview on 07/19/18 at 12:00 PM with the pharmaceutical technician from the pharmaceutical company revealed Resident #160's medications were delivered within 24 hours on 07/15/18 at 5:34 PM. | 2020-09-01 |
| 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 | 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 documentation. Food Service Director #121 verified the food debris buildup on the hot plate holder, tables, cabinets and windows. On 07/19/18 at 1:27 PM, the policy on Cleaning Standards for Food and Nutrition Services revised and dated 06/15/18 was provided by Regional Vice President #144. The policy revealed the purpose was to ensure all food service equipment and areas are clean and sanitary. The process included: Employees utilize the cleaning procedures when completing assigned cleaning duties. Regional Vice President #144 verified the policy was not followed for cleaning equipment of food debris in the kitchen. | 2020-09-01 |
| 39 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 157 | D | 0 | 1 | TKXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based resident, staff and physician interviews and clinical record review, the facility failed to notify the physician timely of a resident incident for one resident reviewed. The failed practice had the potential to affect an isolated number of residents. Resident identifiers: #260. Facility census 145. Findings include: a.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--[MEDICATION NAME] 5-325 milligrams (mg) every six (6) hours as needed for pain --Tylenol 325 mg, 2 tablets every four (4) hours as needed for mild pain. The 02/20/17 admission nursing assessment revealed the resident was not steady moving on and off the toilet and with surface to surface transfer, only able to stabilize with staff assistance. The clinical record was silent regarding any incident involving the resident on 02/22/17 or any administration of as needed pain medication. The record contained no notification of the physician of the incident. During an interview, on 02/23/17 at 12:45 p.m., Resident #260 stated she had an incident in the bathroom the previous evening. The resident stated the nurse aide was in a hurry and did not have the wheelchair close and when she went to get off the toilet. Resident #260 further said, I hit my right foot on the floor. It hurt me. I had to get pain medication for it. I had to have Tylenol and [MEDICATION NAME]. I didn't need it since my first day here. The resident stated her foot was still hurting now. During an interview, on 02/23/17 at 1:58 p.m., LPN #64 stated he was unaware Resident #260 had hurt her foot yesterday evening. LPN #64 stated he would immediately notify the physician about the incident. During an interview, on 02/23/17 at 2:52 p.m., the Director of Nursing (DON) stated she was unaware of the incident regarding Resident #260 until today. The DON expected the staff to have made documentation in the clinical record on the evening shift and reported the incident immediately to the charge nurse, physician and family. The DON stated she was starting an investigation of the incident. During a phone interview, on 02/27/17 at 1:14 p.m., the surgeon stated he expected an immediate assessment of any injury sustained by this resident, and staff would have notified him. The surgeon stated was concerned the resident may have a rupture at the insertion site repair. During an interview, on 02/27/17 at 4:06 p.m., LPN #46 stated she took care of Resident #260 on the evening shift on 02/22/17. LPN #46 stated NA #81 reported to her the resident's foot touched the bathroom floor and did not mention the resident had any pain. LPN #46 stated she did not give the resident any medication for pain, and she did not assess the resident's foot. During an interview, on 02/27/17 at 4:36: p.m., LPN #36 stated she gave Resident #260 two (2) Tylenol about 11:30 p.m. on 02/22/17. LPN #36 verified she did not document she administered the medication. LPN #36 stated she did not assess the resident's foot since it was covered with a sheet. LPN #36 stated the resident reported to her she had hit her right foot on the bathroom floor on the evening shift. During an interview, on 02/28/17 at 10:40 a.m., the DON and Administrator confirmed the lack of timely notification of the physician of a resident incident. | 2020-09-01 |
| 40 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 164 | E | 0 | 1 | TKXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain visual privacy during one (1) of three (3) dressing change observations for Resident #177. The facility failed to maintain privacy for medication packages for three (3) residents (Resident #38, #195 and #185). Resident identifiers: #177, #38, #195, and #185. Facility census 145. Findings include: a.) Resident #177 During a dressing change, on 02/23/17 at 12:00 p.m., Registered Nurse (RN) #137 and Licensed Practical Nurse (LPN) #64 entered the room to perform the dressing change. Resident #177 was in the bed by the window. The window blind was open and facing at street level a parking lot. RN #137 nor LPN #64 closed the window blind. RN #137 pulled the privacy curtain part of the way around the foot of the bed but leaving the mirror over the sink exposed to the resident's roommate. LPN #64 instructed Resident #177 to roll over onto her stomach. LPN #64 removed the dressing exposing a large stage IV pressure ulcer on the resident's coccyx. RN #137 was preparing the new dressing items. The resident's roommate face was seen in the mirror. The roommate had two (2) visiting family members. The roommate stated, you can pull the curtain, so she can have her privacy. LPN #64 then pulled the curtain completely to provide privacy from the mirror. During an interview, on 02/23/17 at 1:08 p.m., RN #137 stated she had thought about closing the window blind during the dressing change but just didn't do it. RN #137 stated she didn't realize the privacy curtain had not be pulled completely to provide privacy. During an interview, on 02/23/17 at 3:03 p.m., the Director of Nursing (DON) stated her expectation was all staff were to provide full visual privacy during dressing changes. b) A random observation of the 800 Hall on 02/23/17 at 8:15 a.m. revealed three (3) visible empty medication cards/packets in the trash can of the medication cart. The following medication cards contained the residents full name and medication orders on the pharmacy label: --Resident #38 - [MEDICATION NAME] 200 mg --Resident #195 - [MEDICATION NAME] 30 mg --Resident #185 - Losartan Potassium 50 mg An interview with Registered Nurse-Nurse Manager(RN-NM) #21 on 02/23/17 at 8:15 a.m. revealed the empty medication cards should not have been in the trash. The RN-NM stated once the medication cards are empty they are shredded. | 2020-09-01 |
| 41 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 272 | D | 0 | 1 | TKXD11 | Based on staff interview, record review, resident interview, and observation, the facility failed to complete an accurate comprehensive assessment for one (1) of eighteen (18) sample residents. The dental status assessment of one (1) resident was inaccurate on the comprehensive minimum data set (MDS). Resident identifier: #33. Facility census: 145. Findings include: a) Resident #33 During the stage 1 observation and interview of Resident #33 conducted on 02/22/17 at 1:00 p.m., she said she had a broken front tooth and used to wear a partial denture. Her mouth had several teeth in various states of wear and decay, with missing teeth evident. During the medical record review performed on 02/28/17, there were dental consultation notes with the following information: --08/09/16 Exam: Generalized Decay; Generalized Periodontal Disease The attached treatment plan included options for replacing missing teeth, specifically dental implants and partial dentures. --08/30/16 Presents for exam and x ray with extractions Further interview with Resident #33 on 02/28/17 at 10:13 a.m. revealed she was looking into getting a new partial and was awaiting an appointment. On 02/28/17 at 12:30 p.m. a review of the most recent comprehensive (annual) MDS with an assessment reference date (ARD) of 09/24/16 found section L Oral/Dental Status with the following assessment: B. No natural teeth or tooth fragment(s) (edentulous). Registered Nurse Assessment Coordinator #102 was interviewed on 02/28/17 at 1:00 p.m. and said the oral assessment in section L was an error. She provided evidence that a correction was made to the MDS prior to the survey exit. | 2020-09-01 |
| 42 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 280 | D | 0 | 1 | TKXD11 | Based on resident interview, medical record review and staff interview, the facility failed to revise a care plan for one (1) of eighteen (18) stage 2 sample residents. The facility did not revise a Brief Interview for Mental Status (BIMS) score. Resident identifier: #12. Facility census 145. Findings include: a) Resident #12 Review of the most recent minimum data set (MDS) with an assessment reference date (ARD) of 12/02/16 revealed a BIMS score of fifteen (15) which indicates the resident is cognitively intact. The residents most recent care plan indicated a BIMS score of five (5) which indicates severely cognitive impaired. On 02/21/17 at 1:00 p.m., Resident #12 was able to answer stage one interview questions without difficulty. During interview on 02/28/17 at 3:45 p.m., registered nurse (RN) #17 stated the BIMS score on the care plan had not been updated from the residents admission and should have been updated to the current BIMS score of 15. | 2020-09-01 |
| 43 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 323 | D | 0 | 1 | TKXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record reviews and review of safety data sheets, the facility failed to prevent accidents by failing to use proper transfer technique for 1 of 1 residents reviewed for accidents, resulting in pain. (Resident #260.) The facility failed to prevent accident hazards by storing chemicals safely (Resident #177.)and storing medications safely. Census 145. The findings are: a.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--Norco 5-325 milligrams (mg) every six (6) hours as needed for pain --Tylenol 325 mg, 2 tablets every four (4) hours as needed for mild pain. The 02/20/17 admission nursing assessment revealed the resident was not steady moving on and off the toilet and with surface to surface transfer, only able to stabilize with staff assistance. The clinical record was silent regarding any incident involving the resident on 02/22/17 or any administration of as needed pain medication. The record contained no notification of the physician of the incident. During an interview, on 02/23/17 at 12:45 p.m., Resident #260 stated she had an incident in the bathroom the previous evening. The resident stated the nurse aide was in a hurry and did not have the wheelchair close and when she went to get off the toilet. Resident #260 further said, I hit my right foot on the floor. It hurt me. I had to get pain medication for it. I had to have Tylenol and Norco. I didn't need it since my first day here. The resident stated her foot was still hurting now. During an interview, on 02/23/17 at 1:58 p.m., LPN #64 stated he was unaware Resident #260 had hurt her foot yesterday evening. LPN #64 stated he would immediately notify the physician about the incident. During an interview, on 02/23/17 at 2:52 p.m., the Director of Nursing (DON) stated she was unaware of the incident regarding Resident #260 until today. The DON expected the staff to have made documentation in the clinical record on the evening shift and reported the incident immediately to the charge nurse, physician and family. The DON stated she was starting an investigation of the incident. During a phone interview, on 02/27/17 at 1:14 p.m., the surgeon stated he expected an immediate assessment of any injury sustained by this resident, and staff would have notified him. The surgeon stated was concerned the resident may have a rupture at the insertion site repair. During an interview, on 02/27/17 at 4:06 p.m., LPN #46 stated she took care of Resident #260 on the evening shift on 02/22/17. LPN #46 stated NA #81 reported to her the resident's foot touched the bathroom floor and did not mention the resident had any pain. LPN #46 stated she did not give the resident any medication for pain, and she did not assess the resident's foot. During an interview, on 02/27/17 at 4:36: p.m., LPN #36 stated she gave Resident #260 two (2) Tylenol about 11:30 p.m. on 02/22/17. LPN #36 verified she did not document she administered the medication. LPN #36 stated she did not assess the resident's foot since it was covered with a sheet. LPN #36 stated the resident reported to her she had hit her right foot on the bathroom floor on the evening shift. During an interview, on 02/28/17 at 7:07 a.m., NA #81 stated she assisted the resident to the bathroom about 8:30 to 9:30 p.m. NA #81 stated the resident got unsteady when getting off the toilet. NA #81 stated, I grabbed her by the waist and sat her back into the wheelchair. The resident hit her foot on the floor. NA #81 stated the resident asked for pain medication because her foot hurt. NA #81 stated she was supposed to use a gait belt to transfer the resident but did not use it. NA #81 stated some resident's just don't like them. During a phone interview, on 02/28/17 at 10:24 a.m., RN #121 stated she worked the night shift on 02/22/17 at 11:00 p.m. until 02/23/17 at 7:00 a.m. RN #121 stated she was unaware of any incident occurring with Resident #260 on the evening shift. RN #121 stated the resident request pain medication at 1:30 a.m. and she gave the resident Norco for her pain. RN #121 stated she did not document the medication administration in the clinical record. RN #121 stated she just got busy and forgot to document the administration of the administration of the administration. During an interview, on 02/28/17 at 10:40 a.m., the Director of Nursing and Administrator confirmed the lack of timely notification of the physician of a resident incident, the lack of timely assessment of resident injury and administration of medication for pain, the lack of following physician orders [REDACTED]. b.) Resident #177 After completion of a dressing change, on 02/23/17 at 12:00 p.m., RN #137 placed an open bottle of 0.25% acetic acid on the resident's window sill above the resident's heater. During an interview, on 02/23/17 at 1:03 p.m., RN #137 stated she left the acetic acid on the window sill, so other staff could have access to it. I didn't want to put it back in the treatment cart. I thought that would be more of an issue. After the interview, RN #137 removed the acetic acid from the window sill and put it in the locked treatment cart. Review of safety data sheet for acetic acid stated solution is corrosive, Causes severe skin burns, eye damage, may be harmful if swallowed, is flammable and to keep away from heat/sparks/open flames/hot surfaces. c) Medications A random observation of the 200 Hall on 02/23/17 at 7:50 a.m., revealed medications on the counter of the nurses's station unattended and accessible to anyone from 7:50 a.m. to 8:00 a.m. The following Resident's medications were observed on the nurses's station counter: --Resident #15 - Ipratropium/Albuterol (3 packs) --Resident #92 - Phenytoin EX 100 mg (56 capsules) --Resident #184 - Clonidine HCL 0.1 mg (56 tablets) --Resident #187 - Celecoxib 200 mg (56 capsules) An interview with Licensed Practical Nurse (LPN) #64 on 02/23/17 at 8:00 a.m. revealed the night shift nurse must have left the medications at the nurse's station. The LPN stated his shift began at 7:00 a.m. The LPN stated the medications should have been locked upon acceptance from the pharmacy. A random observation of the 800 Hall on 02/23/17 at 8:05 a.m. revealed the medication cart was unlocked at the nurses station. The cart was unlocked, unattended, and out of sight of any staff from 8:05 a.m. until 8:12 a.m. The cart contained the medications for all the 800 Hall residents. An interview with Registered Nurse-Nurse Manager (RN-NM) #21 on 02/23/17 at 8:12 a.m. revealed the medication cart should always be locked when not in sight of the nurse. | 2020-09-01 |
| 44 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 371 | E | 0 | 1 | TKXD11 | Based on observations, staff interview and review of FDA food code, the facility failed to serve foods in a sanitary manner. One (1) dietary aide was serving food with polished nails without wearing gloves and one dietary aide was wearing rings with stones on each hand while serving food. This has the potential to more than an isolated number of residents. Facility census: 145. Findings included: On 02/28/17 at 12:15 p.m., Dietary Aide (DA) #132 was plating resident food. DA #132 had polished finger nails and was not wearing gloves. DA #132 stated her nails were natural and were polished. Additionally, on 02/28/17 at 12:15 p.m., DA #26 was plating resident food on resident trays. DA #26 was wearing a diamond like ring on her left ring finger and a pearl like ring on her right ring finger. DA #26 stated she usually wore the rings when working in the kitchen. The Dietary Supervisor #125 instructed DA #26 to remove her rings. DA #26 removed her rings. The Dietary Supervisor instructed DA #132 to put on gloves, which she did. Review of the 2013 FDA Food Code Chapter 2 page 50 states: Unless wearing intact gloves in good repair, a FOOD EMPLOYEE may not wear fingernail polish or artificial fingernails when working with exposed FOOD. Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry including medical information jewelry on their arms and hands. | 2020-09-01 |
| 45 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 431 | E | 0 | 1 | TKXD11 | Based on observation and staff interview, the facility failed to properly store medications. The facility did not ensure resident's medications delivered from the pharmacy were put away in a inaccessible and locked area and did not ensure a medication cart on the 800 Hall was locked. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #15, #92, #184, and #187. Facility census: 145. Findings include: a) A random observation of the 200 Hall on 02/23/17 at 7:50 a.m. revealed medications on the counter of the nurses's station unattended and accessible to anyone from 7:50 a.m. to 8:00 a.m. The following Resident's medications were observed on the nurses's station counter: --Resident #15 - Ipratropium/Albuterol (3 packs). --Resident #92 - Phenytoin EX 100 mg (56 capsules). --Resident #184 - Clonidine HCL 0.1 mg (56 tablets). --Resident #187 - Celecoxib 200 mg (56 capsules). An interview with Licensed Practical Nurse (LPN) #64 on 02/23/17 at 8:00 a.m., revealed the night shift nurse must have left the medications at the nurse's station. The LPN stated his shift began at 7:00 a.m. The LPN stated the medications should have been locked upon acceptance from the pharmacy. b) A random observation of the 800 Hall on 02/23/17 at 8:05 a.m., revealed the medication cart was unlocked at the nurses station. The cart was unlocked, unattended, and out of sight of any staff from 8:05 a.m. until 8:12 a.m. The cart contained the medications for the 800 Hall residents. An interview with Registered Nurse-Nurse Manager (RN-NM) #21 on 02/23/17 at 8:12 a.m., revealed the medication cart should always be locked when not in sight of the nurse. | 2020-09-01 |
| 46 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 441 | D | 0 | 1 | TKXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to follow proper hand hygiene techniques during medication administration for one (1) of twenty six (26) opportunities observed. In addition, the facility failed to perform proper cleaning technique on reusable equipment during one (1) of three (3) dressing change observations. This failed practice affected an isolated number of residents who received medications administered by the facility and of those who had pressure ulcers. Resident identifiers: #126 and #177. Facility census: 145. Findings include: a) Resident #126 An observation of medication administration on 02/28/17 at 08:24 a.m., revealed Licensed Practical Nurse (LPN) #44 attempted to pop a [MEDICATION NAME] 25 milligram (mg) tablet out of the packaging into a medicine cup for Resident #126. The pill missed the cup and fell to the floor. LPN #44 picked up the pill with her bare hands and discarded it. She then popped out a second [MEDICATION NAME] 25 mg tablet into the medication cup and continued with her medication administration for Resident #126 without washing or sanitizing her hands. On 02/28/17 at 10:59 a.m. this matter was discussed with Employee #4, who was responsible for infection control. She agreed that it was an infection control issue. She provided the facility policy titled Handwashing/Hand Hygiene last revised (MONTH) (YEAR). This policy stated to use alcohol-based hand rub or soap and water Before preparing or handling medications. b.) Resident #177 During a dressing change, on 02/23/17 at 12:00 p.m., RN #137 removed scissors from her uniform pocket and cut kling soaked with acetic acid which LPN #64 was using to pack resident #177 coccyx stage IV wound. RN #137 did not clean the scissors prior to use. At the end of the dressing change procedure, RN #137 placed the scissors back into her uniform pocket without cleaning them when she left the room. During an interview, on 2/23/17 at 1:08 pm, RN #137 stated she probably should have cleaned her scissors prior to use and after use. During an interview, on 2/23/17 at 3:03 pm, the Director of Nursing confirmed RN #137 should have cleaned the scissors before and after use during the dressing change. | 2020-09-01 |
| 47 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 514 | D | 0 | 1 | TKXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain a medical record that was complete and accurately for two (2) of eighteen (18) sample residents. Behavior monitoring and bowel pattern tracking was not consistently and/or accurately documented for one (1) resident and a second resident had incomplete medication administration records. Resident identifiers: #258 and #260. Facility census: 145. Findings include: a) Resident #258 1. Behavior sheets A medical record review for Resident #258 on 02/27/17 revealed she had physician's orders [REDACTED]. This medication was first administered on 02/03/17 at 8:00 p.m. She also had an order for [REDACTED]. Although the orders were initiated on 02/03/17, the Behavior/Intervention Monthly Flow Sheet were not documented until night shift of 02/04/17 for both [MEDICATION NAME] and [MEDICATION NAME]. In addition, there were multiple blanks holes on both sheets. The director of nursing (DON) was interviewed on 02/27/17 at 4:39 p.m. and she acknowledged the holes on the sheets were where nursing had not completed the forms. 2. Bowel patterns During the medical record review for Resident #258 on 02/27/17, there were several missing entries in the nurse aide documentation for Bowel Patterns. In addition, the documentation reflected no record of the resident having a bowel movement from night shift on 02/17/17 until evening shift on 02/23/17, as the nurse aides had documented 0 meaning No Bowel Movement. Nurse manager #21 was interviewed on 02/28/17 at 3:05 p.m. and she said that the documentation was inaccurate. She also agreed that the holes in the record resulted in the record being incomplete. c.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--[MEDICATION NAME] 5-325 milligrams (mg) every six (6) hours as needed for pain --Tylenol 325 mg, 2 tablets every four (4) hours as needed for mild pain. The 02/20/17 admission nursing assessment revealed the resident was not steady moving on and off the toilet and with surface to surface transfer, only able to stabilize with staff assistance. The clinical record was silent regarding any incident involving the resident on 02/22/17 or any administration of as needed pain medication. The record contained no notification of the physician of the incident. During an interview, on 02/23/17 at 12:45 p.m., Resident #260 stated she had an incident in the bathroom the previous evening. The resident stated the nurse aide was in a hurry and did not have the wheelchair close and when she went to get off the toilet. Resident #260 further said, I hit my right foot on the floor. It hurt me. I had to get pain medication for it. I had to have Tylenol and [MEDICATION NAME]. I didn't need it since my first day here. The resident stated her foot was still hurting now. During an interview, on 02/27/17 at 4:36: p.m., LPN #36 stated she gave Resident #260 two (2) Tylenol about 11:30 p.m. on 02/22/17. LPN #36 verified she did not document she administered the medication. LPN #36 stated she did not assess the resident's foot since it was covered with a sheet. LPN #36 stated the resident reported to her she had hit her right foot on the bathroom floor on the evening shift. During a phone interview, on 02/28/17 at 10:24 a.m., RN #121 stated she worked the night shift on 02/22/17 from 11:00 p.m. until 02/23/17 at 7:00 a.m. RN #121 stated she was unaware of any incident occurring with Resident #260 on the evening shift. RN #121 stated the resident request pain medication at 1:30 am and she gave the resident [MEDICATION NAME] for her pain. RN #121 stated she did not document the medication administration in the clinical record. RN #121 stated she just got busy and forgot to document the administration of the medication. During an interview, on 02/28/17 at 10:40 a.m., the Director of Nursing and Administrator confirmed the lack of complete and accurate documentation in the clinical record. | 2020-09-01 |
