rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
10246,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-01-11,241,D,1,0,ZFKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview the facility failed to promote a dignified dining experience for one (1) of fourteen (14) sampled residents. Two (2) residents, who shared a room, were not served their meals at the same time. Resident identifier: #6. Facility census: 105. Findings include: a) Resident #6 Observation of room [ROOM NUMBER] revealed both residents who resided in the room were going to have their noon meals in their room. The noon meal was served to Resident #23, the roommate of Resident #6, at 12:00 noon on 01/09/12. Staff provided set up assistance and Resident #23 began feeding herself. At approximately 12:30 p.m., Resident #23 had finished eating and her tray was removed from the room. It was not until approximately 12:45 p.m. , when Resident #6 received her tray and was provided assistance with eating. This resident was in the room, without her meal, the entire time as Resident #23 received and completed her meal. .",2015-05-01
10247,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-01-11,279,D,1,0,ZFKM11,". Based on medical record review and staff interview, the facility's interdisciplinary team failed to develop a comprehensive care plan to address and describe how services would be provided to a resident with a communication deficit due to a loss of hearing. This was true for one (1) of 14 sampled residents. Resident identifier: #19. Facility census: 104. Findings include: a) Resident #19 Review of the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/23/11, revealed the resident had moderate difficulty with hearing. It was noted the speaker had to increase volume and speak distinctly. The resident had the ability to understand others, but missed some / part of the message. Further review of the care area assessment (CAA) summary associated with this MDS found the facility would address communication in the resident's care plan. Review of the care plan failed to find evidence the resident's communication deficits were addressed. Employee #54, the MDS coordinator, was interviewed, at 3:45 p.m. on 01/09/12. She was unable to provide evidence the resident's communication deficits had been addressed in the care plan. .",2015-05-01
10248,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-01-11,312,D,1,0,ZFKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure dependent residents received the necessary services to maintain personal hygiene. Review of documentation of residents' shower schedules found showers were not always provided according to the schedules. This was true for two (2) of five (5) residents whose shower schedules and documentation of those showers, were reviewed. Resident identifiers: #43 and #19. Facility census: 105. Finding include: a) Resident #43 Review of the shower schedule assignment with Employee #71 (the assistant director of nursing (ADON)), on 01/10/12 at 10:30 a.m., revealed the resident was to receive showers on Mondays and Thursdays. Further review of the resident's functional performance record (RFPR) for December 1, 2011 to January 10, 2012, completed by the nursing assistants, revealed the resident should have received eleven (11) showers during this period. The facility provided documentation the resident either received or refused six (6) of the showers scheduled. Employee #71 was unable to determine why the other five (5) showers were not given. b) Resident #19 Medical record review revealed the resident was admitted to the facility on [DATE]. Review of the shower schedule assignment with Employee #71, on 01/10/12 at 10:30 a.m., revealed the resident was to receive showers on Monday and Thursdays. Further review of the resident's RFPR, from 12/16/11 to 01/10/12, revealed the resident should have received seven (7) showers. The resident refused two (2) showers and was out of the facility on one (1) scheduled shower day. Employee #71 was unable to determine the reason the other four (4) showers were not provided as scheduled. .",2015-05-01
10249,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-01-11,323,D,1,0,ZFKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility failed to provide adequate supervision and / or assistive devices to promote prevention of falls. Additionally, the facility failed to assure assistive devices, designed to prevent falls, were installed properly to prevent accidents and to promote resident safety. Resident #55, who was known to be at risk for falls, was not provided with assistive devices. Resident #43 had a physician's orders [REDACTED]. The alarm had been applied incorrectly causing the alarm to malfunction. This practice affected two (2) of four (4) sampled residents who had experienced falls at the facility. Resident identifiers: #55 and #43. Facility census: 104. Findings include: a) Resident #55 The facility failed to provide any assistive devices for to prevent falls after the resident's second admission to the facility. The facility was aware the resident was at risk for falls and had experienced falls during his first admission to the facility. Medical record review found the resident was admitted to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. The hip fracture occurred shortly before the resident's admission to the facility. The resident was admitted with staples in his right hip as a result of the surgery. The resident's first fall at the facility occurred on 11/28/11, when he fell from his bed. The resident was sent to the hospital for evaluation and returned to the facility the same day with no injuries noted. The physician ordered fall mats to be placed at the bedside. On 11/29/11, the resident fell from his bed again. He was sent to the hospital and returned the same day with no injuries noted. The physician ordered a bed alarm to be placed on the bed at all times and a chair alarm to be used when the resident was up in his chair. On 11/30/11 the physician ordered bed bolsters to be placed on the bed at all times. On 12/02/11 the resident was admitted to the hospital for complications associated with his diabetes. The resident returned to the facility on [DATE]. When the resident returned to the facility on [DATE], there were no devices ordered to prevent falls, although the facility had assistive devices in place to prevent falls before his discharge from the facility on 12/02/11. The facility was well aware the resident had experienced two (2) falls in a ten (10) day time period during his first stay at the facility. On 12/15/11, the resident fell from his bed. He did not receive any injuries. On 12/15/11, the physician ordered a bed alarm to be used at all times and bilateral fall mats to be used at the bedside. On 1219/11, the resident fell out of his geri-chair. He was sent to the hospital for evaluation and was complaining of bilateral hip pain. The resident returned to the facility on the same day with no reported injuries. On 12/20/11, the physician ordered a chair alarm to be used at all times when the resident was up in his chair. On 01/09/12 at 1:00 p.m., the director of nursing (DON) was interviewed regarding the falls experienced at the facility by Resident #55. The time lines listed above were reviewed with the DON. The DON stated the resident's condition was different when he returned from the hospital on [DATE] and the devices previously in place to prevent falls were not added when he returned to the facility. The facility knew or should have known the resident had the potential for falls when he returned to the facility on [DATE], based on his previous stay at the facility. Even though his medical condition may have changed while at the hospital, he still continued to experience falls at the facility on 12/15/11 and 12/19/11. The resident did not experience any falls after 12/19/11 when the alarm was re-implemented. b) Resident #43 At 2:35 p.m. on 01/09/12, this resident was observed sitting on the right floor mat beside her bed in her room. She was not calling out for help. Nursing staff were summoned by the surveyor. The following employees responded to the resident's fall: Employee #115, the occupational therapist; Employee #75, the licensed practical nurse: and Employees #33 and #20, nursing assistants. After the resident was assessed and no injuries were found, the employees returned the resident to bed and left the resident's room. Employee #75 was outside the resident's room in the hallway. When asked why the resident's bed alarm was not functioning. Employee #75 replied, ""Because she didn't turn it on."" The surveyor, who had first observed the resident, explained the resident had a bed alarm in place and the bed alarm had failed to sound. Employees #115, #75, #33 and #20 then returned to the resident's room with the surveyor. Employee #20 discovered the bed alarm sensor pad had been placed under the resident's air mattress. Employee #20 stated, ""The weight of the air mattress is keeping the alarm from sounding."" She then removed the bed alarm from under the air mattress and placed it on top of the mattress and under the bed sheet. Employee #20 demonstrated the bed alarm was functioning properly at that time. Review of the manufacture's guidelines for use of the bed alarm sensor pad found, ""The sensor pad is placed on a patient's bed or chair and connected to a control unit. If a patient moves his or her weight from the sensor pad, the control unit issues an audible alert."" The audible alarm was not activated when the resident fell from the bed to the floor as the weight of the air mattress prevented the alarm from sounding. The sensor pad was applied incorrectly to the resident's bed. Furthermore none of the four (4) employees who responded to the residents' fall recognized the alarm did not activate when the resident fell from the bed until questioned by the surveyor.",2015-05-01
10250,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,203,C,0,1,FJI611,". Based on record review and staff interview, the facility failed to provide a discharged resident with the correct name and contact information should the resident wish to appeal her discharge from the facility. Instead, the form listed numerous agencies to which to appeal, none of which were correct. This information was lacking for one (1) resident who was discharged , and was found to be the standardized form that was provided for all residents who were transferred or discharged from the facility. This had the potential to affect all discharged and transferred residents in the facility. Resident identifier: #14. Facility census: 109. a) Resident #14 Record review of a discharged resident's medical record, found a Notice of Transfer or Discharge form, with revision date 11/2009. On this form, the discharged resident was informed of the right to appeal the center's decision for transfer or discharge, and listed multiple agencies with their contact information. None of the listed agencies was the correct appeals agency. During an interview with the administrator, on 09/25/12 at 10:00 a.m., she stated this was the facility's standardized form used for all transfers and discharges. She acknowledged the contact name and contact information of the agency to appeal decisions, was absent on the form. .",2015-05-01
10251,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,225,D,0,1,FJI611,". Based on review of the facility's concern/complaint files, review of the reportable allegations in the facility's abuse/neglect files, staff interview, and review of facility policy and procedure, the facility failed to ensure all allegations of neglect and abuse were reported to the proper State agencies. This was true for two (2) of fifty (50) grievance/concern forms reviewed. Resident identifiers: #5 and #94. Facility census: 109. Finding include: a) Resident #5 Review of the grievance/concern forms found a complaint by the resident's daughter, dated 09/03/12. The daughter reported the resident's wheelchair was dirty, the resident was not shaved on a daily basis, and the resident was not encouraged to drink his supplements. Further review of the grievance/concern forms revealed a second complaint by the resident's daughter, dated 09/11/12. She again alleged the resident was not shaved and feces had dried on the seat and back of the wheelchair. During an interview with the administrator, Employee #46, on 09/25/12 at 3:30 p.m., she verified these allegations had not been reported to the appropriate state authorities. b) Resident #94 Review of the grievance/concern forms found a complaint had been filed by the resident's son on 07/17/12. The son alleged the following, ""At 7pm on 7/13/12 son received call that resident had been waiting for someone to take her to bathroom. He received another call from mother on 7/14/12 at 12:35 that she waited an hour and a half and another call from mother on 7/16/12 she waited for an hour to have call light answered"". During an interview with the administrator, on 09/25/12 at 3:30 p.m., she verified the allegations had not been reported to the proper state agencies. c) Review of the facility's policy and procedure entitled, Abuse and Neglect Prohibition Program found on page 3, ""...Complaint/allegations, observation, or suspicion of neglect, abuse, or misappropriation of personal property must be thoroughly investigated and reported in a consistent and uniform manner, in accordance with state and federal law, and the state of federal survey and certification agency...."" .",2015-05-01
10252,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,242,D,0,1,FJI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, record review, and staff interview, the facility failed to honor the resident's desire / preference to be up in a reclining geri-chair. This was true for one (1) of five (5) residents reviewed for the care area of ""Choices"" in Stage II of the quality indicator survey (QIS). Resident identifier: #154. Facility census: 109. Findings include: a) Resident #154 Observation of the resident in Stage I of the QIS found she was in bed on the afternoon of 09/17/12, and continued to remain in bed during the morning and afternoon of 09/18/12. The resident was positioned on her back during numerous observations made on 09/17/12 and 09/18/12. During an interview with the resident, on 09/19/12 at 9:00 a.m., the resident stated her hip would hurt if she were turned on her left or right sides. She explained she had fractured her hip before coming to the facility in December 2011. When asked about repositioning, she stated she preferred to lay on her back, but does like to get up in her reclining chair. She said she would like to get up daily in the afternoons, but staff tell her there are not enough of them to get her up every day. She stated she is lifted with a lift and two (2) employees. According to the resident, she was certain she had not been up in the geri-chair since her return from the hospital on [DATE]. Review of the medical record found the resident was alert and oriented and had been deemed to have capacity to make medical decisions. It was also noted the resident was the medical decision-maker for her husband who was also a resident at the facility. The resident was interviewed again in her room with the director of nursing (DON), Employee #157, on 09/19/12 at 10:45 a.m. The resident again voiced she would like to get up in her reclining chair daily. She stated she had not been up in her chair for days, as staff would tell her there were not enough staff present to get her up because she required the assistance of two (2) staff members and the use of a lift. She said she would like to be up, no more than two (2) hours at a time and she wanted the DON to make sure staff would put her back to bed after the two (2) hour time limit. The DON assured the resident she would have staff get her up after lunch. On 09/19/12 at 2:00 p.m., the resident was observed up in her reclining geri-chair which she said was comfortable. Further review of the medical record found no evidence the resident was offered the opportunity to get out of bed and be placed in a geri-chair. Review of the resident's minimum data set (MDS) kardex report (the communication form used to detail the residents care to the nursing assistants) on 09/19/12 found directions to the nursing assistants, ""Reclining back wc (wheelchair) with anti-tippers and pommel cushion (symbol for with) foot board when out of bed, up for only 2 hrs. (hours)."" On 09/24/12, review of the medical record found a new kardex had been completed sometime between 09/19/12 and 09/24/12, with new directions for the nursing assistants, ""Resident prefers to be up daily."" On 09/24/12 at 11:00 a.m., the DON was asked if she could provide any evidence nursing staff had offered to get the resident up or any evidence the resident had refused when staff offered to get her out of bed on or before she became aware of the issue on 09/19/12. On 9/24/12 at 3:00 p.m., the DON stated Employee #118, a licensed practical nurse, had some information to present. Employee #118 was then interviewed and he said he did not have any information. In another interview with the DON, at 9:39 a.m. on 9/25/12, she stated she could not provide any evidence the resident was offered, or the resident refused, to be up in the geri-hair on or before the interview on 09/19/12. .",2015-05-01
10253,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,247,D,0,1,FJI611,"Based on resident interview, staff interview and policy review the facility failed to inform a resident she was receiving a new roommate. This was true for one resident who triggered the care area of Admission, Transfer and Discharge. Resident identifier #24. Facility census: 109. Findings include: a) Resident #24 During Stage I of the (QIS) quality indicator survey, Resident #24 stated she was not informed when she received a new roommate. Interview with the social worker Employee #93, at 8:50 a.m. on 09/26/12 verified the resident was not informed when she received a new roommate on 05/30/12. On 09/26/12 at 10:45 a.m., the administrator, Employee #46, presented a Social Services Assessment & Documentation Policy, #JCL-SS-676-0006, dated 12/09. The policy required the social services director/designee to complete a notification of new roommate on, ""... attachment H."" The facility was unable to present verification the policy and procedure was followed and the resident was notified of receiving a new roommate. .",2015-05-01
10254,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,272,D,0,1,FJI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the resident's comprehensive did not accurately reflect the current health status / condition for one (1) of thirty-one (31) residents sampled in stage II of the QIS (Quality indicator survey). Resident identifier: #12. Facility census: 109. Findings include: a) Resident #12 Review of the medical record found the resident was admitted to the facility on [DATE], and was receiving [MEDICATION NAME] 100 mg daily and [MEDICATION NAME] 17 gram powder daily for a [DIAGNOSES REDACTED]. Further review disclosed a facility form entitled, ""The Resident Functional Performance Record."" This form was completed daily by the nursing assistants (NA). The form indicated the resident did not have a bowel movement from the date of admission, on 07/20/12, until 07/28/12. The Resident's minimum data set (MDS) with an assessment reference date (ARD) of 07/27/12, found section (H), bowel patterns, noted no constipation was present. No bowel movements were recorded by NAs from 07/20/12 through 07/27/12, and the Resident was receiving two (2) medications for a [DIAGNOSES REDACTED]. At 9:30 a.m. on 09/26/12, Employee #119, a registered nurse and regional director of clinical services, was interviewed and made aware of the documentation on the MDS. No further information was provided by the facility. .",2015-05-01
10255,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,279,E,0,1,FJI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, and staff interview the facility failed to develop interdisciplinary plans of care for residents in the areas of activities of daily living, nutrition, [MEDICAL TREATMENT], range of motion, and unnecessary medications. This was true for three (3) of thirty-one (31) residents reviewed in Stage 2 of the quality indicator survey. Resident identifiers: #204, #145, and #93. Facility census: 109. Findings include: a) Resident #204 1) During an interview with the resident on 09/18/12 at 2:09 p.m. the resident stated the staff do not help me brush my teeth, they just give me a toothette and tell me I can do it myself. She stated, "" I can do it myself but I would like a toothbrush and toothpaste."" The Resident further explained she recently fell at home and broke her back. She stated, ""I am not suppose to walk alone and the doctor told me if I fell again, I might not be so lucky, I could be paralysed."" She stated if someone would help her to the sink she could brush her teeth. ""Once I get there I can use the toothbrush myself"". The resident also stated that she could put her clothes on but someone had to get them out of the closet for her. ""I have all these needles and tubes coming out of my neck and I am afraid I will pull them out while dressing."" ""I also need a little help with my pants, shoes and socks but the staff tell me I can do this myself."" Review of the admission MDS (minimum data set) with ARD (assessment reference date) of 09/04/12, section (G) functional status, found the resident required extensive assistance of one staff member with dressing and personal hygiene, which included brushing teeth. Extensive assistance was described on the MDS as ""Resident involved in activity, staff provide weight-bearing support."" Review of the facility form entitled, ""Resident Functional Performance Record, (completed by the nursing assistants), found the resident has performed the activities of grooming (mouth care, hair, nails and shave) and dressing (how the resident puts on, fastens and takes off all items and clothing, including braces and splints) independently and without any staff assistance since her admission on 09/12/12. Review of the care plan found a problem, ""Self care deficit change in mobility, pain, unstable health condition, weakness, generalized muscle weakness, difficulty walking and requires extensive assistance with most ADL's (activities of daily living)."" The goal associated with the problem was, ""Personal care needs will be met as evidence by: Will be neat clean, well groomed daily though next review period."" Interventions associated with the problem were, ""encourage resident to do as much for self as able, Offer positive comments when working on ADL's. Give resident choices while giving care, encourage independence, allow time fore dressing and undressing, since the task may be painful, and difficult."" The director of nursing, employee #157, was interviewed on the afternoon 09/25/12. She stated the MDS was coded incorrectly and the Resident could complete her ADL's independently. Employee #62, a register nurse and clinical care manager, who stated she now completes the MDS's was interviewed on 09/26/12 at approximately 10:00 a.m. She stated the MDS was completed correctly and she provided verification from the therapy notes in effect during the assessment date. The current care plan was then reviewed with this employee. The interventions in the care plan were not specific as to how assistance would be provided for dressing. For example, the resident can dress her upper extremities but needs assistance when dressing the lower extremities. The Resident can brush her own teeth but needs assistance to get to the sink. The resident's interview was also discussed with this employee and she agreed the resident was correct in her interpretation of how much assistance she would require. 2) Review of the medical record found the registered dietitian, Employee #30, had completed a Medical Nutrition Therapy Assessment for the resident on 09/18/12. The plan to address the resident's nutritional status was, ""Provide fortified foods q (every) meal to (symbol for increase) available nutrients. Review of the current care plan, with a revision date of 09/19/12, found a problem of, ""Alteration in nutrition status [DIAGNOSES REDACTED]."" The approaches included with this problem did not include providing fortified foods. On 09/24/12 at 2:30 p.m. an interview was held with Employee #62, the clinical care manager, and the administrator to discuss the care plan. A copy of the registered dietitian's report, with the plan to serve a fortified diet, was shown to these employees. No further information was presented to verify the fortified diet was care planned. . . b) Resident #145 Review of the medical record revealed that on 09/21/11, Resident #145 was ordered [MEDICATION NAME] (an anti-anxiety medication) one (1) milligram (mg.) twice daily for anxiety. Approximately two (2) weeks later, the dosage was increased to one (1) mg. three (3) times daily, where it has remained since that time. Review of the care plan for this [AGE] year old resident, found the absence of non-pharmacological interventions to address the symptom of anxiety, and no antecedents that might be known to escalate anxiety. During interview with the Director of Nursing on 09/19/12 at approximately 4:00 p.m., she acknowledged the same lack of non-pharmacological interventions on the care plan to address anxiety. . . c) Resident #93 Review of the medical record on 09/18/12 for Resident #93 discovered the use of the hypnotic medication Ambien. The resident had been [MEDICATION NAME] 09/28/11. Review of the comprehensive care plan for Resident #93 found no interventions in place for the nurses to follow to provide necessary care and services related to the use of Ambiem. Further review of the care plan found no plan for monitoring for side effects/adverse effects for the use of Ambien. On 09/19/12 at 10:35 a.m., Employee #118 (licensed practical nurse) confirmed this information was not on the care plan. .",2015-05-01
