Vanceburg Hills

In the surveyor’s words

From the most serious findings on record at Vanceburg Hills, in the surveyor’s own words.

• Actual harm, isolatedF580Aug 22, 2024

  Based on interview, record review, and review of the facility's policy, the facility failed to notify the resident's physician to alter treatment when the resident's narcotic pain medication had a delay in delivery from the pharmacy for 1 of 28 sampled residents (Resident (R) 76). R76 received his last dose of his pain medication on 08/17/2024. Even though the resident was expressing verbal and nonverbal signs and symptoms of severe pain, the facility did not notify the resident's physician nor did the facility communicate with hospices services. The resident did not receive his pain medication until 08/19/2024. The facility was out of the resident's medication for 40 hours, and the medication was ordered to be administered every three hours as needed. […]

• Actual harm, isolatedF656Aug 22, 2024

  Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement person centered comprehensive care plans for pain, activities, and a significant weight loss for 3 of 28 sampled residents, Resident (R) 76, R34, and R31. This placed the residents at risk for decreased quality of life, quality of care, and further exacerbation of an illness. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised 12/23/2023, indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are… […]

• Actual harm, isolatedF697Aug 22, 2024

  Based on interview, record review, and review of the facility's policies, the facility failed to ensure a resident, who was on end of life hospice services, pain was effectively managed per the physician orders for 1 of 2 residents reviewed for pain out of 28 sampled residents, Resident (R) 76. R76 was ordered Dilaudid (a narcotic pain medication used to treat severe pain) every three hours as needed. R76 was administered his last dose of Dilaudid on 08/17/2024 at 4:00 PM. The facility did not procure the resident's Dilaudid until 08/19/2024, and the medication was administered to the resident at 8:00 AM which indicated the resident went without the pain medication for 40 hours. […]

• No harm, potential for more than minimal, patternF628Jul 15, 2026

  Based on interview, record review, and review of the facility's documents and policy, the facility failed to ensure the resident's representative received in writing notification of a transfer or discharge that included a statement of the resident's appeal rights and the contact information for the state Long-Term Care Ombudsman for 5 out of 5 residents investigated for transfer and/or discharge, Resident (R) 3, R22, R46, R62, and R92.The findings include:Review of the facility's policy titled, Transfer and Discharge, revised 03/20/2025, revealed the facility's transfer/discharge notice would be provided to the resident and the resident's representative and would include the specific reason, effective date, and location of transfer; and explanation of the right to appeal the transfer or… […]

• No harm, potential for more than minimal, isolatedF623Aug 22, 2024

  Based on interview, record review, and review of the facility's policy, the facility failed to provide written notification of a facility-initiated transfer to the resident and responsible party (RP) for 2 (Resident (R) 27 and R46) of 4 residents reviewed for hospitalization in the sample of 28. The failure had the potential to affect the residents and/or their representatives concerning the reason for the transfer and the resident's appeal rights. The findings include: Review of the facility's policy titled, Transfer and Discharge, revised 03/09/2024 revealed, .4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. […]