| 48 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 561 | D | 0 | 1 | X20F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promote one resident's right to make choices about aspects of their life. Specifically, the facility failed to provide a shower to resident #305 as requested. This failed practice had the potential to affect a limited number of residents. Resident identifier: #305. Facility census: 142. Findings included: a) Resident #305 According to the 5/18 physician's orders [REDACTED]. According to the admission progress note, dated 4/28/18, the resident was oriented to person, place, and time and was able to make her needs known. In an interview on 4/30/18 at 4:12 PM, Resident #305 said she had just admitted that past Saturday. She said the hospital never showered her so she really wanted a shower. She wanted to feel clean and thought she would feel much better after she received a shower. She said she had been asking for a shower since she admitted to the facilty. She asked her aide taking care of her that day if she could get a shower and the aide told her she would see what she could do. The resident was tearful during the interview. In an interview on 5/1/18 at 5:03 PM, Resident #305's hair was visibly wet and she was brushing it. She said she had just received a shower, her first since admission, and she felt much better. The resident's 5/18 physician's orders [REDACTED]. An order dated 4/28/18 directed Transfer assist of 2 with gait belt. An order dated 4/30/18 directed Cont (continue) with transfer assist of 2 and gait belt. Pt (patient) non-ambulatory on wing. Shower documentation and progress notes were reviewed on 5/2/18 at 4:50 PM. The shower records revealed an entry on 5/1/18 that documented not applicable, indicating a shower was not provided. Review of the progress notes revealed there was no documentation that a shower was given. The skilled progress note on 4/29/18 indicated the resident required assistance of two with transfers and bed mobility. In an interview on 5/2/18 at 4:31 PM, Licensed Practical Nurse (LPN) #34 said she was the one who admitted the resident after dinner on Saturday night. On admission the resident expressed that the hospital had not showered her in four days or changed her gown, so they had discussed getting her a shower. On Saturday night, staff provided her a bed bath and got her cleaned up. The resident was supposed to receive a shower on Sunday if she still expressed the desire to receive one. LPN #34 said the shower schedule was pre-set based on room numbers. The resident's shower days were Tuesdays and Fridays. She said no showers were scheduled on Sundays, but staff should have provided one, if needed. In an interview on 5/2/18 at 5:10 PM, CNA #121 said she had only worked at the facility for a few weeks and had worked that past Sunday. She said Resident #305 had requested a shower on Sunday, but she did not provide her with one. She explained she thought therapy had to evaluate a new resident before staff could assist the resident in any transfers. She said the resident stayed in bed all day on Sunday as she would not get residents up until therapy evaluated them. She stated she provided the resident with a shower 5/1/18, Tuesday. The Assistant Director of Nursing was present during the interview with CNA #121. She said the resident could have received a shower on Sunday as she requested. She said the facility's protocol was that all new admissions could be transferred with two staff and a gait belt until therapy could evaluate them, or if orders indicated otherwise. In an interview on 5/3/18 at 11:45 AM, the Director of Nursing (DON) said the CNA should have spoken to the nurse about the resident's transfer status. The nurse could have called the doctor to obtain orders, if they were unclear. She said most new admissions were a two assist with a gait belt unless they were walking as they entered the facility or they had non-weight bearing orders. She said residents could receive showers whenever they requested them. There was a shower schedule but if a resident requested a shower, then the staff should provide one. | 2020-09-01 |
| 49 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 582 | E | 0 | 1 | X20F11 | Based on interview and record review, the facility failed to issue liability and appeal notices as required. Specifically, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) letter to Resident #253, issued the incorrect Center for Medicare and Medicaid Services (CMS) form letter to Resident #254 and issued an inaccurately completed SNFABN form letter and an altered NOMNC form letter to Resident #144. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #253, #254, and #144. Facility census: 142. Findings included: a) Review of guidelines Review of the current guidelines for the Centers for Medicare and Medicaid Services instructions for the SNFABN letters of notice, revised 1/18, revealed .Medicare requires SNFs (skilled nursing facilities) to issue the SNFABN (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage) to original Medicare, also called fee-for-service, beneficiaries, prior to providing care that Medicare usually covers . The SNFABN has the following 5 (five) sections for completion: Header, Body, Option Boxes, Additional Information, Signature and Date . SNFs must enter the first and last name of the beneficiary receiving the notice . There are 3 (three) options listed on the SNFABN with corresponding check boxes. The beneficiary must check only one option box . Review of the current guidelines for the CMS instructions for the NOMNC letter of notice revealed, .The NOMNC (Notice of Medicare Non-Coverage) must be delivered at least two calendar days before Medicare covered services end . The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice . b) Resident #253 Review of the clinical record for Resident #253 revealed no SNFABN letter was issued when Medicare benefits ended. c) Resident #254 Review of the clinical record for Resident #254 revealed the SNFABN letter was issued on 1/3/18 and signed, however the form letter was not the correct CMS required form letter. Resident #254 was issued an older version of the SNFABN form letter (CMS R-131) instead of the correct and current form (CMS- ). In addition, the required sections were not completed. d) Resident #144 Review of the clinical record for Resident #144 revealed the SNFABN letter was issued on 4/19/18 and signed, however the form section for Reason Medicare (MONTH) Not Pay, was inaccurately completed according to the CMS instructions. The NOMNC letter was issued on 4/19/18, however was altered from its original form according to the CMS instructions. Page 1 of the NOMNC form ran over onto page 2. e) Staff interviews An interview with the Administrator and the Director of Nursing on 5/3/18 at 11:30 AM revealed they were unaware the SNFABN and NOMNC form letters were not being issued regularly or being completed accurately according to the CMS instruction sheets. The Administrator and the Director of Nursing stated they would refer to the most current CMS instruction sheets for further education. The Administrator stated she felt the missing SNFABN for Resident #253 was an isolated situation and stated she felt the facility had issued the resident a letter but could not provide proof of the issued letter. | 2020-09-01 |
| 50 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 657 | D | 0 | 1 | X20F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to include the resident in the care planning process. Specifically, the facility failed to keep one resident (#108) reviewed for Discharge informed of his progress towards discharge. This failed practice had the potential to affect a limited number of residents. Resident identifier: #108. Facility census: 142. Findings included: a) Facility policy The care planning policy, revised 09/2013, was reviewed on 5/3/18 at 9:15 AM. The policy indicated in pertinent part: .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan . Every effort will be made to schedule care plan meeting at the best time of the day for the resident and family .' b) Resident #108 Resident #108 admitted to the facility on [DATE] and discharged to the community on 4/30/18. According to admission physician's orders [REDACTED]. Review of the 3/22/18 Minimum Data Set (MDS) assessment on 5/2/18 at 11:35 AM. According to the MDS, the resident was cognitively intact with a brief interview of mental status score of 15 out of 15. The MDS assessed he required extensive assistance with all activities of daily living (ADLs). In an interview on 4/30/18 at 1:13 PM, the resident stated he was scheduled to be discharged around 3:00 PM that day. He complained that there was a lack of communication between the facility and himself. He stated he received therapy under his insurance and that staff never discussed his progress with him or discussed when discharge may occur. He said, all of a sudden they came and spoke with him and said they were discharging him in a couple days. He said he appealed the discharge and won, but he did not want to stay at the facility due to the lack of communication. He said they had a meeting with him when he first arrived back in March, but no other meetings since then. He said the staff had an internal meeting every week to discuss residents, but no one ever came and spoke to him about what was talked about in that meeting regarding his care or progress. The resident's record was reviewed on 5/2/18 at 1:15 PM. The discharge care plan, initiated on 3/15/18, identified the resident expressed his wish to discharge home with family. Interventions included reviewing progress towards discharge during scheduled meetings. Review of progress notes revealed no documented conversations with the resident regarding his progress or plans towards discharge. There was no evidence of care conferences that took place during his stay. A Social Services note, dated 3/15/18, revealed the Social Service staff met with the resident, completed the admission packet with him and spoke with his family member by phone. They discussed options in case the resident would be unable to return home. The plan was for the resident to return home with family. Social Services made them aware of their services and assistance. Social Services documented the internal Medicare meeting that occurred each week. The Medicare meeting note dated 4/25/18 revealed the resident's last covered day would be 5/4/18 with long term care being recommended. There was no documentation after the meeting indicating the resident was informed of the upcoming end of therapy. On 4/27/18, Staff #70 documented in the record that she issued the notice of Medicare non coverage to the resident. The notice was discussed with the resident's family member via phone. She discussed the appeal process with both of them. There was no explanation for the 2 day delay between when the facility determined the resident's therapy would end and when the resident was notified. On 4/30/18, Social Services documented the resident was discharging from the facility and which services would be provided at home. A note from the nurse practitioner on 4/30/18 documented in pertinent part, .At this time patient feels he is being thrown out. Discussed situation and insurance and he would continue therapy at home . The Physical Therapy and Occupational Therapy daily progress notes were reviewed on 5/3/18 at 11:20 AM. Review of the notes revealed there was no documentation from therapy discussing the resident's progress with the resident or progress towards discharge. On 4/27/18, the same date the resident was notified his therapy was ending, Physical Therapy documented, Therapist met with patient and spouse and discussed patients D/C (discharge) planning. Educated patient on his progress with therapy to this point and discussed patients future progress and plans. In an interview on 5/2/18 at 1:27 PM, Social Services #51 explained one of the two Social Service staff met with residents within 48 hours of admission. They provided the resident with a packet of information, discussed their history and goals, and the discharge planning process. She said they had an open door policy so if any one wanted to speak to them, they were able to. Social services helped arrange for home services and placements. She said she met with residents regularly to complete MDS assessments. She said the facility had internal Medicare meetings every Wednesday morning. She tried to meet with the residents after that meeting, but mostly met with those that had upcoming discharge date s or that were going to need increased services. She said she always tried to document in the record whenever she had a conversation with a resident or family member. She remembered speaking with Resident #108's family member more than the resident. She stated the family member called every couple weeks to find out what the resident was going to need when he returned home. She further explained when she met with a resident upon admission she told them that they could have a care conference any time they wanted to. She said the short-term residents did not have a set care conference schedule and that the resident, family, or therapy were the ones to typically initiate the scheduling of a care conference. She said the facility did not complete an admission care conference. In an interview on 5/2/18 at 5:33 PM Case Manager #70 said she was the case manager for the residents that had managed care. She helped with discharge planning along with social services. She remembered having a conversation with the resident when she issued his notice of Medicare non-coverage. She explained that he was being discharged by his insurance. She said it was hard to let the resident know when they may be discharged because insurance could cut them off at any time. The interim therapy director was interviewed on 5/3/18 at 10:34 AM. She said therapy discussed progress on a daily basis with residents during their sessions. Those conversations would be documented in their progress notes. She said therapy did not attend care conferences unless they were the ones to request the care conference. Normally a care conference was suggested when the discharge was questionable, which would be if the resident needed placement instead of returning home. She stated she worked directly with Resident #108 and remembered having conversations with the resident about his progress. She remembered speaking with the resident's family member a couple of times as well. She said she was not sure why no care conference was held, but the resident got mad at therapy because they were discharging him. In an interview on 5/3/18 at 11:40 AM, the interim therapy director reviewed the weekly progress notes. She confirmed there was no documentation to indicate the resident was spoken to about his progress towards discharge. She was certain that conversations occurred but could not find any evidence of the conversations. In an interview on 5/3/18 at 12:35 PM the Administrator said the facility met internally every week to discuss short term stay residents. Social Services communicates with the residents and gets the discharge information from the resident, such as their prior level of function and home setting upon admission. Therapy speaks to residents from the beginning as well about discharge planning and how the process worked. She said care conferences should be completed prior to the resident being discharged and therapy would be at that meeting. | 2020-09-01 |
| 51 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 689 | D | 1 | 1 | X20F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to provide adequate supervision in accordance with the resident's plan of care to prevent accidents. Specifically, two (2) residents reviewed for Accidents, the facility failed to follow aspiration precautions when each was allowed to use a straw despite physician's orders [REDACTED]. Resident identifiers: #93 and #8. Facility census: 142. Findings included: a) Resident #93 Review of the care plan, dated 3/5/18, revealed Resident #93 had nutritional risks based, in part, on a recent [DIAGNOSES REDACTED]. Review of the current Kardex (care directives provided for and used by Certified Nurse Aides - CNA) revealed Diet: ST (speech therapy) Orders: no straw protocol w/ liquids. The physician's orders [REDACTED]. Observation on 5/2/18 at 8:43 AM revealed CNA #110 place a breakfast tray in front of Resident #93. The CNA set up the resident's meal, including opening the resident's milk carton, placed it in front of him, and left. A straw was observed on the tray. Resident #93 picked up the straw, removed the paper wrap and placed it in the milk carton. He then began to drink using the straw. CNA #105 and #110 both passed by in the next few minutes, but did not intervene. There was no nurse on the unit during this observation. The meal card on the resident's tray did not identify the resident was not to have straws. In an interview on 5/2/18 at 8:52 AM CNA #110 stated she was not aware the resident was not supposed to have a straw. She said she did not think it was identified on the Kardex. At 9:01 AM CNA #105 stated she did not know Resident #93 was not supposed to have a straw. In an interview on 5/2/18 at 10:41 AM Nurses #3 and #82 explained there were three nurses splitting Unit 5 today. They explained there were extended periods of time they would each be on their other respective units, and so no nurse would be present on Unit 5. Both stated they were not aware Resident #93 should not have a straw, however they were able to locate the physician's orders [REDACTED]. In an interview on 5/02/18 at 11:02 AM, Speech Therapist #158 stated Resident #93 should not have straws as she did not believe his swallow reflex was fast enough to compensate if he had issues. She stated she had not been notified of any coughing or choking that might be related to the resident's use of straws and did not believe he had experienced any ill effects, however she stated he should not be provided one or allowed to use them. b) Resident #8 Observation on 5/02/18 at 5:01 PM revealed Resident #8 propel his wheelchair out of his room. He stated loudly, They took my straws! He explained he had straws in his room that he used daily, I have to drink a lot of water . I had straws but someone came in while I was out of my room and took them. He stated he had been using straws for months. CNA #65 stated she had heard there were issues with residents using straws and she remembered Resident #8's care plan directed he should not have any so she took them. She verified the resident had straws in his room that he used daily, She did not know how long he had been using them, but stated, awhile. According to the 1/24/18 quarterly Minimum Data Set, the resident had a Brief Interview for Mental Status score of 15, indicative of no cognitive loss. The MDS (Section K) revealed the resident exhibited no signs or symptoms of a swallowing disorder. According to the 12/20/16 Modified [MEDICATION NAME] Swallowing Study, located in the resident's record, strategies identified to address the resident's swallowing difficulties included no straws. A physician's orders [REDACTED]. NO STRAW. CUE PT TO USE CHIN TUCK. Review of the most current Kardex revealed thin/regular liquids. Cup only, no straw, cue pt (patient) to use chin tuck. According to the Alteration in Nutrition Care Plan, updated 2/12/18, Resident #8 had a [DIAGNOSES REDACTED]. Interventions included Regular Diet, regular texture, thin/regular liquids. Cup only, no straw, cue pt to use chin tuck; Encourage 6 to 8 glasses of water per day; Suction cup to be provided at all meals. In an interview on 5/03/18 at 9:35 AM, the Administrator and Director of Nursing (DON) stated staff should follow the care plans. They verified Resident #8 should not have had straws according to his most current orders. In an interview on 05/03/18 at 11:13 AM, Therapist #139 reviewed Resident #8's therapy notes. She stated Resident #8 should not have straws. She verified that order was current and based on his last skilled speech therapy services. In an interview on 5/3/18 at 12:50 PM, the Assistant DON #88, stated there had been no observed swallowing issues for Resident #8 since his diet had been upgraded. She stated staff are expected to follow physician's orders [REDACTED]. | 2020-09-01 |
| 52 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 698 | D | 0 | 1 | X20F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate care with the [MEDICAL TREATMENT] Center for Resident #126, one of one residents reviewed for [MEDICAL TREATMENT]. The facility failed to ensure communication from the [MEDICAL TREATMENT] Center following the resident's treatment was reviewed and recorded. This failed practice had the potential to affect a limited number of residents. Resident identifier: #126. Facility census: 142. Findings included: a) Resident #126 Review of the resident's record revealed Resident #126 was admitted to the hospital 4/16-21/18. She readmitted to the facility 4/21/18. Review of physician's orders [REDACTED]. The record revealed the resident refused [MEDICAL TREATMENT] on 4/24/18, but went on 4/28/18 and 5/1/18. physician's orders [REDACTED]. Staff were directed, in the order, to put results in computer. Review of the electronic record revealed one weight for 4/28/18 and no weights for 5/1/18. In addition, a dietary progress note, dated 5/2/18 indicated .Current [MEDICAL TREATMENT] labs are unavailable to me here at this time. The [MEDICAL TREATMENT] labs were recommended to be obtained by our facility at today's morning/clinical meeting. In an interview on 5/2/18 at 1:34 PM, Licensed Nurse #82 was asked how the [MEDICAL TREATMENT] center and the facility communicate. She explained she did not work the floor very often, but had been pulled to do so that day. She stated they used to have a little form, with pre and post weights. Vital signs. She looked through the resident's record but was unable to locate any communication. In an interview on 5/2/18 at 1:37 PM, the Assistant Director of Nursing #88, stated We have a little form, with weights, treatment changes. Might be in her packet. Probably downstairs with (Receptionist). Let me go check. At 5/2/18 at 1:51 PM Staff #33 provided a blank copy of the [MEDICAL TREATMENT] Patient Data Sheet. It goes in the envelope and the van driver takes it to [MEDICAL TREATMENT], then they fill it out, bring it back. I don't know what happens then, I guess the nurse puts it in the computer? This resident went to the hospital. I wonder if we didn't make her a packet (to send to [MEDICAL TREATMENT]) when she got back? I will go do that. At 5/2/18 at 2:00 PM, ADON #88 stated she asked the transportation driver what he did with the papers he brought back from the [MEDICAL TREATMENT] Center. She said he left the envelope in the resident's room after each appointment. ADON #88 located the 4/28 and 5/1/18 [MEDICAL TREATMENT] Patient Data Sheets in the resident's room. She stated the nurse should have obtained and reviewed them and put them in the chart. She explained if medication orders changed or something significant occurred at [MEDICAL TREATMENT], the center would usually call and notify the facility. However, the [MEDICAL TREATMENT] Center recorded vital signs, weights, lab results and other communication on the forms and the facility should still be obtaining these. | 2020-09-01 |