10256,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,282,D,0,1,FJI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure licensed nursing staff followed the facility's written plan of care for addressing bowel elimination and the facility's care plan for obtaining blood pressure. This was true for three (3) of (31) thirty-one residents reviewed in Stage 2 of the QIS (quality indicator survey.) Resident identifiers: #12, #118, and #207. Facility census: 109. Findings include: a) Resident #12 Review of the Resident's care plan, initiated on 07/25/12, found the problem, ""Bowel elimination alteration; constipation related to: lack of exercise, pain medications."" The goal associated with this problem was: ""Resident will be free of constipation as evidence by having a BM (bowel movement) at least q (every) three days thru review period."" Interventions for obtaining the goal included, ""Evaluate need for medications that causes constipation; record BM (bowel movement) note size and consistency, report any abnormalities to Licensed nurse, certified Nursing aide report to licensed nursing staff on 3rd day if no BM for further follow-up; observe bowel sounds as indicated, administer medications as ordered to prevent constipation."" The Resident Functional Performance Record, completed daily by the nursing assistants, for Resident #12 had no bowel movements recorded from the date of admission, 07/20/12, through 07/28/12, when the resident had a medium bowel movement. Review of the nursing notes found an entry for 07/31/12 at 11:30 a.m., ""Resident complained of being constipated gave enema at 11:30 a.m., resident stated still no relief, told oncoming nurse at 3:00 p.m., She stated she see what she can give her."" Review of the nursing notes found no documentation from the oncoming nurse regarding the resident's reports of constipation on 07/31/12. The Medication Administration Record [REDACTED]. Additionally, there was no evidence the nurse administering the enema on 07/31/12 received an order from the resident's physician for the enema. Review of the Resident Functional Performance Record found no evidence the resident had a bowel movement on 07/31/12. Her next bowel movement occurred sometime during the day shift on 08/01/12, when a medium bowel movement was recorded. At 9:30 a.m. on 09/26/12, Employee #119, a registered nurse and regional director of clinical services, was interviewed regarding the facility's bowel protocol. She verified the facility did not have any policy or procedures regarding bowel functioning, or standing orders to treat constipation. She said the nurses knew to call the physician if a resident had no bowel movement in three (3) days. Employee #119 was unable to find any written documentation to support her statement. When questioned as to how the facility monitored bowel functioning to prevent fecal impaction, Employee #119 replied the residents' functional performance records were reviewed at morning meetings. If a resident had no bowel movement for three (3) days, the physician was contacted for intervention. A copy of the Functional Performance Record for Resident #12 was presented to Employee #119. Documentation from the nursing assistants verified the resident had no bowel movements from 07/20/12 to 07/28/12, when a medium bowel movement was recorded. Employee #119 was asked if physician intervention was requested during this time frame. She was unable to provide evidence the physician was contacted, or evidence the issue was addressed by the facility. Employee #119 stated she did not know why the facility had not noticed the lack of bowel movements at the daily meetings. A copy of the care plan was reviewed with Employee #119. No further information was provided to verify the facility followed the care plan interventions listed above. Employee #119 verified an order had to be obtained from the physician before giving an enema. She was unable to find documentation the physician was contacted and ordered the enema. No further information was provided to verify nursing staff monitored the resident for bowel sounds, encouraged fluids, reviewed any medications that could have contributed to the resident's constipation, or contacted the physician when the resident had no bowel movement for three (3) days, as directed by the care plan. . . b) Resident #118 Review of this resident's current care plan revealed a goal, ""Blood pressure will remain within acceptable limits, systolic between 100-150 and diastolic between 60-90 through next review."" The target date, and revised target date, for that goal, was 07/13/12 and 10/09/12, respectively. Review of the Medication Administration Record [REDACTED]. Review of the electronic medical records revealed the last documented blood pressure reading was on 04/27/12. The next blood pressure reading was recorded on a nursing assessment dated [DATE]. There were no other blood pressure recordings, during this time frame, to assess if the resident's blood pressure fell within the care plan's acceptable parameters. On 09/19/12 at 5:45 p.m., a registered nurse, Employee #72, produced ""Assessment"" policy #CL-676-0005. The policy statement revealed, ""It is the center's policy to assess each resident upon admission, re-admission, and quarterly or with significant change in condition."" Employee #72 explained the facility did not have a specific blood pressure/vital signs policy. Interim director of nursing, Employee #157, verified this on 09/20/12 at 10:00 a.m. . . c) Resident #207 Resident #207 was a [MEDICAL TREATMENT] patient, who went for [MEDICAL TREATMENT] treatments on Tuesday, Thursday, and Saturday. Review of the care plan and ""Quick Reference Guide"" identified the facility was supposed to monitor pre and post vital signs, obtain pre and post weights, and observe the site after [MEDICAL TREATMENT] for excess bleeding. Review of the medical record, on 09/24/12, found the facility was not consistently obtaining vital signs prior to and after the resident's return from [MEDICAL TREATMENT]. The facility also failed to obtain pre and post weights from the [MEDICAL TREATMENT] center after each [MEDICAL TREATMENT] treatment. On 09/17/12 the facility obtained a faxed copy of the pre and post weights for the resident's previous visits on 09/15/12, 09/13/12, and 09/11/12. The weights were not obtained following each visit as required by the care plan. Review of a nursing interdisciplinary progress note revealed Employee #68(nurse) failed to assess the resident's site upon return to the facility on [DATE]. Employee #90 (nurse) failed to obtain vital signs prior to [MEDICAL TREATMENT] on the same day. According to the Medication Administration Record, [REDACTED]""Quick Reference Guide"" used by the facility. During an interview with Employee #68 on 09/25/12, at approximately 1:45 p.m., she confirmed she did not assess the resident after Resident #207 returned from [MEDICAL TREATMENT] on 09/18/12. .",2015-05-01
10257,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,309,G,0,1,FJI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and policy and procedure review, the facility failed to consistently administer pain medication when a resident complained of pain, failed to evaluate and assess the resident's pain, failed to assess the efficacy of the pain medication after administration, failed to follow the resident's care plan interventions to alleviate / treat pain, and failed to follow the facility's policy and procedures for assessment, management, monitoring and evaluating the effectiveness of the pain management program. The facility failed to monitor the resident's bowel regimen, secure physician's orders [REDACTED]. The facility also failed to assess a resident who received [MEDICAL TREATMENT] services upon return from the [MEDICAL TREATMENT] center, and failed to follow their care plan and guidelines for assessment of a resident receiving [MEDICAL TREATMENT]. This was true for two (2) of thirty-one (31) residents reviewed in Stage II of the QIS (quality indicator survey). Resident identifiers: #12 and #207. Facility census: 109. Findings include: a) Resident #12 1. Review of the medical record found an alert, oriented Resident who had been deemed to have capacity to make medical decisions. The Resident was admitted to the facility on [DATE] at 5:30 p.m. for rehabilitation after surgery to repair a [MEDICAL CONDITION] upper arm. An admission nursing note written at 5:30 p.m. on 07/20/12 found, ""...Resident is complaining of pain, repositioned till (sic) medication arrives...."" There was no documentation to determine if the repositioning was effective. The resident's medication admission orders [REDACTED]. There were no other medications prescribed to treat the resident's pain upon admission. Further review of the medication record found the [MEDICATION NAME] was not administered on 07/20/12. The first dose of [MEDICATION NAME] was administered at 10:30 p.m. on 07/22/12, two (2) days after the resident complained of pain. The medical record contained no evidence the resident's pain was assessed, treated or eliminated on 07/20/12. Review of the Medication Administration Record [REDACTED]. On 07/20/12, the day of the resident's admission, the facility completed a pain evaluation. The evaluation found the residents pain was acute and daily. The intensity of the pain had not been completed. According to the evaluation, the resident was cognitively intact and described her pain as aching, and affecting her completion of activities of daily living (ADLs) and mobility. Medications, cold, and positioning were listed as currently and historically managing the resident's pain. Documentation revealed, ""Resident stated the [MEDICATION NAME] had been effective in controlling her pain."" It was not clear from the evaluation as to how the resident knew the [MEDICATION NAME] was effective in managing her pain. Included on the MAR indicated [REDACTED]?"" The directions to nursing staff were, ""Assess resident pre-medication and post medication. 0-10 scale."" The rating scale was not completed on 07/20/12. On 07/21/12 the resident's pain was rated as a 10/0 on the MAR indicated [REDACTED]. On 7/22/12, the MAR indicated [REDACTED]. There was no follow up documentation to determine if the medication was effective. On 07/23/12 at 1:35, a nurse noted, ""Resident complain of pain. Rated pain at a 6. [MEDICATION NAME] was given for pain. Resident stated that pain was still rated @ (symbol for at) 6. Positioned resident in bed (symbol for with) ice on shoulder to help relieve pain. Will cont. (continue) to monitor. Call light in reach."" There was no further documentation the treatment was effective and no further assessment of the resident's pain. Review of the MAR found no evidence the medication, [MEDICATION NAME], was administered on 07/23/12, although the nurses note contained documentation the medication was administered. The next nursing note was written on 07/24/12, (time was not documented), ""Resident stated [MEDICATION NAME] was not helping pain and requested Tylenol. Order obtained for 650 mg q (every) 6 hours for pain PRN of Tylenol. Will continue to monitor."" Tylenol was administered on three (3) occasions on 07/24/12. The pain was rated as a 0 on all three (3) occasions, although the MAR indicated [REDACTED]. It was unclear if the pain was rated as a 0 before or after administration of the medication. Further review of the MAR found the resident received [MEDICATION NAME] at 11:00 p.m. on 07/24/12. According to the documentation on the MAR, the resident was not having any pain. A nursing note, dated 07/25/12 at 12:00 p.m. ""...receives Tylenol 650 mg PRN for pain, seems effective."" Again on 07/25/12, review of the MAR found the resident's pain was rated as a 0 on three (3) separate occasions (day, afternoon and night shift). If was unknown if this rating was before or after the administration of the medication of Tylenol. Further review of the MAR found the resident received Tylenol at 12:25 p.m. and 8:48 p.m. On 07/26/12 the resident's pain was rated as a 6 on the MAR indicated [REDACTED].) There was no further documentation present to determine if the pain was relieved. Tylenol was not administered on the afternoon shift of 07/26/12. [MEDICATION NAME] was administered at 8:35 p.m. on 07/26/12. The next nursing note referencing the resident's pain was written on 07/27/12, ""Resident up and down out of bed. Complaints of pain to shoulder and bladder, states having problems urinating. Given Tylenol 650 mg. Resident states meds. (medication) don't help (symbol for with) pain. U/A urinalysis ordered awaiting results. Cont. (continue) to monitor..."" There was no rating of the resident's pain on 07/27/12 and no documentation to determine if the pain was relieved with Tylenol. Review of the MAR indicated [REDACTED]. Tylenol was administered on four (4) separate occasions with no rating of the resident's pain before or after the administration of Tylenol. On 07/29/12, 07/30/12 and 07/31/12 Tylenol was administered on two separate occasions on each day with the residents pain rated as 0. Again there was no documentation to determine if the Resident's pain was a 0 before or after the administration of the Tylenol. From 07/27/12, until the resident was discharged from the facility on 08/03/12, no further nursing notes were written indicating an assessment of the resident's pain. Review of the MAR found Tylenol was the only medication administered for pain on 08/01/12. Review of the resident's MDS (Minimum Data Set) with ARD (assessment reference date) of 07/27/12, section ( J), revealed the resident rated her pain as almost constant and severe over the last five (5) days. The care plan, initiated on 07/23/12, identified pain related to [MEDICAL CONDITION] humerus with s/p (status [REDACTED]."" Interventions included: ""Monitor pain on scale of 1-10, position pillows as needed for comfort, administer pain medication as per MD (doctors) orders and note the effectiveness. Notify MD if pain not reduced, encourage resident to communicate presence of pain, assist to reposition for comfort, implement relaxation and/or distraction techniques to assist with pain control, document/report complaints and non-verbal signs of pain."" Review of the facilities policy for Pain Management Program policy and procedure, PRN (as needed) Pain Medication, directed use of the form PRN Pain Management Flow Sheet. ""...when [MEDICATION NAME] are administered in response to an episode of pain, licensed nurses must document their evaluation, treatment, and the effectiveness of the treatment on the PRN Pain Management Flow Sheet."" Further instructions for licensed nurses was documentation of the following information: ""1. Pain evaluation and treatment, date and time, pain rating, non-pharmacological treatments provided, location of the pain, medication dose, administering nurses's signature and initials."" ""2. Effectiveness of treatment: date and time, pain rating level of sedation, nurses signature and initials."" The medical record contained two (2) copies of the PRN Pain Management Flow Sheets. One listed the resident's name at the bottom, but neither copy had been completed. The facility failed to follow their policy and procedure to complete the flow sheets as required in #1 and #2 above. The Policy further directed the interdisciplinary team to: ""1. Identify residents with pain, 2. Develop an individual pain management program, 3. Implement the program, 4. Monitoring and evaluating the effectiveness of the program."" The policy detailed why pain management was important. It contained the statement, ""Studies indicate that 45-80% of nursing home residents have substantial, untreated pain. Additionally, a study of the standardized MDS data shows that 41% of elderly people who are admitted to a nursing home continue to experience moderate-to-severe pain, even up to 60-80 days later..."" ""The goal of this program is to manage the resident's pain to optimize their quality of life. Pain management is an important component of our care process-part to take seriously. The goal of the interdisciplinary team is to promptly identify pain and develop an effective Pain Management Plan...."" Review of the nurse practitioners visit on 07/25/12 found the written statement, ""Resident admitted post hospitalization for post surgical repair of left humerus fracture post fall. Had complaints of drainage from op (operation) site and pain..."" There were no details on how the pain would be treated. An interview was conducted with the administrator, Employee #46, and the interim director of nursing (DON), Employee #157 at 10:30 a.m. on 09/20/12. The above information was discussed with both employees. The DON verified the facility failed to complete the PRN Pain Management Flow Sheet as required by their policy and procedure, and failed to follow the policy for pain management. She stated she did not know why the facility waited for two (2) days before administering the resident's pain medication, when the resident was complaining of pain. She stated she was not at the facility at the time of the resident's admission and could not account for the care the resident received. Another interview was conducted with the administrator and Employee #62, the clinical care manager, on 09/24/12 at 2:46 p.m., regarding the above findings and no further information was received. Further review of the nursing notes found the resident was discharged to her home on 08/03/12. Nursing staff continued to chart on the resident on 08/05/12 and 08/06/12 with both entries documenting""...call light within reach."" Employee #62 and the administrator were presented with the following question, ""If staff were evaluating her pain daily, then why were nursing notes written after the resident was discharged to home?"" These staff members were unable to answer this question and were unable to provide further evidence the facility was assessing, monitoring, and implementing an effective pain management program. 2) Review of the nursing notes found an entry for 07/31/12 at 11:30 a.m., ""Resident complained of being constipated gave enema at 11:30 a.m., resident stated still no relief, told oncoming nurse at 3:00 p.m., She stated she see what she can give her."" Review of the nursing notes found no documentation from the oncoming nurse regarding the resident's reports of constipation on 07/31/12, or if the enema had been effective. Further review of the MAR found no evidence the enema was given. Additionally, there was no evidence the nurse administering the enema received an order for [REDACTED]. The Resident Functional Performance Record, completed daily by the nursing assistants, found no bowel movement was recorded for 07/31/12. The next recorded bowel movement was on the afternoon shift of 08/01/12, when the resident had a medium bowel movement. Further review of the Resident Functional Performance Record, found the resident did not have a bowel movement from 07/20/12, the day of admission until 07/28/12, when she had a medium bowel movement. The resident resided at the facility for eight (8) days with no recorded bowel movement and no evidence of any staff intervention. The DON (director of nursing) and administrator were interviewed at 10:30 a.m. on 09/20/12. The DON verified the nurse would have to have a physician's orders [REDACTED]. She was unable to provide any written evidence this was completed. The DON was also asked for a copy of the facility's bowel protocol, and the facility's policy for bowel functioning and monitoring to prevent fecal impaction. The DON presented the following, ""If resident complains of constipation and or has no bowel movement for three days notify physician and follow physician orders."" The information was typed on facility letterhead stationary and was not dated. At 9:30 a.m. on 09/26/12, Employee #119, a registered nurse and regional director of clinical services, was interviewed regarding the facility's bowel protocol. She verified the facility did not have a bowel policy or protocol. When asked how the facility monitored bowel functioning to prevent fecal impaction, she replied the resident's functional performance record was reviewed at morning meeting, and if the resident had no bowel movement for three (3) days, the physician would be contacted for intervention. A copy of the resident's functional performance record was presented to this employee. Documentation from the nursing assistants verified the resident had no bowel movement from 07/20/12 to 07/28/12. This employee was asked if physician intervention had been requested in this time frame. She was unable to present any evidence the physician was contacted or evidence the issue was addressed by the facility. She stated she did not know why the facility had not noticed the lack of bowel movements at the daily meetings. She verified an order was required from the physician before giving an enema to a resident. Further review of the MAR found the resident was receiving [MEDICATION NAME] 100 mg daily and [MEDICATION NAME] 17 gram powder daily for a [DIAGNOSES REDACTED]. Review of the Resident's care plan, initiated on 07/25/12, found the problem, ""Bowel elimination alteration; constipation related to: lack of exercise, pain medications."" The goal associated with this problem was: ""Resident will be free of constipation as evidence by having a BM (bowel movement) at least q (every) three days thru review period."" Interventions included, ""Record BM. note size and consistency. Report any abnormalities to Licensed nurse. Certified Nursing aide report to licensed nursing staff on 3rd day if no BM for further follow-up."" At the close of the survey, no further information was provided by the facility. . . b) Resident #207 Resident #207 was a [MEDICAL TREATMENT] patient. She went to [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday. Review of the physician's orders [REDACTED]. Further review of the care plan and ""Quick Reference Guide"" identified the facility was also to monitor pre and post vital signs, obtain pre and post weights, and observe the site after [MEDICAL TREATMENT] for excess bleeding. Review of the medical record, on 09/24/12, found the facility had not been consistently obtaining vital signs prior to and after the resident returned from [MEDICAL TREATMENT]. The facility also failed to obtain pre and post weights from the [MEDICAL TREATMENT] center. On 09/17/12, the facility obtained faxed pre and post weights for the visits for 09/15/12, 09/13/12, and 09/11/12. According to the physician's orders [REDACTED]. Review of a nursing interdisciplinary progress note revealed Employee #68 (nurse) failed to assess the resident's site upon return to the facility on [DATE]. Employee #90 (nurse) failed to obtain vital signs prior to [MEDICAL TREATMENT] on the same day. According to the Medication Administration Record, [REDACTED]""Quick Reference Guide"" used by the facility. During an interview with Employee #68 on 09/25/12, at approximately 1:45 p.m., she confirmed she did not assess the resident after [MEDICAL TREATMENT] on 09/18/12. .",2015-05-01
10258,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,311,D,0,1,FJI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, resident interview, and staff interview, the facility failed to ensure one (1) of three (3) residents received the necessary specialized rehabilitative services related to the proper fit of her wheelchair. Resident #24 was found with bruising to her arms related to the improper fit of her wheelchair. Resident identifier: # 24. Facility census: 109. Findings include: a) Resident #24 Observation of Resident #24, at 9:27 a.m. on 09/18/12, during Stage I of the survey, found she had bruises to her left lower arm. When the resident was asked how she got the bruises, she stated her wheelchair was too big for her, and ""It is hard for me to move the wheels with my hands."" She further added the wheels rubbed the inside and tops of her arms. The resident stated she had talked with Employee #142 (certified occupational therapy assistant) related to her issue with the wheelchair, a week prior to this interview. She also said no one had talked to her since the day she told Employee #142 about the problems with her wheelchair. Record review, on 09/24/12 11:42 a.m., discovered this resident had a [DIAGNOSES REDACTED]. nerve compression). The resident had also complained of her shoulder feeling stiff. She had an x-ray of the left shoulder which found decreased range of motion of the left shoulder. Review of the physical therapy notes, on 09/24/12 at 11:45 a.m., found the resident was propelling when in her wheelchair for short distances following set up. Observation of Resident #24, on 09/24/12 at 1:30 p.m., found her sitting in the wheelchair in the therapy department. Employee #131 (physical therapist) had the resident reach and use her hands to pull her chair around. The resident could place her hands on the wheel, but when she tried to wheel the wheelchair, her arms rubbed the top of the wheel at the same time. The inside of her arms were rubbing on the top of the wheel and she could not move the brake with her hand. This resident told the therapist again, during this observation, that she continued to have difficulty rubbing her hands on the wheelchair. Review of the medical record, on 09/25/12 at 9:40 a.m., with Employee #72 (Registered Nurse/unit manager) found no assessments made by therapy related to the fit of the wheelchair. Employee #72 confirmed at that time they had no other information on the chart. During an interview with Employee #131 (physical therapist), on 09/12/12, it was revealed Employee #131 did not receive notice this resident was having trouble with her wheelchair. On 09/25/12 at 11:35 a.m., Employee #131 confirmed there was no evidence a staff member reported any concerns made by this resident related to the fit of her wheelchair. Employee #131 confirmed the resident was assessed after surveyor intervention. As a result, accessories were added to the resident's wheelchair to make it easier for her to maneuver the chair. The facility also obtained protective sleeves to prevent further bruising and skin tears to this resident's arms. On 09/26/12, at approximately 9:30 a.m., Employee #142 (certified occupational therapist assistant) stated this resident had told her she was having trouble with her wheelchair the week before. On 09/26/12 at 09:35 a.m., Employee #136, the physical therapist assistant (PTA), stated he did an evaluation, but had not documented his evaluation. .",2015-05-01
