Continuous Care Center Wheeling Hospital

Inspectors wroteBased on record review, staff interview and observation, the facility failed to ensure food was stored in accordance with professional standards for food service. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 128.

Inspectors wroteBased on record review, staff interview and observations, the facility failed to ensure a comprehensive care plan for fall interventions was developed. The failed failed practice had the potential to affect a limited number of residents. Resident Identifier: #75. Facility census: 128.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to ensure an accurate medical record for fall intervention orders and provide documentation of the method of bathing. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #75 and #104. Facility Census: 128.

Inspectors wroteBased on medical record reviews and staff interviews, the facility failed to ensure the physician was notified of changes regarding resident's physical status. This was true for three (3) of 27 sample residents. The physician was not notified of urinalysis results for Resident #112, and for Residents #4 and #98 there was no notice of weight loss/gain. Resident identifiers: #112, #4, and #98. Facility census: 115.

Inspectors wroteBased on record review and staff interview, the facility failed to follow physician orders. Medication used to control blood sugar in people with diabetes mellitus was not administered within physician's parameters and documented in accordance with professional standards of practice. Blood glucose levels were not obtained as ordered. High blood sugars were not reported to the physician. The facility failed to have a documented order for a tube feeding. The facility failed to notify the physician when a resident had an abnormal urinalysis culture. This affected 8 (eight) of 27 residents reviewed during the long-term care survey process. Resident identifiers: #10, #22, #47, #15, #4, #68, #112, #5. Facility census: 115.

Inspectors wroteBased on policy review, record review and staff interview, the facility failed to ensure resident falls resulting in serious bodily injury were reported in a timely manner to the appropriate state agencies. The failure to make a timely report and to report to the correct state agencies was true for two (2) of two (2) sample residents for falls. Resident identifiers: #56 and #14 . Facility census: 115.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of one (1) residents reviewed for the category of PASARR, during the long-term care survey. Resident identifier #98. Facility census 115.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure resident safety and sanitary storage, handling and consumption of food in a personal refrigerator. Resident identifier: #68 Facility census: 115.

Inspectors wroteBased on observation and staff interviews, the facility failed to maintain the garbage storage area in a sanitary condition. It was discovered the dumpster had a work glove, a food container and newspaper on the ground around the dumpster. Facility census: 115.

Inspectors wroteBased on record review and staff interview, the facility failed to electronically submit to CMS complete and accurate direct care staffing information data by the required deadline for the FY Quarter 3 2023 (April 1 - June 30). This was a random opportunity for discover. Facility census: 115.

Inspectors wroteBased on facility documentation and staff interview, the facility failed to have required members sign in at the Quality Assessment and Assurance (QAA) meetings. This failed practice had the potential to affect all residents residing at the facility. Facility census: 115.

Inspectors wroteBased on record review, staff interview and policy review, the pharmacist failed to identify and report a drug irregularity during the initial medication review and reconciliation. Resident #207's as needed antianxiety medication lacks a 14 day time limit. In addition, the Medication Regimen Review (MRR) policy lacks time frames for the different steps in the review process and does not identify the steps the pharmacist must take when identifying an irregularity that requires urgent action to protect the resident. This is true for one (1) of five (5) reviewed for unnecessary medications and the policy has the potential to more than a limited number of residents residing in the facility. Resident identifier: 207. Facility census: 113.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure wheelchair arms were in good repair for a resident. This was a random opportunity for discovery. The failed practice was true for one (1) of 22 sampled residents. Resident identifier: #4. Facility census: 113.

Inspectors wroteBased on medical record review and staff interview, the facility failed to report a fall with major injury for Resident #99. This practice affected one (1) of three (3) residents reviewed for falls during the Long Term Care Survey Process. Resident identifier: #99. Facility census: 113.

Inspectors wroteBased on medical record review and staff interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessments for two (2) of 22 residents reviewed during Long-Term Care Survey (LTCSP). The MDS for Resident #3 did not accurately reflect resident was receiving hospice. And Resident #100's MDS did not accurately reflect a diagnosis of an infection. Resident identifier: Resident #3 and Resident #100. Facility Census: 113 Findings Included: a) Resident #3 A Review of the Resident #3 Significant change MDS on 06/20/22 with Assessment Reference Dates (ARD) of 03/19/22 discovered the following: Section O titled Special treatment procedure and programs, Section K Hospice Care was coded as: No. Section J titled Health Conditions, Section J1400 Prognosis was coded No. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to revise Resident #3's care plan for update medication for dementia with behaviors that was discontinued. This is true for one (1) of 22 residents reviewed for care plans. Resident identifier: Resident #3. Facility Census: 113.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide oxygen therapy in accordance with professional standards of practice. The oxygen tubing was not labeled to indicate when it was last changed for two (2) of two (2) residents reviewed for the area of respiratory care. Resident identifiers: Residents #53, #71. Facility census: 113.

Inspectors wroteBased on medical record review and staff interview, the facility failed to develop an order for the care and treatment of a vascular assess catheter for hemodialysis. This was discovered for one (1) of (1) residents reviewed for dialysis during the Long Term Care Survey Process. Resident #163 had no order for the care and treatment of his vascular access catheter for hemodialysis. Resident identifier: Resident #163. Facility census: 113.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed provide pharmaceutical services to meet the needs of each resident. Medication current being received by Resident #26 was expired. This was a random opportunity for discovery. Resident identifier: #26. Facility census: 113.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #207's as needed anti-anxiety medication was limited to 14 days. This is true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier: #207. Facility census: 113.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide special eating utensils for Resident #48. This was a random opportunity for discovery. Resident identifier: #48. Facility census: 113.

Inspectors wroteBased on observations and staff interview, the facility failed to store food in accordance with professional standards for food service safety. During the kitchen tour it was discovered the bins containing sugar and flour were not dated. This had the potential a limited number of residents receiving nourishment from the kitchen. Facility census: 113.

Inspectors wroteBased on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Staff failed to don appropriate personal protective equipment (PPE) for a resident in contact isolation. This was a random opportunity for discovery. Resident identifier: #100. Facility census: 113.