| 53 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 725 | E | 1 | 1 | X20F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review the facility failed to ensure an adequate number of nurses and certified nursing assistants (CNAs) were present on a regular basis to provide care and supervision to residents. This resulted in extended call light response times, delays in meal delivery and assistance with eating, failure to follow care plans with regards to swallowing precautions, and extended periods of time where no staff were available on a unit. This failed practice had the potential to affect more than a limited number of residents. Facility census: 142. Findings included: a) Resident Council Review of Resident Council meeting minutes revealed residents voiced concern about staffing at the 3/6/18 meeting. Specifically, Extended call light response time was voiced. A resident discussed having had to wait 1.5 hours for her call light to be answered. (She needed a bed pan). The identified action was that the facility will reinforce to all staff that all employees are responsible for answering all call light. Additionally, residents voiced a concern regarding the Shortage of qualified nursing staff. The facility noted they would be offering another CNA class within the following months and that volunteers are continuously being sought. In addition, Coverage for extensive call-offs was voiced. Administration identified benefits being offered in an attempt to hire new staff. In a Resident Council meeting held as part of the survey process on 5/1/18 at 11:00 AM, residents voiced ongoing concerns about staffing. One resident stated her roommate recently waited an hour to be put to bed. She stated the staff working are very good, there just are not enough staff to meet needs timely. Resident #21 stated on night shift, she frequently waited 45 minutes to be placed on the bed pan and then another 45 minutes to be taken off the bedpan. Several other residents at the meeting reported waiting to be gotten out of bed in the morning, or put into bed at night. They stated the issue seemed to be with staff availability. Weekends were reported to be the worst. Residents stated they have complained about the staffing issue, individually and through Resident Council and they feel the only response they get is what the facility is trying to do to hire new staff. The residents stated they did not get answers as to what would be implemented to ensure they get the care they need now. b) Observations Observation on 4/30/18 at 1:18 PM revealed Resident #58 in bed. Her lunch tray was on her bedside table, covered. The meal has not been set up, nor has the resident been assisted. At 1:28 PM CNA #110 entered the room and began to feed the resident. After a minute, she left the room to get some ice water for the resident, returned and began feeding her again. At 1:35 PM, she told the resident she had to go check on some people and will be back. She returned at 1:43 PM and again began to feed her. There were no other staff observed on the unit at this time. Observations on 5/2/18 revealed two residents (#s 91 & 8) using/possessing straws that had physician's orders [REDACTED]. This occurred on Unit 5, where the nurse's and CNAs frequently float, meaning there were extended periods of time with no nurse and only one CNA providing care / supervising up to 22 residents. See F689. Observation on 5/2/18 at 6:36 AM revealed the call light for room [ROOM NUMBER] sounding. At 6:40 AM, the call lights for 706 and 711 were sounding. No staff were observed on either the 600 or 700 hall. At 6:42 AM, a CNA was observed exiting a resident room on the 600 unit and entering room [ROOM NUMBER]. She stated she was covering both units and had been in a resident room on the 600 unit, so had not heard the call lights on the 700 unit. Observation on 5/3/18 at 12:23 PM on Unit 5 revealed two call lights sounding (rooms [ROOM NUMBERS]). There were no staff visible. Resident #8 was sitting by the nurse's station. He stated, I just want a drink of water. There's no one here. Been here awhile, no one to help. A lunch tray for Resident #107 was sitting on the nurse's station. The resident in room [ROOM NUMBER] called out nurse several times. At 12:38 PM, CNA #105 exited a resident room, where the door had been closed. She stated she had been providing personal care and was the Only staff here right now. c) Interviews In interviews on 5/2/18 on night, day and evening shift, as well as day shift on 5/3/18, CNAs and nurses, who all expressed concern about repercussions if their names were used and spoke on the condition of confidentiality, stated they worked short frequently and float on units, meaning they are not always available to provide timely care. They expressed a great deal of concern about the safety and care of their residents. They stated the facility was trying to hire new staff and day and evening shifts during the week were well covered, but night shift and weekends, especially when staff called in, were the concerning ones. In an interview on 5/2/18 at 6:24 AM, a CNA who worked the night shift explained she frequently was assigned to cover two units. She stated the units were physically separated and so she did not know if a call light was going off or a resident needed help on one unit while she was on the other. She stated she was very concerned about her ability to protect residents and provide timely care. She stated she had expressed this concern to her supervisor, but she was told that was the staffing pattern. She stated there was often only one nurse on the floor, for 4 units, which made it difficult if more than one resident needed nursing care. In an interview on 5/2/18 at 6:52 AM, a CNA who worked the night shift stated she did not feel comfortable when asked to cover two units, as she did not feel she could provide good care to everyone on two units. She stated she could not see or hear call lights for the second unit when you were on the first. You don't know if someone fell , you don't know how long they have been waiting. She explained there was frequently only one nurse on the floor, for four units and if someone fell or was sick, the nurse would be occupied for an extended period of time making it difficult for other residents to receive nursing care. On 5/2/18 there were 2 CNAs on Unit 5 for the evening shift. At 4:39 PM, a phone call to the Unit notified them one of the CNAs on Unit 5 would be pulled to Unit 3 at 7:00 PM. The CNAs, speaking to each other, stated they would have to put residents in bed before supper, as many of them require 2 staff to do so and there would only be one staff member after 7:00 PM. They stated one CNA would not have time or be able to put all the residents to bed by herself. In an interview on 5/3/18 at 8:49 AM the Assistant Director of Nursing #88, stated she is in charge of scheduling. She explained the facility has 7 units. 2 have a maximum of 20 residents, the other 5 have 22 beds. The facility attempts to schedule one CNA to 10-11 residents (2 CNAs per unit) on day and evening shifts. ADON #88 stated with call-ins, they are sometimes closer to one CNA with 15 residents. On the night shift, they attempt to schedule one CNA per unit. ADON #88 stated she knows staff frequently have to float between units, due to a lack of available staff. On 5/3/18 at 8:20 AM the Daily Staffing Postings for the past 3 months were reviewed. They revealed numerous shifts in which only 5 CNAs were scheduled, when the facility had a census of between 141-145. This gave each CNA up to 28 residents each, much higher than the one to 15 the ADON stated the facility felt comfortable with. For example, on 2/11/18, the night shift (for a census of 144), had 4 nurses and 5 CNAs. On night shift Friday, 3/2/18, 5 CNAs and 2 nurses were scheduled. On night shift Monday, 4/9/18, for a census of 147, 5 CNAs and 4 nurses were scheduled. On the night shift Sunday, 4/15/18, 5 CNAs and 3 nurses were scheduled; night shift Saturday 4/21/18 had 6 CNAs and 3 nurses. In an interview on 5/3/18 at 8:57 AM, the Administrator explained the facility has implemented numerous strategies to attempt to recruit and retain employees. She acknowledged it was an ongoing struggle due to a lack of certified staff and numerous other employers in the area. She acknowledged residents complained about the lack of staff at a recent Resident Council meeting. She stated she was not aware staff were telling residents they were unable to take breaks or that they were working short. She stated staff should not be telling residents this. | 2020-09-01 |
| 54 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 805 | E | 1 | 1 | X20F11 | > Based on observation, interview and record review, the facility failed to ensure food was prepared in a form to meet individual needs of the residents. Specifically, the facility failed to ensure proper pureed texture and failed to follow recipes for pureed food items for 12 residents that received a pureed texture out of 146 residents. This failed practice had the potential to affect more than a limited number of residents. Facility census: 142. Findings included: a) Facility policy The Progressive dysphagia diet: Puree policy, revised 01/2018, was provided by the Assistant Director of Nursing (ADON) #88 on 5/3/18 at 9:00 AM. The policy documented in pertinent part, .The diet uses slurried, blenderized, or pureed food that has a moist, pudding-like consistency without pulp or small food particles . Blenderized foods do not require chewing. They should have a pudding-like consistency without lumps (i.e., sour cream or mayonnaise thickness/moistness). All foods are appropriate if the consistency is pureed smooth without fibrous particles . b) Observations On 5/1/18 at 11:34 AM, Cook #119 was observed to remove two pans from the oven to take their temperatures. Cook #119 stated one was the mechanical texture pork and one was the pureed pork. The pureed pork was observed to have a similar texture as the mechanical pork. It appeared chunky. At 11:36 AM, the pureed cabbage was pulled out of the oven. The cabbage was observed to have visible chunks of cabbage in it. Staff began to plate meals for the lunch service at 11:54 AM, including pureed meals. The pork and cabbage were observed to be very chunky and the cabbage was watery. At 12:02 PM, the pureed pork and cabbage were taste tested . Neither of the puree food items had a smooth texture. Particles of meat and cabbage could be visualized and felt. On 5/2/18, the preparation of the pureed foods was observed from 10:08 AM to 10:30 AM. At 10:08 AM, Cook #119 was observed to place a third of the mixed vegetables in a 2.5 quart food processor. She processed the mixed vegetables and placed some melted butter and hot water in the mixture. She placed the pureed vegetables in a pan and proceeded to puree another third of the vegetables and then the last third of the vegetables. She placed the pureed vegetables together in the same pan. The texture was observed to have small particles from the vegetables in it. It was not smooth. She did not use a recipe while making the puree vegetables. She also did not taste it. The process of making the vegetables a third at a time could result in an inconsistency of texture throughout the mixture. At 10:24 AM, Cook #119 started making the pureed fish. She took one full pan of fish from the oven and spit it into two deep pans. She placed one pan into the 2.5 quart food processor and started to process the food along with some water. She checked the consistency with a spatula and put more water in the mixture. She then processed it again. At 10:27 AM, she placed the fish back into the pan. At 10:28 AM, the pureed vegetables and fish were taste tested . The vegetables were not completely smooth. They contained small particles from the vegetables that could be visibly seen and felt. The week 3 menu was reviewed on 5/1/18 at 11:10 AM. The lunch meal for Tuesday, 5/1/18, consisted of roast pork and haluski (a cabbage and noodle blend). The lunch meal for Wednesday, 5/2/18, consisted of lemon baked fish and California blend vegetables. The pureed recipes were reviewed on 5/3/18 at 9:30 AM. The pureed roast pork recipe was for 13 servings. The recipe called for 2 pounds and 7 ounces of roast pork, half cup and 2.5 tablespoons of thickener, and 2 5/8 cups of hot water. The method consisted of: 1. Place portions of meat (2 oz (ounces) each, no bone) needed into a food processor. Process to a fine texture. 2. Prepare slurry for the meat with the thickener and hot liquid. Mix well with a wire whip. 3. Add 1/2 of the slurry to the meat; process for 1 minute. If too dry, add more slurry until meat is pudding consistency. 4. With a rubber spatula, scrape down sides of the bowel; reprocess 30 seconds. The pureed haluski recipe was for 13 servings. The recipe called for 2 quarts and 1 3/4 cups of haluski, 1/4 cup and 1 1/4 tablespoons of thickener, and 2 cups of hot water. The method consisted of: Place portions needed from regular prepared recipe into a food processor. Process to a fine texture. Prepare a slurry with the thickener and hot liquid. Add the slurry to the processed noodle/cabbage mixture. Process until smooth. The pureed lemon baked fish recipe was for 13 servings. The recipe called for 13 fish, 3/4 cups and 1 tablespoon of thickener, and 2 5/8 cups of hot water. The method consisted of: Place portions needed from regular prepared recipe into a food processor. Process to a fine texture. For every 5 portions needed, prepare a slurry with 5 tbsp (tablespoons) and 1 cup hot liquid (water, milk, or broth); mix well with a wire whip. Add 1/2 of the slurry; process for 1 minute. If too dry, add more slurry until meat is pudding consistency with a rubber spatula, scrape down sides of the bowel; reprocess 30 seconds. The California blend vegetables recipe was for 13 services. The recipe called for 1 quart and 2 1/2 cups of vegetables and 1/4 cups and 2 1/2 tablespoons of thickener. The method consisted of: Remove portions needed from regular prepared recipe and place into a food processor. Process until fine; for every 5 portions needed, add 2.5 tbsp thickener; process until smooth. Scrape down sides of the bowl with a rubber spatula; reprocess 30 seconds. c) Interviews In an interview on 5/1/18 at 12:20 PM Cook #119 said there were 12 residents that received a pureed diet. She had made the pureed pork and cabbage. She said she always tasted the purees when she made them. She was told the purees were always supposed to be the consistency of mashed potatoes. She felt the pureed pork and cabbage were the appropriate consistencies. In an interview on 5/2/18 at 10:35 AM Cook #119 said she used to robo coupe for heavy meats and used the food processor for all other items. The recipe book was underneath the preparation table. She said she did not use the recipe book because she had been making purees for so long that she knew how it was supposed to look. She said she went by how each food item looked. She said the purees should never have pieces in them, as that was a good way for residents to choke. She said cabbage was hard to puree and get smooth but she thought all the purees for Tuesday and Wednesday were the appropriate consistency. In an interview on 5/3/18 at 10:08 AM the Dietary Manager stated she preferred when the cooks used the recipe book when making the pureed foods. Some of the cooks knew what the recipes were because they had made them so many times. She said the consistency of the purees should always be smooth with no chunks. She did not provide any oversight to ensure the purees were the appropriate consistency. She left it up to the cook to determine if it was the correct smoothness. If the cook did not think it was smooth enough then they would ask her what she thought. She said they used the robo coupe for bigger items and the processor for smaller items. The process for making the mixed vegetables was described to the Dietary Manager. She said the cooks should not be pureeing items in portions. It should all be done at once so the consistency was the same throughout the mixture. The cooks should use the robo coupe for everything unless it could all fit into the processor at once. She expected the cooks to taste test the puree to ensure it tasted good and was the proper consistency. | 2020-09-01 |
| 55 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 812 | D | 0 | 1 | X20F11 | Based on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety in one of one kitchens. Specifically, the facility failed to ensure staff conducted proper hand hygiene and transported clean utensils in a sanitary manner. This failed practice had the potential to affect a limited number of residents. Facility census: 142. Findings included: a) Facility policy The Safety and Sanitation policy, revised 12/14/17, was provided by the Director of Nursing on 5/3/18 at 1:20 PM. The policy directed, in pertinent part: VII. Hand washing . 1. When to wash: i. After working with or cleaning dirty equipment or utensils . l. Between glove changes . q. Between any dirty to clean task . VII. Glove use . 1. Single use gloves: c. Wash hands thoroughly before and after wearing or changing gloves. Bacteria will build up under gloves and should be washed away after wearing gloves . 3. Cloth gloves: a. (MONTH) not be used in direct contact with food . b) Observations On 4/30/18 at 8:40 AM, during the initial tour, two trash cans were observed close to the handwashing sink. One trash can had a foot pedal that opened the top. The other trash can had a lid on top that had to be manually opened. Multiple observations were made on 5/1/18 from 11:10 AM to 12:25 PM. At 11:30 AM, Cook #119 was observed to mix cabbage and noodles togethers. During this process, the food mixture touched her oven mitt that was holding onto the pan. At 11:37 AM, Cook #119 was observed to gather the serving utensils to serve from the steam table. While transporting the utensils to the steam table, she held the ladle for the gravy up next to her chest, touching her shirt. Her shirt was visibly dirty with food debris. At 11:45 AM, Dietary Staff #89 was observed spreading butter on slices of bread, while wearing gloves. When she was finished with the butter, she covered it with plastic wrap and pulled a pen out of her shirt to write the date. Wearing the same gloves, she proceeded to place the buttered bread in a pan and grab slices of cheese to make grilled cheeses. Cook #119 served the lunch meal from the steam table. Multiple observations were made during the lunch service from 11:54 AM to 12:25 PM. While Cook #119 served, she was observed to place two to three plates along the steam table. She then leaned across the plates to get food from the back of the steam table. As she did this, her shirt touched the plates. This process was observed several times. From 11:10 AM to 12:25 PM, multiple observations were made of staff changing their gloves without washing their hands between glove changes. Food preparation was observed on 5/2/18 from 10:00 AM to 10:30 AM. At 10:02 AM, Cook #119 was observed to leave the kitchen with a measuring cup full of butter. She was observed to use the microwave in the staff break room. She came back into the kitchen at 10:05 AM and the butter was melted. She did not wash her hands when she returned to the kitchen. She proceeded to prepare the pureed foods and used the butter for the vegetables. At 10:09 AM, after Cook #119 made a batch of pureed vegetables in the food processor, the blade fell out as she poured the mixture into the pan. She touched the blade, rinsed it off under some water, and then placed it back into the processor. She proceeded to make other portions of pureed vegetables. At 10:18 AM, Cook #119 was observed to dry off her hands and place the paper towel in the trash can with the manual lid on top of it. She had to touch the trash can lid to place the paper towel inside. Cook #119 stated that the trash can with the manual lid was the trash can they used for everything, including after they washed their hands. She said the trash can with the pedal was used for salad preparation. At 10:24 AM, Cook #119 grabbed the food processor pieces and spatula that had been sanitized in the three-compartment sink. While transporting the food processor pieces and spatula to the preparation area, she held the pieces up against her shirt. Her shirt was visibly soiled with food debris. From 10:00 AM to 10:30 PM, multiple observations were made of staff changing their gloves without washing their hands between glove changes. c) Interviews In an interview on 5/3/18 at 10:08 AM the Dietary Manager stated every time a staff member changed gloves, they were supposed to wash their hands. Staff were also supposed to wash their hands each time they entered the kitchen. If they left to go to the breakroom, then they needed to wash their hands when they returned. She stated she did not know why there was not a microwave in the kitchen but said staff should not have to go to the break room to use the microwave for food preparation. She said when transporting clean utensils, they should be carried away from the body. If the utensils touched the body, such as a shirt, then that was unsanitary. Clothing was not supposed to touch plates as meals were being served from the steam table. | 2020-09-01 |
| 56 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 842 | D | 0 | 1 | X20F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately transcribe, in the medical record, the correct amount of nutritional supplement ordered for one of five residents reviewed for nutritional weight loss. Resident identifier: #98. Facility census: 142. Findings included: a) Resident #98 The medical record was reviewed on 5/2/18 at 11:45 AM. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had verbal behaviors, received diuretics and had depression and anxiety. The Plan of Care dated 3/26/18 for Nutritional Status as evidenced by significant weight loss revealed the goal for the resident to consume appropriate amounts of food and fluids to maintain nutritional status. The plan of care revealed interventions to maintain weight through the next review that included the following: assist as needed to consume foods and/or supplements and fluids offered at and between meals, provide supplements per orders: Med Pass 2.0 (Dietary Supplement) 3 ounces, 4 times per day. On 5/2/18 at 1:54 PM the Medication Administration Records (MAR) for (MONTH) and (MONTH) (YEAR) were reviewed. The MARs for (MONTH) (YEAR) and up to 4/21/18 revealed the resident received Med Pass 2.0, 3 ounces, 4 times per day. On 4/21/18 at 11:30 AM, according to the MAR, the resident started receiving Med Pass 2.0, 2 ounces, 4 times per day. On 5/2/18 at 2:13 PM, a Dietary Communication form dated 4/20/18 by Registered Dietician (RD) #120 was reviewed. The dietary request directed: 1. Prosource Plus (Dietary Supplement) 1 ounce twice a day. 2. Please document the percentage of Med Pass 2.0 and magic cups that are already ordered in the MAR. The physician's orders [REDACTED]. The original order dated 12/10/15 directed Med Pass 2.0 before meals and at bedtime 3 ounces (4 times a day). A physician's orders [REDACTED]. On 5/3/18 at 11:52 AM the nutritional notes were reviewed. A nutritional note dated 5/3/18 indicated Please clarify the order for Med Pass 2.0 to be 3 ounces, 4 times per day. Document the percentage consumed in the MAR. Discontinue the order for Med pass 2.0, 2 ounces, 4 times per day as previously ordered. On 5/3/18 at 12:00 PM RD #120 was interviewed. RD #120 reviewed the documentation in the medical record regarding the recommendation he made on 4/20/18. He stated in (MONTH) (YEAR) when dietary recommendations were made the nurse must have put the wrong amount of the Med Pass 2.0 into the computer. RD #120 stated the order was for Med Pass 2.0 3 ounces four times a day, but the documentation revealed the nurses were giving only 2 ounces four times a day. In an interview on 5/3/18 at 12:04 PM, Registered Nurse (RN) #41 verified the nurse entered the incorrect amount of supplement into the computer, causing the resident to miss 4 ounces of the supplement daily. RN #41 stated at the beginning of each month the nurses do a recapitulation to ensure that physician's orders [REDACTED]. RN #41 verified the nurse missed this error, as there was no new physician order [REDACTED]. | 2020-09-01 |
| 57 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 880 | D | 0 | 1 | X20F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain an infection prevention program designed to help prevent the development and transmission of diseases and infections. Specifically, the facility failed to keep Resident #301's [MEDICAL CONDITION] tubing off of the floor. This failed practice had the potential to affect a limited number of residents. Resident identifier: #301. Facility census: 142. Findings included: a) Resident #301 Resident #301 admitted to the facility on [DATE]. According to the 5/18 physician orders, [DIAGNOSES REDACTED]. The resident had orders for a [MEDICAL CONDITION]. Review of the 4/24/18 Minimum Data Set (MDS) assessment, on 5/2/18 at 9:05 AM revealed Resident #301 was in a vegetative state with no discernible consciousness. He required total care for all activities of daily living (ADL). He was identified as receiving [MEDICAL CONDITION] care, suctioning, and oxygen. Multiple observations were made of the resident throughout the day from 4/30/18 to 5/3/18. During each of these observations, the resident's [MEDICAL CONDITION] tubing was observed to be very long, with the tubing laying on the floor touching multiple objects next to the resident's bed. Specific observations included the following: On 4/30/18 at 10:57 AM, 5/1/18 at 4:51 PM, 5/2/18 at 12:01 PM, 5/2/18 at 4:58 PM and 5/3/18 at 8:49 AM, the resident's [MEDICAL CONDITION] tubing was observed laying on the floor touching multiple objects next to the resident's bed. On 5/2/18 from 7:53 AM to 8:11 AM, [MEDICAL CONDITION] care was observed to be given by Licensed Practical Nurse (LPN) #4. She suctioned the resident, cleaned around the [MEDICAL CONDITION], and changed the soiled gauze around the [MEDICAL CONDITION]. The [MEDICAL CONDITION] tubing was observed to be laying on the ground the entire time the treatment occurred. In an interview on 5/3/18 at 8:55 AM, LPN #4 observed the resident's [MEDICAL CONDITION] tubing. She acknowledged the tubing was laying directly on the floor. She said the tubing should not be on the floor because of bacteria and for the draining of the humidity. There was a bag on the tubing that caught the excess liquid/humidity. She said it was supposed to be tied to the bed but the tie had broken. She said the resident had not had any infections and was doing well. She proceeded to get new tubing and change it. After she changed the tubing, the tubing was tied to the bed and off of the floor. In an interview on 5/3/18 at 9:16 AM, the Assistant Director of Nursing said [MEDICAL CONDITION] tubing should never touch the floor. Anything that touches the floor has the potential for infection. She said the tubing should be tied to the bed, so it was off the floor. In an interview on 5/3/18 at 10:44 AM, the Director of Nursing said [MEDICAL CONDITION] tubing should never be laying on the floor. She explained bacteria could potentially get in the [MEDICAL CONDITION] area. | 2020-09-01 |
| 58 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 550 | E | 0 | 1 | WJ7O11 | Based on observation and staff interview, the facility failed to treat each resident with respect and dignity, and failed to care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life. A nurse conducting medication administration did not knock or announce herself before entering Resident's rooms. This practice affected three (3) of four (4) residents observed during medication administration. Resident identifiers: #11, #71, and #101. Facility census: 140. Findings included: a) Observation An observation of Registered Nurse (RN) #5 during medication administration, on 08/05/19 at 08:05 AM, revealed the RN did not knock on the doors and announce herself before entering the rooms of Resident #11, #71, and #101. b) Interview An interview with RN #5, on 08/05/19 at 8:15 AM, revealed she usually knocks on the doors but forgot to because she was being observed and was nervous. | 2020-09-01 |
| 59 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 558 | D | 0 | 1 | WJ7O11 | Based on observation, record review, staff interview and policy review, the facility failed to provide reasonable accommodations to a resident. The facility failed to ensure resident's call light was within reach. This failed practice affected two (2) of 31 residents. Resident identifier: #130 and #111. Facility census: 140. Findings included: a) Resident #130 An observation, on 07/29/19 at 11:49 AM, revealed Resident #130's sheets and call light was laying on the floor by the foot of the bed. Resident #130 was in bed and unable to reach call light. An interview with Licensed Practical Nurse (LPN) #122, on 07/29/19 at 11:54 AM, confirmed call light was on floor and out of reach of Resident #130. LPN stated, I will go pick up her call light and change her sheets since hers are on the floor. A policy review Answering the Call Light with Revised date (MONTH) 2010. Policy stated, Step four (4) When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. b) Resident #111 An observation of the Resident, on 07/30/19 at 08:39 AM, revealed she was in bed. The call light was hanging off the side of the bed and was not within reach of the Resident. An interview with the Resident, on 07/30/19 at 8:40 AM, revealed she did not know where her call light was. An interview with Nurse Aide (NA) #100, on 07/30/19 at 8:45 AM, revealed all call lights should be within reach while residents are in bed. The NA placed the call light within reach. | 2020-09-01 |