10259,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,312,D,0,1,FJI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, medical record review, and staff interview, the facility failed to ensure a dependent resident received assistance with grooming and oral hygiene. This was true for (1) one of three (3) residents reviewed in Stage 2 of the QIS (quality indicator survey) who triggered the care area of activities of daily living (ADLs) regarding cleanliness and grooming. Resident identifier: #204. Facility census: 109. Findings include: a) Resident #204 During an interview with the resident, on 09/18/12 at 2:09 p.m., the resident stated, ""Staff do not help me brush my teeth, they just give me a Toothette and tell me I can do it myself."" She stated, "" I can do it myself but I would like a toothbrush and toothpaste."" The resident further explained she recently fell at home and broke her back. She stated, ""I am not supposed to walk alone and the doctor told me if I fell again, I might not be so lucky, I could be paralyzed."" She stated if someone would help her to the sink she could brush her teeth. She said, ""Once I get there I can use the toothbrush myself."" The resident also stated she could put her clothes on, but someone had to get them out of the closet for her. She said, ""I have all these needles and tubes coming out of my neck and I am afraid I will pull them out while dressing. I also need a little help with my pants, shoes and socks, but the staff tell me I can do this myself."" Further review of the medical record found the resident was admitted to the facility on [DATE] for short term rehabilitation. Review of section (G) functional status,in the admission minimum data set (MDS) with an assessment reference date (ARD) of 09/04/12, revealed the resident required extensive assistance of one (1) staff member with dressing and personal hygiene, which included brushing teeth. Extensive assistance was described on the MDS as ""Resident involved in activity, staff provide weight-bearing support."" Review of the facility form entitled, ""Resident Functional Performance Record,"" completed daily by the nursing assistants, found the resident had not received any support from staff for grooming (mouth care, hair, nails and shave) and dressing (how the resident puts on, fastens and takes off all items and clothing, including braces and splints) from 09/08/12 through 09/25/12. The director of nursing was interviewed on the afternoon of 09/25/12. She stated the MDS was coded incorrectly and the resident could complete her ADL's independently. Employee #62, a registered nurse, who stated she completed the MDSs, was interviewed on 09/26/12, at approximately 10:00 a.m. She stated the MDS was completed correctly. She provided verification from the therapy notes in effect during the assessment date. Employee #62 further explained the occupational therapist had been working with the resident to complete grooming and dressing. She provided a copy of a form entitled, ""Nursing / Rehabilitation ADL Crosswalk"" which explained when therapy had provided moderate and minimal assistance. This translated to extensive assistance coding on the MDS. The therapy grading scale for moderate assistance was defined as: ""Resident performs up to 50% of the activity 3 or more times in 5 days. Caregiver performs 50-75% of the task assisting the resident through all or part of the activity."" Minimal assistance was defined as: ""Resident performs up to 75% of the activity 3 or more times in 5 days. Caregiver performs 25% of the task and may guide resident through parts of the task."" An interview with Employee #14, a certified occupational therapy assistant, treating the resident, was conducted at 10:12 a.m. on 09/25/12. The therapist explained if the resident was provided set up assistance she could dress her upper body by herself, but not her lower body. She said she had tried some reach assist training with her lower body, but the resident was bending and twisting too much. This had to be stopped until the resident could see her physician. She stated, ""At this point we don't have a follow up x-ray from her doctor so I wouldn't want her to do this. I don't know how stable her back is at this time."" She stated the resident was unsteady and someone should be with her when she is dressing. When asked if the resident should get her clothes from the closet, she stated staff would have to provide stand by assistance for the resident. When questioned about how the resident would brush her teeth, she stated the resident could brush her own teeth with stand-by assistance to get to the sink. Review of the occupational therapy notes, dated 09/14/12 found, ""... pt. (patient) able to complete ADL's of bathing and dressing for UB (upper body) with min. (minimal) A (assistance) and CGA (contact guard assistance) and for LB (lower body) (symbol for with) mod. (moderate) A (assistance)... pt. (patient) demos. (demonstrates) deconditioning and limited trunk flex. (flexibility)...pt. (patient) demos. (demonstrates) ability to complete functional transfers and mobility (symbol for with) min, (minimal) A (assistance) (symbol for with) walker and occasional loss of balance..."" Review of a grievance concern form found the resident had asked a therapist, Employee #138, to make a complaint on her behalf on 09/12/12. The complaint read as follows, ""On 09/12/12 resident reported to me at approximately 8:45 a.m. (name of CNA) was asked for assistance to get dressed for therapy. Resident stated CNA (certified nursing assistant) came in and left grooming/personal care items and left room and when CNA returned would stick her head into room and instead of assisting, resident states CNA would state, 'Oh, looks like you are able to do it on your own,' and walk out. Resident requires stand by assist for safety and CNA should be in room to supervise dressing. Resident states this has happened 2 days in a row on day shift. Resident has no complaints with night shift. Resident asked that I report this to someone."" Employee #138 was interviewed by telephone on 09/26/12 at 9:00 a.m. This employee verified this was her statement and the resident had asked her to report the above situation. Employee #138 stated she reported it to the facility social worker. Review of the MDS Kardex report (completed by the licensed nursing staff and used by the nursing staff to provide care) found guidance to the nursing assistants. It noted the resident was independent with dressing and personal hygiene. The above information was discussed with the administrator on 09/25/12, at approximately 10:30 a.m. No further information was provided to verify the resident was provided assistance, by from nurse aids with grooming and dressing, even though the therapist documented the resident required minimal to moderate assistance and contact guide assistance with dressing. .",2015-05-01
10260,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,325,D,0,1,FJI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and record review, the facility failed to provide services to ensure a resident's nutritional status was maintained. A therapeutic diet was not provided for one (1) of three (3) residents in Stage 2 of the QIS (quality indicator survey), who were reviewed for the care area of nutrition. Resident identifier #204. Facility census: 109. Findings include: a) Resident #204 Review of the medical record found the registered dietitian, Employee #30, completed a Medical Nutrition Therapy Assessment for the resident on 09/18/12. The plan to address the resident's nutritional status was, ""Provide fortified foods q (every) meal to (symbol for increase) available nutrients."" Further review of the assessment found the resident's admission weight was 98.4 pounds on 09/08/12. By 09/10/12 the resident's weight had decreased to 97.8 pounds. On 09/24/12 at 11:45 a.m., Employee #117, a registered dietician, was asked to describe a fortified diet. She stated the facility had five (5) different food items for fortified diets. The food items used for fortified diets were cereal, cream soup, potatoes, [MEDICATION NAME] milk, and super pudding. On 09/24/12 at 11:50 p.m. the cook, Employee #29, was asked what items were being served that day for residents on a fortified diet. He stated he was serving cream of tomato soup for the fortified diets. At 11:55 a.m. on 09/24/12, the resident was observed eating her lunch in the dining room. Employee #117 was asked to point out the fortified food item or items on the resident's tray. She stated, ""There isn't one, but I will get her some pudding."" .",2015-05-01
10261,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,353,F,0,1,FJI611,". Based on observation and staff interview the facility failed to designate a nurse to serve as a charge nurse. On 09/16/12 the facility did not have a nurse designated as a charge nurse. The facility also failed to deploy an appropriate number of staff to serve residents the evening meal, or to ensure morning snacks/supplements were consumed. This practice had the potential to affect all facility residents. Facility census: 109. Findings include: a) Charge nurse The facility was entered on 09/16/12, at approximately 5:30 p.m. Upon entrance to the facility the nurse (Employee #110) at the front desk was asked for the nurse in charge. Employee #110 (licensed practical nurse) stated, ""I don't know who that would be, we don't have one."" Further investigation discovered the South Hall nurse was always designated as the charge nurse. During an interview on 09/16/12, at approximately 6:45 p.m.,. with the South Hall nurse, Employee #74 (licensed practical nurse), she was not aware she was in charge. Employee #74 stated, ""I thought I was in charge of the fire drills."" Review of the staffing sheet for 09/16/12, identified the facility had not designated anyone as a charge nurse for the evening shift on 09/16/12. This information was conveyed to Employee #46 (administrator) on 09/16/12, at approximately 7:45 p.m. b) Deployment of Staff to Assist with Dining. 1) The facility was entered on 09/16/12, at approximately 5:30 p.m. The evening meal was being served at this time. Upon entrance to the facility, Employee #110 (licensed practical nurse) and an unidentified nurse aide were sitting at the front desk. Employee #110 stated, ""I'm working as an aide not a nurse today."" She further stated, ""The evening meal is being served now."" According to Employee #17 (dietary aide) the trays were delivered to the halls at these approximate times: South Hall 1st cart - 5:00 p.m. 2nd cart - 5:03 p.m. East Hall 1st cart - 5:20 p.m. 2nd cart - 5:27 p.m. North Hall 1st cart - 5:30 p.m. 2nd cart - 5:35 p.m. 2) Observation of the East Hall found only two (2) employees attempting to pass trays, Employee #96 (nurse aide) and Employee #48 (licensed practical nurse). At approximately 5:40 p.m., the trays were being delivered on the end of East Hall by only those two (2) staff members. Employee #17 stated, ""The trays for East Hall were sent out at 5:20 p.m."" 3) Review of the schedule for 09/16/12 identified the East hall was staffed with two (2) nurse aides and two (2) licensed practical nurses. One (1) of the nurses (Employee #109) and the other nurse aide (Employee #61) were working in the dining room. They were not available to pass the trays on the halls. 4) Further observation on 09/16/12 discovered an additional covered cart with resident trays was sitting in the middle of the East Hall at 5:45 p.m. This cart still contained trays which had not yet been delivered to the residents.. At the end of the East Hall, an additional cart, which was not covered, was observed with approximately eight (8) resident trays still on it. The only trays being passed on the East Hall were the trays at the end of the hall by Employee #48 and #96. At approximately 6:10 p.m., the two (2) employees (#48 and #96) made their way to the other end of the East hall and began delivering trays from the second and third carts. The third cart was not covered. Both carts had been sitting in the hall unattended since 5:27 p.m., according to Employee #17. Cart number #3 was not a covered cart as the other two (2) carts. The aides began passing the trays when kitchen staff were asked to take temperatures of the food, at approximately 6:10 p.m. on 09/16/12. Employee #38 (dietary aide) verified the temperatures of the food on the cart. The meal for the day was Swedish Meatballs and beets. All the trays also contained milk or some type of dairy product. The milk was poured in a glass. It was 50 degrees. The temperature of the Swedish Meatballs was 100 degrees. Employee #38 was shown an uncovered tray which belonged to Resident #93. Employee #38 confirmed the food was too cold and the milk was too hot to be served. She further stated, ""We don't have enough food to prepare all new trays, but I can replace Resident #93's tray. Resident #93 was sitting in his wheelchair at his doorway waiting on his meal at 5:45 p.m. Resident #164 stated, ""It's always this late before we get to eat then it's cold. I have complained before to the administrator."" He then went outside and did not wait for his meal to be delivered. After surveyor intervention, the two (2) nurse aides microwaved the residents food and the dietary aide replaced the milk. During an interview with an unidentified family member on 09/16/12, at approximately 6:20 p.m., the family member stated, ""I always come in to feed my father, and he's lucky if he gets his evening meal by 6:00 p.m. then it's cold."" On 09/16/12 at approximately 6:45 p.m., an unidentified staff member stated, ""I'm glad you recognize there is not enough of us to serve everyone."" 5) Observation of the tray delivery on 09/16/12 found the first food cart was delivered to the North Hall at 5:30 p.m. and the second cart was delivered to North Hall at 5:35 p.m. At 6:15 p.m. the last tray still remained on the first cart. At 6:15 p.m., Employee #37, a dietary aide was asked to take the temperature of Resident #34's tray. The meatballs and noodles were 108 degrees. The Resident's milk was 60 degrees. At 6:35 p.m., Employee #37 was asked to take the temperatures of the two reminding trays on the second cart, Resident's #137 and #105. The temperatures of the meatballs and noodles was 90 degrees and the milk was 60 degrees. At 6:45 p.m. on 09/16/12, Employee #37 was asked for a copy of the food temperature record. Employee #37 stated she had taken and recorded the temperatures of the noodles and meatballs before the food left the kitchen. The recorded temperatures were found to be within acceptable ranges. The temperature of the milk had not been recorded on the food temperature record. Employee #37 stated she was not in charge of taking the temperature of the beverages. She stated Employee #17 should have taken the temperature of the milk and recorded this temperature on the food temperature log. c) During Stage I of the quality indicator survey, Residents #154 and #204 complained about the temperatures of the food. Resident #154 was interviewed at 1:37 p.m. on 09/17/12 and Resident #204 was interviewed at 2:07 p.m. on 09/18/12. Both residents stated the food was never hot because it took too long to pass the trays. d) Review of the resident council minutes, for 06/06/12, found residents had previously complained of low staffing in the evenings. The facility commented the issue was resolved on 06/06/12. e) During the initial tour of the facility on 09/16/12, health shakes, which were those served for the 10:00 a.m. snack on 09/16/12, were found sitting on the over-the-bed tables of Residents #5 and #145. The daughter of Resident #5 was present when the health shake was discovered. Employee #39, a nursing assistant, was present when the health shake was found for Resident #145. .",2015-05-01
10262,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,356,C,0,1,FJI611,"., Based on observation and staff interview the facility failed to post the number and the actual hours worked for the evening of 09/16/12. The facility did not have posted the actual hours and number of licensed and unlicensed staff directly responsible for resident care. This practice had the potential to affect all residents and visitors. Facility census: 109. Findings include: a) The facility was entered on 09/16/12 at approximately 5:30 p.m. During tour of the facility, it was discovered the facility did not have the numbers posted for licensed and unlicensed staff responsible for providing care to the residents. This finding was confirmed with Employee #99 (staffing coordinator) and Employee #46 (administrator) on 09/16/12, upon visual observation of the daily staffing sheet. .",2015-05-01
10263,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,364,F,0,1,FJI611,". Based on observation, staff interview, food temperature measurement, and resident interview, the facility failed to ensure food was served at the proper temperature. Hot foods were not hot and cold foods were not cold at the time of receipt by the residents. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 109. Findings include: a) North Hall Food Temperatures Observation of the tray delivery, on 09/16/12, found the first food cart was delivered to the North Hall at 5:30 p.m. and the second cart was delivered to North Hall at 5:35 p.m. At 6:15 p.m. the last tray still remained on the first cart. At 6:15 p.m., Employee #37, a dietary aide, was asked to take the temperature of Resident #34's tray. The meatballs and noodles were 108 degrees. The resident's milk was 60 degrees. At 6:35 p. m., Employee #37 was asked to take the temperatures of the two (2) reminding trays on the second cart, for Residents #137 and #105. The temperature of the meatballs and noodles was 90 degrees and the milk was 60 degrees on each tray. At 6:45 p.m. on 09/16/12, Employee #37 was asked for a copy of the food temperature record. Employee #37 stated she had taken and recorded the temperatures of the noodles and meatballs before the food left the kitchen. The recorded temperatures were found to be within acceptable ranges. The temperature of the milk had not been recorded on the food temperature record. Employee #37 stated she was not in charge of taking the temperature of the beverages. She stated Employee #17 should have taken the temperature of the milk and recorded this temperature on the food temperature log. . . b) East Wing Food Temperatures The facility was entered on 09/16/12 at approximately 5:30 p.m. The evening meal was being served at this time. Upon entrance to the facility Employee #110 (licensed practical nurse) and an unidentified nurse aide were sitting at the front desk. Upon inquiry, Employee #110 stated, ""The evening meal is being served now."" According to Employee #17 (dietary aide) the trays were delivered to the halls at the approximate times. South Hall 1st cart - 5:00 p.m. 2nd cart - 5:03 p.m. East Hall 1st cart - 5:20 p.m. 2nd cart - 5:27 p.m. North Hall 1st cart - 5:30 p.m. 2nd cart - 5:35 p.m. At approximately 5:40 p.m., the trays were being delivered on the end of East Hall by two (2) staff members. Employee #17 stated, ""The trays for East Hall were sent out (from the kitchen) at 5:20 p.m."" Further observation on 09/16/12 discovered an additional cart, with undelivered resident trays, was sitting in the middle of the East Hall at 5:45 p.m. At the end of the East Hall was an additional cart with approximately eight (8) resident trays on it. The only trays being passed on the East hall were those being passed by the two (2) staff members, Employee #48 and #96. At approximately 6:10 p.m.,Employees #48 and #96 made their way to the other end of the East Hall and began delivering trays from the second and third carts. Both carts had been sitting in the hall since 5:27 p.m., according to Employee #17. The meal for the day was Swedish meatballs and beets. All the trays also contained milk or some type of dairy product. The milk was in a beverage tumbler. At approximately 6:10 p.m. on 09/16/12, a dietary staff member, Employee #38, was asked to take the temperatures of the foods on these two (2) remaining food carts. The temperature of the Swedish Meatballs was 100 degrees and the milk was 50 degrees. Employee #38 confirmed the hot food was too cold and the milk was too hot to be served. She further stated, ""We don't have enough food to prepare all new trays, but I can replace Resident #93's tray."" c) During an interview with an unidentified family member on 09/16/12 at approximately 6:20 p.m., the family member stated, ""I always come in to feed my father, and he's lucky if he gets his evening meal by 6:00 p.m. then it's cold."" d) During stage 1 of the quality indicator survey, Residents #154 and #204 complained about the temperatures of the food. Resident #154 was interviewed at 1:37 p.m. on 09/17/12 and Resident #204 was interviewed at 2:07 p.m. on 09/18/12. Both residents stated the food was never hot.",2015-05-01
10264,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,371,F,0,1,FJI611,". Based on observation and staff interview, the facility failed to store and serve food under sanitary conditions for one (1) of eight (8) observed residents. Resident #93's meal tray was sitting uncovered on a non-enclosed cart in the hallway. Additionally, the food storage area in the kitchen was not found in a clean and sanitary condition. This practice had the potential to affect all residents receiving nutrition from the kitchen. Facility census: 109. a) Resident #93 During observation of the evening meal on 09/16/12, at approximately 5:45 p.m., a non-enclosed cart was discovered on the East Wing hallway. Observation of this food cart at 5:45 p.m. revealed it contained an uncovered meal for Resident #93. The lid was only half covering the food. The meal tray was delivered to the hallway at approximately 5:20 p.m., according to Employee #17 (dietary aide). At 6:10 p.m., observation revealed a nurse aid preparing to serve the tray to Resident #93. This nurse aid was stopped from serving meal, by the surveyor, since the tray was in the hallway uncovered since 5:20 p.m. On 09/16/12 at approximately 6:15 p.m., Employee #37 confirmed the tray was uncovered and the tray was replaced after surveyor intervention. During the initial tour of the facility on 09/16/12, health shakes provided for the residents at 10:00 a.m. on 09/16/12, were found sitting on the over-the-bed tables in the rooms of Residents #5 and #145. The daughter of Resident #5 was present when the health shake was discovered. Employee #39, a nursing assistant, was present when the health shake was found for Resident #145. These products were no longer at safe temperatures for ingestion. . . b) At 10:00 a.m. on 09/17/12, observation of the food storage pantry in the kitchen was conducted with Employee #117, a registered dietitian. Observation of the refrigerator, used to store the facility's milk, found numerous pools of spilled milk in the bottom of the refrigerator. A rack in the refrigerator was rusted. The bottoms of the milk jugs stored on this rack were covered with black lines identical to the lines of rust on the rack. The floor of the pantry was littered with pieces of paper and food crumbs. Dirty, black shoe prints were observed on the floor throughout the pantry. Eight (8) metal racks, with three (3) shelves each, stored the facility's canned foods and dry food items. All of these shelves were rusted and covered with dust and debris. Employee #117 stated she would clean the refrigerator and take care of the shelves. She stated that housekeeping was responsible for cleaning the floor in the kitchen/pantry area and she would have the floor cleaned. c) On 09/24/12 at 3:24 p.m., observation of the kitchen with Employee #111, the dietary manager, found a return air filter in the ceiling, located at the end of the steam table, covered in lint and dust. .",2015-05-01
10265,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,428,D,0,1,FJI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure a gradual dose reduction was attempted after recommended by the consultant pharmacist and agreed upon by the resident's physician. Resident identifier: #145. Facility census: 109. Findings include: a) Resident #145 Review of the medical record revealed this [AGE] year old resident with dementia was admitted to the facility on [DATE], and was ordered Ativan (an anti-anxiety medication) one (1) milligram (mg.) twice daily for anxiety, on 09/21/11. Approximately two (2) weeks later, the dosage was increased to one (1) mg. three (3) times daily, where it has since remained. Review of the medical record found only one pharmacy request, on 07/03/12, for a Gradual Dose Reduction (GDR) of the Ativan, since the initiation of this medication. On 07/03/12 a gradual dose reduction (GDR) was recommended by the consultant pharmacist, to consider reducing the Ativan dosage to 0.5 mg. three (3) times daily, with the eventual goal of discontinuation of the medication, if possible. However, the physician declined to decrease the dose at that time. Review of a hand-written physician's progress note, dated 07/03/12, revealed the resident had a ""nervous tremor,"" and the physician's intent was to continue the Ativan and observe. During interview with the director of nursing on 09/19/12, at approximately 4:00 p.m., she said she thought this resident had two (2) attempts at a GDR of the Ativan in the past year. No information was provided to support this statement was provided prior to exit.",2015-05-01
10266,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,431,E,0,1,FJI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on inspection of the medication storage areas and staff interview, the facility failed to properly store medications. Observation of the medication room found opened injectable medications that had not been dated when opened to ensure use within the appropriate time frames for the medication. Facility census: 109. Findings include: a) Observation of the medication storage room, on 09/24/12, at approximately 3:29 p.m., found one (1) open vial of purified protein derivative (PPD - a test for [DIAGNOSES REDACTED]) and one (1) open vial of Novolin R insulin. Neither vial had been dated when opened to ensure the medication was not used beyond 28 days for Novolin or 30 days for the PPD, as recommended by the manufacturer. Observation of the medication room was conducted with Employee #48 (licensed practical nurse) on 09/24/12, at approximately 3:20 p.m. Employee #48 immediately disposed of the open medications. .",2015-05-01
10267,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,441,E,0,1,FJI611,". Based on observation, staff interview, and policy review, the facility failed to maintain infection control procedures to aid in the prevention and/or spread of infection within the facility. Fourteen (14) residents with oxygen concentrators were found to have outdated oxygen tubings currently in use. There were twenty-five (25) residents in the facility with concentrators in their rooms. Two (2) residents also had outdated tubing on their nebulizers, machines which deliver inhaled aerosol medications. Two (2) of the fourteen (14) residents had improperly stored nebulizer masks. Any of these situations could potentially increase the risk of acquiring infection in the respiratory tract. Resident identifiers: #69, #39, #26, #8, #67, #65, #71, #46, #207, #10, #95, #209, #106, #208, #93. Facility census: 109. Findings include: a) Resident #69 Observation on 09/16/12, at approximately 6:00 p.m., found the oxygen concentrator was currently in use. The tubing on this resident's concentrator was tagged and dated as last changed on 09/07/12. Review of the facility's infection control guidelines and care of resident care equipment, with revision date October 2009, revealed that oxygen tubings must be changed weekly, and the nebulizer tubings must be changed every 72 hours. b) Resident #39 Observation on 09/16/12, at approximately 6:00 p.m., found the oxygen concentrator was currently in use. The tubing on this resident's concentrator was tagged and dated as last changed on 09/07/12. c) Resident #26 Observation on 09/16/12, at approximately 6:00 p.m., found the oxygen concentrator was currently in use. The tubing on this resident's concentrator was tagged and dated as last changed on 09/07/12. On 09/16/12 at 6:15 p.m., licensed nurse, Employee #74, verified the oxygen tubings were outdated on the above three (3) concentrators, and made plans to have them changed. d) Resident #8 Observation on 09/16/12, between 6:30 p.m. and 7:00 p.m., found the oxygen concentrator was currently in use. The tubing on this resident's concentrator was tagged and dated as last changed on 09/07/12. e) Resident #67 Observation on 09/16/12, between 6:30 p.m. and 7:00 p.m., found the oxygen concentrator was currently in use. The tubing on this resident's concentrator was tagged and dated as last changed on 09/07/12. f) Resident #65 Observation on 09/16/12, between 6:30 p.m. and 7:00 p.m., found the oxygen concentrator was currently in use. The tubing on this resident's concentrator was tagged and dated as last changed on 09/07/12. g) Resident #71 Observation on 09/16/12, between 6:30 p.m. and 7:00 p.m., found the oxygen concentrator was currently in use. The tubing on this resident's concentrator was tagged and dated as last changed on 09/07/12. h) Resident #93 Observation on 09/16/12 between 6:30 p.m. and 7:00 p.m., found the tubing of the nebulizer machine was outdated. It was tagged and dated as last changed on 09/07/12. i) Resident #46 Observation on 09/16/12, between 6:30 p.m. and 7:00 p.m., found the oxygen concentrator was currently in use. The tubing on this resident's concentrator was tagged and dated as last changed on 09/07/12. j) Resident #207 Observation on 09/16/12, between 6:30 p.m. and 7:00 p.m., found the oxygen concentrator was currently in use. The tubing on this resident's concentrator was tagged and dated as last changed on 09/07/12. The tubing of the nebulizer machine was also outdated. It was tagged and dated as last changed on 09/07/12. The nebulizer machine was in the chair between the two (2) beds. The mask of the nebulizer was face down and had direct contact with the chair. k) Resident #10 Observation on 09/16/12, between 6:30 p.m. and 7:00 p.m., found the oxygen concentrator was currently in use. The tubing on this resident's concentrator was tagged and dated as last changed on 09/07/12. The tubing for the portable oxygen tank was also outdated. It was tagged and dated as last changed on 09/07/12. l) Resident #95 Observation on 09/16/12, between 6:30 p.m. and 7:00 p.m., found the oxygen concentrator was currently in use. The tubing on this resident's concentrator was tagged and dated as last changed on 09/07/12. The tubing for the portable oxygen tank was also outdated. It was tagged and dated as last changed on 09/07/12. m) Resident #209 Observation on 09/16/12, between 6:30 p.m. and 7:00 p.m., found the oxygen concentrator was currently in use. The tubing on this resident's concentrator was tagged and dated as having been changed on 09/07/12. The tubing for the portable oxygen tank was also outdated. It was tagged and dated as last changed on 09/07/12. n) Resident #106 Observation on 09/16/12, between 6:30 p.m. and 7:00 p.m., found the oxygen concentrator was currently in use. The tubing on this resident's concentrator was tagged and dated as last changed on 09/07/12. o) Resident #208 Observation on 09/16/12, between 6:30 p.m. and 7:00 p.m., found the nebulizer machine was sitting on the floor beside the bed The nebulizer mask was face down and had direct contact with the floor. p) On 09/16/12, at approximately 7:00 p.m., licensed nurse, Employee #109, verified the tubings were outdated on all the above mentioned concentrators, portable oxygen tanks, and nebulizer machines, and made plans to have them changed. She said Resident #208 had recently transferred to that bed, and apparently the bedside table was not moved, hence the nebulizer machine and mask on the floor. She spoke of plans to take care of that nebulizer, mask and tubing, as well as the nebulizer equipment for Resident #208. During interview with Employee #83 on 09/16/12 at approximately 7:15 p.m., she said a central supply department employee changes all the oxygen tubings every Friday, which should have most recently occurred on 09/14/12. During interview with the administrator on 09/16/12 at 7:25 p.m.., she said the oxygen tubings were supposed to be changed weekly. Review of the facility's infection control guidelines and care of resident care equipment, with revision date October 2009, revealed that oxygen tubings must be changed weekly, and the nebulizer tubings must be changed every 72 hours.",2015-05-01
10268,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,490,G,0,1,FJI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on the results of the QIS (quality indicator survey) beginning on 09/16/12 and staff interview, the governing body failed to ensure all deficient practices cited during a complaint survey conducted on 04/04/12 were corrected, as alleged in the plan of correction signed by the administrator on 05/04/12. Deficient practices remained in the following Federal Regulatory Groupings: Resident Behavior and Facility Practices, Quality of Life, and and Quality of Care. This deficient practice had the potential to affect all residents who reside in the facility. Facility census: 109. Findings include repeat deficiencies in the following areas: a) Resident Behavior and Facility Practices Review of the facility's concern/complaint files, review of the reportable allegations in the facility's abuse/neglect files, staff interview, and review of facility policy and procedures revealed the governing body failed to ensure all allegations of neglect and abuse were investigated and reported. b) Quality of Life 1) Review of medical records and staff interviews revealed the governing body failed to ensure an accurate,comprehensive assessment of the resident's functional capacity was completed for each resident. 2) Review of medical records, resident interview, and staff interview revealed the governing body failed to ensure a comprehensive care plan was completed for each resident. c) Quality of Life Review of medical records, staff interview, and policy and procedure review,revealed the governing body failed to assure residents maintained the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being in accordance with the comprehensive assessment and plan of care. The staff failed to provide appropriate care and services for one resident resulting in actual harm. The facility failed to monitor the resident's bowel regimen, secure physician's orders [REDACTED]. The facility also failed to assess a resident who received [MEDICAL TREATMENT] services upon return from the [MEDICAL TREATMENT] center, and failed to follow their care plan and guidelines for assessment of a resident receiving [MEDICAL TREATMENT]. Additionally pain medications were not consistently administered when a resident complained of pain, and pain was not evaluated and assessed. .",2015-05-01
10269,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,514,C,0,1,FJI611,". Based on observation and staff interview, the facility failed to maintain complete clinical information which was readily accessible for resident care. Review of the facility's medical records found less than two (2) months of clinical information in residents' charts. This practice affected all residents on the QIS survey sample. Additionally, the facility continued to document nursing information on a resident who was discharged from the facility. Resident identifier:#12. Facility census: 109. Findings include: a) Thinning of Medical Records Observation of the medical records for residents during the entire survey beginning on 09/16/12, discovered only one (1) month and seventeen (17) days of nursing information was accessible on the residents' medical records. According to the facility's ""Active Medical Record Index With Thinning Guidelines,"" the facility was supposed to leave three (3) months of current nursing information on the chart. On 09/26/12, at approximately 1:15 p.m., Employee #83 (medical records director) stated, ""Sometimes the charts get too full and I have to thin them."" b) Resident #12 Review of the medical record found this resident was discharged to home on 08/03/12. Further review of the nurses' notes found nursing staff continued to document in this resident's medical record, after the resident no longer resided in the facility, as though the resident was in the building on 08/05/12 and 08/06/12. Both nursing notes referenced, "" ...call light within reach. "" The administrator and the director of nursing were made aware of the above situation on 09/20/12 at 10:30 a.m. No further information was provided by the facility.",2015-05-01
10270,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,520,G,0,1,FJI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to implement and monitor actions to ensure that previously cited deficient practices were corrected. The process did not assure that practices were being consistently applied to prevent negative outcomes in areas where the facility's governing body was aware they have been deficient in the past. The QIS (quality indicator survey), beginning on 09/16/12 found four (4) repeated deficiencies cited in the complaint survey conducted on 04/04/12. One repeated deficient practice with continuing non-compliance was cited at a severity level of actual harm. These practices have the potential to affect all residents at the facility. Facility census: 109. Findings include: a) Quality Assessment and Assurance Committee During the QIS survey conducted on 09/16/12, the survey team found continuing non-compliance with four (4) regulatory requirements which were found to be deficient during the complaint survey conducted on 04/04/12. The following areas remained non compliant: 1) Resident Behavior and Facility Practices Review of the facility's concern/complaint files, review of the reportable allegations in the facility's abuse/neglect files, staff interview, and review of facility policy and procedures revealed the QAA committee failed to implement and monitor actions to ensure all allegations of neglect and abuse were investigated and reported. 2) Quality of Life a) Review of medical records and staff interviews revealed the QAA committee failed to implement and monitor actions to ensure an accurate,comprehensive assessment of the resident's functional capacity was completed for each resident. b) Review of medical records, resident interview, and staff interview revealed the QAA committee failed to implement and monitor actions to ensure a comprehensive care plan was completed for each resident. 3) Quality of Life Review of medical records, staff interview, and policy and procedure review,revealed the QAA committee failed to implement and monitor actions to ensure residents maintained the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being in accordance with the comprehensive assessment and plan of care. The staff failed to provide appropriate care and services for one resident resulting in actual harm. The facility failed to monitor the resident's bowel regimen, secure physician's orders [REDACTED]. The facility also failed to assess a resident who received [MEDICAL TREATMENT] services upon return from the [MEDICAL TREATMENT] center, and failed to follow their care plan and guidelines for assessment of a resident receiving [MEDICAL TREATMENT]. Additionally pain medications were not consistently administered when a resident complained of pain, and pain was not evaluated and assessed. 4) The current administrator was interviewed at 11:17 a.m. on 09/26/12. She stated she was not the administrator of record when the prior deficient practices occurred. .",2015-05-01
10271,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,502,D,0,1,FJI611,". Based on medical record review, and staff interview the facility failed to provide physician ordered laboratory services for one (1) of ten (10) sampled residents. . Resident identifier: #207. Facility census: 109 Findings include: a) Resident #207 Review of the medical record, on 09/24/12, found Resident #207 was ordered a PT/INR to be obtained on 09/14/12. Further review of the medical record discovered the facility did not obtain the laboratory (lab) test as ordered by the physician. On 09/25/12, at approximately 11:35 a.m., Employee #63 stated she did not know why the lab test was not obtained for the resident on 09/14/12.",2015-05-01
10272,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-11-28,365,D,0,1,FJI612,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and observation of the resident's meal and meal ticket, the facility failed to ensure a resident who was care planned for weight loss received a therapeutic diet as prescribed by the physician. This was true for one (1) resident who was randomly observed. Resident Identifier: #154. Facility census: 106. Findings include: a) Resident #154 On 11/27/12 at 12:37 p.m., the resident was observed eating her meal in her room. When asked about her meal she stated, ""I am suppose to get milk with every meal and I don't have any."" Observation of the resident's meal found she had received iced tea as directed by her tray ticket. Review of the medical record found a physician's orders [REDACTED]. Further review of the care plan found a problem of, ""Alteration in nutrition status AEB (as evidenced by) significant wt. (weight) loss x (times) 30 d (days) per 09/10/12...."" An approach for this problem was, ""Provide 8 oz (ounces) milk q (every) meal."" Employee #112, the dietary manager was interviewed at 2:25 p.m. on 11/27/12. She stated she was not aware the resident was to receive 8 ounces of milk with each meal. This employee stated she does not attend the care planning meetings, the registered dietitian attends the care plan meetings. She stated she would add the milk to the resident's tray ticket. .",2015-05-01
10273,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-12-18,369,D,0,1,FJI613,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, and staff interview, the facility failed to ensure a resident received all food items in individual bowls as directed by the physician's orders [REDACTED]. Resident identifier: #49. Facility census: 107. Findings include: a) Resident #49 Observation of the noon meal, in the dining room on 12/13/12, found the resident's tray ticket directed all foods were to be served in bowls. However, the resident's potatoes were served on a plate. Employee #62, a licensed nurse, was seated at the table with Resident #49. This employee observed the tray ticket and stated she did not know why the potatoes were not in a bowl as were the other food items on the resident's tray. Further review of the medical record found a physician's orders [REDACTED]."" An interview was conducted with the dietary manager, Employee #106, at 10:15 a.m. on 12/18/12. The dietary manager verified the resident's food items were to be served in bowls and stated this was a recommendation from the therapy department. Employee #119, the speech therapist, was interviewed at 10:30 a.m. on 12/18/12. She stated the diet was ordered due to the resident's [DIAGNOSES REDACTED]. This served as tactile stimulation for the resident cuing her to feed herself. .",2015-05-01
10274,FAIRHAVEN REST HOME INC,515021,"700 MADISON AVENUE, PO BOX 2806",HUNTINGTON,WV,25727,2009-08-06,279,D,0,1,7LLN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a care plan for all issues identified on the comprehensive assessment including the triggered resident assessment protocols (RAPs). This was evident for one (1) of ten (10) sampled residents. The facility also failed to develop a care plan to address care for a diabetic resident. This was evident for one (1) random resident. Resident identifiers: #36 and #17. Facility census: 40. Findings include: a) Resident #36 Resident #36's comprehensive assessment, dated 06/24/09, identified the problem of falls, resulting in a decision to develop a care plan for that issue. The care plan mentioned the risk of falls as it related to [MEDICAL CONDITION] drug use, but it failed to identify appropriate interventions to address the fall risk. The director of nursing was made aware of this at 9:30 a.m. on 08/06/09. During interview with the consultant pharmacist on 08/05/09 at 9:30 a.m., she clarified that gradual dose reductions (GDRs) had been made in a timely manner since admission. The dosage of antidepressant [MEDICATION NAME] was decreased in December 2008 and will be due for another GDR before December 2009, since the resident had been on it for greater than one (1) year. The anti-anxiety medication [MEDICATION NAME] had a GDR on 02/13/09 and is due for another GDR again in August 2009. The antidepressant [MEDICATION NAME] had a second GDR in July 2009, decreasing the dosage from 100 mg daily at the time of admission down to 50 mg, then reduced again down to 37.5 mg. The GDRs were not mentioned in Resident #36's care plan, especially as they related to the need for staff to monitor the resident's responses to adjustments in the medication regimen with respect to the potential for falls. b) Resident #17 Resident #17's [DIAGNOSES REDACTED]. Medication pass observation, on 08/05/09 at 4:10 p.m., revealed she had an elevated blood sugar of 483 which required coverage of 12 units of [MEDICATION NAME]-R insulin in addition to her scheduled dose of [MEDICATION NAME] 70/30 insulin 11 units. The medication nurse (Employee #11) said this resident's blood sugars were always up and down. During reconciliation of the medication pass the following morning, Resident #17's medical record revealed her care plan did not identify diabetes nor interventions for diabetic care needs. The care plan revealed blood sugars were to be assessed by staff four (4) times per day as listed under the laboratory section. The diet was listed as no added salt / low concentrated sweets under the nutrition section of the care plan. Interview with the director of nursing, on 08/06/09 at 9:30 a.m., revealed she was updating Resident #17's care plan at this time and would include more thorough diabetic care issues than the current plan of care contained. .",2015-05-01
10275,FAIRHAVEN REST HOME INC,515021,"700 MADISON AVENUE, PO BOX 2806",HUNTINGTON,WV,25727,2009-08-06,323,E,0,1,7LLN11,"Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. This was evident for residents on the third floor and had the potential to affect all ambulatory or self-wheeled residents housed on that floor. Third floor resident census: 20. Facility census: 40. Findings include: a) The door alarms to the four (4) exit doors on the third floor were Radio Shack units which could be set to chime when opened, alarm loudly when opened, or lock. The units were visible and within easy reach of ambulatory residents or those sitting in wheelchairs. The mechanisms that set the parameters for the units were thin plastic bars that could be slid with the touch of a fingertip to set the unit to chime, alarm, lock, or turn the unit off in a similar manner one would find on an alarm clock. Two (2) of the doors at each end of the unit opened to stairwells leading to outside exits. One (1) door close to the nurse's desk opened to a stairwell leading to the second floor. This door was set to chime to alert staff that the door had been opened. This door immediately opened to the first step with no landing between the door and the stairwell. Hence, a resident would be able to open the door and either exit or fall down the stairs if staff were not in the immediate vicinity to prohibit it. The fourth door was beside the latter and led to the stairwell going up to the fourth floor. It, too, was set to chime when opened. All four (4) doors could be opened from inside the stairwells to enter the third floor. On 08/03/09 at 6:42 p.m., the exit door at the end of the room 300-305 hallway was found to be unlocked and with no alarms sounding when opened. Employees #13, #25, and #24 staffed the floor and came to inspect the door being opened with no alarms sounding nor lock to prevent its opening. They immediately summoned a maintenance worker. The maintenance employee demonstrated how the mechanism was set to alarm loudly when the door was opened, and no one was able to determine how it came to be unlocked and with no alarm. The two (2) exit doors in the middle of the hallway were set to chime when opened, and staff reported they would be able to hear the chimes whenever the doors were opened. The exit door at the other end of the hall at the room 312-318 end of the hallway was set to alarm loudly in an ear splitting alarm when the door was opened. At 7:30 p.m., these findings were reported to the administrator (Employee #2). On 08/04/09, the physical environment director (Employee #44) stated he would order magnetic locks for the four (4) exit doors on the third floor similar to the locks on the second floor. The locks on three (3) of four (4) second floor exit doors can only be activated by entering a numeric code to allow opening. The fourth exit door leads to the stairwell leading upstairs to the third floor and chimes when opened. In the meantime, Employee #44 stated he can utilize a temporary method to block the third floor door alarms from being able to be pushed to the ""off"" position until the new locks arrive. The State survey agency's program manager was notified of the door lock / alarm situation and directed notification of the life-safety code program manager. Subsequently, the life-safety code program manager spoke directly with the administrator and physical environment director to address corrective action.",2015-05-01
10276,"ST. JOSEPH'S HOSPITAL, D/P",515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2011-05-11,329,D,0,1,09KX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure each resident's medication was free of unnecessary drugs. One (1) of fourteen (14) Stage II sample residents received medications for an excessive duration with no gradual dose reduction (GDR) attempts for [MEDICATION NAME] and/or [MEDICATION NAME] or documentation stating such GDR attempts were clinically contraindicated. Resident identifier: #16. Facility census: 16. Findings include: a) Resident #16 Review of Resident #16's medical record disclosed this [AGE] year old female was admitted on [DATE] with [DIAGNOSES REDACTED]. Her admission physician's orders [REDACTED]."" On 05/20/10, the physician ordered: ""[MEDICATION NAME] 30 mg po HS (at bedtime) for depression."" There was no evidence in the record of an attempted GDR of these medications, although the behavior monitoring records for this resident revealed there had been NO behaviors associated with depression and/or anxiety in the preceding four (4) months. A review of the physician's progress notes found only brief comments about the medications as follows: - 04/11/10 - ""[MEDICATION NAME] controls [DIAGNOSES REDACTED]."" - 08/31/10 - ""...staff report she does get anxious...Continue [MEDICATION NAME] as ordered,..."" - 10/08/10 - ""Cont Rx (prescription), [MEDICATION NAME] & [MEDICATION NAME] effective & necessary."" - 10/16/10 - ""[MEDICATION NAME] 1 mg TID."" (This was in response to a flagged alert from nursing for the physician to address the use of psychoactive medications.) During an interview with the director of nurses at 8:30 a.m. on 05/11/11, she stated she had flagged the progress notes when she realized no GDR had been done. She acknowledged that the entry above was the only response to her alert. In an interview with the consultant pharmacist at 8:45 a.m. on 05/11/11, she acknowledged, after reviewing the resident's record, that she had only questioned the use of [MEDICATION NAME] one (1) time, shortly after admission, with the following entry in the record: ""5/4/10 - Is [MEDICATION NAME] for tremors, anxiety, or both?"" She stated she had inquired, after seeing the physician's progress note that the [MEDICATION NAME] was controlling ""[DIAGNOSES REDACTED]"". The pharmacist stated she did not receive a response to that inquiry and admitted she had not questioned the physician again since the resident's admission about either of these drugs. She also agreed the medical record showed no evidence of a [DIAGNOSES REDACTED]. Further review revealed no comprehensive assessment or care plan for tremors in the resident's medical record. During an interview with the physician at 8:28 a.m. on 05/11/11, he stated he did not realize the ""[DIAGNOSES REDACTED]"" he mentioned in the original history and physical had not been entered in the resident's record as an active diagnosis. He stated the resident has been on [MEDICATION NAME] to control anxiety, and thus lessening the tremor, for many years, and he said he would review the resident's record and address the indications for using the [MEDICATION NAME] and [MEDICATION NAME] and why he did not choose to attempt a GDR. .",2015-05-01
10277,"ST. JOSEPH'S HOSPITAL, D/P",515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2011-05-11,371,F,0,1,09KX11,". Based on observation, staff interview, and facility policy review, the facility failed to maintain recommended minimum safe holding temperatures for hot foods prior to service. Facility census: 16. Findings include: a) On 05/09/11 at 11:48 a.m., steam table temperatures were taken near the end of the luncheon meal tray line. They were taken by the facility's dietary manager (Employee #15) at the surveyor's request, and she confirmed the temperatures as follows: - Grilled Cheese Sandwich - 130 degrees Fahrenheit (F)- Home Fries - 132 degrees F b) On 05/10/11 at 11:50 a.m., steam table temperatures were again taken near the end of the luncheon meal tray line. They were taken by a dietary staff member (Employee #14) at the surveyor's request, and she confirmed the temperatures as follows: - Hot Dog - 115 degrees F - Chili Sauce - 130 degrees F - Baked Beans - 120 degrees F c) The facility's policy / procedure was obtained from the dietary manager at 12:08 p.m. on 05/10/11. Review of the Nutrition Services Policy Manual, Chapter Seven (VII), Section G, Food Quality Standards, found under the heading ""Policy"": ""To provide a procedure for checking all food items for quality and safety prior to service to all patients and visitors."" Item ""d"" under the heading ""Procedure"" stated: ""Hot food will be held at 140 degrees F during service."" The 2005 Food Service Code states hot food holding temperature should be at least 135 degrees. The code states danger zone holding temperatures are between 41 degrees F and 135 degrees F. .",2015-05-01