| 60 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 584 | E | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to ensure comfortable and safe temperature levels for residents. The facility did not ensure the temperature range of 71 to 81 degrees Fahrenheit was maintained in the resident's Day/Dining Rooms. Three (3) Day/Dining Rooms tested higher than 81 degrees while being used by residents. The facility also failed to ensure a Broda Chair was not damaged and a wall in a resident's room was in good repair. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #62, #82, #21, #48, #110, & #115. Room identifiers: 100 Hall Day/Dining Room, 500 Hall Day/Dining Room, 600 Hall Day/Dining Room, 700 Hall Day/Dining Room, and the 800 Hall Day/Dining Room. Facility census: 140. Findings included: a) Temperature Observations An observation during the initial tour of the facility, on 07/29/19 at 11:15 AM, revealed the 100 Hall Day/Dining Room, 500 Hall Day/Dining Room, 600 Hall Day/Dining Room, 700 Hall Day/Dining Room, and 800 Hall Day/Dining Rooms all felt hot. There were no fans and the air conditioning units were only blowing warm air. These rooms are used as the main dining rooms for each hallway in the facility. An observation of the 600 Hall Day/Dining Room, on 07/29/19 at 12:55 PM, revealed the room felt hot. Resident #62 was attempting to eat her lunch and was visibly sweating. A room thermometer affixed to the wall read 83 Degrees Fahrenheit. No staff were present. There were no fans and the air conditioning units were only blowing warm air. An observation of the 800 Hall Day/Dining Room, on 07/29/19 at 1:15 PM, revealed Nurse Aide (NA) #100 was assisting two (2) residents with their lunch. The room felt hot. There were no fans and the air conditioning units were only blowing warm air. An observation of the 700 Hall Day/Dining Room, on 07/29/19 at 2:15 PM, revealed a room thermometer affixed to the wall read 82 Degrees Fahrenheit. Two residents were in the room at the time of the observation. There were no fans and the air conditioning units were only blowing warm air. b) Temperature Interviews/Record Review An interview with Resident #82, on 07/29/19 at 11:41 PM, revealed the day room where we eat here on wing one is hot and the air conditioner has been out for a while. The Resident revealed on 07/28/19 the room got as hot as 84 degree Fahrenheit and that it was too hot to eat in there. An additional interview with Resident #82, on 07/29/19 at 3:00 PM, revealed, I eat in the dining room because there is nowhere else to eat. I really don't like to eat in my room. An interview with Resident #21, on 07/29/19 at 12:10 PM, revealed the dining room is so hot but there is nowhere else to eat. An additional interview with Resident #21, on 07/29/19 03:00 PM, revealed I eat in the dining room because there is nowhere else to eat. I have tried to eat at all the other dining rooms in the other wings but they are just as hot if not hotter. A family interview with Resident #48's husband, on 07/29/19 at 12:44 PM, revealed, the Day/Dining Room on Wing 100 had no air conditioning. He stated the air conditioning had not been working for a while. Resident #48's husband stated, they have the unit on the wall blowing as a fan from outside but it has only made the rooms hotter especially on the hottest days. Resident #48's husband stated, I bought a room thermometer and brought it to the facility to watch how hot it gets in the room. The room temperature has been as hot as 86 degrees Fahrenheit. Resident #48's husband stated I have addressed the air conditioning issue with the facility multiple times but the problem has yet to be fixed. An interview with Resident #62, on 07/29/19 at 1:00 PM, revealed the dining room is always hot. The Resident asked can't you see me sweating? The Resident stated she had complained to multiple staff members about the temperature but nobody had addressed her complaints. The Resident stated the only other place she can eat is in her room and she does not want to do that. An interview with NA #100, on 07/29/19 at 1:20 PM, revealed the Day/Dining Rooms have been hot for months. The NA stated it makes it hard to do my job and I know the residents hate it. The NA stated the rooms have been hot all summer. The NA stated the rooms have never been closed when she works. An interview with Registered Nurse (RN) #5, on 07/29/19 at 1:30 PM, revealed the facility has been too hot the past few months. The RN stated the administration ignores the hot temperatures while they sit in their air conditioning downstairs. The RN stated multiple residents eat in the Day/Dining Rooms on each unit daily with no air conditioning or fans. The RN stated she had never seen the Day/Dining Rooms closed. The RN stated the residents have no other places to eat their meals besides in their rooms which is no kind of life. An interview with the Maintenance Director in the 800 Hall Day/Dining Room, on 07/29/19 at 1:45 PM, revealed the facility addressed the hot Day/Dining Rooms in (MONTH) 2019. The Maintenance Director stated the air conditioning units either do not work or cannot cool the Day/Dining Rooms adequately during the summer. The Maintenance Director stated the resolution set by the Administrator and himself was to close the Day/Dining Rooms when the temperature went above 81 degrees Fahrenheit. The Maintenance Director stated the facility had ordered new portable air conditioner units but they had to be utilized in other areas of the facility. The Maintenance Director verified the room felt hot and stated no residents should be in here until we get the permanent air conditioners installed. The Maintenance Director stated I thought they were closing these rooms on days like today. The Maintenance Director stated some of the rooms have wall thermometers and some do not. The Maintenance Director stated the facility bought a thermometer gun recently to test temperatures daily but is unsure who is checking them. Further interview with the Maintenance Director, on 07/29/19 at 2:15 PM, revealed he found the thermometer gun and would check the temperatures in the Day/Dining Rooms. The following Day/Dining Room temperatures were recorded at 2:15 PM on 07/29/19 with the facility's thermometer gun: 600 Hall Day/Dining room [ROOM NUMBER].0 800 Hall Day/Dining room [ROOM NUMBER].5 The Maintenance Director verified on 07/29/19 at 2:20 PM the wall thermometer in the 600 Hall Day/Dining room read 83 Degrees Fahrenheit. An interview with the Administrator, on 07/29/19 at 3:00 PM, revealed he stated I am not confirming anything or divulging any information about the temperatures and what we have in place. An interview with the Corporate Consultant (CC) #154, on 07/29/19 at 3:15 PM, revealed she would check into the temperature situation and report back. Further interview with the Administrator, on 07/29/19 at 3:30 PM, revealed the facility had addressed the hot temperatures and put a plan in place on 06/01/19. The Administrator provided the written plan, dated 06/01/19, that stated hot temperatures identified in several areas throughout the facility which included Morning/evening temperature checks and documented to monitor ambient conditions. A review of the temperature logs revealed they were only recorded on 07/08/19 and 07/09/19. The log stated to call the Administrator if temperatures are above 82 Degrees. The temperatures recorded on those days were: 100 Hall-12:30 PM 83.5 Degrees Fahrenheit 300 Hall-12:30 PM 82 Degrees Fahrenheit 600 Hall-12:30 PM 82 Degrees Fahrenheit 700 Hall-12:30 PM 82.5 Degrees Fahrenheit The Administrator stated he had no other temperature logs from 06/01/19 to 07/29/19. The Administrator stated he could not provide any evidence the high temperatures recorded on the logs were addressed. The Administrator stated he could not provide any further documentation the facility had protected the residents from the high temperatures in the facility since 06/01/19. An interview with the CC #154, on 08/05/19 at 12:30 PM, revealed the facility had no written policy for room temperatures. The CC stated we follow life safety code and the regulation of keeping temperatures between 71 and 81 degrees Fahrenheit. | 2020-09-01 |
| 61 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 602 | D | 1 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure the resident's medications were not diverted to an unlicensed person for administration. A nurse gave [MEDICATION NAME] to a van driver to give to a resident while out of facility for an appointment. This is true for one (1) of two (2) complaint/concerns reviewed. Resident identifier: #239. Facility census: 140. a) Resident #239 Review of a complaint/concern with a date of 02/14/19 revealed a statement by registered nurse (RN) #94, explaining both she and the night nurse signed out, the pain medication, and placed the medication in a bag, and instructed the van driver to give the medication at 12:00 PM on this same date. The dosage is not revealed in the note. A grievance investigation form completed by risk manager RN #136 reveals, Resident left for at 7:15 AM for an appointment and medication was given to the van driver. According to Resident #239 she was given the medication, by the van driver, at approximately 8:30 AM. Resident #239's (MONTH) 2019 Medication Administration Record [REDACTED]. A new order with a start date of 02/13/19 is to give [MEDICATION NAME] 15 mg every four (4) hours as needed for pain. The first dose of this order was given on 02/13/19 at 7:54 PM. On 02/14/19 the MAR indicated [REDACTED]. Review of documentation concerning this matter found. 1. Van driver #63 was given the mediation by RN #94 who instructed the van driver to give to the resident at 12:00 PM. 2. A note written by the director of nursing reveals she spoke to van driver #63, who stated RN #94 gave him medication in a bag with instructions to give the medication to Resident #239 at 12:00 PM. This documentation is not signed by van driver #63. It is signed by the DON with a date of 02/15/19. 3. A note written by SS #111 in which Resident #239 stated she did not feel like it was not right for the van driver to give her [MEDICATION NAME]. 4. A note written by RN #136, with a date of 02/14/19 reveals, Van driver was given [MEDICATION NAME] tab to hand to this resident. He did not administer the med. Upon review of MARS, only dose documented was at 1 am on 2/14. Nursing supervisor said she was given [MEDICATION NAME] again around 4:35 am, but this dose was not documented on her MARS. Resident left for appointment @ 7:15 am. Med sent to appointment was given per resident from the van driver approximately at 8:30 am. Not documented on MARS upon return to facility same day. Appointment at 9 am. Resident returned around 11:15 am. Information given to Dir of Nurs to investigate by gathering witness statements and determining if resident right were violated. Email sent to Dir of Nurs on 2/25/as a follow up in regarding to resolving this grievance., On 07/31/19 at 4:00 PM the director of nursing expressed the incident was not reported to OHFLAC. A self-medication administration evaluation on 02/15/19, occurred after the incident. On 08/05/19 at 3:58 PM the DON agreed sending medication with the van driver was inappropriate. | 2020-09-01 |
| 62 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 609 | D | 1 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to identify and report an allegation of abuse/neglect related to a threat to discharge Resident #239, if she refused to go to an appointment and an allegation the nursing staff gave [MEDICATION NAME] to the van driver to dispense to Resident #239, while out of the facility. This is true for one (1) of two (2) complaint concerns reviewed. Resident identifier: #239. Facility census: 140. Findings included: Review of a complaint/concern with a date of 02/14/19 revealed Resident #239 reported to Social Services (SS) #111 on 02/14/19 a threat was made by facility staff that she would be discharged if she did not go to an appointment scheduled for this same day. She also reported the van driver was given [MEDICATION NAME] to dispense to her while on the trip. Further review found no evidence a Reportable was completed and sent to the Office of Health Facility Licensure and Certification (OHFLAC) concerning the allegations. On 07/31/19 at 4:00 PM the director of nursing expressed the incident was not reported to OHFLAC. On 08/05/19 at 3:58 PM the DON agreed sending medication with the van driver was inappropriate. | 2020-09-01 |
| 63 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 610 | D | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview the facility failed to thoroughly investigate an allegation of abuse/neglect related to a threat to discharge Resident #239, if she refused to go to an appointment and an allegation the nursing staff gave [MEDICATION NAME] to the van driver to dispense to Resident #239, while out of the facility. This is true for one (1) of two (2) complaint concerns reviewed. Resident identifier: #239. Facility census: 140. Findings included: a) Resident #239 Resident #239 filed a grievance with Social Services, (SS) #111, on 02/14/19 concerning a threat made by facility staff that she would be discharged if she did not go to an appointment scheduled for this same day. In addition, Resident #239 complained she did not believe the nursing staff should give [MEDICATION NAME] to the van driver to dispense to her, while out of the facility. On 02/14/19 the complaint/grievance form was signed by SS #111, and the risk manager registered nurse (RN), #136. The DON signed the resolution section of the complaint/grievance on 02/15/19 documenting the grievance was resolved and the complainant is satisfied. There no evidence the facility thoroughly investigated these allegations. On 02/25/19 RN #136, sent an e-mail to the DON an information statement regarding completing an investigation, by gathering witness statements and determining if Resident #239's rights were violated. On 07/31/19 at 4:00 PM the director of nursing expressed a thorough investigation did not occur related to the allegation of threatening to discharge Resident #239, and to medication being sent with the van driver. On 08/05/19 at 3:58 PM the DON agreed sending medication with the van driver was inappropriate. | 2020-09-01 |
| 64 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 623 | D | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the Ombudsman of resident transfers to an acute care setting. This was found for two (2) of two (2) residents reviewed for hospitalization s. Resident identifiers: #133 and #130. Facility census: 140. Findings included: a) Resident #133 Review of the medical record on 07/31/19, revealed Resident (R) #133 was admitted to the facility on [DATE] and discharged to the hospital after a fall on 05/29/19. The medical record is silent in regard to the Ombudsman being notified of the unplanned transfer and admission to the hospital. During an interview on 07/31/19 at 1:20 PM, social workers (SW) #134 and #111, acknowledged the Ombudsman was not notified. SW #134 stated, We just started notifying the Ombudsman on 07/01/19, after the new Administrator identified the issue. b) Resident #130 During a medical record review on 07/31/19 at 1:19 PM, found no evidence of a bed hold or ombudsman notification for hospitalization s on 04/28/19, 05/31/19 and 06/30/19. Employee #111 and Employee #134 reported on 07/31/19 at 1:20 PM, the facility just started notifying the ombudsman on 7/1/19. On 07/31/19 at 1:30 PM, Employee #40 and Employee #147 explained she (Resident #130) is on Medicaid so it is automatically a twelve (12) day bed hold. Upon further inquiry Employee #40 stated, We just heard that we need to notify the ombudsman for hospitalization s. Employee #40 and Employee #147 verified the medical record did not contain any notification for hospitalization s on 04/28/19, 05/31/19 and 06/30/19. | 2020-09-01 |
| 65 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 625 | D | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide the resident and/or family with a copy of the Bed-Hold notification on admission and/or at the time of transfer. This was found for one (1) of two (2) residents reviewed for hospitalization . Resident identifier: #133. Facility census: 140. Findings included: a) Review of the medical record on 07/31/19, revealed Resident (R) #133 was admitted to the facility on [DATE] and discharged to the hospital after a fall on 05/29/19. The medical record is silent regarding the resident and/or Medical Power of Attorney receiving information related to the facility's bed-hold policy on admission or at the time of the unplanned transfer to the hospital. Social Worker (SW) #111 reported the business office staff review the bed-hold policy with the resident and/or family on admission. SW #111 reviewed the electronic medical record and confirmed it lacked any information related to this policy. At 11:42 AM on 07/31/19, the Business office Manager (BOM) acknowledged she reviews the bed-hold policy with the resident and/or family on admission and a signed copy is placed in the medical record. The BOM reported the nurse is to complete a second bed-hold notification when the resident is transferred to the hospital. On 07/31/19 at 12:30 PM, SW #134, verified R#133's medical record lacks any information indicating the bed-hold policy was reviewed and/or given to the resident and/or family during admission or at the time of the hospital transfer. | 2020-09-01 |
| 66 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 640 | D | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to transmit a resident assessment within 14 days after completion. This was true for one (1) of 31 residents reviewed. Resident identifier: #1. Facility census: 140. Findings included: a) Review of the medical record on 07/31/19, revealed Resident (R) #1 was admitted to the facility on [DATE] and discharged to home 02/26/19. The status section of the electronic minimum data set (MDS) assessment for the five (5) day admission assessment dated [DATE], the 14-day assessment dated [DATE] and the discharge return not anticipated assessment dated [DATE], all state assessment was never added to batch. The status section of R #1's MDS assessments was reviewed by corporate consultant (CC) #152 and Registered Nurse Assessment Coordinator (RNAC) #33, during an interview on 07/31/19 at 3:45 PM. CC#152 acknowledged the status was marked incorrectly and the discharge assessment was never submitted. CC #152 corrected the discharge assessment and submitted it during this interview. | 2020-09-01 |
| 67 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 641 | D | 0 | 1 | WJ7O11 | Based on record review, staff interview and Minimum Data Set (MDS) Resident Assessment Instrument (RAI) version 3.0 manual, the facility failed to ensure the accuracy of a MDS for a resident receiving Hospice services. This practice was found for one (1) of one (1) residents reviewed for Hospice services. Resident identifier: #130. Facility census: 140. Findings included: a) Resident #130 On 07/31/19 at 11:45 AM, review of the medical record revealed Resident #130 was admitted to Hospice services on 07/19/19. Review of the significant change MDS with assessment reference date (ARD) of 07/21/19 discovered the following: Section J, titled Health Conditions, J1400 Prognosis, coded as: NO. MDS RAI version 3.0 manual coding instructions for J1400 Prognosis (typed as written): . --Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. After review of the significant change MDS with ARD of 07/21/19 on 07/31/19 at 11:55, Employee #152 stated, Yes, the manual states it should be coded yes because the resident is on Hospice. But the coordinator was waiting on physician documentation. Yes, if you follow the manual which they are supposed to, it is coded wrong. | 2020-09-01 |
| 68 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 656 | D | 0 | 1 | WJ7O11 | Based on record review, hospice contract review and staff interview, the facility failed to implement and/or develop a comprehensive person-centered care plan. A resident's call light was not within reach as directed by their care plan and a resident receiving hospice services did not have a care plan that included a detailed description of the services being provided. These practices affected two (2) of thirty-one (31) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #111 and #130. Facility census: 140. Findings included: a) Resident #111 An observation of the Resident, on 07/30/19 at 08:39 AM, revealed she was in bed. The call light was hanging off the side of the bed and was not within reach of the Resident. An interview with the Resident, on 07/30/19 at 8:40 AM, revealed she did not know where her call light was. An interview with Nurse Aide (NA) #100, on 07/30/19 at 8:45 AM, revealed all call lights should be within reach while residents are in bed. The NA placed the call light within reach. A review of the Resident's Care Plan, on 07/30/19 at 10:15 AM, revealed the focus History of falls with the intervention keep call light within reach. The Care Plan was initiated on 3/31/2017. b) Resident #130 On 07/31/19 at 11:45 AM, review of the medical record revealed Resident #130 was admitted to Hospice services on 07/19/19. Review of the care plan revealed an intervention created on 07/19/19 stating (typed as written): . Hospice staff to visit to provide care, assistance and/or evaluation . The care plan lacked a goal related to Hospice care and/or services. After review of the care plan on 07/31/19 at 12:35 PM, the Director of Nursing (DON) agreed the care plan was not individualized with measurable goals and interventions. She further agreed the care plan did not specify what Hospice staff would visit and when the visits would occur. | 2020-09-01 |
| 69 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 657 | D | 0 | 1 | WJ7O11 | Based on resident interview, record review and staff interview the facility failed to ensure a resident was invited to a care plan meeting. The facility failed to ensure a resident had the right to participate in choosing treatment options and was given the opportunity to participate in the development, review and revision of the care plan. The failed practice affected one (1) of 31 residents. Resident identifier: Resident #7. Facility census: 140. Findings included: a) Resident #7 A resident interview, on 07/29/19 at 1:00 PM, Resident #7 revealed questions about medication orders and administration. Resident #7 stated, I have tried to ask the nurses and doctors about my meds but they are always too busy, I would like to know what medications I am taking and why I need to take them. A record review, on 07/31/19 at 10:00 AM, revealed a social service note dated for 07/24/19 that stated, SW talked with brother (name of brother), MPOA, and updated him on IDT review. He is not interested in having a quarterly review meeting. He visits regularly and is aware of (resident's name) condition and daily routine. (Resident's name) continues attending activities of choice and interacts well with other residents. He is aware to contact SW with questions/concerns. A second social service note found dated for 05/24/18, stated, SW talked with brother (brother;s name) by phone and updated him on IDT review of treatment plan and asked if he would like to schedule a meeting. (Brother's name) visits regularly and is aware of (resident's name) condition and daily routine. He was not interested in having a meeting. (Resident's name) attends activities of choice and interacts well with staff, residents and visitors. He is well adjusted to long term care and aware to contact SW with questions/concerns. Further record review, on 07/31/19, revealed Resident #7 has a current Brief Interview for Mental Status (BIMS) of 15. An interview with Social Worker (SW) #134, on 07/31/19 at 11:08 AM, revealed no documentation that Resident # 7 was ever invited to a care plan meeting. SW #7 stated, I always talk to Resident #7's Medical Power of Attorney (MPOA) with Resident #7 present about the Care Plan Meetings after meeting is held. SW #134 confirmed the facility completes Care Plan Meetings and then updates the MPOA and Resident #7 after meeting occurred. | 2020-09-01 |