10278,"ST. JOSEPH'S HOSPITAL, D/P",515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2011-05-11,428,D,0,1,09KX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the pharmacist failed to identify and report irregularities in the medication regimen of one (1) of fourteen (14) Stage II sample residents, who continued to receive psychoactive medications without gradual dose reduction (GDR) attempts when indicated. Resident identifier: #16. Facility census: 16. Findings include: a) Resident #16 Review of Resident #16's medical record disclosed this [AGE] year old female was admitted on [DATE] with [DIAGNOSES REDACTED]. Her admission physician's orders [REDACTED]."" On 05/20/10, the physician ordered: ""Remeron 30 mg po HS (at bedtime) for depression."" There was no evidence in the record of an attempted GDR of these medications, although the behavior monitoring records for this resident revealed there had been NO behaviors associated with depression and/or anxiety in the preceding four (4) months. A review of the physician's progress notes found only brief comments about the medications as follows: - 04/11/10 - ""Ativan controls [DIAGNOSES REDACTED]."" - 08/31/10 - ""...staff report she does get anxious...Continue Ativan as ordered,..."" - 10/08/10 - ""Cont Rx (prescription), Ativan & Remeron effective & necessary."" - 10/16/10 - ""Ativan 1 mg TID."" (This was in response to a flagged alert from nursing for the physician to address the use of psychoactive medications.) During an interview with the director of nurses at 8:30 a.m. on 05/11/11, she stated she had flagged the progress notes when she realized no GDR had been done. She acknowledged that the entry above was the only response to her alert. A drug regimen review, completed by the pharmacist on 05/04/11, resulted in the physician being asked the following: ""Is Ativan for tremors, anxiety, or both?"" This query was never answered, but the monthly pharmacy reviews from 06/08/10 through 05/11/11 all indicated there were NO recommendations. In an interview with the consultant pharmacist at 8:45 a.m. on 05/11/11, she acknowledged, after reviewing the resident's record, that she had only questioned the use of Ativan one (1) time, shortly after admission, with the following entry in the record: ""5/4/10 - Is Ativan for tremors, anxiety, or both?"" She stated she had inquired, after seeing the physician's progress note that the Ativan was controlling ""[DIAGNOSES REDACTED]"". The pharmacist stated she did not receive a response to that inquiry and admitted she had not questioned the physician again since the resident's admission about either of these drugs. She also agreed the medical record showed no evidence of a [DIAGNOSES REDACTED]. She acknowledged being aware that a GDR should either have been attempted or a valid medical reason recorded in the resident's chart to provide a rationale for not attempting a GDR, and she admitted that she did not notify either the physician or the director of nurses of this. During an interview with the physician at 8:28 a.m. on 05/11/11, he stated he did not realize the ""[DIAGNOSES REDACTED]"" he mentioned in the original history and physical had not been entered in the resident's record as an active diagnosis. He stated the resident has been on Ativan to control anxiety, and thus lessening the tremor, for many years, and he said he would review the resident's record and address the indications for using the Ativan and Remeron and why he did not choose to attempt a GDR.",2015-05-01
10279,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2012-01-30,278,D,1,0,LNV211,". Based on record review and staff interview, the facility failed to ensure the minimum data set (MDS) assessment accurately reflected the status of the resident. An MDS assessment, with an assessment reference date (ARD) of 01/18/12, indicated a resident had not had any falls since his last assessment. The nursing notes indicated he had fallen on 12/02/11. The assessment did not reflect the falls correctly for one (1) of nine (9) sampled residents. Resident identifier: #60. Census: 159. Findings Include: a) Resident #60 A review of this resident's most recent MDS assessment, with an ARD of 01/18/12, found in Section ""J1800"" the resident was not coded as having had any falls since his prior assessment. It was noted his prior assessment was a significant change assessment completed on 10/19/11. Review of the nursing notes for this resident found he had suffered from a fall in his room on 12/02/11. During an interview with the MDS nurse (Employee #68), on 01/29/2011 at 9:40 a.m., it was identified the computer program pulled this information from an assessment that was completed when a resident had a fall. He verified Resident #60's assessment was not accurate and stated he would complete a modification. .",2015-05-01
10280,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2012-01-30,280,D,1,0,LNV211,". Based on record review, observation, and staff interview, the facility failed to revise a care plan to reflect the treatments and interventions the resident was receiving. The care plan for Resident #9 stated she was to be in a low bed with landing strips. This resident was observed to be in bed in a high position with a special air flotation mattress on her bed. No landing strips were observed at that time. It was identified these interventions had been revised and were no longer appropriate for this resident, but were still in the interdisciplinary care plan. This was true for one (1) of nine (9) sampled residents. Resident identifier: #9. Facility Census: 159. Findings include: a) Resident #9 Resident #9 was observed multiple times from 01/26/12 to 1/30/12. She was observed to be in a bed with a special air flotation in a high position. There were no landing strips, or mats of any kind, on the floor. This resident was identified as being total care and required total assistance for bed mobility because she was not able to move herself in the bed. Review of the interdisciplinary care plan identified the resident was considered at risk for falls. This care plan was revised on 01/02/12. The interventions included ""low bed with landing strips and bed bolster to edge of bed to define perimeter and alert resident to the edge of the bed"". It was observed these interventions were not being followed as the resident was in a high bed with a specialty mattress and no mats or bolsters were observed on her bed. The director of nursing (DON) was interviewed at 2:00 p.m. on 01/30/12. She verified Resident #9 had not been in a low bed with landing strips and bolsters for a long time. She confirmed the care plan had not been revised to reflect those changes. .",2015-05-01
10281,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2012-01-30,318,D,1,0,LNV211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to provide appropriate treatment to prevent a further decline in range of motion, and worsening of contractures, for a resident who already had these impairments. Resident #9 did not have her palm guard applied to her left hand as recommended by previous therapy treatments, and as ordered by the physician, for prevention of further contractures of this hand. This was true for one (1) of nine (9) sampled residents. Resident Identifier: #9. Facility Census: 159. Findings Include: a) Resident #9 This resident was observed in bed on her back at 1:00 p.m. on 01/26/12. She was noted to have contractures of her hands present. She did not have any devices in her hands at that time. This resident was observed again, at 10:00 a.m. on 01/27/12. It was noted again she had contractures present with no devices in her hands. The nurse (Employee # 157) was interviewed on 01/27/12 regarding the resident's contractures. He stated the resident was supposed to have a splint on her hand. He looked around the room and in the drawers, but did not find the splint that was ordered to be used for the resident's hand. The physician's orders [REDACTED]. It was noted there was an order for [REDACTED]. The care plan included an intervention of ""left palm guard from 8 am to 2 pm. Provide gentle Nrsg (nursing) ROM (range of motion) prior to application"". The days (01/26/12 and 01/27/12) this resident was observed without this device in her hand, were within the time frame it was prescribed to be worn, on both days. An interview was conducted with the restorative nursing supervisor (Employee #25). She was questioned about the staff instructions and use of this device. She stated the resident used to have this applied by restorative nursing, but now her caregivers are instructed to do this daily. She provided a sheet, that had been completed on 02/21/11, by occupational therapy. The document included the goal for this device was to ""maintain current ROM (range of motion) to her left hand and prevent further contractures."" The instructions for the use of this device were written out to state ""please apply palm guard to left hand at 8 am and remove at 2 pm. Please provide daily skin checks and report any redness, [MEDICAL CONDITION], and/or skin breakdown to nursing"". .",2015-05-01
10282,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2012-01-30,328,D,1,0,LNV211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to ensure a resident received the appropriate care and treatment to meet her special needs. The resident had a [MEDICAL CONDITION] and was receiving oxygen therapy. Observation of the resident's oxygen equipment found the humidifier, to provide humidity to her [MEDICAL CONDITION], was empty. There was no moisture being provided to her airway. Her oxygen concentrator was also observed to have no filter present in the side of the concentrator. This practice had the potential to cause more than minimal harm if oxygen was administered in this manner for a prolonged period of time. This practice affected one (1) of three (3) residents who were receiving oxygen through a [MEDICAL CONDITION]. Resident identifier: #9. Facility Census: 159. Findings include: a) Resident #9 This resident's room was entered at 10:50 a.m., with a nurse, Employee #157, on 01/27/11. Observation revealed there was no water in the humidifier bottle on the oxygen to provide humidity to the resident's airway while oxygen was being administered. There was no condensation in the tubing or the bottle, indicating the water had been out for some time. Employee #157, a nurse, was questioned about the humidity bottle. He stated the nurses take care of it and it is usually changed before the bottle goes empty. He obtained another bottle of water from the resident's oxygen supplies and attached it to the resident's oxygen. The oxygen concentrator and filter on the side of the concentrator were observed. There was no filter present in the compartment of the concentrator where the filter should have been. Employee #157 was questioned about this. He stated respiratory therapy maintained the concentrators and nurses did not take care of the filters. He confirmed it was the nurses' responsibility to maintain the humidity to the residents' oxygen. The respiratory therapist (Employee #191) was interviewed at 11:45 a.m. on 01/27/12. She was questioned about the humidifier bottles. She stated the humidifier bottle should never go dry. Employee #191 stated there was a line on the bottle to indicate when the bottle should be changed. This was to prevent the bottle from going dry. She explained staff should change the bottle when the water level was to that line. Employee #191 stated it was very bad for the airway when the humidity was not there. She stated, without humidity, the mucus got thick and hardened when dry air blew into the airway. Employee #191 stated usually the humidifier bottle lasted a day and a half. She was also questioned about the oxygen concentrators. She stated there was an assistant that changed out the machines. The assistant was also responsible for the filters and maintenance to ensure everything was functioning properly. She was made aware of the filter missing from Resident #9's concentrator. .",2015-05-01
10283,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2012-01-30,465,D,1,0,LNV211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to ensure a bed was clean and as sanitary as possible for a resident who had multiple special needs and was bedridden. The resident had a specialty mattress. When the sheets and blankets were lifted, the mattress was observed to be soiled and covered with specks of what appeared to be dried skin. The resident had side rails to the upper quarter sections of the bed. These side rails were observed to be dirty and covered with dust and particles. This was observed for one (1) of nine (9) sampled residents. Resident identifier: #9. Facility Census: 159. Findings include: a) Resident #9 During an observation of [MEDICAL CONDITION] care for Resident #9, it was noted this resident also had a feeding tube and a [MEDICAL CONDITION]. She was in the bed much of the time due to her condition. The nurse (Employee #157) was asked to raise the covers on the bed so the resident's positioning could be observed. Observation revealed the resident's mattress was covered with dried white flakes which appeared to be dried skin. The mattress was also very dirty and had stained. Additionally, the side rails on the top quarter of the bed had dust and particles all over them. This observation was discussed and confirmed with Employee #157. He stated he would get someone to clean the resident's bed. .",2015-05-01
10284,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2012-01-30,514,D,1,0,LNV211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, record review, policy review, and staff interview, the medical records for two (2) of nine (9) sampled residents were not complete and / or accurately documented. The facility's policy for documentation of [MEDICAL CONDITION] care and documentation for [MEDICAL CONDITION] suctioning were not followed for Resident #9. The facility also did not maintain accurate bowel records for Resident #90. Resident identifiers: #90 and #9. Facility Census: 159. Findings Include: a) Resident #90 This resident had a [DIAGNOSES REDACTED]. She also had some problems with constipation. She had diabetes, high blood pressure, chronic pain, dehydration, and [MEDICAL CONDITION]. The resident received daily medications for her bowels for regularity purposes. The resident was having problems with constipation as evidenced by review of her January 2012 bowel records. On 01/03/12, the resident's third day without a bowel movement, the facility's bowel protocol was initiated according to facility policy. The resident did not have a bowel movement. So on the fourth day (01/04/12), the next step of the bowel protocol was implemented by inserting a rectal suppository. According to the nursing notes, the resident (who was alert and oriented) did not want further interventions until waiting to see whether the suppository worked for her by the next day. The nurse called the doctor, on 01/07/12, due to the resident's constipation. The doctor ordered an enema. The nurse administered the enema, but no bowel movement resulted. She called the physician and orders were received to transfer the resident to the hospital. Her admitting [DIAGNOSES REDACTED]. The medical record contained documentation the resident had results from the suppository. The documentation noted she had an extra-large bowel movement on 01/05/12 on the midnight shift, and an extra-large bowel movement on 01/06/12 on the day shift. During an interview with Employee #86, a nurse, regarding this discrepancy on 01/29/12, she stated the bowel record was not accurate. She stated someone went back and marked the bowel movements after she administered the medication to the resident. The nurse stated the resident told her she had not had a bowel movement. Additionally, on some days there was documentation the resident did not have a bowel movement and also on the same day there was documentation the resident had a large bowel movement. It was not possible to determine which was accurate for this resident. At that time, it was confirmed bowel records were not accurate for this resident. b) Resident #9 During an observation of Resident #9's [MEDICAL CONDITION] suctioning and care, on 01/27/12 at 10:50 a.m., the nurse (Employee # 151) was observed suctioning the resident and providing [MEDICAL CONDITION] care according to the facility's policy. The policy for these procedures concluded with instructions of what information needed to be documented in the medical record. The policy and procedure for [MEDICAL CONDITION] Suctioning instructed to document the following: ""38.1 Date and time of procedure 38.2 Amount, color, and consistency of secretions 38.3 Breath Sounds, respiratory rate, cough effort pre and post procedure 38.4 Patients response to suctioning."" The policy and procedure for [MEDICAL CONDITION] care instructed documentation as follows: ""33.1 Date and time of procedure 33.2 Observations of skin at stoma site 33.3 Breath sounds, heart rate, respiratory rate, and cough effort pre and post procedure 33.4 Patients response to the procedure."" This information was not recorded in the medical record following the resident's [MEDICAL CONDITION] care. The treatment record was reviewed. This review revealed only a place to initial that [MEDICAL CONDITION] care had been done. There was no assigned space for documentation of the other things which required assessment and documentation according to the facility's policy. Although the nurse was observed listening to breath sounds and assessing the resident prior to the procedure, there was nothing documented regarding this, as required by facility policy. .",2015-05-01
10285,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-04-14,174,D,0,1,KZR811,". Based on resident interview, observation, and staff interview, the facility failed to provide reasonable access to the use of a telephone where calls can be made without being overheard, for one (1) of thirty-seven (37) Stage II sample residents. Resident identifier: #42. Facility census: 115. Findings include: a) Resident #42 During an interview with Resident #42 on 04/13/11 at 5:00 p.m., she complained she did not have a private way to have a conversation with her son when he calls her. She stated facility staff has to come to her room, get her out of bed, and take her to the nursing station to receive telephone calls - where everyone could hear her. She stated she wanted to remain in her room to speak with her son when he called. Observation of the telephones present at the nursing station noted a portable phone was on the countertop. On 04/13/11 at 5:09 p.m., a member of the maintenance staff (Employee #26) inspected the portable phones purchased for resident use at 5:09 p.m. on 04/13/11. He stated a switch was missing and the phones were not functional. The facility failed to maintain the portable phones intended for residents to make private calls. .",2015-05-01
10286,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-04-14,225,D,0,1,KZR811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to immediately and accurately report and/or thoroughly investigate allegations of involving resident neglect / abuse for two (2) of three (3) allegations reviewed. Additionally, the facility failed to reach a reasonable conclusion based on the results of its internal investigation for one (1) of the two (2) allegations of neglect reviewed, during which the facility verified that a nursing assistant turned off a resident's call light and did not return to render the requested assistance to the bathroom (after which the resident sustained [REDACTED]. Resident identifiers: #182 and #145. Facility census: 115. Findings include: a) Resident #182 Review of the facility's records of allegations of neglect found the facility reported an allegation of neglect which occurred on 03/28/11 involving a nursing assistant (Employee #102) and contained the following language: ""It is alleged that CNA (certified nursing assistant) went into resident's room (Resident #182) and turned off call light and did not provide care to the resident."" Review of the facility's five-day follow-up report found the facility did not substantiate the allegation of neglect; however, the report included the following narrative: ""CNA did answer call light and turned light off. He told resident he would be right back. He left the room to finish assisting another resident. He returned to resident's room to provide assistance. Care was provided to resident."" Review of the handwritten statement signed by Employee #102 on 03/30/11 found the following language: ""On Monday from about 2 pm to about 8 p.m., I had been in resident's room about 17 times. Each time I went into the room, she asked each time for assistance to use the bathroom. I helped her to the bathroom, left her for privacy in the bathroom and told her to use the call light when she was done. She did use her call light and I went into the bathroom and assisted her back in bed. Prior to resident falling, her call light was on, (""I entered room and asked her to wait because I had another fall risk using the bathroom at that time."") The resident's light came back on one or two more times prior to me finishing with the other resident. Once I finished with the other resident, I returned to (Resident #182's name) and found her sitting on the floor in the upright position..."" Review of the facility's fall report revealed Resident #182 was found sitting on the floor beside her bed at 8:30 p.m. on 03/28/11 with no apparent injuries. The report documented the resident stated she did not realize the foot of her bed was elevated, and when she ""scooted down to transfer to w/c (wheelchair) the bed was too high"", and she slid down the bed and in the floor. The report documented the resident had a history of [REDACTED]. The facility failed to disclose to the Nurse Aide Registry that Resident #182 sustained a fall following Employee #102's failure to immediately provide assistance to the resident. The facility did not disclose that the resident's bed was not in a low position when Employee #102 left the resident's room without providing requested assistance. The facility did not reach a reasonable conclusion by not substantiating the allegation of neglect, when the investigation revealed Employee #102 turned the resident's light off without providing assistance and did not assure the resident's bed was in a low position, and the resident sustained [REDACTED]. -- b) Resident #145 Review of an allegation of neglect / abuse found that, on 03/25/11, a family member of Resident #145's roommate stated a nursing assistant (Employee #17) pulled a sheet out of Resident #145's hand, causing her to bump her face on the bedside table. Review of the facility's investigation found no statement from the family member making the allegation. An interview with social worker (Employee #42), on 04/14/11 at 5:35 p.m., elicited that no statement was obtained from the family member. Employee #42 stated the family member was difficult to reach, but this social worker could provide no evidence of attempts to contact the family member to obtain a statement. The facility failed to obtain statements from all the witnesses prior to finding the allegation to be unsubstantiated. A thorough investigation was not conducted prior to making this determination. .",2015-05-01
10287,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-04-14,247,D,0,1,KZR811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, medical record review, and staff interview, the facility failed to notify residents in advance, prior to changing a resident's room or roommate, for three (3) of thirty-seven (37) Stage II sample residents. Resident identifiers: #53, #68, and #74. Facility census: 115. Findings include: a) Resident #53 The resident stated, in an interview conducted during Stage I of the survey on 04/05/11 at 11:15 a.m., that she had been moved to a different room and she did not feel staff gave her any notification. She was just moved and put in an isolation room and she did not like being by herself. b) Resident #68 A review of nursing notes, dated 01/14/11, revealed receipt of a physician's orders [REDACTED]. and roommate"". Another nursing note, dated 02/21/11, revealed: ""Resident transferred from room (#) to room (#) ... introduced to staff and roommate."" Another nursing note, dated 02/28/11, stated: ""Resident moved to room (#) ... Oriented to room and roommate."" Interview with this resident, during Stage I of the survey, revealed she did not feel she was given proper notification prior to these room changes occurring. c) Resident #74 Review of a change of condition documentation form revealed that, on 01/25/11, the resident was ""moved from room (#) to room (#). RP (responsible party) aware and consents to move. Resident oriented to new room mate and surroundings."" Another nursing note stated that, on 03/23/11, ""resident moved to room (#). RP aware."" This resident was considered by the facility to be interviewable and able to receive notification of such issues. d) Interview with a licensed practical nurse (LPN - Employee #128), in the mid-afternoon of 04/11/11, revealed the notations in the medical records of Residents #68 and #74 appeared to indicate the residents were moved without any discussion or without an opportunity to see the new room or meet the new roommate ahead of time. .",2015-05-01
10288,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-04-14,253,E,0,1,KZR811,". Based on observation and staff interview, the facility failed to provide maintenance services necessary to maintain the resident environment in good repair. This was evident in six (6) rooms on the Dogwood unit and had the potential to affect more than a minimal number of residents. Facility census: 115. Findings include: a) Rooms #302, #407, #408, #412, #414, and #117 While conducting resident interviews and room observations in Stage I of the survey, the rooms identified above were found to have scuff marks on bathroom walls near the hand sinks and many scrapes and gouge marks on the bathroom doors. This damage made the rooms unsightly and rendered the surfaces not easily cleanable. This was discussed with the maintenance supervisor (Employee #26) in the mid-afternoon on 04/12/11. He was aware of these issues and reported having implemented a plan to repair the damage. .",2015-05-01
10289,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-04-14,279,D,0,1,KZR811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility did not a develop care plan to address resident-specific concerns identified through the comprehensive assessment process for one (1) of thirty-seven (37) Stage II sample residents. Resident identifier: #42. Facility census: 115. Findings include: a) Resident #42 Review of the medical record found Resident #42 was ordered [MEDICATION NAME] 0.5 mg at bedtime on an as needed (PRN) basis. Review of the care plan found the facility did not develop interventions to provide clear and specific parameters as to what condition(s) should be present prior to administering this psychoactive medication. An interview with the facility's care plan nurses (Employees #125 and #5), on 04/14/11 at 6:22 p.m., confirmed the use of PRN [MEDICATION NAME] was not included in the resident's care plan. .",2015-05-01
10290,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-04-14,309,D,0,1,KZR811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, observation, staff interview, and policy review, the facility failed to ensure a resident, with physician's orders [REDACTED]. This practice affected one (1) of thirty-seven (37) Stage II sample residents. Resident identifier: #134. Facility census: 115. Findings include: a) Resident #134 1. Medical record review, conducted on 04/06/11, revealed this [AGE] year old female resident attended [MEDICAL TREATMENT] three (3) times per week related to a [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE]. On 11/23/10, the physician ordered a daily fluid restriction as follows (quoted as typed): ""Fluid restriction 1700cc's: dietary to provide 240ml with breakfast and dinner and 480ml with lunch. Nursing to provide 120 on 11-7: 360 on 7-3, and 240 on 3-11."" (NOTE: 1 cubic centimeter (cc) = 1 milliliter (ml).) Subsequent record review revealed the resident was determined, on 04/09/11, to not possess the capacity to understand and make her own medical decisions. -- 2. In an interview on 04/11/11 at approximately 2:00 p.m., the resident reported the facility had previously restricted how much fluid she drank, but she did not think they were doing that now. Observation found a pitcher with water on her overbed table. The resident said she did not like people telling her what to do, and when she wanted something to drink, she did not want anyone telling her she could not do something. -- 3. Review of Resident #134's care plan found the following problem statement (Date Initiated: 11/22/10): ""Risk for fluid output exceeding intake characterized by fluid volume deficit; dry skin and mucous membranes, poor skin turgor and integrity related to: decreased independent access to fluids, nausea / vomiting, uncontrolled health conditions, pain, laxatives / enema use, [MEDICAL TREATMENT], 1700 ml fluid restriction, able to consume fluids independently after set up."" The goal associated with this problem was: ""Show no signs of dehydration."" The interventions to assist the resident in achieving this goal were (quoted as typed): ""Observe effectiveness and side effects of laxatives. Observe resident for signs of dehydration (tenting skin, dry mouth, etc). Report to MD if present. Observe resident for signs of pain. Offer water / ice chips q 2 hrs (every two hours) or upon each encounter. Please straw in glass so resident can drink independently. Record frequency, consistency and amount of emesis. Administer [MEDICATION NAME] per MD orders."" These interventions were all initiated on 11/22/10, and no revisions / additions were made to this list of interventions after that date. - Further review of the resident's care plan found another problem statement (Date Initiated: 11/19/10), stating: ""Potential for altered nutritional status related to: catabolic illness ([MEDICAL CONDITION] with [MEDICAL TREATMENT]), fluid restriction, advanced age, subpar meal intakes at times. Weight fluctuations expected with fluid gains and losses r/t (related to) [MEDICAL TREATMENT]."" One of the interventions associated with this problem statement was: ""I&O every shift."" This intervention was initiated on 02/11/11. - Nowhere in the care plan was direction provided to staff regarding how the fluids were to be administered across a 24-hour period and by what discipline(s) (e.g., dietary, licensed nurses, nurse aides, activities, etc.), to ensure her total daily fluid intake did not exceed 1700 cc. -- 4. An interview with the dietary manager (Employee #60), on 04/11/11 at approximately 3:00 p.m., confirmed there were special instructions regarding what fluids came from the dietary department for Resident #134. The dietary department's special instructions were to send 240 cc with breakfast and dinner and 480 cc came with the lunch meal. -- 5. In an interview on 04/11/11 at approximately 4:30 p.m., Employee #6 (a nurse aide) reported she knew she could give Resident #134 a total of 240 cc of fluid on evening shift. She said she knew the resident liked chocolate milk and ice cream, and she usually had one (1) chocolate milk and two (2) ice cream treats on the evening shift. She also said she gave the resident ice chips once per shift. She presented the resident's kardex (a device or system for paper-based record-keeping). The oral / nutrition section of the kardex stated: ""Restrict fluids Amt: 1700."" -- 6. On 04/12/11 at approximately 9:15 a.m., the registered dietician (RD - Employee #87) verified the resident's care plan did not address the resident's non-compliance with the fluid restriction. The RD said the resident likes to feel she controls her medical decisions, and she likes to eat foods that are not ideal for her due to her health status. The RD stated she had offered the resident things to satisfy her thirst, such as lemon drops, but the resident refused these at the present time. She said she would continue to offer these things to the resident in the future, because the resident may change her mind and want them. When asked, the RD did not have a policy regarding fluid restrictions. She did not know if the nursing department had a policy to address this issue. The RD also said she had reviewed the resident's weights before and after [MEDICAL TREATMENT] treatments. The [MEDICAL TREATMENT] center had not taken a lot of fluid off the resident at these treatments; therefore, it appeared that, even though the resident had not complied fully with the fluid restriction, the negative impact to her had been minimal thus far. -- 7. On 04/12/11 at approximately 9:45 a.m., the assistant director of nursing (ADON - Employee #118) agreed the facility could devise a better way of breaking down how much fluid the resident received on each shift by each discipline. -- 8. On 04/12/11 at approximately 1:50 p.m., a licensed practical nurse (LPN - Employee #112) reported the nurse aides do not always tell her before they give the resident fluids. She reviewed her medication administration record (MAR) and stated she could give the resident 360 cc of fluid on day shift. The MAR did not break down what amount of fluid nurses were to give the resident just for each medication pass. -- 9. Further review of Resident #134's medical record revealed a physician's orders [REDACTED]. A review of the resident's fluid intake / output record revealed staff had not been measuring the resident's urinary output. The facility recorded the number of times the resident voided, but not the amount of each void. According to the director of nursing (DON - Employee #82), the resident wore an incontinence brief, which made measuring and recording urinary output impossible. The director of nursing also said she contacted the physician after the question of recording outputs arose, and he elected to discontinue the order for recording output or urine. -- 10. On 04/12/11, the DON provided a copy of the facility's policy titled ""Hydration"" (effective 05/09). At Item #7 on Page 2 stated the following (quoted as typed): ""The Licensed Nurse monitors residents on Fluid Restriction. - Must have a physician order [REDACTED]. - May be placed on I&O - Fluid provision will be divided between, Nutritional Services and Nursing Services in accordance with the resident's preference. - The total amount is to be divided between the 3 shifts and amount allotted will be documented on the I&O worksheet, the MAR and communicated to those providing care to the resident. - Document the breakdown of fluids for each shift - -- Non-meal fluids -- Fluids with meals -- Amount of fluids allowed for each med pass"" -- 11. According to Resident #134's MAR, the resident could receive a total of 120 cc of fluid on the 11:00 p.m. - 7:00 a.m. (11-7) shift; 360 cc of fluid on the 7:00 a.m. - 3:00 p.m. (7-3) shift; and 240 cc of fluid on the 3:00 p.m. - 11:00 p.m. (3-11) shift. The facility had not further broken down this information to identify to staff how much fluid on each shift the resident was to receive from the nurses (during medication administration) versus the nurse aides (during hydration passes and/or with between meal snacks). As found during the interviews with Employees #6 and #112 noted above, both the nurse aide and the LPN thought each could offer the resident the total amount of fluids allotted on their respective shifts. The DON thought the nurse aides were informing the licensed nurses when they gave the resident fluids. -- 12. On 04/12/11 at approximately 3:00 p.m., the DON reported she would re-educate her nursing staff on the fluid restriction process and make it more understandable for them. .",2015-05-01
10291,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-04-14,371,F,0,1,KZR811,". Based on observations and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices had the potential to affect all facility residents who received nourishment from the dietary department. Facility census: 115. Findings include: a) Observations, on the initial tour of the dietary dietary department on 04/04/11, revealed dietary staff had placed a pan of gravy on the steam table at approximately 3:10 p.m., for the evening meal which was to be served at 5:00 p.m. This practice of having food on the steam table greater than thirty (30) minutes prior to meal time had the potential to affect the palatability, flavor and nutritional value of the food product. b) Additional findings during the initial tour were as follows: 1. The lids of bins in which sugar, flour, etc., were stored were found to be in need of cleaning. Food debris and crumbs which were on these lids had the potential fall into the products stored inside when the lids were opened, causing contamination. 2. In the reach-in refrigerator, there were trays of food items, such as individual cups of juice, cottage cheese, fruits, etc., that had no labels or dates to indicate when they were opened. Without dates, dietary staff would not be able to determine how long these items have been stored or whether they were still safe for consumption. .",2015-05-01
10292,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-04-14,428,D,0,1,KZR811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, the facility failed to ensure the physician acted upon irregularities in the resident's medication regimen reported by the pharmacist, as evidenced by failure of the physician to provide a rationale for refusing to accept a recommendation for action regarding irregularities identified by the pharmacist Two (2) of thirty-seven (37) Stage II sample residents were affected. Resident identifiers: #155 and #106. Facility census: 115. Findings include: a) Resident #155 review of the resident's medical record revealed [REDACTED]. Continue Fiber tab for [DIAGNOSES REDACTED]. and 2. Change Surfak to Senokot-S one tablet daily (contains senna and docusate."" The physician's response was: ""No changes."" No rationale was provided regarding why this dose reduction should not be attempted for this resident. b) Resident #106 Review of this resident's medical record, on 04/08/11, revealed the consultant pharmacist noted an irregularity on 02/07/11. The pharmacist's consultation report noted the resident had been taking Ambien 10 mg daily at bedtime since January 2010. The pharmacist asked the physician to consider a gradual dose reduction to Ambien 5 mg at bedtime. The physician's response was: ""No changes."" No rationale was provided regarding why this dose reduction should not be attempted for this resident. .",2015-05-01
10293,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-04-14,246,D,0,1,KZR811,". Based on observation, resident interview, and staff interview, the facility failed to ensure the call light was readily accessible for use by one (1) of forty (40) Stage I sample residents. Resident identifier: #21. Facility census: 115. Findings include: a) Resident #21 Observation, on 04/06/11 at 3:06 p.m., found Resident #21's call light was on the floor underneath the bed, and the resident was not able to reach the call light. When interviewed at that time, the resident stated, ""I can't reach my call light. It is under my bed."" On 04/14/11 at 7:10 p.m., an interview with the director of nursing (Employee #82) confirmed the resident's call light should have been in reach. .",2015-05-01
10294,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-04-14,280,D,0,1,KZR811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview, observation, and staff interview, the facility failed to revise the care plans of two (2) of thirty-seven (37) Stage II sample residents, to address the fluid needs of a resident (#134) who was non-compliant with a daily fluid restriction ordered by her physician, and to reflect changes in a resident's (#27) overall plan of care when the physician discontinued the use of sequential compression devices (SDCs). Facility census: 115. Findings include: a) Resident #134 1. Medical record review, conducted on 04/06/11, revealed this [AGE] year old female resident attended [MEDICAL TREATMENT] three (3) times per week related to a [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE]. On 11/23/10, the physician ordered a daily fluid restriction as follows (quoted as typed): ""Fluid restriction 1700cc's: dietary to provide 240ml with breakfast and dinner and 480ml with lunch. Nursing to provide 120 on 11-7: 360 on 7-3, and 240 on 3-11."" (NOTE: 1 cubic centimeter (cc) = 1 milliliter (ml).) Subsequent record review revealed the resident was determined, on 04/09/11, to not possess the capacity to understand and make her own medical decisions. -- 2. In an interview on 04/11/11 at approximately 2:00 p.m., the resident reported the facility had previously restricted how much fluid she drank, but she did not think they were doing that now. Observation found a pitcher with water on her overbed table. The resident said she did not like people telling her what to do, and when she wanted something to drink, she did not want anyone telling her she could not do something. -- 3. Review of Resident #134's care plan found the following problem statement (Date Initiated: 11/22/10): ""Risk for fluid output exceeding intake characterized by fluid volume deficit; dry skin and mucous membranes, poor skin turgor and integrity related to: decreased independent access to fluids, nausea / vomiting, uncontrolled health conditions, pain, laxatives / enema use, [MEDICAL TREATMENT], 1700 ml fluid restriction, able to consume fluids independently after set up."" The goal associated with this problem was: ""Show no signs of dehydration."" The interventions to assist the resident in achieving this goal were (quoted as typed): ""Observe effectiveness and side effects of laxatives. Observe resident for signs of dehydration (tenting skin, dry mouth, etc). Report to MD if present. Observe resident for signs of pain. Offer water / ice chips q 2 hrs (every two hours) or upon each encounter. Please straw in glass so resident can drink independently. Record frequency, consistency and amount of emesis. Administer [MEDICATION NAME] per MD orders."" These interventions were all initiated on 11/22/10, and no revisions / additions were made to this list of interventions after that date. Nowhere in the care plan was direction provided to staff regarding how the fluids were to be administered across a 24-hour period and by what disciplines (e.g., dietary, licensed nurses, nurse aides, activities, etc.), to ensure her total daily fluid intake did not exceed 1700 cc. There was also no mention anywhere in her care plan of the resident's refusal to adhere to the daily fluid restriction, which she self-reported during the above-referenced interview. -- 4. An interview with the dietary manager (Employee #60), on 04/11/11 at approximately 3:00 p.m., confirmed there were special instructions regarding what fluids came from the dietary department for Resident #134. The dietary department's special instructions were to send 240 cc with breakfast and dinner and 480 cc came with the lunch meal. -- 5. On 04/12/11 at approximately 9:15 a.m., the registered dietician (RD - Employee #87) verified the resident's care plan did not address the resident's non-compliance with the fluid restriction. The RD said the resident likes to feel she controls her medical decisions, and she likes to eat foods that are not ideal for her due to her health status. The RD stated she had offered the resident things to satisfy her thirst, such as lemon drops, but the resident refused these at the present time. She said she would continue to offer these things to the resident in the future, because the resident may change her mind and want them. -- 6. The facility knew the resident had refused to comply with the 1700 cc daily fluid allotment and had refused interventions to help quench her thirst (such as lemon drops). However, the interdisciplinary team did not develop additional interventions, nor did they address these refusals in the resident's care plan. On 04/14/11 at approximately 8:30 p.m., the facility had no additional information to provide regarding this concern. --- b) Resident #27 Review of Resident #27's care plan, on 04/08/11, revealed an intervention for: ""SCDS (sequential compression devices) to bilateral lower extremities..."", which was initiated on 07/29/10. The last documented review of the care plan by the interdisciplinary team was on 03/23/11. Review of the resident's current physician's orders [REDACTED]. At the time the care plan was reviewed, the SCDs had been discontinued by the physician; however, the care plan was not revised to reflect this change. .",2015-05-01
10295,MOUND VIEW HEALTH CARE,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2012-01-18,323,G,1,0,7L5411,". . Based on record review, interview with a clerk at the State Police office, an interview with an individual with the Division of Motor Vehicles, review of facility documents, and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. A resident was transported in the facility van without adequate safeguards to prevent an accident with injury. She sustained a fall while en route to an appointment in the facility's vehicle. Actual harm was incurred as she suffered a hematoma to her head and pain in her buttocks. Staff transported the resident to a nearby hospital. This was found for one (1) of five (5) residents reviewed. Resident #35. Facility census: 117 Findings include: a) Resident #35 This resident experienced a fall, on 11/29/11 at 9:25 a.m., while being transported in the facility's van to a scheduled appointment with a consultant psychiatrist. Review of the medical record of Resident #35, on the afternoon of 01/17/12, found she had been assessed as a falls risk upon admission on 01/3/11. The resident had an interdisciplinary care plan in place for being at risk for falls due to impaired mobility, unsteady gait, requiring extensive assistance with most activities of daily living (ADL's), incontinence of bowel and bladder, cerebrovascular accident (stroke), Alzheimer's / dementia, difficulty in walking, muscle weakness, physical agitation and resisting care. She also was identified as being at risk for elopement related to wandering without regard to safety and angry outbursts. Her minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/17/11, documented she required extensive assistance of two (2) or more persons for moving in bed, transferring to or from bed, chair, wheelchair, or to a standing position, and walking. Review of facility accident / incident reports, on 01/18/12 at 8:00 a.m., found Resident #35 had twenty-nine (29) documented falls since her admission on 01/03/11. All of these falls involved staff finding the resident on the floor after attempting to stand or transfer without assistance. According to the reports, sometimes staff were responding to a sounding monitor alarm, and at other times they just found her on the floor. According to the records, she had sustained injuries associated with the falls on 02/12/11, 03/01/11, 03/30/11, 10/15/11, and 11/17/11. A statement by the nurse regarding a fall, on 03/15/11 at 3:30 a.m., included (typed as written): "". . . this nurse step away from nurses' station for a minute & when this nurse walked back to station found resident sitting on floor in front of her wheelchair."" Many episodes of aggressive behaviors were documented in the medical record. These often commenced suddenly and for no apparent reason. The resident was prescribed Remeron 7.5 mg orally every day for depression, Seroquel 50 mg three (3) times every day for dementia with behaviors, and Haldol 2 mg by intramuscular injection every eight (8) hours as needed for agitation. These psychoactive medications were being monitored by the consultant psychiatrist during quarterly visits. It was en route to such a visit that the fall took place at 9:25 a.m. on 11/29/11. Review of nurses' notes, for the night before the 11/29/11 van trip revealed the resident had one of her unpredictable behaviors at 1:00 a.m. on 11/28/11. The nursing documentation stated (typed as written), ""Punching CNA's with both fists after CNA redirects resident from eloping from 200 wing, 400 wing, 300 wing, and front door - biligerent / cursing. Redirection effective for short periods."" The incident report for the fall of 11/29/11 at 9:25 a.m. was reviewed at 3:30 p.m. on 01/16/12. The location of the incident was documented as ""bus."" Persons present were listed as the social services aide, Employee #6, and a registered nurse (RN), Employee #132. The type of occurrence was listed as ""fall."" The form was marked to indicate the fall was not witnessed. Under the section ""Describe the Specific Incident"" was recorded (typed as written): ""Transporting (resident's name) to Appt (appointment): In facility bus. (Resident) fell to the right side, in her W/C (wheelchair). W/C attached with all 4 safety locks in place. (Resident) stated 'My butt hurts.' "" Under the section ""Actions / Interventions"" was recorded (typed as written): ""Neuro cks (checks) were done. Eyes PERRLA (pupils equal, round, reactive to light and accommodation), Grips equal, ROM (range of motion) - she was able to move All extremities, abduction to bilateral lower extremities without discomfort. (Resident) stated 'My butt hurts'. Findings - raised area to Rt. Side of head. Went to ER (emergency room ) at (name of hospital)."" A visit was made to the hospital at 4:00 p.m. on 01/17/12. Review of records from the emergency room visit, on 11/29/11 at 10:15 a.m., found the statement: ""Was in wheelchair in van when it toppled over & hit her head & now tailbone / buttocks hurt also complains right hand hurt."" The record indicated the resident had a three (3) cm hematoma to the right parietal lobe of her head, a contusion of her right hand, and no bruising or tenderness to the buttocks / tailbone. She was subsequently admitted for exacerbation of chronic obstructive pulmonary disease (COPD). An interview was conducted with an RN, Employee #132, at 9:30 a.m. on 01/17/12. She was asked about the incident of 11/29/11 with Resident #35 in the facility bus. She stated she and the social services aide, Employee #6, had taken Resident #35 in the bus to go to an appointment with the psychiatrist. She said Employee #6 was driving and she was sitting on one of the bench seats, towards the front. She was getting papers ready that would need to be presented at the appointment. She was placing them in the front passenger side bench seat when something happened. She turned and saw that Resident #35 ""had fallen."" She said all four (4) straps securing the wheels of the chair were still fastened in place, but the whole wheelchair was laying over to the right with the resident still partially in it. She checked the resident, called the facility to ask them to notify the responsible party, and they decided to turn back and stop at the emergency roiagnom on the way back to the facility to be on the safe side, because they ""were very close."" She was asked whether she had any idea what caused the fall. She stated since she did not see it, she could not say for sure, but the resident may have tried to get up. She stated the resident was unpredictable, and could change her behaviors very suddenly. She stated there was no safety restraint or shoulder harness in use on the wheelchair. An interview was conducted with the social services aide, Employee #6, at 11:00 a.m. on 01/17/12. She was the driver of the van on the morning of 11/29/11. She stated the RN, Employee #132, was seated on the second row of bench seats on the passenger side, and Resident #35 was in her wheelchair at the very back of the bus on the driver's side. She said she was going around a left turn slowly when she heard ""(Resident's name) is on the floor."" She pulled off the road. According to the aide, the resident was on her right side, still partially in the wheelchair. It was bent over to the right as well. She said the wheelchair was distorted, like it had collapsed sideways with the wheels laying over. She said there was no safety restraint on the wheelchair. Employee #6 was asked if she had any opinion as to what may have happened. She said she had noticed the resident was somewhat sleepy and groggy that morning. She felt the resident may have dozed off, was awakened going around the curve, tried to get up, leaned against the chair, and it gave way or collapsed. During an observation of the inside of the facility van, on 01/18/12 at 1:30 p.m., Employee #6 pointed out there were three (3) rows of bench seats with a center aisle. She pointed out the second row of bench seats on the passenger side where the nurse had been seated, placing papers on the seat in front of her at the time of the fall. She also pointed out the area at the back entrance of the bus on the driver's side, where the wheelchair had been secured to the floor of the bus. The lift was