| 70 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 679 | E | 1 | 1 | WJ7O11 | > Based on resident interviews, staff interviews, van specifications and family interview, the facility failed to implement an on-going resident centered activities program that meets resident preferences. This has the potential to effect more than a limited number. Resident identifiers: #82, #48, #21. Facility census: 140. Findings included: a) Resident #82 An interview with Resident #82, on 07/29/19 at 11:40 PM, revealed, the activities can be very juvenile at times. Resident #82 stated one activity was to finger paint. As an adult I will finger paint with my grandchildren maybe but for an adult activity? Resident #82 revealed finger painting made her feel belittled and degraded. b) Resident #48 A family interview with Resident #48's husband, on 07/29/19 at 12:42 PM, revealed Resident #48 enjoyed being around other residents even though no one can understand what is said by her. Resident #48's husband stated, A couple of weeks ago they had a movie night and when I found out Resident #82 was not invited and sat out in the hall looking in at the movie I raised a fit about that. Resident #48's husband stated, the residents had nothing in the building to stay occupied so I bought the 30 puzzles for residents laying here in the day room for them to have something to do. c) Resident #21 An interview with Resident #21, on 07/29/19 at 2:10 PM, revealed, the activities provided by the facility is not always enjoyable when other residents disrupt the group. Resident #21 stated, they have two vans for transportation and usually only one driver so this does not allow everyone to go to activities when off site. On 07/29/19 at 3:00 PM during Resident Council meeting, residents voiced concerns about activity programs often starting late, and the inability for the facility to transport groups of people out in the community. They explained the vans are not available due to all the medical appointments. Thirteen (13) of sixteen (16) residents in the Resident Council meeting would like to go out in the community for meals, and events, at least one (1) time per month. The group also expressed groups are planned so everybody in the group can participate, are sometimes juvenile, and do not meet higher functioning resident interests. At 9:00 AM on 07/31/19 the facility activity director explained the facility generally plan two outing a year in which most residents can participate, Geri-camp in October, and Olgebay Christmas lights in December. The activity director explained the facility currently has herself and two (2) full time activity assistants. The program does not have a specific van available for activities transport or a full time van driver that is always available to transport residents for community activities. She went on to explain there is usually not enough staff to take a group of residents into the community. The facility has two (2) six (6) passenger vans. One can transport three (3) residents in wheelchairs and the additional van can transport one (1) resident in a wheelchair. These are also used for medical appointment transportation. On 08/05/19 at 8:00 AM regional director of operations #154, met with the survey team concerning activities. She explained the facility has outside activities at the facility but does not schedule on-going community activities. Review of the Facility Assessment, Part three (3) titled, Facility resources needed to provide competent support and care for our resident population every day and during emergencies, included Social Services/Other. The average productive hours per month documentation is; Activity Director 0.0 hours, Activities Supervisor 17.14 hours, and Activities Other 82.80 hours. On 07/31/19 at 2:00 PM a request was made to the cooperate director of operations to explain what part of the facility assessment refers to activities. She explained the general care areas to provide person-centered/directed care: Psycho/social/spiritual support: includes activity requirements. .Provide opportunities for social activities/life enrichment (individual, small group, community); Support community integration if resident desires; . | 2020-09-01 |
| 71 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 684 | D | 1 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, Hospice service contract and staff interview, the facility failed to ensure prescribed Hospice services were provided to a resident in accordance with professional standards of practice. This practice was found for one (1) of one (1) Hospice resident reviewed during the survey. In addition the facility failed to ensure staff followed physician orders [REDACTED]. This practice was found for one (1) of thirty-one (31) residents reviewed during the survey. Resident identifiers: #130 and #233. Facility census: 140. Findings include: a) Resident #130 On 07/31/19 at 11:45 AM, review of the medical record revealed Resident #130 was admitted to Hospice services on 07/19/19 for a terminal health condition. Continued review of the medical record found no evidence of documentation of further Hospice care visits following her admission to Hospice services. Review of the Hospice care plan created on admission was silent for the identification of services to be provided. After reviewing the medical record on 07/31/19 at 12:35 PM, the Director of Nursing (DON) was unable to locate documentation of Hospice visits following Resident #130's initial admission to Hospice services. The DON stated, I am sure that they have been here to visit, but there is nothing to prove it. I agree their care plan does not even tell who is going to visit and when. Review of the facility agreement/contract with the contracted Hospice services provided by the DON revealed the following (typed as written): .III Services provided by Hospice: .C. Hospice shall develop the Plan of care to be provided to the Home specifying information pertinent to the resident's treatment. The Plan will be updated bi-weekly by the hospice team . M. Documentation of all visits by Hospice staff shall be placed on the Home chart at the time of the visit . b) Resident #233 Review of medical records for Resident #233, found an order with a start date of 07/26/19 to give Meropenem Solution one (1) gram intravenously (IV), to treat an infection. On 07/30/19 at 11:16 AM a bag of Meropenem Solution hanging on a pole contained liquid which was approximately one (1) inch from the bottom of the bag, that had not been delivered to the resident intravenously. At this time registered nurse (RN) #97 agreed she had disconnected the IV medication and agreed all of the medications was not delivered to the resident and stated I could have run it all. Registered nurse #97 then removed the IV medication from the pole. | 2020-09-01 |
| 72 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 689 | D | 0 | 1 | WJ7O11 | Based on observation and staff interview, the facility failed to provide an environment free of accident hazards over which it had control. The facility failed to secure hot liquids from resident's access. The 700 Hall Nourishment Room contained a coffee maker that was left unattended and brewing with hot coffee in the pitcher. The room, which is located on the resident hallway, had no door and was accessible to anyone. There was a resident observed seated in a wheelchair at the entrance of the Nourishment Room. No staff was in sight of the Nourishment Room at the time of the observation. The coffee inside the pitcher was tested to be 184.6 degrees Fahrenheit by the facility's Maintenance Director. An observation of the first floor lobby, on 07/29/19 at 4:30 PM, revealed three (3) male residents sitting in the lobby. Resident #121 was observed independently pouring a cup of coffee from a coffee maker that was on a counter in the lobby. The coffee maker, which was unsupervised at the time of the observation, had coffee readily available. The coffee was then poured into a cup and tested at 161 degrees Fahrenheit. The facility also failed to secure chemicals and sharp objects and to keep resident area floor's dry. All the deficient practices had the potential to affect more than a limited number of residents residing in the facility. Room identifiers: 700 Hall Nourishment Room, First Floor Lobby, 600 Hall Soiled Utility Room, and 100 Hall Shower Room. Facility census: 140. Findings included: a) 700 Hall Nourishment Room An observation of the 700 Hall Nourishment Room, on 07/29/19 at 11:30 AM, revealed a coffee maker noted to be brewing with six (6) ounces of coffee in the pot. The coffee was situated on the countertop approximately three (3) inches from the edge of the counter. There was no separation or door to the Nourishment Room from the resident hallway. Residents were observed walking by as well as one resident seated in a wheelchair at the entrance of the Nourishment Room. An interview with Licensed Practical Nurse (LPN) #1, on 07/29/19 at 11:30 AM, revealed the coffee was for staff and not the residents. The LPN verified that any mobile Residents in the facility had access to the coffee maker. A temperature test conducted by the facility's Maintenance Director, on 07/29/19 at 11:50 AM, revealed the coffee was 184.6 Degrees Fahrenheit. An interview with the Maintenance Director, on 07/29/19 at 11:50 AM, revealed the Maintenance Director stated that's pretty hot, I did not know this coffee maker was here. Further observations, on 07/29/19 at 12:00 PM, revealed six (6) other Nourishment Rooms within the facility had coffee makers on their counters with brewing capacity and supplies. An interview with the Administrator, on 07/29/19 at 12:26 PM, revealed he had been notified of the coffee on the 700 Hall and its temperature of 184.6 degrees Fahrenheit. The Administrator stated he had taken care of it. b) First Floor Lobby An observation of the First Floor Lobby, on 07/29/19 at 4:30 PM, revealed a self-service coffee maker. Three residents were noted to be seated in wheelchairs, in close proximity to the coffee maker. Resident #121 was serving himself coffee from the coffee maker unsupervised. A temperature test of the coffee maker, on 07/29/19 at 04:30 PM, revealed the coffee was 161 Degrees Fahrenheit. The temperature was verified by the Assistant Director of Nursing (ADON). The ADON stated I will take care of that right now. An interview with the Administrator, on 07/29/19 at 05:15 PM, revealed he was aware of the self-service coffee maker in the First Floor Lobby. c) 600 Hall Soiled Utility Room An observation of the 600 Hall, on 07/30/19 at 10:00 AM, revealed the room labeled Soiled Utility Room was unlocked. No staff were in sight of the room at the time of the observation. The room contained the following items in an unlocked cabinet: One (1) bottle of Peroxide Multi-Surface Cleaner and Disinfectant with the warning Keep out of reach of children. Ten (10) capped shaving razors Two (2) unsecured razor blades Fifteen (15) tacks Four (4) large glass vases An interview with Registered Nurse (RN) #105, on 07/30/19 at 10:10 AM, revealed the room should have never been unlocked. The RN stated she would ensure the room was locked. d) Wing one (1) Shower Room A resident interview, on 07/31/19 at 9:00 AM, revealed a concern in the shower room. Resident #21 stated, when I go into the shower the water overflows onto the floor. Resident #21 stated, with all the water on the floor someone is going to fall and get hurt. An observation of Wing one (1) Shower Room, on 07/31/19 at 12:05 PM, revealed a shower that water flowed out the sides of the shower stall onto the bathroom floor. An immediate staff interview with Certified Nursing Assistant (CNA) #6, on 07/31/19 at 12:05 PM, revealed, The shower water flows out on the floor a lot. CNA #6 stated, if you hold the handheld shower head it doesn't flow over into the floor as bad. | 2020-09-01 |
| 73 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 692 | D | 0 | 1 | WJ7O11 | Based on family interview, record review, staff interview, the facility failed to ensure a resident maintained an acceptable parameter of nutritional status. A resident who was admitted under weight, was not weighed after a decline in status. This is true for one (1) of nine (9) residents reviewed for nutrition. Resident identifier: #126. Facility census: 140. Findings included: a) Resident #126 On 07/29/19 at 12:25 PM Resident #126's wife expressed she did not think the facility was weighting her husband, she requested his weight be obtained, and she is concerned about how very thin he is. Review of medical records found the admit weight on 06/21/19 to be one-hundred and thirteen (113) pounds. Additional weights on 07/07/19, 07/05/19, remained at (113) pounds. On 07/12/19 the residents weight was one-hundred and twelve (112) pounds. On 07/31/19 the surveyor requested the facility weight the resident. The residents weight was one-hundred and seven (107) pounds which represents a five (5) percent weight loss between 07/12/19 and 07/31/19. Observation of the resident during the survey found the resident to appear very weak, and with very low energy. The facility followed the weight admission orders [REDACTED]. | 2020-09-01 |
| 74 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 741 | D | 1 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility to failed to provide competent staffing for the care and services delivered to maintain resident safety and attain the highest practicable physical mental and psychosocial well-being of each resident. The facility failed to thoroughly investigate an allegation of neglect related to threatening a resident with discharge and an incident in which a nurse gave [MEDICATION NAME] to a van driver to give to a resident while out of the facility. This is true for one (1) of two (2) compliant/concerns reviewed. Resident #239. Facility census. 140. Findings included: a) Resident #239 Review of medical records revealed a physician order [REDACTED]. The first dose of this order was given on 02/13/19 at 7:54 PM. The previous order with a start date of 01/23/19 was [MEDICATION NAME] 15 mg every six (6) hours as needed for pain. Review of a complaint/concern with a date of 02/14/19 revealed a statement by registered nurse (RN) #94, explaining both she and the night nurse signed out, the pain medication, and placed the medication in a bag, and instructed the van driver to give the medication at 12:00 PM on this same date. The dosage is not revealed in the note. A grievance investigation form completed by risk manager RN #136 reveals, Resident left for at 7:15 AM for an appointment and medication was given to the van driver by nursing staff. According to Resident #239 she was given the medication, by the van driver, at approximately 8:30 AM. Review of documentation concerning this matter found. 1. Van driver #63 was given the mediation by RN #94 who instructed the van driver to give to the resident at 12:00 PM. 2. A note written by the director of nursing reveals she spoke to van driver #63, who stated RN #94 gave him medication in a bag with instructions to give the medication to Resident #239 at 12:00 PM. This documentation is not signed by van driver #63. It is signed by the DON with a date of 02/15/19. 3. A note written by SS #111 in which Resident #239 stated she did not feel like it was not right for the van driver to give her [MEDICATION NAME]. 4. A note written by RN #136, with a date of 02/14/19 reveals, Van driver was given [MEDICATION NAME] tab to hand to this resident. He did not administer the med. Upon review of MARS, only dose documented was at 1 am on 2/14. Nursing supervisor said she was given [MEDICATION NAME] again around 4:35 am, but this dose was not documented on her MARS. Resident left for appointment @ 7:15 am. Med sent to appointment was given per resident from the van driver approximately at 8:30 am. Not documented on MARS upon return to facility same day. Appointment at 9 am. Resident returned around 11:15 am. Information given to Dir of Nurs to investigate by gathering witness statements and determining if resident right were violated. Email sent to Dir of Nurs on 2/25/as a follow up in regarding to resolving this grievance., On 0805/19 at 3:58 PM the DON agreed sending medication with the van driver was inappropriate. | 2020-09-01 |
| 75 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 755 | E | 1 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to safely provide pharmaceutical services including administering drugs to meet the needs of resident. The facility failed to utilize only persons authorized by state or local, regulations to administer medication to a resident. A nurse gave medication to a van driver to give to a resident while out of the facility. This is true for one (1) of two (2) complaint/concerns reviewed. Resident identifier: #239. Facility census: 140. Findings included: a) Resident #239 Review of complaint concerns found a note written by social services #111 in which Resident #239 stated she did not feel like it was right for the van driver to give her [MEDICATION NAME] (a highly additive medication). A complaint/concern with date of 02/14/19 includes a statement by register nurse (RN) #94 explaining she and the night nurse signed out, the pain mediation, and placed it in a bag, and instructed the van driver to give the medication at 12:00 PM on this same date. On 02/15/19 a note by the director nursing (DON) reveals, van driver #63 confirmed he was given medication by nursing staff to give to Resident #239 while out of the facility for a medical appointment. On 02/14/19 risk manager RN #136 documented [MEDICATION NAME] was sent with the van driver #63 and the van driver gave it to the resident at approximately 8:30 AM, and this dose of medication was not on the Medication Administration Record [REDACTED] On 0805/19 at 3:58 PM the DON agreed sending medication with the van driver was inappropriate. b) Incomplete Narcotic Counts On 07/31/19 at 4:31 PM, a review of the Controlled Substance Forms on the 200 hall with Licensed Practical Nurse (LPN) #143 revealed nurses failed to initial the sheets at the change of shift after controlled medications were counted. LPN #143, confirmed medication counts are to be completed between two (2) nurses at the change of shift and both nurses are to initial the forms. Further review at this time found incomplete Controlled Substance Forms on both medication carts on the 200 and 300 hall and the single cart located on the 100 hall. The Assistant Director of Nursing (ADON) acknowledged the Controlled Substance Forms were incomplete during an interview on 07/31/19 at 4:32 PM. Copies of the last six (6) months of the Controlled Substance Forms for all departments were requested at this time. Additional Controlled Substance Forms were received on 08/05/19 at 8:30 AM. Multiple pages were missing and to conserve time the team chose to focus on the past two (2) months. Findings are below: --Wing 100 - lacks nursing signatures on 6/2, 6/3, 6/4, 6/5, 6/7, 6/8, 6/9, 6/12, 6/13, 6/15, 7/22, 7/23, 7/24, 7/26, 7/27, 7/28, 7/29, 7/30, and 7/31. ***No Controlled Substance signature forms were presented for 6/16 - 7/21/19. --Wing 200 - lacks nursing signatures on 7/28, 7/29, 7/30, and 7/31. ***No Controlled Substance signature forms were presented for the period of 05/19/19 through 07/27/19. --Wing 300 - No Controlled Substance signature forms were presented after 05/11/19 --Wing 500 - lacks nursing signatures on 6/9, 6/10, 6/11, 6/12, 6/13, 6/14, 7/28, 7/29, 7/30, and 7/31. ***No Controlled Substance signature forms were presented for the period of 06/16/19 through 07/27/19. --Wing 600 - lacks nursing signatures on 6/9, 6/10, 6/11, 6/12, 6/13, 6/14, 6/15, 7/14, 7/15, 7/17, 7/18, 7/19, 7/20, 7/28, and 7/29. ***No Controlled Substance forms were presented for the period of 6/16/19 through 07/13/19. --Wing 700 - lacks nursing signatures on 7/28, and 7/30. ***No Controlled Substance signature forms were presented for the period of 06/01/19 through 07/27/19. --Wing 800 - lacks nursing signatures on 6/4, 6/6, 6/8, 7/28, 7/29, and 7/31. ***No Controlled Substance signature forms were presented for the period of 06/09/19 through 07/27/19. On 08/05/19 at 9:52 AM, a review of the pharmacist's Controlled Substance Audit dated 02/08/19 with the ADON revealed eight (8) missing nursing signatures on the Controlled Substance Forms. The ADON reported staff was educated on this issue. On 08/05/19 at 10:30 AM, the ADON presented a copy of the staff education titled Controlled Substances Accountability. The ADON confirmed the education was completed on 08/01/19, after the survey team identified the incomplete controlled substance forms. | 2020-09-01 |
| 76 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 756 | F | 0 | 1 | WJ7O11 | Based on policy review and staff interview, the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the monthly medication regimen review (MRR) process. This practice has the potential to affect all residents. Facility census: 140. Findings included: a) The facility policy titled Consultant Pharmacist Reports with an effective date of (MONTH) 23, 2019, states the Consultant Pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. --Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next medication review. In the event of a problem requiring the immediate attention of the prescriber, the responsible prescriber or physician's designee is contacted by the consultant pharmacist or the facility, and the prescriber response is documented on the consultant pharmacist review record or elsewhere in the resident's medical record. --Recommendations are acted upon and documented by the facility staff and/or the prescriber in non-urgent cases within 30 days. If the prescriber does not respond to the recommendations directed to him/her, the Director of Nursing (DON) and/or the consultant pharmacist, may contact the Medical Director. The policy lacked specific time frames for facility notification including Physician notification and response time for urgent and non-urgent recommendations. After review of the facility MRR policy on 07/31/19 at 3:25 PM, the Director of Nursing (DON) verified the policy did not contain detailed specific time frames for facility notification including Physician notification and response time for urgent and non-urgent recommendations. She stated, the pharmacist is here monthly, does notify us in writing and there has not been a problem. | 2020-09-01 |
| 77 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 761 | E | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure drugs and biological's used in the facility were stored and labeled in accordance with currently accepted professional principles. Multiple opened medications stored in the 100, 200, and 300 Hall Medication Carts were unlabeled and undated. This practice had the potential to affect more than a limited number of residents. Facility census: 140. Findings include: a) 100 Hall Medication Cart An observation of the 100 Hall Medication Cart, on 08/05/19 at 8:26 AM, revealed the following items: --One (1) bottle of opened and undated Fiber Caps. --Two (2) bottles of opened and undated Senna tablets. --One (1) bottle of opened and undated [MEDICATION NAME] tablets. --One (1) unidentified white pill was at the bottom of the medication cart. --One (1) package of opened and undated [MEDICATION NAME] Sodium tablet. An interview with Registered Nurse (RN) #5, on 08/05/19 at 8:30 AM, revealed all medications should be dated when opened. b) 200 Hall Medication Cart An observation of the 200 Hall Medication Cart, on 08/05/19 at 8:38 AM, revealed the following items: --One (1) package of Gas-X with an expiration of 03/2014. --One (1) package of [MEDICATION NAME] with an expiration of (YEAR). --One (1) opened package of [MEDICATION NAME] Suppositories with no open date. An interview with Licensed Practical Nurse (LPN) #113, on 08/05/19 at 8:40 AM, revealed she was not sure why the medications had not been dated or thrown away. c) 300 Hall Medication Cart An observation of the 300 Hall Medication Cart, on 08/05/19 at 8:52 AM, revealed the following items: --One (1) weekly pill [MEDICATION NAME] with three unidentified (3) pills in each of the seven (7) daily spots. There was no name on the [MEDICATION NAME]. --One (1) bottle of opened and undated Sodium [MEDICATION NAME]. --One (1) pack of opened and undated Sore Throat [MEDICATION NAME]. --Two (2) bottles of opened and undated Cough Suppressant. An interview with LPN #7, on 08/05/19 at 8:53 AM, revealed she did not know who the pill [MEDICATION NAME] belonged to. She also did not know what pills were inside the [MEDICATION NAME]. The LPN stated when medication is opened then the package or bottle should be dated as to when it was opened. | 2020-09-01 |