noted to be on the passenger side when not in use. The administrator, Employee #42, was interviewed at 1:50 p.m. on 01/17/12. He stated the facility had owned the bus since 2008. After receiving the call the resident had fallen, he and the maintenance director had gone to the hospital to see what had happened. He said the medical power of attorney (MPOA) was there, and was upset because the resident had not yet been taken inside to the emergency room . Employee #42 stated they did not seatbelt anyone in a wheelchair at that time, however, they did seatbelt residents who were seated on the bench seats. He said apparently, the resident threw herself to the right side, because she collapsed the wheelchair. He was asked for any facility policies, procedures, and / or operations manuals that came with the bus. Training records for operators of the bus and / or the equipment were also requested. An interview was conducted with the director of nursing (DON), Employee #43, at 2:00 p.m. on 01/17/12. She clarified there was a safety belt on the wheelchair lift, but not on the wheelchairs themselves. She said they do now utilize safety belts in the wheelchairs depending upon the resident. She said there was no policy regarding when use of a safety belt would be appropriate. The DON said Resident #35 had many challenging behaviors. She described the resident as being violent at times, with unpredictable behaviors. She stated sometimes it required up to four (4) to six (6) employees to maintain her safety and the safety of others. Later in the afternoon of 01/17/12, the administrator advised there was a manual for operation of the lift, but no other manuals had been found. He stated there was no policy or procedure covering use of the van for transporting residents, and no records of any training of staff. He provided a two (2) page hand-written note delineating how to use the lift and to secure wheelchairs to the floor with the straps and metal hooks that were part of the bus equipment. It was noted that there was a sentence that said ""Make sure any residents in seats have seat belts fastened before leaving."" There was nothing specific to wheelchairs. A visit was made to the local detachment of the West Virginia State Police at 8:00 a.m. on 01/18/12. The clerk was asked about West Virginia seat belt laws pertaining to wheelchair transport. He replied that the law did not specifically address the subject, but leaves it up to other agencies, such as the Division of Motor Vehicles, to develop rules and recommendations on the subject. A telephone call was made to the Division of Motor Vehicles at 8:45 a.m. on 1/18/12. They stated they follow the Americans with Disabilities Act (ADA) on the subject, which says disabled persons are entitled to the same safety protections as other passengers, and gives specifications for safety belts and shoulder restraints. However, these were only recommendations, as there were currently no laws, codes, rules, or regulations that required use of safety restraints in wheelchairs during transportation. The facility's individualized assessment and care plan for Resident #35 noted she required extensive assistance of two (2) or more staff for transfers. They had documented a history of falls that had previously occurred as the result of her attempting to stand or transfer unassisted. There was an extensive record of her unpredictable and often abrupt behaviors, sometimes requiring multiple staff intervention. There was documentation of her being up at 1:00 a.m. the night before the trip, punching staff with both fists and trying to elope. There was no evidence of any policy, procedure, or staff training record related to safe transport of residents in the facility bus. The facility was aware of the resident's unpredictable behaviors, sometimes requiring several staff members to maintain her safety. They were also aware of the resident's history of frequent falls related to attempts to stand and transfer without assistance. With this knowledge, the facility had an obligation to individualize the resident's environment, including her environment during transportation in the facility's van, to ensure she was free from accident hazards over which the facility had control, and to ensure the provision of adequate supervision and assistive devices to prevent avoidable accidents. The facility did not protect the resident from an avoidable accident when they sent the resident out in the facility van, with only one (1) staff person available to supervise (the other staff member was driving the van) and assist her while the vehicle was in motion. This person was also sitting on one of the bench seats, towards the front, getting papers ready for the resident's appointment. The resident was not in the employee's view, as she had to turn to the see the resident ""had fallen"" when she realized something had happened. .",2015-05-01
10296,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2012-01-06,225,D,1,0,TQXO11,". Based on staff interview, family interview, and review of facility documents related to complaints, the facility failed to ensure all allegations of neglect were reported immediately to the administrator and other officials as required by State and federal regulations. A family member had filed a written complaint with the facility regarding the care a resident had received. The facility had not reported the allegation, nor had it investigated the identified concerns One (1) of five (5) sampled residents was affected. Resident identifier: #87. Facility census: 114. Findings include: a) Resident #87 Upon entrance to the facility to conduct this unannounced complaint investigation, the administrator (Employee #104) was provided a list of requested information to assist in the investigation. One (1) of the items requested included all complaints received by the facility during the previous three (3) months. Review of the documents provided found no instances where the facility would be required to report allegations of abuse/neglect to the administrator or other officials as required. An interview was conducted with Resident #87's family member on the evening of 01/04/12. The family member stated she had filed a written complaint with nursing on 12/22/11. The family member stated she had included numerous allegations which would constitute neglect, and had given it to the nurse. She stated the nurse provided a copy of the document. Further review of the documents provided by the facility on the morning of 01/05/12 found no record of the complaint. The administrator and director of nursing were informed of the family member's assertion that a written complaint had been filed with a nursing staff member, on 12/22/11, which had not been included in the information provided to this surveyor. On the evening of 01/05/12, the administrator provided the family member's 12/22/11 complaint. The administrator stated it was located in the social worker's office. An interview with the social worker (Employee #86), at 5:20 p.m. on 01/05/12, elicited the complaint was slid under her door when she returned from vacation on 12/27/11 or 12/28/11. She stated she did not notify the administrator or report the allegations. The administrator stated at that time she was unaware of the complaint until having located it in the social worker's office. Review of the document in question found allegations of the facility failing to provide physician notification when the family member believed the resident was suffering from a respiratory infection. After one (1) week of no physician notification, the family member had insisted either the nursing staff contact the doctor, or the family member would on 12/17/11. The staff contacted the physician and obtained an order from the physician for a chest x-ray. The resident was determined to have pneumonia. The family member's complaint further alleged the facility had failed to ensure the resident had received adequate nutrition and had lost 30 pounds since admission on 12/08/11. The family member further alleged staff were not providing adequate hygiene care with the resident having been found with stool wedged in her vagina on four (4) different days. The facility failed to ensure the allegations of neglect lodged by this interested family member were reported and investigated as required by State and federal regulations. .",2015-05-01
10297,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2012-01-06,362,F,1,0,TQXO11,". Based on observation, staff interview, and review of the ""Food and Drug Administration (FDA) Food Code 2009"": Chapter 3- Food, the facility failed to ensure the dietary manager, employed to carry out the functions of the dietary service, was competent to direct support personnel in safe food handling related to the requirements for cooling potentially hazardous foods to prevent the potential outbreak of foodborne illness. This practice had the potential to affect all residents currently residing in the facility who receive an oral diet. Facility census: 114. Findings include: a) During random observations of the noon meal service, on 01/04/12 at 1:00 p.m., two (2) tall clear plastic containers filled with food were noted to be sitting on the steam table counter. A subsequent observation, at 2:30 p.m. on 01/04/12, found these two (2) containers sitting on the shelf of the main cooler. The cover on one (1) of the containers was labeled ""soup."" The dietary manager, Employee #52, stated the tall container labeled ""soup""contained left-overs utilized for making soup for the residents. It was noted this container consisted of a layer of peas, a layer of carrots, a layer of cooked potatoes, and a top layer of pork chunks. When asked when the ""leftovers"" would be utilized to prepare soup, Employee #52 stated she would have to look at the menu. The second container was determined to contain cooked potatoes. Employee #52 was asked to take the temperature of the two (2) containers. She determined the temperature of both containers registered 115 degrees Fahrenheit (F). When asked what the required cooling times and temperatures were, she stated that she would have to look it up. Review of the ""FDA Food Code 2009: Chapter 3- Food"", Section 3.501.14 Cooling, found foods were to be cooled within 2 hours from 135 degrees Fahrenheit to 70 degrees F and within a total of 6 hours from 135 degrees F to 41 degrees F or less. Further review of Review of the ""FDA Food Code 2009: Chapter 3- Food"", section 3-501.15 (A), found the following: ""Cooling shall be accomplished in accordance with the time and temperature criteria specified under 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; ... ."" The facility failed to ensure the director of the dietary department was knowledgeable concerning safe food handling related to the safe cooling of potentially hazardous foods. The director was unable to provide direction to support personnel concerning placing hot foods in shallow pans to ensure safe and effective cooling in compliance with FDA Food Code requirements. .",2015-05-01
10298,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2012-01-06,371,F,1,0,TQXO11,". Based on observation, staff interview, and review of the ""Food and Drug Administration (FDA) Food Code 2009: Chapter 3- Food,"" the facility failed to ensure appropriate methods were utilized for the cooling of potentially hazardous foods to prevent the potential outbreak of foodborne illness. This practice had the potential to affect all residents currently residing in the facility who received an oral diet. Facility census: 114. Findings include: a) During random observations of the noon meal service, on 01/04/12 at 1:00 p.m., two (2) tall clear plastic containers filled with food were noted to be sitting on the steam table counter. A subsequent observation, at 2:30 p.m. on 01/04/12, found these two (2) containers sitting on the shelf of the main cooler. The cover on one of the containers was labeled ""soup."" The dietary manager, Employee #52, stated the tall container labeled ""soup"" was left-overs used for making soup for the residents. It was noted this container contained a layer of peas, a layer of carrots, a layer of cooked potatoes, and a top layer of pork chunks. When asked when the ""leftovers"" would be utilized to prepare soup, Employee #52 stated she would have to look at the menu. The second container was determined to contain cooked potatoes. Employee #52 was asked to take the temperature of the two (2) containers. She determined the temperature of both containers registered 115 degrees. When asked what the required cooling time and temperature were, she stated that she would have to look it up. Review of the 'FDA Food Code 2009: Chapter 3- Food,' section 3-501.15 (A), found the following: ""Cooling shall be accomplished in accordance with the time and temperature criteria specified under 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans;..."". The facility failed to utilize a safe cooling method in accordance with FDA Food Code requirements. .",2015-05-01
10299,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2012-01-06,441,F,1,0,TQXO11,". Based on observation and staff interview, the facility failed to provide goods and services in a manner to help prevent the development and transmission of disease and infection. A dietary staff member was observed to contaminate dietary tray cards with bodily fluids, and activity staff failed to ensure plastic chips utilized to play bingo were sanitized between use. These practices had the potential to affect all residents currently residing in the facility. Facility census: 114. Findings include: a) During random observations of the main dining room, on the afternoon of 01/03/12, residents were noted playing bingo. The residents were utilizing large plastic chips as markers for the bingo cards. After the bingo game ended, activity personnel, including the activity director, Employee #1, were observed placing all the large plastic chips into one Ziploc plastic bag. During an interview with Employee #1, at 3:30 p.m. on 01/03/12, she was asked what the procedure was for sanitizing the large plastic bingo chips between uses by residents. She stated they washed the chips in soapy water in the dining room between uses. When asked how long it had been since the bingo chips had been cleaned, Employee #1 stated that it had been hectic and had probably been weeks since they were cleaned. b) During observations of the bingo activity on the afternoon of 01/03/12, a dietary employee (Employee #62) was noted seated at a table in the dining room away from the activity. She was observed repeatedly wiping her nose with the backs and palms of her right and left hands and on her shirt sleeves. It was noted she was touching tray cards designed for placement on resident trays during meal service. The above observation was reported immediately to the dietary manager, Employee #52. Employee #62 entered the dietary department and was asked if she had a cold. She agreed she had a cold. Employee #52 was asked what she would do with the tray cards which Employee #62 had handled after wiping her nose. Employee #52 stated that she would reprint them. .",2015-05-01
10300,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2012-01-06,492,E,1,0,TQXO11,". Based on observation, staff interview, and review of ""The Health Insurance Portability and Accountably Act of 1996 (HIPAA)"", the facility failed to ensure individually identifiable health information was safeguarded for four (4) of one hundred fourteen (114) current facility residents and eight (8) former residents. Resident identifiers: #52, #107, #106, and #97. Facility census: 114. Findings include: a) Residents #52, #107, #106, #97, and eight former residents Observation of the dumpster area, on 01/04/12 at 2:45 p.m., noted Employee #85, a business office employee, exiting the building with two (2) large clear plastic bags of what appeared to be shredded paper. The contents of one (1) of the clear plastic bags spilled onto the loading dock. Employee #85 reentered the building to obtain another bag. Inspection of the paper spilled on the loading dock found it contained twelve (12) intact pages of weekly skin assessments. These contained resident names, room numbers, and assessments of the condition of their skin. These assessments included explicit information concerning the condition of abdominal folds, groin folds, beneath breasts, etc. Employee #85 was asked why these documents had not been shredded. The employee stated the shredder had broken. Review of the HIPAA Act found the facility was a covered entity responsible for safeguarding protected health information. The facility failed to comply with this requirement. .",2015-05-01
10301,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,329,D,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for two (2) of twenty-one (21) Stage II sample residents, to assure their drug regimen was free of unnecessary drugs including drugs without adequate monitoring. One (1) resident was receiving an antipsychotic medication for behaviors with no evidence those behaviors continued to be present. One (1) resident was receiving a medication for lowering cholesterol levels without evidence of recommended lab studies to assure their safety. Resident identifiers: #34 and #31. Facility census: 34. Findings include: a) Resident #34 When reviewed on 05/05/10, the resident's medical record disclosed he was receiving [MEDICATION NAME] 50 mg two (2) times daily for agitation. The resident had been receiving the medication since 07/29/09. When reviewed for behaviors associated with the agitation, documentation suggested the resident became agitated when staff attempted to persuade him to shower. The record disclosed nurses' notes on only two (2) occasions, 02/10/10 and 03/02/10, both associated with attempts to bath resident. The resident's behavior monitoring sheets for February 2010 through April 2010 disclosed agitated behaviors on three (3) occasions in March 2010. The resident's care plan, when reviewed, disclosed the following problem statement identified by staff on 05/12/09: ""Behavior problem related to verbally abusive behavior as evidenced by verbally abusive."" On 02/03/10, the care plan problem stated, ""D/C (discontinue) no behavior issues for some time now."" A pharmacy recommendation, dated 12/23/09, requested the resident's attending physician attempt a gradual dose reduction of the medication. The physician stated ""no change"" and did not decrease the medication. The physician declined an additional request for a gradual dose reduction attempt on 04/15/10, with no explanation given. These findings were brought to the attention of the vice president of nursing services (Employee #32) and the unit's director of nurses (Employee #31) at 11:50 a.m. on 05/13/10. Employee #31 stated the resident did have behaviors and there had been unsuccessful attempts to reduce the medication dosage in the past. At the time of exit from the facility on 05/12/10 at 5:00 p.m., staff had provided no evidence of attempts to decrease this resident's medication. b) Resident #31 Medical record review revealed this resident was receiving [MEDICATION NAME]. According to the manufacturer's recommendations, liver function should be monitored for residents who use this medication. This resident was not monitored for liver function. .",2015-05-01
10302,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,274,D,0,1,MM9U11,". Based on medical record review and staff interview, the facility failed to complete a comprehensive assessment when a significant change in status occurred for one (1) of twenty-one (21) Stage II sample residents. This resident had significant declines in both mood state and self-performance of bathing, but a significant change in status assessment was not completed. Resident identifier: #53. Facility census: 34. Findings include: a) Resident #53 Review of this resident's medical record, and interview with the social worker (Employee #30) on 05/12/10 at 10:20 a.m., revealed this resident had experienced declines in mood indicators and activities of daily living (ADL) self-performance since admission on 12/12/09. Comparison of the resident's comprehensive admission assessment (with an assessment reference date (ARD) of 12/22/09) and her first abbreviated quarterly assessment (with an ARD of 03/24/10) revealed the following: - Resident #53 only had one (1) indicator of depression, anxiety, and/or sad mood present on admission (coded at Item E.1.m.). However, on her quarterly assessment completed three (3) months later, the assessor noted the presence of six (6) indicators of depression, anxiety, and/or sad mood (coded at Items E1.a., E1.c, E1.d, E1.h, E1.i, and E1.n.). - In Section G, physical functioning and structural problems, the resident exhibited a significant decline in self-performance of bathing from ""2"" (physical help limited to transfer only) on admission to ""4"" (total dependence) three (3) months later. This significant decline in status was not identified when the quarterly assessment was reviewed and signed by the interdisciplinary team on 03/25/10. No comprehensive assessment was completed in recognition of this significant change in status as of 05/12/10. On 05/12/10 at 10:40 a.m., this information was brought to the attention of the assessment coordinator (Employee #25). At that time, Employee #25 confirmed the changes and confirmed that a comprehensive assessment had not been completed as required - within fourteen (14) days after the facility determined, or should have determined, that a significant change in the resident's physical or mental condition had occurred. .",2015-05-01
10303,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,431,B,0,1,MM9U11,". Based on observation and staff interview, the facility failed to assure the safe storage of drugs and biologicals, by retaining a vial of immunization past the manufacturer's expiration date and storing it in a refrigeration rather than in the freezer as recommended. This practice had the potential to affect any resident with orders for this medication. Facility census: 34. Findings include: a) On 05/11/10 at 9:20 a.m., observation of the facility's medication storage room, including the medication storage refrigerator used to store all medications requiring refrigeration for facility residents, found a boxed ampul with a label reading ""Varicella Virus Vaccine"". The labeled box also stated the medication should be stored at an average temperature of 5 degrees Fahrenheit (F), and the noted expiration date of the medication was 19 March 2010. The refrigerator temperature at that time was 46 degrees F. Two (2) licensed practical nurses (LPNs - Employees #21 and #22) were present at the time ,and although neither of the nurses had any idea why the medication was there or who it was for, they both confirmed the medication was beyond the expiration date and was not stored as recommended on the label. .",2015-05-01
10304,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,492,C,0,1,MM9U11,". Based on record review and staff interview, the facility failed to provide the opportunity to request a demand bill for residents who were discontinued from Medicare-covered skilled services, as required to comply with 42CFR489.21(b). This practice affected all residents who were discontinued from Medicare-covered skilled services. Facility census: 34. Findings include: a) Review of the information provided residents who were discontinued from Medicare-covered skilled services, with the social worker (SW - Employee #30) on 05/11/10, revealed the facility was not providing the residents or their responsible parties an opportunity to request a demand bill when skilled services were discontinued. At that time, the SW provided copies of the letters sent, which did not include the information required to request a demand bill. He was unaware of any other forms required, and the facility had not been providing these notices to applicable Medicare residents. Therefore, no resident was offered the opportunity to request a demand bill. .",2015-05-01
10305,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,364,E,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to assure pureed foods were attractive when served. The pureed food items flattened out and ran together on the plates. In addition, garnishes were not provided residents who were ordered pureed diets. This practice affected each of the eight (8) residents who had a physician's orders [REDACTED]. Findings include: a) On 05/11/10 at 12:05 p.m., observation was made of food service in the kitchen. Pureed beef, pureed noodles, and pureed green beans were served the residents requiring pureed diets. All these products were thin and without form. They flattened and ran together on the plates, creating an unattractive and unappetizing presentation. At the time of the observation, the thin pureed foods were brought to the attention of Employee #90, the dietary manager (DM). The DM confirmed the pureed foods should have a shape / form and the pureed foods served at the meal did not, making the meal unattractive. Additionally, garnishes (to add interest and contrast to the meal) were used at this meal for residents who were not ordered pureed foods; however, garnishes were not provided residents who required pureed foods. .",2015-05-01
10306,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,371,F,0,1,MM9U11,". Based on observation and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which had the potential to result in food contamination and compromised food safety. These practices had the potential to affect all facility residents who received nourishment from the dietary department. Facility census: 34. Findings include: a) On 05/11/10 at 11:50 a.m., soup bowls and water pitchers were observed stacked inside each other. They contained moisture, creating a medium for bacterial growth. At this time, the situation was brought to the attention of the dietary manager (DM). The DM confirmed the bowls and pitchers should have been air dried prior to stacking inside each other b) Observation, at 11:50 a.m. on 05/11/10, also revealed the inside finish was worn off several plastic soup bowls. Once the finish is gone, these food service items cannot be effectively sanitized. .",2015-05-01