| 78 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 802 | E | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review and temperature logs review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of nutritional services. The facility failed to provide staff that exhibited competent skills sets in hygiene and food preparation. The failed practice had the potential to affected more than an unlimited number of residents. Facility census: 140. Findings included: a) Kitchen An observation, on 07/30/19 at 11:13 AM, revealed Dietary Cook (DC) #93 washed and dried hands with a paper towel. DC #93 preceded to a trash can and used hand to lift the lid and throw away the paper towel. An immediate interview with Dietary Supervisor (DS) #142 revealed no concern with hand washing practice. DS #142 stated DC was supposed to use the trash can around the corner with the foot pedal. DS #142 immediately took the trash can with manual lid out of the kitchen area. An observation, on 07/30/19 at 11:40 AM, revealed DS #142's hand washing practice. DS #142 washed hands, turned the water facet off with her washed hands and then manually used the lever on the paper towel dispenser with washed hands. DC #93 was observed next and also washed hands, turned the water facet off with her washed hands and then manually used the lever on the paper towel dispenser with washed hands. An immediate interview with DS #142, stated, I have always done it this way. DS #142 stated, If I wash my hands and am not allowed to touch the handles of the sink how am I supposed to turn the sink off? An observation, on 07/30/19 at 11:41 AM, revealed DC #53 transferring hot metal containers with a dirty towel. DC #53 placed towels on a soiled countertop and used towels to transfer metal containers of food from the oven to countertop. DC #53 was observed holding the metal containers by the top inside of the metal container with the dirty towels. An immediate interview with DS #142 confirmed the use of a dirty towel to transfer hot metal containers was not a sanitary practice. An observation, on 07/30/19 at 11:55 AM, revealed the mechanical meat was taken out of the oven and placed on the counter to be temped. The mechanical meat was temped and ready to be served. The mechanical meat was visibly burned. Without surveyor intervention, the burned meat would have been served to residents. An immediate interview with DS #142 confirmed the mechanical meat was burned and directed the dietary staff to discard. An observation, on 07/30/19 at 12:05 PM, revealed DC #14, touched nonfood items cross contaminating hands and food. DC #14 was observed touching table top and bread bag while prepared sandwiches for residents. An immediate interview with DC #14 revealed lack of knowledge of cross contamination. DC #14 stated, I am new I did not know that was considered cross contamination and wrong. An observation, on 07/30/19 at 12:14 PM, revealed DC #53 prepared the mechanically altered and pureed meat. DC #53 was observed placing the plastic top if the puree machine on the dirty table and back on the machine. An immediate interview with DC #53 revealed, I knew I cross contaminated just as soon as I put that piece back on there. An observation, on 07/30/19 at 12:18 PM, revealed DC #53 temping food. DC # 53 stated that meats should be cooked at a temp of 140 degrees Fahrenheit (F). DS # 142 stated meat should be cooked to 150 degrees F. An interview with Dietitian, on 07/30/19 at 2:00 PM, confirmed meat should be cooked to a temperature of 165-degree F. An observation, on 07/30/19 at 12:35 PM, revealed DC #14 cross contaminating the residents' plates. DC #14 placed the red suction used to obtain resident plates on dirty table and continued to use dirty suction on plates. This affected 10 plates before observed. An immediate interview with DS #142 confirmed cross contamination and directed DC #14 to place suction a clean towel and not directly on dirty table. An observation, on 07/30/19 at 12:40 PM, revealed DC #53 cross contaminating. DC #53 was observed touching nonfood items with clean gloves that was used for serving the food. An immediate interview with DC #53 and DS #142 confirmed cross contamination. DS #142 directed DC #53 to wash hands and put new pair of clean gloves on prior to serving any more food. An observation, on 07/30/19 at 12:50 PM revealed DC #35 caught second mistake on a tray. DC #35 caught to regular trays prepared when tray should have been both mechanically altered trays. An observation, on 07/30/19 at 1:00 PM, revealed DC #93 touch tops of counters and served food with the same gloved hands. An immediate interview with DC #93 stated, I didn't even realize I was doing that. An observation, on 07/30/19 at 1:13 PM, revealed DC #35 caught the fifth wrong tray made as a regular diet tray when tray should have been mechanically altered or pureed. An immediate interview with DS #142 revealed DC #35 is in that serving position because mistakes are made regularly and DC #35 has a history to find the mistakes before they go out of the kitchen area. An interview with DC #35, on 07/30/19 at 1:14 PM, stated, I am off on Thursdays, I hope there are no mistakes when I am off. An observation, on 07/30/19 at 1:20 PM, revealed DC # 85 wore hairnet in an inappropriate way. DC # 85 had hairnet that covered half of head with bangs in front of head not covered. An immediate interview with DS #142 confirmed hairnet did not cover DC # 85 hair entirely. DS #142 directed DC #85 to cover entire hair with hairnet. An observation on 07/30/19 at 1:25 PM revealed DC #35 caught sixth tray with the wrong dietary needs for resident. Tray was made as a regular diet tray but should have been made as a mechanically altered tray. An interview with DS #142 stated, that is his job to ensure the residents get the correct diet as he is the best at catching all the mistakes. An observation, on 07/30/19 at 1:28 PM, revealed DC # 93 cutting meat on a visibly soiled counter. DC # 93 was observed cutting meat on a visibly soiled countertop and then placed cut meat on a resident's tray. An immediate Interview with DS #142 and DC #93 confirmed preparing food in an unsanitary manner. DC #93 stated, where do you want me to cut the meat for the plate then? DS #142 immediately directed DC #93 why cutting the meat on the table was unsanitary. A staff interview with DS #142, on 07/30/19 at 1:30 PM, revealed DS #142 displeasure with kitchen staff and future training. DS #142 stated, They are a lost cause. DS #142 stated had [AGE] years of experience worked in the facility kitchen. DS # 142 stated, I have only been DS since Oct (YEAR) and have not been able to take the Safe Serve certification yet. An observation, on 07/30/19 at 1:48 PM, revealed a brown shelled bug with antennas crawling on the kitchen wall above the steam tables. An immediate interview with Dietitian occurred and bug was pointed out to Dietitian. The Dietitian stated, Oh that stinks. The bug was not obtained off the wall and then disappeared to wander the kitchen. A review of temperature logs, on 08/05/19 at 8:00 AM, revealed multiple incomplete temperature log forms for breakfast, lunch and dinner between the dates of 06/01/19 and 07/30/19. An interview with Dietitian, on 08/05/19 at 8:55 AM, confirmed, the policy is to take temps on foods to ensure food is served at the right temperature. A policy review of Handwashing/Hand Hygiene Policy with Revised date of (MONTH) (YEAR), on 08/05/19 at 9:15 AM, stated, Washing Hands Step three (3) Dry hands thoroughly with paper towel and then turn off faucets with a clean, dry paper towel. | 2020-09-01 |
| 79 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 804 | E | 0 | 1 | WJ7O11 | Based on observation, resident interview, test tray results and staff interview, the facility failed to serve food that is palpable, attractive, at safe temperatures, and with accuracy related to each residents tray card. This is true for 13 tray cards reviewed for the long term care survey process. This practice has the potential to effect more than a limited number. Resident identifiers: #181, #27, #94, #126, #49, #36, #238, #108, #231, #102, #119, #21, and #383. Facility census: 140. Findings included: a) The following tray cards with issues of accuracy include: 1. Resident #181 Resident: #181's noon meal on 07/30/19 had two (2) percent(%) milk. The tray card called for whole milk. 2. Resident #27 Resident #27's breakfast meal on 07/30/19 had french toast, dipped in eggs. The tray card reveals NO EGGS. 3. Resident #94 Resident #94's noon meal, on 07/30/19 did not include, a roll, and whole milk as listed on tray card. During interview at 1:45 PM, licensed nurse (LPN) #19, explained she did not think the resident would drink whole milk. 4. Resident #126 Resident #126's breakfast meal on 07/30/19 had 2% milk did not have syrup. The tray card reveals whole milk and syrup. 5. Resident #49 Resident #49's breakfast meal on 07/30/19; the tray card reveals resident to receive a renal diet. The resident did not receive juice as listed on the tray card. The resident prefers some kind of juice. She explained she could not receive orange juice because of being on a renal diet but was not offered an alternative juice. 6. Resident #36 The tray also included a banana which is high in potassium. Resident #36 explained her breakfast tray usually has a banana which is high in potassium. Potassium should be limited on a renal diet Resident #36's breakfast meal on 07/30/19, included french toast which appeared soggy. The resident did not eat and explained the french toast was soggy. 7. Resident #238 Resident #238's breakfast tray on 07/30/19 had 2% milk. The tray card lists whole milk. Resident #238 explained she request coffee but got hot water. The resident had put cream in hot water but could not drink. 8. Resident #108 Resident #108's breakfast tray on 07/30/19 did not include juice or syrup, both listed on the tray card. Also, received 2% milk with tray card listing whole milk. After surveyor request, the staff offered juice and called the kitchen for syrup. 9. Resident Council Meeting On 07/29/19 at 3:00 PM ten (10) of sixteen (16) residents attending Resident Council meeting agreed food served from the kitchen is often not palpable, and different from the tray card. 10. Interviews On 08/06/19 at 7:30 AM the dietary manager explained meals are dipped to the tray and then checked for accuracy before sending the tray to the floor. Also, that juice is passed out by staff on the floor. She also explained that the common fresh fruit sent to the residents, is bananas, apples and oranges. According to the dietary manager 2% milk has always been placed on trays but whole milk has been ordered. b) Dissatisfaction with food served 1. Resident # 36 An interview with Resident #36, on 07/29/19 at 12:03 PM, revealed a dislike to the food served. 2. Resident # 231 An interview with Resident #231, on 07/29/19 at 12:09 PM, revealed the food is poor. 3. Resident # 102 An interview with resident #102, on 07/29/19 at 12:09 PM, revealed the food is not good. 4. Resident # 119 An interview, on 07/29/19 at 04:01 PM, noted Resident #119 complained of receiving cold food and when soups are served, soups almost always required reheating because of cold temperatures. 5. Resident # 21 An interview with Resident # 21, on 07/29/19 at 12:12 PM, revealed the food is not the best. Resident #21 stated, they served my sandwich with the bread on top of the beets making it soggy. This has happened on many occasions. An additional interview with Resident # 21, on 07/31/19 at 9:00 AM, revealed, breakfast was served at a decent time however the minors scramble was not eaten due to the appearance of the food. Resident # 21 stated, the breakfast came at a decent time this morning but yesterday the food was late all day. 6) Resident # 383 and Test Tray An observation of food tray cart delivery on 07/31/19 at 1:10 PM to Wing five (5). The first tray was passed at 1:15 PM. A test tray of Resident # 383's tray was conducted at 1:26 PM. Resident # 383's tray was the last tray to be served in the cart. The tray was placed on the nurse's desk and both the surveyor and kitchen thermometers were used. The Dietitian thermometer and surveyor thermometer both revealed the same temperature for the coleslaw. The thermometers revealed the same reading and calibration. The results of the test tray were: --[NAME]slaw = 71 degrees Fahrenheit (F) --Baked Beans = 100 degrees F --Pulled Pork Sandwich = 118 degrees F --Milk-= 50 degrees F A taste test was conducted, on 07/31/19 at 1:28 PM, after the temping of the food items. The baked beans tasted good. The pulled pork had spice and tasted good. The coleslaw was warm and very bland. The milk was not tasted. An immediate interview with the Dietitian, on 07/31/19 at 1:28 PM, during the taste test revealed knowledge of the coleslaw being bland. The Dietitian stated, Oh you have to have some salt and pepper when eating coleslaw. Dietitian did not remark on the temperature of the food. A review of temperature logs, on 08/05/19 at 8:00 AM, revealed multiple incomplete temperature log forms for breakfast, lunch and dinner between the dates of 06/01/19 and 07/30/19. An interview with Dietitian, on 08/05/19 at 8:55 AM, confirmed, the policy is to take temps on foods to ensure food is served at the right temperature. | 2020-09-01 |
| 80 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 809 | E | 0 | 1 | WJ7O11 | Based on observation, resident interview, staff interview, record review and policy review, the facility failed to ensure no more than 14 hours elapsed between evening meals and breakfast. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #90 and #111. Hall identifier: 500 Hall. Facility census: 140. Findings included: a) Observations An observation of the 500 Hall, on 07/30/19 at 8:00 AM, revealed that breakfast trays had not been delivered to the floor or served yet. Further observation of the 500 Hall, on 07/30/19 at 8:30 AM, revealed that breakfast trays had not been brought to the floor or served yet. An observation of the 500 Hall, on 07/30/19 at 8:50 AM, revealed the trays were brought to the floor and the staff began to distribute them. b) Interviews An interview with Resident #90, on 07/30/19 at 7:30 AM, revealed she was hungry and sick of always waiting on breakfast. The Resident stated breakfast is not usually served on the 500 Hall until around 9:00 AM. The Resident stated her evening meal the day before was delivered at 5:45 PM. An interview with Resident #111, on 07/30/19 at 8:00 AM, revealed the meals are always late on the 500 Hall. An interview with Nurse Aide (NA) #104, on 07/30/19 at 8:40 AM, revealed the breakfast trays had not yet arrived. The NA stated they are always late on this hall. The NA stated this is the last hall to get trays in the whole building. The NA stated the trays usually come between 8:30 AM and 9:00 AM. The NA stated this is a daily thing. An interview with the Dietary Supervisor (DS), on 07/30/19 at 12:45 PM, revealed the 500 Hall is the last hall to receive trays. The DS stated breakfast should be served by 8:00 AM to all floors but that is only on a perfect day. c) Policy Review A review of the facility policy titled Meal Service with an effective date of 05-16-16. was conducted on 07/31/19. The policy stated Not more than 14 hours will elapse between the serving of the evening meal and the breakfast meal. The policy listed the evening meal time as 5:30 PM to 6:00 PM and the breakfast meal time as 7:30 AM to 8:00 AM. | 2020-09-01 |
| 81 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 812 | E | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, test tray and review of temperature logs, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility failed to label and date food items in the walk-in refrigerator, freezer and dry storage area. The facility failed to prepare food in a safe and sanitary manner. The failed practice had the potential to affect more than unlimited number of residents. Facility census: 140. Findings included: a) Kitchen initial tour During the initial tour of the kitchen accompanied by the Dietary Supervisor (DS) #142, on 07/29/19 at 11:00 AM, revealed several food items not labeled or dated. The list of food items found were: --A metal container full of individual packets for salad dressing were found in the walk-in refrigerator dated 04/08/19. --Two (2) medium sized frozen cheese pizzas were found in the refrigerator with no date. --One (1) Full box of Baker Source garlic bread found in the freezer with box lid open and ice on garlic bread. Garlic bread appeared to be freezer burnt. --Two (2) brown bags of tri patties hash browns found in the freezer unlabeled and not dated. --Four (4) bags of Rice Crispies, two (2) pound bags, found in dry storage area not dated. --Five (5) bags of Corn Flakes, two (2) pound bags, found in dry storage area not dated. --Two (2) Pork Roast Gravy Mix, 11.3 ounces' packets, found in dry storage area not dated. An immediate interview with DS #142, on 07/29/19, acknowledged all items were not dated or labeled. DS #142 had dietary staff date and label items as items were found. b) Kitchen follow-up visit During the follow up visit in the kitchen, on 07/30/19, revealed several observations and interviews. The findings included multiple issues related to preparation of food in a safe and sanitary manner. An observation, on 07/30/19 at 11:13 AM, revealed Dietary Cook (DC) #93 washed and dried hands with a paper towel. DC #93 preceded to a trash can and used hand to lift the lid and throw away the paper towel. An immediate interview with Dietary Supervisor (DS) #142 revealed no concern with hand washing practice. DS #142 stated DC was supposed to use the trash can around the corner with the foot pedal. DS #142 immediately took the trash can with manual lid out of the kitchen area. An observation, on 07/30/19 at 11:40 AM, revealed DS #142's hand washing practice. DS #142 washed hands, turned the water facet off with her washed hands and then manually used the lever on the paper towel dispenser with washed hands. DC #93 was observed next and also washed hands, turned the water facet off with her washed hands and then manually used the lever on the paper towel dispenser with washed hands. An immediate interview with DS #142, stated, I have always done it this way. DS #142 stated, If I wash my hands and am not allowed to touch the handles of the sink how am I supposed to turn the sink off? An observation, on 07/30/19 at 11:41 AM, revealed DC #53 transferring hot metal containers with a dirty towel. DC #53 placed towels on a soiled countertop and used towels to transfer metal containers of food from the oven to countertop. DC #53 was observed holding the metal containers by the top inside of the metal container with the dirty towels. An immediate interview with DS #142 confirmed the use of a dirty towel to transfer hot metal containers was not a sanitary practice. An observation, on 07/30/19 at 11:55 AM, revealed the mechanical meat was taken out of the oven and placed on the counter to be temped. The mechanical meat was temped and ready to be served. The mechanical meat was visibly burned. Without surveyor intervention, the burned meat would have been served to residents. An immediate interview with DS #142 confirmed the mechanical meat was burned and directed the dietary staff to discard. An observation, on 07/30/19 at 12:05 PM, revealed DC #14, touched nonfood items cross contaminating hands and food. DC #14 was observed touching table top and bread bag while prepared sandwiches for residents. An immediate interview with DC #14 revealed lack of knowledge of cross contamination. DC #14 stated, I am new I did not know that was considered cross contamination and wrong. An observation, on 07/30/19 at 12:14 PM, revealed DC #53 prepared the mechanically altered and pureed meat. DC #53 was observed placing the plastic top if the puree machine on the dirty table and back on the machine. An immediate interview with DC #53 revealed, I knew I cross contaminated just as soon as I put that piece back on there. An observation, on 07/30/19 at 12:18 PM, revealed DC #53 temping food. DC # 53 stated that meats should be cooked at a temp of 140 degrees Fahrenheit (F). DS # 142 stated meat should be cooked to 150 degrees F. An interview with Dietitian, on 07/30/19 at 2:00 PM, confirmed meat should be cooked to a temperature of 165-degree F. An observation, on 07/30/19 at 12:35 PM, revealed DC #14 cross contaminating the residents' plates. DC #14 placed the red suction used to obtain resident plates on dirty table and continued to use dirty suction on plates. This affected 10 plates before observed. An immediate interview with DS #142 confirmed cross contamination and directed DC #14 to place suction a clean towel and not directly on dirty table. An observation, on 07/30/19 at 12:40 PM, revealed DC #53 cross contaminating. DC #53 was observed touching nonfood items with clean gloves that was used for serving the food. An immediate interview with DC #53 and DS #142 confirmed cross contamination. DS #142 directed DC #53 to wash hands and put new pair of clean gloves on prior to serving any more food. An observation, on 07/30/19 at 12:50 PM revealed DC #35 caught second mistake on a tray. DC #35 caught to regular trays prepared when tray should have been both mechanically altered trays. An observation, on 07/30/19 at 1:00 PM, revealed DC #93 touch tops of counters and served food with the same gloved hands. An immediate interview with DC #93 stated, I didn't even realize I was doing that. An observation, on 07/30/19 at 1:13 PM, revealed DC #35 caught the fifth wrong tray made as a regular diet tray when tray should have been mechanically altered or pureed. An immediate interview with DS #142 revealed DC #35 is in that serving position because mistakes are made regularly and DC #35 has a history to find the mistakes before they go out of the kitchen area. An interview with DC #35, on 07/30/19 at 1:14 PM, stated, I am off on Thursdays, I hope there are no mistakes when I am off. An observation, on 07/30/19 at 1:20 PM, revealed DC # 85 wore hairnet in an inappropriate way. DC # 85 had hairnet that covered half of head with bangs in front of head not covered. An immediate interview with DS #142 confirmed hairnet was not covering DC # 85 hair entirely. DS #142 directed DC #85 to cover entire hair with hairnet. An observation on 07/30/19 at 1:25 PM revealed DC #35 caught sixth tray with the wrong dietary needs for resident. Tray was made as a regular diet tray but should have been made as a mechanically altered tray. An interview with DS #142 stated, that is his job to ensure the residents get the correct diet as he is the best at catching all the mistakes. An observation, on 07/30/19 at 1:28 PM, revealed DC # 93 cutting meat on a visibly soiled counter. DC # 93 was observed cutting meat on a visibly soiled countertop and then placed cut meat on a resident's tray. An immediate Interview with DS #142 and DC #93 confirmed preparing food in an unsanitary manner. DC #93 stated, where do you want me to cut the meat for the plate then? DS #142 immediately directed DC #93 why cutting the meat on the table was unsanitary. A staff interview with DS #142, on 07/30/19 at 1:30 PM, revealed DS #142 displeasure with kitchen staff and future training. DS #142 stated, They are a lost cause. DS #142 stated had [AGE] years of experience worked in the facility kitchen. DS # 142 stated, I have only been DS since Oct (YEAR) and have not been able to take the Safe Serve certification yet. An observation, on 07/30/19 at 1:48 PM, revealed a brown shelled bug with antennas crawling on the kitchen wall above the steam tables. An immediate interview with Dietitian occurred and bug was pointed out to Dietitian. The Dietitian stated, Oh that stinks. The bug was not obtained off the wall and then disappeared to wander the kitchen. An observation on 07/30/19 at 4:11 PM, revealed approximately 12 gnats flying in the kitchen area. An interview with DC #126, on 07/30/19 at 4:13 PM, revealed the facility had a history of [REDACTED].#126 stated the bugs had been coming in through the floor drain. DC #126 stated the Dietitian placed green foam bug deterrents on the floor at night time but they are taken and put away during the daytime in the Dietitian office. A policy review of Handwashing/Hand Hygiene Policy with Revised date of (MONTH) (YEAR), on 08/05/19 at 9:15 AM, stated, Washing Hands Step three (3) Dry hands thoroughly with paper towel and then turn off faucets with a clean, dry paper towel. c) Food distribution wing five (5) An observation of food tray cart delivery to Wing five (5) on 07/31/19 at 1:10 PM. The first tray was passed at 1:15 PM. A test tray was conducted at 1:26 PM. The test tray was the last tray to be served in the cart. The tray was placed on the nurse's desk and both the surveyor and kitchen thermometers were used. The Dietitian thermometer and surveyor thermometer both revealed the same temperature for the coleslaw. The thermometers revealed the same reading and calibration. The results of the test tray were: --[NAME]slaw = 71 degrees Fahrenheit (F) --Baked Beans = 100 degrees F --Pulled Pork Sandwich = 118 degrees F --Milk-= 50 degrees F A taste test was conducted, on 07/31/19 at 1:28 PM, after the temping of the food items. The baked beans tasted good. The pulled pork had spice and tasted good. The coleslaw was warm and very bland. The milk was not tasted. An immediate interview with the Dietitian, on 07/31/19 at 1:28 PM, during the taste test revealed knowledge of the coleslaw being bland. The Dietitian stated, Oh you have to have some salt and pepper when eating coleslaw. Dietitian did not comment on the temperature of the food. A review of temperature logs, on 08/05/19 at 8:00 AM, revealed multiple incomplete temperature log forms for breakfast, lunch and dinner between the dates of 06/01/19 and 07/30/19. An interview with Dietitian, on 08/05/19 at 8:55 AM, confirmed, the policy is to take temps on foods to ensure food is served at the right temperature. d) Food distribution wing eight (8) An observation on 07/30/19 at 01:30 PM, revealed a partially eaten tray sitting on the counter in the nourishment area on Wing 8. The tray had been served and some food eaten by R#41. The tray lid was off and food exposed with a gnat flying around the food. The tray had Mashed potatoes, opened ice cream, ground red meat with 1/2 meat eaten, ground beige items and milk. An interview with CNA#43, on 07/30/19 at 01:30 PM, verified the partially eaten tray for Resident #41 was placed on the counter in the nourishment room with the lid off the food items. CNA #43 further stated I stuck that tray in here because I did not know where to put it. d) 500 Hall Nourishment Room An observation of the Nourishment Room, on 07/29/19 at 11:00 AM, revealed the room had no door and was readily accessible to any resident. The room contained the following items in unlocked cabinets: --Twenty-Five (25) packets of Smart Balance Buttery Spread with the label Keep Refrigerated. --Twenty (20) packets of undated McDonalds Ketchup. --Three (3) packets of undated grape jelly. One (1) packet was open. --Fifteen (15) packets of undated saltine crackers. Three (3) packets were open. --Eight (8) packets of undated peanut butter. --One (1) container of undated and opened[NAME]House Coffee. --Fifteen (15) packs of undated honey mustard dressing. --Twenty (20) packs of undated hot chocolate --Twenty (22) packs of undated mustard --Five (5) packs of undated mayonnaise. --Eight (8) containers of undated coffee creamers. An interview with Nurse Aide (NA) #104, on 07/29/19 at 11:05 AM, revealed she had no idea what the dates were for the food items. The NA stated she would discard the undated and opened food items. | 2020-09-01 |
| 82 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 849 | D | 0 | 1 | WJ7O11 | Based on medical record review, Hospice service contract and staff interview, the facility failed to ensure in accordance with the agreement/contract prescribed Hospice services were provided to a resident. This practice was found for one (1) of one (1) Hospice resident reviewed during the survey. Resident identifier: #130. Facility census: 140. Findings included: a) Resident #130 On 07/31/19 at 11:45 AM, review of the medical record revealed Resident #130 was admitted to Hospice services on 07/19/19 for a terminal health condition. Continued review of the medical record found no evidence of documentation of further Hospice care visits following her admission to Hospice services. Review of the Hospice care plan created on admission was silent for the identification of services to be provided. Review of the facility agreement/contract with the contracted Hospice services provided by the Director of Nursing (DON) revealed the following (typed as written): --Hospice shall develop the Plan of care to be provided to the Home specifying information pertinent to the resident's treatment. The Plan will be updated bi-weekly by the hospice team . --Documentation of all visits by Hospice staff shall be placed on the Home chart at the time of the visit . After reviewing the medical record on 07/31/19 at 12:35 PM, the DON was unable to locate documentation of Hospice visits following Resident #130's initial admission to Hospice services. The DON stated, I am sure that they have been here to visit, but there is nothing to prove it. I agree their care plan does not even tell who is going to visit and when. In addition the DON agreed the Hospice services company did not adhere to their contract regarding the care plan and documentation. | 2020-09-01 |
| 83 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 867 | E | 0 | 1 | WJ7O11 | Based on facility record review, staff interview, and review of deficient practices identified during the survey, the facility failed to maintain an effective Quality Assurance Committee to develop and implement appropriate plans to correct identified quality deficiencies and coordinate the facility's required implementation of all regulatory changes. No attempts were made to correct nurses' failure to sign off narcotic counts at shift change after the pharmacist identified the concern. This has the potential to affect all residents residing in the facility. Facility census: 140. Findings include: a) On 07/31/19 at 4:31 PM, a review of the Controlled Substance Forms on the 200 hall with Licensed Practical Nurse (LPN) #143 revealed nurses failed to initial the sheets at the change of shift after controlled medications were counted. LPN #143, confirmed medication counts are to be completed between two (2) nurses at the change of shift and both nurses are to initial the forms. Further review at this time found incomplete Controlled Substance Forms on both medication carts on the 200 and 300 hall and the single cart located on the 100 hall. The Assistant Director of Nursing (ADON) acknowledged the Controlled Substance Forms were incomplete during an interview on 07/31/19 at 4:32 PM. On 08/05/19 at 9:52 AM, a review of the pharmacist's Controlled Substance Audit dated 02/08/19 with the ADON revealed the pharmacist identified missing signatures during a random audit of the change of shift count forms. On 08/05/19 at 3:17 PM, a review of the Quality Assurance & Performance Improvement Plan 2019 presented with the Quality Assurance & Performance Improvement (QAPI) policy revealed the facility did not address the incomplete controlled substance forms. An interview was conducted with the Administrator, the person in charge of Quality Assurance #136 and Corporate Consultant (CC) #154 on 08/05/19 at 3:30 PM. The Administrator and CC #154 confirmed they were unaware of results of the pharmacist's 02/08/19 findings of missing signatures during a random audit of the change of shift count forms. CC #154, acknowledged a plan was initiated on 08/01/19, after the survey team identified the concern. | 2020-09-01 |
| 84 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 880 | F | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy and procedure review, the facility failed to maintain an effective infection control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. Observation of pressure ulcer dressing changes revealed no use of a barrier, soiled dressing placed on an overbed table next to water pitcher and drinking glasses and failure to change gloves when going from the buttocks area to the residents back. During medication administration, residents medication was placed on the resident's overbed table without any type of barrier. In addition, the laundry room lacked separation between the clean and soiled areas to prevent cross contamination and failed to change contaminated gloves while changing a resident's tube feeding. Three (3) breakfast trays were found in the Nutrition room [ROOM NUMBER] hall after the lunch meal had been returned to the kitchen. One of the breakfast tray was from a resident who was on isolation precautions. This practice has the potential to affect more than a limited number of residents. Resident identifiers: #116, #76, #115, #101, #98. Facility census: 140. Findings included: a) Resident #116 On 07/30/19 at 10:22 AM observation of pressure ulcers dressing change with Licensed Practical Nurse (LPN) #1 revealed clean dressings were placed on the residents bed. b) Resident #76 On 07/31/19 at 10:52 AM observation of pressure ulcer dressing change by LPN #1 revealed there was no barrier placed on the overbed table or was the overbed bed cleaned prior to opening pressure ulcer dressings. The soiled dressing was placed on the overbed table next to the Resident #76 water pitcher and drinking cups. In addition, obtained marking pen from pocket, dated the dressing, and placed the pen back into pocket with contaminated gloves. c) Resident #115 Observation of a pressure ulcer dressing on 07/31/19 at 11:37 AM with LPN #1 revealed the coccyx area was cleaned and then the pressure ulcer on the back was cleaned without changing contaminated gloves. In addition, no barrier was used on the overbed table nor was a trash can and/or plastic bag used to dispose of soiled dressings and/or 4x4 (gauze pad) used to clean the pressure ulcers. On 08/05/19 at 12:45 PM a review of the facility policy titled Dressings, Dry/Clean found the following: 1. Clean bedside stand. Establish a clean field. 2. Place the clean equipment on the clean field. 3. Tape a biohazard or plastic bag on the bedside stand or use a waste basket below clean field. 7. Pull glove over dressing and discard into plastic or biohazard bag. 15. Cleanse the . Clean from the least contaminated area to the most contaminated area. 18. Discard disposable items into the designated container. The Director of Nursing (DON) and the Assistant DON - Infection Control Nurse (ICN) agreed the policy and procedure were not followed during the Pressure Ulcer dressing changes on the 08/05/19 at 12:45 PM. d) 300 Hall On 07/29/19 at 12:33 PM the three-hundred (300) hall observation of the three-hundred (300) with one breakfast tray (already used by resident), placed on the counter top. Licensed nurse (LPN) #143 explained the resident takes longer to eat and the tray would be sent to the kitchen with lunch trays, and agreed the tray should have been sent to the kitchen upon the resident completing the breakfast meal. Again on 07/30/19 at 12:45 PM the (300) hall nutrition room had three (3) breakfast trays (already used by resident), placed on the counter top with one of these trays belonging to a resident in isolation for, extended spectrum beta-lactamases (ESBL) infection in the urine. Licensed nurse #8 explained the kitchen should have been called to pick up the trays. e) Laundry room On 07/30/19 at 10:20 AM, an observation of the laundry area with Housekeeper #123 revealed one room with washing machines on one wall, dryers along the opposite wall and a large cart of bagged soiled linen sitting between the rows of machines. During this observation, Housekeeper #123 confirmed there was no separation between the clean and soiled laundry. The Infection Control Nurse/Assistant Director of Nursing confirmed the laundry room lacked separation to prevent cross contamination during an interview on 07/30/19 at 11:00 AM. f) Resident #98 - Tube feeding On 07/30/19 at 1:10 PM, Licensed Practical Nurse (LPN) #140, donned clean gloves and began preparing Resident (R) #98's tube feeding. LPN #140, filled two (2) feeding bags, one with tap water and the other with [MEDICATION NAME] 1.5. LPN #140 picked up the trash can with her gloved right hand, placed the can by the bedside, primed the feeding pump and feeding tubing and attached the feeding to R#98's gastric tube without changing her right glove. During an interview immediately following this observation. LPN #140 confirmed she contaminated her glove when she picked up the trash can and should have immediately changed it before proceeding. g) Resident #101 - Medication Administration An observation of medication administration, on 08/05/19 at 8:17 AM, revealed Registered Nurse (RN) #5 took pills from the medication cup and poured them onto Resident #101's bedside table without any kind of barrier or cleansing of the surface first. An interview with RN #5, on 08/05/19 at 8:19 AM revealed she stated I should have put down a barrier on the table. It is the only way he will take his pills. | 2020-09-01 |
| 85 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 925 | E | 0 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain an effective pest control program so that the facility is free of pests. The facility failed to maintain a kitchen area that was free from bugs. The failed practice had the potential to affect an more than a limited number of residents. Facility census: 140. Findings included: a) Kitchen An observation, on 07/30/19 at 1:48 PM, revealed a brown shelled bug with antennas crawling on the kitchen wall above the steam tables. An immediate interview with Dietitian occurred and bug was pointed out to Dietitian. The Dietitian stated, Oh that stinks. The bug was not obtained off the wall and then disappeared to wander the kitchen. An observation on 07/30/19 at 4:11 PM, revealed approximately 12 gnats flying in the kitchen area. An interview with DC #126, on 07/30/19 at 4:13 PM, revealed the facility had a history of [REDACTED].#126 stated the bugs are coming in through the floor drain. | 2020-09-01 |
| 86 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 947 | D | 0 | 1 | WJ7O11 | Based on employee records and staff interview the facility failed to ensure continuing competence of nurse aides (CNA) included dementia management and abuse prevention training. Two (2) CNA's lacked dementia care and one (1) CNA lacked abuse prevention training as required. The failed practice affected two (2) of five (5) CNA's employed by the facility. Employee identifiers: #1 and #4. Facility census: 140. Findings included: a) Employee #1 An employee record review, on 08/06/19 at 8:39 AM, of CNA's in-service trainings was conducted. Employee #1 lacked training in the areas of Dementia Management and Abuse Prevention courses as required. An interview with ADoN, on 08/06/19 at 8:39 AM, revealed no other documentation availability for Employees #1 regarding in-service completion. ADoN stated, that is all the information for training we could find. b) Employee #4 An employee record review, on 08/06/19 at 8:39 AM, of CNA's in-service trainings was conducted. Employee #4 lacked training in the area of Dementia Management as required. An interview with ADoN, on 08/06/19 at 8:39 AM, revealed no other documentation availability for Employees #4 regarding in-service completion. ADoN stated, that is all the information for training we could find. | 2020-09-01 |
| 87 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-12-18 | 583 | E | 1 | 0 | 0M5911 | > Based on observation and staff interview, the facility failed to protect the personal privacy of residents including personal and medical information. Documents containing personal and medical information for multiple residents were left unattended on a medication cart and in a staff bathroom. Personal identifiers including residents' names, date of births, social security numbers, phone numbers, addresses, medications, diagnoses, and other health information were accessible. This was a random observation. This practice affected eight (8) residents. Resident identifiers: #11, #12, #13, #14, #15, #16, #17, and #18. Facility census: 144. Findings include: a) Medication Cart A random observation on 12/18/17 at 9:45 a.m., on the 800 Wing, revealed Resident #11's Pre-Admission Screening form was left on a medication cart uncovered and unattended. The Pre-Admission Screening form contained the following personal information: --Resident's name --Resident's address --Resident's phone number --Resident's Social Security Number --Resident's date of birth --Resident's Medicare Number An interview with Licensed Practical Nurse (LPN) #2, on 12/18/17 at 9:50 a.m., revealed the Pre-Admission Screening form should have never been left on top of the medication cart unattended. b) Staff Bathroom A random observation on 12/18/17 at 10:10 a.m., on the 500 Wing, revealed a bin of folders in the staff bathroom. The bin containing information for Resident #12, #13, #14, #15, #16, #17, and #18 was readily accessible for anyone using the restroom. The folders within the bin contained multiple Minimum Data Set assessments, Care Plan Team Meeting Summaries, and admission records. These documents contained: --Resident's names --Resident's Social Security Numbers --Resident's date of births --Resident's diagnoses --Resident's treatment and medical information An interview with LPN #2, on 12/18/17 at 10:15 a.m., revealed the the bin of folders had been in the bathroom for a while. The LPN stated he was not sure why medical information was being kept in the bathroom. | 2020-09-01 |
| 88 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-12-18 | 689 | E | 1 | 0 | 0M5911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. Chemical substances, shaving razors, skin treatments, needles, and a knife, were unsecured and accessible to residents on the 500, 600, and 800 Wings. This practice had the potential to affect more than a limited number of residents. Facility census: 144. Findings include: a) 500 Wing A tour of the 500 Wing, on 12/18/17 at 9:50 a.m., revealed the Shower Room door was open. The room contained the following items: --Five (5) containers of Medspa Shave Cream with the warning Keep out of reach of children. --One (1) container of Medline Shampoo & Body Wash with the warning Caution-Keep out of reach of children-Avoid contact with eyes. --One (1) container of [MEDICATION NAME] Maltodextrin Powder Dressing. b) 600 Wing A tour of the 600 Wing, on 12/18/17 at 10:15 a.m., revealed the Nutrition Room was open for access by anyone. On the top shelf in the unlocked cabinet was a knife with approximately an 8 inch blade. An interview with Licensed Practical Nurse (LPN) #1, on 12/18/17 at 10:20 a.m., revealed she had no idea why the knife was in the cabinet. The LPN stated she would ensure the knife was taken away immediately. c) 800 Wing A tour of the 800 Wing, on 12/18/17 at 10:25 a.m., revealed one (1) container of [MEDICATION NAME] Solution 4%-Antiseptic/Antimicrobial Skin Cleanser was on the counter of the nurses station unattended. The container had the warning Keep out of reach of children-If swallowed get medical help or contact a Poison Control Center right away. Further touring of the 800 Wing, on 12/18/17 at 10:30 a.m., revealed the Examining Room had a key in the door and was accessible to anyone. The room contained the following items: --Seven (7) containers of Medspa Shave Cream with the warning Keep out of reach of children. --Seven (7) containers of Medline Shampoo & Body Wash with the warning Caution-Keep out of reach of children-Avoid contact with eyes. --Nine (9) containers of Medline Cornstarch Body Powder with the warning Keep out of reach of children-Keep powder away from face to avoid inhalation-Do not use on broken skin. --Ten (10) containers of Medline Mouthwash with the warning Keep out of reach of children-In case of accidental ingestion seek professional assistance or contact a Poison Control Center immediately. --Five (5) boxes of Top Value-Denture Cleanser Tabs with the warning Keep out of reach of children-In case of accidental ingestion seek professional assistance or contact a Poison Control Center immediately. --Two (2) containers of Medline Saline Enema with the warning Keep out of reach of children-If swallowed get medical assistance or contact a Poison Control Center right away. --One (1) container of MicroKill Bleach Germicidal Wipes with the warning Keep out of reach of children-Hazard to humans and animals-Causes moderate eye irritation. --One (1) container of Medline [MEDICATION NAME] Wound Cleanser. --Six (6) Blood sugar testing lancets. --Twenty-five (25) Insulin syringes --One Hundred (100) capped razors --Five (5) BD Insyte Autoguard 24 Gauge IV Needles. --Three (3) BD Insyte Autoguard 22 Gauge IV Needles. --Three (3) BD Insyte Autoguard 20 Gauge IV Needles. An interview with LPN #2, on 12/18/17 at 10:40 a.m., revealed the Shower Room on the 500 Wing is always open and should not have the products in it. The LPN stated the Examining Room on the 800 Wing should not have had a key in it and should never be accessible to the residents. The LPN stated he forgot to put away the [MEDICATION NAME] skin cleanser off the nurses station. | 2020-09-01 |
| 89 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-03-13 | 580 | D | 1 | 0 | 6GC411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, and policy and procedure review, the facility failed to promptly notify a resident's physician and responsible party when there was an accident involving injury, a significant change in the resident's condition including a need to alter treatment significantly for one (1) of five (5) residents reviewed. The facility failed to immediately notify a resident's representative when there were new orders involving care and treatment upon return from the hospital. Resident identifier:: R1 The findings included: a) Resident #1 (R1) Record review on 3/11/19, noted R1 had sustained a fall on 01/26/19, at 12:10, resulting in a laceration to the face. R1 was taken to the hospital for care and further treatment. R1 was released back to the nursing facility on 01/26/19, with the following change in orders: --[MEDICATION NAME] Suspension Reconstituted 250 milligrams {mg} / 5 milliliters {ml}. Give 10 ml by mouth four times a day for periorbital laceration status [REDACTED]. --Neuro checks per facility policy times 72 hours --Therapy to evaluate wheelchair status [REDACTED].>Further review of the medical record on 3/12/19, revealed no evidence the resident's responsible party had been notified of the orders upon return from the hospital. A review of the policy and procedure, Changes in Resident Condition, revision date, (MONTH) (YEAR), noted under Guideline 2. prompt notification is required when there is a need to alter treatment significantly. An interview with the Director of Nursing (DON), on 03/12/19, at 01:26 PM, revealed there was no documentation of the medical power of attorney (MPOA) for R1 being notified of the new orders for Cepahalexin suspension , the neuro checks or therapy evaluation when R1 had returned from the hospital. The DON further stated I did not see where the MPOA was notified and agreed notification was not done in accordance with facility policy. | 2020-09-01 |
| 90 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-03-13 | 656 | D | 1 | 0 | 6GC411 | > Based on observation, record review, resident interview, and staff interview, the facility failed to ensure the implementation of individualized care plan interventions related to high fall risks. Call lights were not within reach for residents as directed by their care plans. This practice affected two (2) of five (5) residents reviewed for high fall risks. Resident identifiers: #3 and #4. Facility census. 182. Findings include: a) Resident #3 An observation of the Resident, on 03/12/19 at 10:05 AM, revealed the Resident was in bed. The Resident's call light was under the bed and out of reach of the resident. An interview with Licensed Practical Nurse (LPN) #100, on 03/12/19 at 10:10 AM, revealed the Resident's call light should be within reach at all times. The LPN placed the Resident's call light on the bed within reach of the Resident. A review of the Care Plan was conducted on 03/12/19 at 11:15 AM. The Care Plan dated 01/21/19 with a focus of Actual fall and continues to be at risk for falls with the intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. b) Resident #4 An observation of the Resident, on 03/12/19 at 10:30 AM, revealed the Resident was up in his wheelchair in his room watching television. The Resident's call light was under the opposite side of the bed where he was sitting and out of reach of the resident. An interview with the Resident, on 03/12/19 at 10:32 AM, revealed the Resident did not know where his call light was. The Resident stated I do not see it anywhere. An interview with Nurse Aide (NA) #101, on 03/12/19 at 10:35 AM, revealed the Resident does not need his call light near him because he is more mobile than most other residents. A review of the Care Plan was conducted on 03/12/19 at 11:30 AM. The Care Plan dated 02/25/19 with a focus of Actual fall and continues to be at risk for falls with the intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. | 2020-09-01 |
| 91 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-03-13 | 689 | D | 1 | 0 | 6GC411 | > Based on observation, record review, resident interview, and staff interview, the facility failed to provide an environment free from accident hazards over which it had control. Call lights were not within reach for high fall risk residents as directed by their care plans. This practice affected two (2) of five (5) residents reviewed for high fall risks. Resident identifiers: #3 and #4. Facility census. 182. Findings included: a) Resident #3 An observation of the Resident, on 03/12/19 at 10:05 AM, revealed the Resident was in bed. The Resident's call light was under the bed and out of reach of the resident. An interview with Licensed Practical Nurse (LPN) #100, on 03/12/19 at 10:10 AM, revealed the Resident's call light should be within reach at all times. The LPN placed the Resident's call light on the bed within reach of the Resident. A review of the Care Plan was conducted on 03/12/19 at 11:15 AM. The Care Plan dated 01/21/19 with a focus of Actual fall and continues to be at risk for falls with the intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. b) Resident #4 An observation of the Resident, on 03/12/19 at 10:30 AM, revealed the Resident was up in his wheelchair in his room watching television. The Resident's call light was under the opposite side of the bed where he was sitting and out of reach of the resident. An interview with the Resident, on 03/12/19 at 10:32 AM, revealed the Resident did not know where his call light was. The Resident stated I do not see it anywhere. An interview with Nurse Aide (NA) #101, on 03/12/19 at 10:35 AM, revealed the Resident does not need his call light near him because he is more mobile than most other residents. A review of the Care Plan was conducted on 03/12/19 at 11:30 AM. The Care Plan dated 02/25/19 with a focus of Actual fall and continues to be at risk for falls with the intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. | 2020-09-01 |
| 92 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 550 | E | 1 | 0 | R6BQ11 | > Based on observation, staff interview, and policy review, the facility failed to ensure residents were treated with dignity and respect. A staff member was yelling at a resident during care and a catheter bag was not covered . This practice affected two (2) of eleven (11) residents observed. Resident identifiers: #4 and #8. Facility census: 178. Findings included: a) Resident #8 A random observation by two surveyors on the A Hall on the 4th floor, on 04/17/18 at 7:40 AM, revealed Nurse Aide (NA) #22 was getting Resident #8 dressed in the Resident's room. NA #22 was heard yelling loudly and forcibly Jesus, what the hell are you doing to Resident #8. NA #4 was also present in the room. When both NAs exited the room NA #22 stated Oh my God, there is state. An interview with NA #22, on 04/17/18 at 7:42 AM, revealed the NA was helping Resident #8 get dressed. The NA stated the resident must be dizzy because she would not cooperate like usual. The NA stated she laid the Resident back down due to her functioning level at the time of care. An observation of the Resident, on 04/17/18 at 7:45 AM, revealed the Resident was lying in bed. The Resident was unable to answer yes and no questions. An interview with the Administrator, on 04/17/18 at 7:50 AM, revealed that any abusive behavior is not tolerated and the situation would be investigated immediately. An interview with the District Director of Clinical Services (DDCS), on 04/17/18 at 9:30 AM, revealed both NA #22 and #8 were suspended and a full investigation had begun. The DDCS stated all residents in the facility were immediately being interviewed and checked for abuse. The DDCS stated the behavior of CNA #22 was absolutely abuse and was highly unacceptable. The DDCS stated any kind of abuse would never be acceptable or tolerated at any of my facilities. A review of the facility policy titled OP 00 Abuse & Neglect Prohibition, with a revision date of (MONTH) (YEAR), was conducted on 04/18/18 at 9:45 AM. The policy stated Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint. b) Resident #4 A random observation of Resident #4, on 04/16/18 at 11:05 AM, revealed the Resident's urinary catheter bag was full of urine and uncovered. An interview with NA #1, on 04/16/18 at 11:07 AM, revealed catheter bags are to be covered at all times. NA #1 stated the Resident's catheter bag needed emptied and covered. | 2020-09-01 |
| 93 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 558 | D | 1 | 0 | R6BQ11 | > Based on observation, resident interview, and staff interview, the facility failed to provide services with reasonable accommodation for residents. A resident's over the bed light cord was not long enough to be easily reached and a resident could not access his bathroom due to the door being locked. This practice affected two (2) of eleven (11) residents observed. Resident identifiers: #10 and #11. Facility census: 178. Findings included: a) Resident #10 An observation of the Resident, on 04/16/18 at 11:10 AM, revealed the Resident's over the bed light cord was approximately 6 inches long. An interview with the District Director of Clinical Services (DDCS), on 04/16/18 at 11:15 AM, revealed the Resident could not easily reach the over the bed light cord without having to get up out of bed. b) Resident #11 An observation of the Resident's room, on 04/16/18 at 11:25 AM, revealed the Resident's bathroom door was locked. The bathroom was not occupied at the time of the observation. An interview Resident #11, on 04/16/18 at 11:27 AM, revealed the door to the bathroom is locked almost daily. The Resident stated he has to go to room next door to enter his bathroom. The Resident stated whoever uses the bathroom in that room keeps the door locked preventing him from getting in. An interview with the DDCS, on 04/16/18 at 11:30 AM, revealed she had no idea Resident #11 was being locked out of his bathroom. The DDCS stated she would take care of the issue. | 2020-09-01 |
| 94 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 583 | E | 1 | 0 | R6BQ11 | > Based on observation and staff interview, the facility failed to protect the personal privacy of residents including medical and health information. A medication re-order sheet was left unattended on medication cart in the hallway. Personal identifiers including residents' names, medications, and other health information were viewable by any person in the hall. This was a random observation. This practice affected five (5) residents. Resident identifiers: #20, #21, #22, #23, #24, and #25. Facility census: 178. Findings included: a) Medication Re-Order Sheet A random observation of the 3rd Floor B-Hall, on 04/16/18 at 11:45 AM, revealed a medication re-order sheet was left on top of the medication cart. The medication re-order sheet contained the following: -Resident #20-Resident's name, room number, medication, and dosage -Resident #21-Resident's name, room number, medication, and dosage -Resident #22-Resident's name, room number, medication, and dosage -Resident #23-Resident's name, room number, medication, and dosage -Resident #24-Resident's name, room number, medication, and dosage -Resident #25-Resident's name, room number, medication, and dosage An interview with Licensed Practical Nurse (LPN) #10, on 04/16/18 at 11:48 AM, revealed the LPN should not have left the medication re-order sheet unattended on the medication cart. The LPN stated she usually turns the paper over or takes it with her when away from the cart so that no patient information can be seen by others. | 2020-09-01 |
| 95 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 584 | E | 1 | 0 | R6BQ11 | > Based on observation and staff interview, the facility failed to ensure a safe, clean, comfortable and homelike environment for 3 of 11 sampled residents. The facility failed to ensure the resident's room was in good repair, clean and /or homelike. Resident identifiers: #8, #3 and #4. Facility census: 178. Findings included: An observation on 04/17/18 at 10:30 AM, revealed a lack of personal items noted in Resident #8's room. An interview with the District Director of Clinical Services, on 04/17/18, at 12:20 PM, verified it was uncertain why Resident #8 did not have personal effects making the room homelike. It was further stated, staff would assess resident's preferences and assist the resident to make the room homelike. An observation of Resident #3's room, on 04/16/18 at 11:05 AM, revealed a plastic glove laying under a chair. An additional observation, on 04/17/18, at 7:30 AM, revealed a plastic glove laying under the same chair and debri on the floor, in the area close to the door. c) Resident #4 An observation of Resident #4, on 04/16/18 at 11:05 AM, revealed paint missing along with paint chips hanging from the ceiling above the bed. An interview with the District Director of Clinical Services (DDCS), on 04/16/18 at 11:10 AM, revealed the ceiling would be taken care of immediately. | 2020-09-01 |
| 96 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 600 | E | 1 | 0 | R6BQ11 | > Based on observation, staff interview, and policy review, the facility failed to ensure residents were free from verbal abuse and mistreatment. A staff member was yelling at a resident during care. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #8. Facility census: 178. Findings included: a) Resident #8 A random observation by two surveyors on the A Hall on the 4th floor, on 04/17/18 at 7:40 AM, revealed Nurse Aide (NA) #22 was getting Resident #8 dressed in the Resident's room. NA #22 was heard yelling loudly and forcibly Jesus, what the hell are you doing at Resident #8. NA #4 was also present in the room. When both NAs exited the room NA #22 stated Oh my God, there is state. An immediate interview with NA #22, on 04/17/18 at 7:41 AM, revealed the NA was helping Resident #8 get dressed. The NA stated the resident must be dizzy because she would not cooperate like usual. The NA stated she laid the Resident back down due to her functioning level at the time of care. An observation of the Resident, on 04/17/18 at 7:43 AM, revealed the Resident was lying in bed. The Resident was unable to answer yes and no questions. An interview with the Administrator, on 04/17/18 at 7:50 AM, revealed that any abusive behavior is not tolerated and the situation would be investigated immediately. An interview with the District Director of Clinical Services (DDCS), on 04/17/18 at 9:30 AM, revealed both NA #22 and #8 were suspended and a full investigation had begun. The DDCS stated all residents in the facility were immediately being interviewed and checked for abuse. The DDCS stated NA #22 works all over the facility. The DDCS stated the behavior of NA #22 was absolutely abuse and was highly unacceptable. The DDCS stated abuse would never be acceptable or tolerated at any of my facilities. A review of the facility policy titled OP 00 Abuse & Neglect Prohibition, with a revision date of (MONTH) (YEAR), was conducted on 04/17/18 at 9:45 AM. The policy stated Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint. | 2020-09-01 |
| 97 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 684 | E | 1 | 0 | R6BQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to ensure that 5 of 11 sampled residents received care and treatment in accordance to the comprehensive assessment and plan of care. Heels were not floated for Resident #1, Resident #2, and Resident #4. Fall mats were not provided for Resident #7, and Resident #9. Resident identifiers: #1. #2, #4, #7 and #9. Facility census: 178. Findings included: a) Resident #2 A review of the medical record for Resident #2 revealed a physician's orders [REDACTED]. An observation made of Resident #2, while in bed, on 04/16/18, at 11:45 AM, revealed the resident's right sock was off her foot, laying on the floor, and her right heel was positoined directly on the bed. Both heels were not being floated in accordance with physician's orders [REDACTED]. An interview with the District Director of Clinical Services, on 04/17/18, at 12:15 PM, verified understanding of following physician orders [REDACTED]. b) Resident #1 A review of the medical for Resident #1, on 04/16/18, revealed a physician's orders [REDACTED]. An observation made of Resident #1, while in bed, on 04/17/18, at 07:20 AM, revealed the resident's heels were not floated in accordance with physician's orders [REDACTED]. An interview with the District Director of Clinical Services, on 04/17/18, at 12:15 PM, verified understanding of following physician orders [REDACTED]. c) Resident #7 An observation of Resident #7 on 04/17/18 at 7:20 AM, revealed a bruised area on the right side of the resident's face. A review of the medical record for Resident #7, on 04/17/18, revealed Resident #7 had sustained a fall on 04/16/18 at 10:44 AM. The facility implemented the Fall Protocol related to the fall occurrence. Resident was to have a fall mat to right side of bed. An observation made, 04/17/18 at 09:25 AM, revealed no fall mat present beside Resident #7's bed. On 04/17/18, at 09:40 AM, an interview with Staff #4 verified there was no fall mat beside Resident #7's bed. It was further stated by Staff #4, the mat should have been in place after the fall meeting and should be in place now. d) Resident #4 An observation of Resident #4, on 04/16/18 at 11:05 AM, revealed the Resident's heels were not floated. An interview with Nurse Aide (NA) #1, on 04/16/18 at 11:08 AM, revealed the Resident's heels are to be floated while in bed. A review of Resident #4's physician orders, on 04/16/18 at 12:25 PM, revealed an order for [REDACTED]. A review of the Care Plan was conducted on 04/16/18 at 1:35 PM. The Care Plan, with a creation date of 01/23/18, contained the focus the Resident has actual skin issues with the intervention Elevate bilateral lower extremities on pillows while in bed to float heels-verify placement. e) Resident #9 A random observation of Resident #9, on 04/17/18 at 8:20 AM, revealed the Resident's fall mat was off the floor beside the bed and leaned against the wall. The Resident was in bed at the time of the observation. An interview with Licensed Practical Nurse (LPN) #30, on 04/17/18 at 8:22 AM, revealed the fall mat was supposed to be on the floor beside Resident #9's bed. The LPN stated she saw the mat against the wall earlier and forgot to put it back beside the bed. The LPN stated the housekeeper must have moved it while cleaning and not put it back. A review of Resident #4's physician orders, on 04/17/18 at 10:30 AM, revealed an order for [REDACTED]. A review of the Care Plan was conducted on 04/17/18 at 10:35 AM. The Care Plan, with a creation date of 03/13/18, contained the focus the Resident has experienced an actual fall and continues to be at risk for falls with the intervention Floor mat to right side of bed-verify placement. | 2020-09-01 |
| 98 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 880 | E | 1 | 0 | R6BQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and record review, the facility failed to carry out proper infection control practices. A resident's sheets and bed had multiple areas stained with blood, a staff member failed to ensure contact isolation procedures were utilized, and several resident's oxygen tubing was on the floor and not dated. This practice affected six (6) of eleven (11) residents observed. Resident identifier: #1, #2, #5, #7, #10, and #11. Facility census: 178. Findings include: a) Resident #10 An observation of Resident #10, on 04/16/18 at 11:00 AM, revealed the Resident was lying in bed. At the time of the observation the Resident's sheets and bed railings had multiple areas that were stained with blood. An interview with Certified Nursing Assistant (CNA) #50, on 04/16/18 at 11:00 AM, revealed the Resident must have scratched an open area and got blood on her bed and sheets. The CNA stated she would ensure the sheets were changed and the bed cleaned immediately. b) Resident #5 An observation of Resident #5, on 04/16/18 at 11:20 AM, revealed the Resident was lying in bed. The Resident was on contact isolation. CNA #1, entered the resident's room, pulled up her covers, and exited the room. The CNA did not wash her hands before or after touching the resident's covers nor use gloves. The CNA did not use any isolation equipment that was provided at the Resident's door. An interview with CNA #1, on 04/16/18 at 11:24 AM, revealed the Resident is on contact isolation. The CNA stated as long as she did not touch the resident then she did not have to wear any gloves or isolation precautions while in the room. An review of the Resident's physician orders, on 04/16/18 at 11:35 AM, revealed an order for [REDACTED]. A review of the facility policy titled Standard and Transmission-Based Precautions-Contact Precautions, with a revision date of 02/2018, was conducted on 04/16/18 at 11:45 AM. The policy stated for someone on Contact Precautions the following should be done Hand hygiene should be completed prior to donning gloves-Gloves should be worn while providing care for the resident-Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately-A gown should be donned prior to entering the room. c) Resident #11 An observation of the Resident, on 04/16/18 at 11:25 AM, revealed the Resident's oxygen tubing was on the floor and was not labeled. The Resident was using the oxygen at the time of the observation. An interview with Respiratory Therapist (RT) #50, on 04/17/18 at 10:00 AM, revealed the facility does not date the oxygen tubing when it is changed. The RT stated all oxygen tubing should be changed every seven days. The RT stated with the facility's current practice of not dating the tubing then there is no proof it was really changed. The RT stated no oxygen tubing should be on the floor. d) Resident #1 Observation of Resident #1's room , on 04/16/18, at 11:50 AM, revealed the resident's oxygen tubing was on the floor and the tubing was not dated. e) Resident #2 Observation of Resident #2's room, on 4/16/18, at 11:45 AM, revealed the resident' oxygen tubing was not dated. f) Resident #7 Observation of Resident #7's room, on 04/17/18, at 9:25 AM, revealed the resident's nebulizer tubing was not dated. An interview with Respiratory Therapist (RT) #50, on 04/17/18 at 10:00 AM, revealed the facility does not date the oxygen tubing when it is changed. The RT stated all oxygen tubing should be changed every seven days. The RT stated with the facility's current practice of not dating the tubing then there is no proof it was really changed. The RT stated no oxygen tubing should be on the floor. | 2020-09-01 |
| 99 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 924 | E | 1 | 0 | R6BQ11 | > Based on observation and staff interview, the facility failed to ensure handrails were securely and firmly affixed to the walls. Several handrails throughout the facility were coming undone and were loose. This practice had the potential to affect more than a limited number of residents. Handrail identifiers: WV Building-A Hall, WV Building-B Hall, and WV Building C-Hall. Facility Census: 178. Findings included: a) Handrails A random observation of the WV Building A-Hall, B-Hall, and C-Hall, on 04/17/18 at 8:45 AM, revealed multiple loose handrails. The handrails were coming loose on the ends causing them not to be securely and firmly attached to the walls. An interview with the District Director of Clinical Services (DDCS), on 04/17/18 at 9:40 AM, revealed she was not aware of the handrails coming undone but would ensure they were looked at immediately. The DDCS stated the handrails should be secure. | 2020-09-01 |
| 100 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-08-23 | 679 | D | 0 | 1 | TKSO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, observations and review of policy and procedure for activities, the facility failed to invite and provide activities of interests for two of three residents reviewed for activities. Resident identifiers: #74 and #80. Facility census: 176. Findings included: a) Resident #74 1. Resident #74's medical record was reviewed on 08/22/18 at 09:46 AM. The resident was admitted on [DATE]. The Admission Minimum Data Set (MDS) assessment Section I revealed the resident had [DIAGNOSES REDACTED]. Section G0110, required extensive assistance of two with transfers. Section F0500, Interview for Activity Preferences, responses from the resident were reviewed and revealed that is was very important to have books, newspaper or magazines to read, music, news, group activities, favorite activities, religion and fresh air. The resident's activities care plan, dated 05/15/18, was reviewed on 08/22/18 at 10:18 AM. The care plan revealed the resident had an anticipated short stay and had interventions that included the following: ensure that the activities the resident attend are compatible with known interests, invite the resident to activities, provide a program of activities that is of interest, provide activity calendars, review resident activation needs, staff will informally visit on a regular basis to ensure leisure needs are being met, the resident needs assistance/escort to activity functions, attending church services, when resident chooses not to participate in organized activities, the resident prefers to spend time in room listening to music or reading. Observations were made of the resident on 08/20/18 at 03:35 PM of the resident in bed and awake. The television that was in front of the bed was not on. On 08/21/18 at 12:12 PM the resident was observed lying in bed asleep. On 08/22/18 at 08:57 AM the resident was observed in bed and had just finished breakfast, at 10:58 AM the resident was asleep in bed. On 08/23/18 at 9:24 AM the resident was observed in bed in room awake, the television was not on and there was no music on. On 08/22/18 at 10:34 AM the Individual Activity Participation Records for May, June, (MONTH) and (MONTH) (YEAR) were reviewed. The documentation revealed in the past four months that Resident #74 only participated in music one time, cards/other games one time and received mail twice. The resident refused glamour nails once. There were no other refusals documented on the participation records. On 08/22/18 at 11:00 AM, Activity Assistant (AA)#21 was interviewed. AA #21 stated that she used to be the Activity Director but stepped down and was an Activity Assistant. AA #21 was asked if she invited Resident #74 to the group activities and she stated she had not invited the resident any this month. She stated she did not invite her to come to activities, realized she should and that was a mistake. She stated she made informal visits to Resident #74's room, but nothing specific based on her activity preferences. On 08/23/18 at 11:06 AM, Activity Assistant (AA) #22 was interviewed. AA #22 stated she provided activities on the unit. AA #22 stated she did not invite Resident #74 to come to activities when the resident was in bed. On 08/23/18 at 11:07 AM, Activity Director (AD) #80 was interviewed regarding Resident #74. AD #80 verified the staff did not provide invitations for the resident to attend scheduled activities based on the resident's individual activity preferences and should have. b) Resident #80 2. Resident #80's record review was reviewed on 08/21/18 at 03:51 PM. The Annual Minimum Data Set (MDS), dated [DATE], Section I had [DIAGNOSES REDACTED]. Section G0110 revealed the resident required extensive assistance of two for transfers and revealed in Section F0500, Interview for Activity Preferences, responses from the resident were as follows: very important to have music, news, pets, group activities, fresh air, favorite activities and religious activities. The Resident #80's care plan, dated 7/31/18, was reviewed on 08/21/18 at 04:03 PM. The care plan revealed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs. The care plan interventions included: ensure that the activities the resident attend are compatible with known interests and preferences, compatible with individual needs and abilities, introduce the resident to residents with similar background and interests, invite the resident to scheduled activities, provide a program of activities that is of interest, provide activity calendars, resident needs assistance/escort to activity functions, when resident chooses not to participate in organized activities the resident prefers to sit up in wheelchair in hall and socialize among peers, watch television for social and sensory stimulation. Observations were made on 08/20/18 at 03:27 PM of the resident lying in bed awake. There was no television on the wall in front of the resident's bed. Only a television wall mount was there and no radio or music was playing. Observations were made on 08/21/18 at 12:11 PM of the resident lying in bed awake. There was no television on the wall mount and there was no radio or music playing. On 08/21/18 at 04:08 PM the Individual Activity Participation Records for June, (MONTH) and (MONTH) (YEAR) were reviewed. The documentation recorded on Individual Activity Participation Records revealed that Resident #80 attended cards/other games and a religious activity one time in (MONTH) (YEAR). Further review of the Individual Activity Participation Records dated June, (MONTH) and (MONTH) (YEAR) revealed documentation that the resident was provided television and visits with family or friends every day in June, (MONTH) and (MONTH) (YEAR). On 08/21/18 at 02:09 PM, Activity Assistant (AA) #160 was interviewed. AA #160 stated she had not invited the resident to any group activities. AA #160 verified the Individual Activity Participation Record for (MONTH) (YEAR) revealed television was provided to the resident every day. AA #160 stated the resident was independent with television and watched it in her room. AA#160 walked with this writer to the resident's room and verified the resident did not have a television in front of her bed that she could operate independently. Observations were made of the resident's roommate with a television, but the cubicle curtain was observed closed. AA #160 stated she didn't invite the resident to activities because she was in bed. AA #160 provided the resident's care plan and stated she goes by the care plan to provide activities to the resident but verified she didn't follow it. On 08/21/18 at 02:20 PM Resident Care Specialist (RCS) #91 was interviewed. RCS #91 stated the activity staff invite the resident to activities. RCS #91 stated Resident #80 couldn't get out of bed on her own and required assistance of two staff to get out of bed. RCS #91 stated the nursing staff or activity staff could assist to take the resident to the activity if the resident wanted to go. On 08/21/18 at 02:50 PM Activity Director (AD) #80 was interviewed. AD #80 verified on the Individual Activity Participation Records for the past three months the resident received visits with family or friends every day and was independent in watching television every day. AD #80 verified there was no television in the Resident #80's room. AD #80 verified there had been no radio in the resident's room until today and that music was listed as a preference of the resident on the care plan. AD #80 was not aware the resident had no visitors and had a caseworker listed as a primary contact person. On 08/21/18 at 03:32 PM Licensed Practical Nurse (LPN) #41 was interviewed. LPN #41 stated had not seen any family or friends visit and the resident's contact person was a caseworker that she had to call if there were concerns regarding the resident. On 08/23/18 at 11:06 AM Activity Assistant (AA) #22 was interviewed. AA #22 stated she provided activities on the unit but does not invite residents to come to group activities when the residents are still in bed. AA #22 verified she did not invite Resident #80 to join the scheduled activities on the unit per the care plan. On 08/23/18 at 11:07 AM, Activity Director (AD) #80 was interviewed regarding both Resident #74 and Resident #80. AD #80 verified that the activity staff failed to invite the resident to scheduled activities, failed to provide a television or music based on individual preferences of the resident. AD #80 also verified for both Resident #74 and #80 that if the residents were not up and out of bed, the Activity Assistants should still ask the resident if they wanted to come to activities. If the residents wanted to come, the Activity Assistants should inform the nursing staff to assist with getting the residents up so they could attend the activity. AD #80 verified if the nursing staff did not get the resident up out of bed when asked, it should be reported to her or nursing staff. AD #80 verified that if the resident did not want to get out of bed to attend a group activity, the activity assistants should provide things to do in their room based on the Individual Activity Preferences on the care plan. If the resident refused, it should be documented on the Individual Activity Participation Records as a refusal. AD #80 verified the staff did not follow the care plan to invite the residents to scheduled activities. AD #80 provided the Policy on Activities Program on 08/23/18 at 11:08 AM. The policy was reviewed and revealed that activities are provided to meet the assessment and interests of each resident. The resident's interests are assessed upon admission and according to the Resident Assessment Instrument (RAI) manual with MDS reference periods and a comprehensive care plan is developed and reviewed and revised as needed. AD #80 verified the policy wasn't followed to provide activities to Residents #74 and #80. | 2020-09-01 |
| 101 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-08-23 | 695 | D | 0 | 1 | TKSO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that one resident's oxygen therapy was monitored for the need and effectiveness of oxygen therapy and failed to document respiratory signs and symptoms, changes in oxygen administration, and/or results of oxygen therapy. This affected one of one resident reviewed for oxygen therapy in the sample of 28. Resident identifier: #92. Facility census: 176. Findings included: a) Resident #92 Resident #92's medical record was reviewed on 08/22/18 at 02:17 PM. Resident #92 is severely cognitively impaired according to the Minimum Data Assessment, dated 05/24/18. Resident #92 had [DIAGNOSES REDACTED]. Resident #92 had a physician's orders [REDACTED]. The order further stated that the oxygen should be titrated to keep oxygen levels above 92%. There were no oxygen saturation levels documented in the medical record. There were no progress notes regarding the resident's respiratory signs and symptoms, the time or reason oxygen was administered, or the result of oxygen therapy. Resident #92's care plan, target date 08/21/18, listed interventions to observe for signs and symptoms of acute respiratory insufficiency such as anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, and somnolence. Resident #92 was observed in bed receiving oxygen therapy via nasal canula on 08/20/18 at 11:35 AM, 08/21/18 at 01:39 PM, 08/21/18 at 5:45 PM, and 08/22/18 at 10:10 AM at 2 L/M. On 08/22/18 at 02:49 PM Resident #92 was observed receiving oxygen at 3.5 L/M via the nasal canula. On 08/22/18 at 02:49 the Unit Coordinator/Licensed Practical Nurse (LPN) #55 confirmed that Resident #92's oxygen level was set at 3.5 L/M. LPN #55 stated that the order is for 2 L/M as needed, but that the oxygen can be titrated up to keep saturation levels greater than 92% per the physician's orders [REDACTED]. LPN #55 said, There should be oxygen saturation levels for her. LPN #55 obtained Resident #92's oxygen saturation level and reported it was 95 - 96%. On 08/22/18 at 03:01 PM LPN #75 was interviewed. LPN #75 confirmed that she was the nurse caring for Resident #92 on that day. LPN #75 said she checked Resident #92's oxygen concentrator a couple hours ago and it was on 2 L/M. LPN #75 said she checked Resident #92's oxygen saturation level at that time and it was 97%. LPN #75 said she did not record the result in the medical record. On 08/22/18 at 03:14 PM the Director of Nursing (DON) was interviewed. The DON said that oxygen saturation levels should be checked as needed depending on what symptoms the resident is displaying. The DON said, They should not put oxygen on her unless she is displaying signs and symptoms, or her saturation levels are below 92%. The facility's Oxygen Administration Policy, revised (MONTH) 2010, was reviewed on 08/22/18 at 03:30 PM. The policy stated in part, D[NAME]UMENTATION: In the Nurse's notes and Treatment Administration Record (TAR) and/or Medication Administration Record [REDACTED]. | 2020-09-01 |