10307,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,309,D,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for two (2) of twenty-one (21) Stage II sample residents. One (1) resident had no follow-up assessments or monitoring after two (2) falls, and another resident's ill-fitting socks were causing indentations in the resident's lower legs. Resident identifiers: #31 and #12. Facility census: 34. Findings include: a) Resident #31 Medical record review, on 05/12/10, revealed this resident fell on [DATE], and was taken to the emergency room (ER) for evaluation. The next note, also on 03/08/10, described the resident being brought back from the ER and the resident's current condition. There were no nursing notes, between 03/08/10 and 03/15/10, seven (7) days later. The note on 03/15/10 did not mention the fall. There was no evidence the facility did any type of follow-up assessment or monitoring of the resident after the fall on 03/08/10. This resident fell again on 04/29/10 at 1930 (7:30 p.m.) and was taken to the ER. According to the medical record, the resident returned to the facility at 2200 (8:36 p.m.). There were no nursing notes regarding the fall and no evidence of any assessment or monitoring for the next three (3) days, until 05/02/10 at 1240 (12:40 p.m.). Interview with the vice president of patient care services (Employee #32), at 9:45 a.m. on 05/13/10, revealed nursing staff were supposed to complete follow-up assessments after any fall. Employee #32 reviewed the medical record and was unable to find any assessments following the fall on 03/08/10. Additionally, Employee #32 confirmed there should have been follow-ups between 04/29/10 and 05/02/10. -- b) Resident #12 At 2:00 p.m. on 05/12/10, during an interview with this resident, observation revealed the elastic tops of both of the resident's socks were making indentations in her legs just above her ankles. Review of the resident's medical record and care plan revealed nothing relative to assuring the resident's socks were not too tight on her legs. This was of particular concern, because the resident had [DIAGNOSES REDACTED]. .",2015-05-01
10308,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,411,D,0,1,MM9U11,". Based on observation, resident interview, and staff interview, the facility failed to obtain needed dental services for one (1) of twenty-one (21) Stage II sample residents. The facility had identified the resident's teeth were in poor condition and that she needed dental care; however, this service had not been obtained or pursued by the facility. Resident identifier: #31. Facility census: 34. Findings include: a) Resident #31 During an interview with this resident on 05/04/10 at 3:30 p.m., she stated she often had toothaches. Upon inquiry, the resident stated she had not mentioned the toothaches to facility staff, nor had she been seen by a dentist. Broken and carious teeth were observed as the resident spoke. At one (1) point, the resident opened her mouth to display the condition of her teeth. Observation revealed her teeth were in extremely poor condition. On 05/12/10, the resident's initial care plan (dated 02/15/10) and the first review of the care plan (dated 04/22/10) were reviewed. The care plans identified broken and carious teeth as one (1) of the resident's problems. There was an intervention, originally dated 02/15/10, for social services to ""Coordinate arrangements for dental care..."" As of 05/12/10, there was no evidence this had occurred. At 10:40 a.m. on 05/12/10, this information was brought to the attention of the care plan / assessment nurse (Employee #25). At that time, Employee #25 confirmed the condition of the resident's teeth and stated dental services had not been arranged, because the resident was only receiving Medicare services when she was admitted . Employee #25 stated the facility was waiting until the resident became Medicaid-eligible and planned to arrange dental services at that time. Upon inquiry, Employee #25 checked the resident's records and reported the resident became Medicaid-eligible on 03/06/10. As of 05/12/10, arrangements for dental care for this resident had not been initiated. Employee #25 confirmed the dental care should have already been implemented for the resident. .",2015-05-01
10309,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,282,D,0,1,MM9U11,". Based on medical record review, resident interview, observation, and staff interview, the facility failed to implement a care plan for one (1) of twenty-one (21) Stage II sample residents. This resident had a care plan related to broken teeth and dental caries which was not implemented by the facility. Resident identifier: #31. Facility census: 34. Findings include: a) Resident #31 During an interview with this resident on 05/04/10 at 3:30 p.m., she stated she often had toothaches. Upon inquiry, the resident stated she had not mentioned the toothaches to facility staff, nor had she been seen by a dentist. Broken and carious teeth were observed as the resident spoke. At one (1) point, the resident opened her mouth to display the condition of her teeth. Observation revealed her teeth were in extremely poor condition. On 05/12/10, the resident's initial care plan (dated 02/15/10) and the first review of the care plan (dated 04/22/10) were reviewed. The care plans identified broken and carious teeth as one (1) of the resident's problems. There was an intervention, originally dated 02/15/10, for social services to ""Coordinate arrangements for dental care..."" As of 05/12/10, there was no evidence this had occurred. At 10:40 a.m. on 05/12/10, this information was brought to the attention of the care plan / assessment nurse (Employee #25). At that time, Employee #25 confirmed the condition of the resident's teeth and stated dental services had not been arranged, because the resident was only receiving Medicare services when she was admitted . Employee #25 stated the facility was waiting until the resident became Medicaid-eligible and planned to arrange dental services at that time. Upon inquiry, Employee #25 checked the resident's records and reported the resident became Medicaid-eligible on 03/06/10. As of 05/12/10, arrangements for dental care for this resident had not been initiated. Employee #25 confirmed the dental care should have already been implemented for the resident. .",2015-05-01
10310,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,311,E,0,1,MM9U11,". Based on observations and staff interview, the facility failed to assure six (6) of thirty-four (34) residents, identified through random observations, were provided services to assure maintenance or improvement of their ability to feed themselves. Resident identifiers: #67, #14, #2, #29, #53, and #13. Facility census: 34. Findings include: a) Residents #14, #13, #2, and #67 Observation of the evening meal was conducted beginning at 5:45 p.m. on 05/03/10. Ten (10) residents ate in their rooms that evening. These four (4) residents needed prompting and encouragement to eat their meals. No staff members were observed monitoring the hallways to provide necessary prompting and encouragement to these residents, who were not eating. The only time a staff member was observed on the hallway was at 6:17 p.m., when one (1) nursing assistant went to see if the residents were finished with their meals. 1. Resident #14 - At 6:00 p.m., this resident was asleep with her uneaten meal in front of her. She had eaten nothing. 2. Resident #13 - At 6:00 p.m., this resident was asleep with her meal in front of her. She had eaten approximately 25% of her meal. 3. Resident #2 - At 6:00 p.m., this resident was asleep with her meal in front of her. She had eaten approximately 25% of her meal. 4. Resident #67 - At 6:05 p.m., this resident had stopped eating and was just sitting quietly in her room. The meal was still in front of her. She had eaten approximately 10% of her meal. -- b) Resident #67 In addition to the evening meal observation on 05/03/10, this resident was observed during the evening meal at 6:00 p.m. on 05/12/10. The resident was asleep with her uneaten meal in front of her. At 6:05 p.m., the director of nursing (DON) was asked to observe this situation, and she did. At that time, the DON confirmed the resident required prompting and encouragement at meals. -- c) Observations were made in the dining room at the evening meal on 05/03/10 and at the noon meal on 05/04/10. Several residents were seated at tables which were so high, the residents had to raise their arms in an unnatural position to reach their food. -- d) Resident #53 This resident laid her head on the table, in front of her meal, while eating in the dining room at 1:15 p.m. on 05/05/10. Twice she sat up, looked at her meal, then laid her head back on the table and fell asleep again, with her meal in front of her. She had consumed approximately 25%. Every now and again, the resident awoke and took a drink of milk, then laid her head down and fell back to sleep. No one offered her prompting or encouragement to stay awake and eat her meal. -- e) Resident #29 This resident was seated at the same table as Resident #53, while eating in the dining room, at 1:15 p.m. on 05/05/10. She was just sitting with her plate of uneaten food in front of her. No one offered her prompting or encouragement to eat her meal. .",2015-05-01
10311,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,281,E,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to assure that services provided met current professional standards of quality, by administering the medication [MEDICATION NAME], to four (4) of ten (10) residents observed during medication administration, outside of the recommendations for use by the manufacturer of the medication. Resident identifiers: #3, #8, #6, and #15. Facility census: 34. Findings include: a) Residents #3 and #8 During medication administration by a licensed practical nurse (LPN - Employee #22) on 05/11/10 at 9:00 a.m. and 10:17 a.m. respectively, Residents #3 and #8 were observed receiving their medications. At that time, both residents received [MEDICATION NAME], a [MEDICAL CONDITION] replacement medication. The LPN, when questioned, confirmed the residents had just finished their breakfast. Review of the Internet website www.drugs.com disclosed the following statement: ""Take [MEDICATION NAME] as a single dose, preferably on an empty stomach, one-half to one hour before breakfast. The drug is absorbed better on an empty stomach."" b) Residents #6 and #15 During medication administration by Employee #22 on 05/12/10 at 9:00 a.m., Residents #6 and #15 were observed receiving their medication. At that time, both residents received [MEDICATION NAME], a [MEDICAL CONDITION] replacement medication. The LPN, when questioned, confirmed the residents had just finished their breakfast. Review of the Internet website www.drugs.com disclosed the following statement: ""Take [MEDICATION NAME] as a single dose, preferably on an empty stomach, one-half to one hour before breakfast. The drug is absorbed better on an empty stomach."" When interviewed on 05/12/10 at 11:00 a.m., another LPN (Employee #28) stated she had spoken to the unit's consulting pharmacist concerning this information the previous evening, and the pharmacist agreed with this information and stated she had planned to submit that recommendation on her next visit to the unit. .",2015-05-01
10312,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,272,D,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, record review, and resident interview, the facility failed, for three (3) of twenty-one (21) Stage II sample residents, to complete initial and/or periodic comprehensive assessments of each resident's functional capacity, to include assessments of skin condition, bladder continence, and nutritional status. Resident identifiers: #9, #31, and #53. Facility census: 34. Findings include: a) Resident #9 When interviewed on 05/03/10 at 3:45 p.m. about the status of Resident #9's skin integrity, Employee #18 (a licensed practical nurse - LPN) stated the resident had an open area on each heel and he ""came from hospital with them."" When reviewed on 05/12/10, the resident's medical record disclosed this [AGE] year old had been admitted to the facility from a local hospital on [DATE], following repair of a [MEDICAL CONDITION] that he had incurred at home. The resident's nursing admission assessment made no mention of skin breakdown other than describing the area of the surgical wound on the resident's left hip. Nursing notes and physician orders [REDACTED]. A nurse's note, dated 02/03/10 at 12:20 p.m., stated, ""Resident complained of heels hurting this am (morning). Heel up (sic) off bed. Both heels black area. Told charge nurse."" Orders were received, and treatment was started to the heels at that time. An additional nurse's note, dated 03/01/10, stated a physician questioned the resident and his wife related to the areas on his heels, and both the resident and his wife agreed that his heels had been sore since he was at home, prior to his hospitalization for the [MEDICAL CONDITION]. When interviewed on 05/12/10 at 4:07 p.m., the facility's care plan and assessment nurse (Employee #25) confirmed the skin integrity of the resident's heels, according to the resident and family, had been somehow compromised at the time of admission to the ECU. This employee stated the ECU protocol for skin assessments was for an assessment to be completed on the resident at the time of admission and then monthly thereafter by the nurse, unless there was a recognized skin issue; then, a weekly skin assessment (wound assessment) was completed. This nurse further confirmed that no assessment of the resident's heels had been completed until the resident complained of pain on 02/03/10. The resident's MDS documents, when reviewed, disclosed that both the admission MDS (with an assessment reference date (ARD) of 01/17/10) and the Medicare 14-Day MDS (with an ARD of 01/24/10) made no mention, in Section M, of the resident having any skin breakdown. The resident's next MDS (with an ARD of 02/09/10) described the resident, in Section M, as having four (4) Stage IV pressure ulcers. -- b) Resident # 31 Medical record review, on 05/12/10, revealed this resident was incontinent of bladder when admitted on [DATE]. A six-page bladder incontinence assessment form was found in the medical record; however, it had not been completed. This form also contained the protocols for assessing residents with urinary incontinence. At 2:00 p.m. on 05/12/10, the director of nursing (DON - Employee #31) and the vice president of patient care services (Employee #32) were asked if they would locate a completed bladder incontinence assessment for this resident. Each reviewed the medical record and checked other sources, then confirmed no such assessment had been completed. At 11:00 a.m. on 05/13/10, the resident was interviewed regarding her incontinence. At that time, the resident stated she could feel the urge to urinate and would like to be continent of urine if at all possible. -- c) Resident #53 Review of this resident's medical record, on 05/12/10, revealed a weight of 101.4 pounds (#) on 03/02/10, and a weight of 94.6# on 04/02/10. There was no evidence the resident was reweighed to confirm or dispute this six and seven-tenths percent (6.7%) weight loss in one (1) month. If the weight loss were accurate as recorded, the facility should have immediately acted on this significant weight loss. There was no evidence the weight loss had been further assessed or addressed. Interview with Employee #32, at 2:05 p.m. on 05/12/10, revealed nursing staff should have reweighed the resident when there was such a variance in weight. When asked how staff would know this should be done, Employee #32 stated, ""They just know to do so, but they did not."" When a request was made for a policy and procedure regarding weights, Employee #32 stated no such policy existed. .",2015-05-01
10313,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,279,E,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, observation, and resident interview, the facility failed, for seven (7) of twenty-one (21) Stage II sample residents, to develop a comprehensive plan of care that accurately described the services to be furnished to each resident to assist in attaining or maintaining the highest practicable physical, mental and/or psychosocial well being. Two (2) residents had no care plan related to the use of an indwelling Foley urinary catheter, one (1) resident had no care plan related to urinary incontinence, one (1) resident had no care plan for pressure ulcers, one (1) resident had no care plan for the restoration of bladder function, one (1) resident had no care plan for the need for a nutritional assessment, and one (1) resident had a care plan with inappropriate / unexplainable interventions. Resident identifiers: #32, #18, #33, #9, #31, #2, and #53. Facility census: 34. Findings include: a) Resident #32 When reviewed on 05/12/10, the resident's medical record disclosed the resident had been admitted to the Extended Care Unit (ECU) on 12/21/09, following hospitalization for a broken pelvis. At the time of admission to the ECU from acute care, the resident had in place an indwelling Foley urinary catheter. The catheter was removed, according to nurse's notes on 01/12/10. An interview with a licensed practical nurse (LPN - Employee #28), on 05/12/10 at 9:52 a.m., disclosed that facility protocol was typically to remove catheters within twenty-four (24) hours of admission unless there was a [DIAGNOSES REDACTED]. The LPN further stated this resident had a broken pelvis and personally requested that the catheter remain in place. On 01/12/10, the resident agreed to have it removed. The medical record contained no physician's order for the removal of the catheter, no evidence of any attempt by staff to assess the resident's ability to regain continence, and no evidence of any attempt at bladder re-training prior to the removal of the catheter. The resident's minimum data set (MDS) assessments for the previous several months were reviewed. An admission MDS, with an assessment reference date of 10/18/09, stated in Section H that the resident was continent of bowel and bladder (both coded ""0"") with no devices or appliance (such as an indwelling catheter) present. A second admission MDS (with an ARD of 01/05/10) was identical as the above mentioned, although nurse's notes and staff interview stated the resident did have an indwelling catheter present between the dates of 12/21/09 and 01/12/10. A quarterly MDS (with an ARD of 04/05/10) stated the resident was continent of bowel (coded ""0"") and mostly incontinent of bladder (coded ""4""). Although the MDSs inaccurately denied the presence of the indwelling catheter on any assessment, these findings would indicate the resident had been continent of urine prior to her hospitalization and placement of the indwelling catheter and that urinary continence may possibly have been attainable following the removal of the catheter. The resident's current care plan, when reviewed, contained no mention of urinary incontinence. The care plan / assessment nurse (Employee #25) confirmed, when interviewed on 05/12/10, that the resident's care plan did not reflect necessary services in the area of urinary incontinence or a plan to assist the resident in restoring as much normal bladder function as possible. -- b) Resident #18 During an interview related to the use of an indwelling catheter for this resident on 05/04/10, Employee #28 stated the catheter was used periodically for wound healing then removed. The LPN further stated the resident was transferred with a mechanical lift and did not like to go back to bed after she gets up, thus causing re-current breakdown in her skin integrity. Medical record review, on 05/10/10, describe the presence of a Stage I pressure ulcer at this time. A physician's telephone order,dated 03/22/10, stated, ""Insert F/C (Foley catheter) to aid in healing decub to buttock, re-evaluate in 7 days."" On 05/10/10 at 1:45 p.m., observation found the resident in the activity room with the catheter drainage bag suspended under her wheelchair enclosed in a protective cloth bag to conceal it. The resident's most current care plan, when reviewed, disclosed a problem identified by staff on 11/16/09 and reviewed on 02/10/10, stating this resident had ""actual pressure ulcer or altered skin integrity related to urinary incontinence, poor mobility as evidenced by recurring Stage II to coccyx."" The care plan made no mention of the use of an indwelling catheter. Employee #28, when interviewed on 05/10/10, confirmed the resident's care plan had not been updated at the time of the insertion of the indwelling catheter to reflect the resident's current status and necessary services. -- c) Resident #33 When interviewed on 05/04/10 related to the presence of an indwelling Foley urinary catheter for this resident, Employee #28 stated this resident had a Foley catheter due to severe [MEDICAL CONDITION] of the lower legs. The resident was stated to be voiding down her legs, making the skin condition worse. When reviewed on 05/12/10, the resident's medical record revealed the resident was admitted to the ECU on 03/18/10. She had been hosptalized on [DATE], when, according to hospital reports, she presented to the emergency department with pain in her right leg. Her provisional [DIAGNOSES REDACTED]. The resident was re-hosptalized on [DATE] and remained hospitalized until 04/26/10, at which time, according to a nursing readmission assessment on this day, the resident returned to the ECU with an indwelling Foley urinary catheter to assist with wound healing. The resident, when observed on numerous occasions during the course of the survey between 05/03/10 and 05/13/10, was noted to have a Foley catheter drainage bag which was suspended on the bottom of her wheelchair and enclosed in a protective cloth bag. The resident's care plan, when reviewed, disclosed a problem identified by staff for this resident on 04/04/10 as follows: ""Potential for complications related to urinary incontinence. Incontinent at times (sic). Also doesn't like to sit on toilet, she tries to stand over toilet and urine runs down legs."" The care plan made no mention of the resident's indwelling catheter or needs associated with its use. Employee #28 confirmed, when interviewed on 05/12/10, this resident's care plan did not address the care needs associated with her indwelling catheter. -- d) Resident #9 When interviewed on 05/03/10 at 3:45 p.m. about the status of Resident #9's skin integrity, Employee #18 (a licensed practical nurse - LPN) stated the resident had an open area on each heel and he ""came from hospital with them."" When reviewed on 05/12/10, the resident's medical record disclosed this [AGE] year old had been admitted to the facility from a local hospital on [DATE], following repair of a [MEDICAL CONDITION] that he had incurred at home. The resident's nursing admission assessment made no mention of skin breakdown other than describing the area of the surgical wound on the resident's left hip. Nursing notes and physician orders were reviewed in their entirety for this resident. A nurse's note, dated 02/03/10 at 12:20 p.m., stated, ""Resident complained of heels hurting this am (morning). Heel up (sic) off bed. Both heels black area. Told charge nurse."" Orders were received, and treatment was started to the heels at that time. An additional nurse's note, dated 03/01/10, stated a physician questioned the resident and his wife related to the areas on his heels, and both the resident and his wife agreed that his heels had been sore since he was at home, prior to his hospitalization for the [MEDICAL CONDITION]. When interviewed on 05/12/10 at 4:07 p.m., the facility's care plan and assessment nurse (Employee #25) confirmed the skin integrity of the resident's heels, according to the resident and family, had been somehow compromised at the time of admission to the ECU. This employee stated the ECU protocol for skin assessments was for an assessment to be completed on the resident at the time of admission and then monthly thereafter by the nurse, unless there was a recognized skin issue; then, a weekly skin assessment (wound assessment) was completed. This nurse further confirmed that no assessment of the resident's heels had been completed until the resident complained of pain on 02/03/10. The resident's MDS documents, when reviewed, disclosed that both the admission MDS (with an assessment reference date (ARD) of 01/17/10) and the Medicare 14-Day MDS (with an ARD of 01/24/10) made no mention, in Section M, of the resident having any skin breakdown. The resident's next MDS (with an ARD of 02/09/10) described the resident, in Section M, as having four (4) Stage IV pressure ulcers. The resident's ""wound assessment and progress review"" document stated, on 05/09/10, the resident had a Stage II pressure ulcer on his left heel that was identified on 02/03/10. The resident's plan of care, when reviewed 05/12/10, made no mention of the resident's pressure ulcers, only the potential for skin breakdown related to incontinence and immobility. Employee #25, when interviewed on 05/12/10 at 3:00 p.m., confirmed the resident's care plan did not address the presence of pressure ulcer(s) or the care needs / services associated with skin breakdown. -- e) Resident #31 Medical record review, on 05/12/10, revealed this resident was incontinent of bladder when admitted on [DATE]. Review of the resident's care plan revealed no plan regarding an attempt at restoring normal bladder function. The resident's care plan regarding bladder incontinence, originating on 02/15/10 and updated on 04/22/10, was: ""Will be clean and dry with use of incontinence products and prompt incontinence care through review date."" The interventions were to check for incontinence and change clothing after incontinence, etc. There were no care plans to assist the resident in regaining bladder continence. This was confirmed by Employee #28 when interviewed at 1:00 p.m. on 05/12/10. At 11:00 a.m. on 05/13/10, the resident was interviewed regarding her incontinence. At that time, the resident stated she could feel the urge to urinate and would like to be continent if at all possible. -- f) Resident #2 Medical record review, on 05/12/10, revealed this resident was underweight and had experienced additional weight loss. Review of the resident's care plan revealed a goal for the resident to maintain a stable weight. One (1) of the interventions for this goal was: ""Provide and serve supplements as ordered."" The resident was to be provided the nutritional supplement Ensure with each meal and for her 2:00 p.m. and 8:00 p.m. snacks. At 1:00 p.m. on 05/12/10, Employee #28 was asked to provide evidence the Ensure was offered and how much Ensure the resident was consuming. Employee #28 stated it was not documented in her medical record, because the resident's son provided the Ensure. The facility had a care plan to provide Ensure but had no means of assuring the Ensure was offered according to the care plan and/or if the supplement was consumed by the resident as planned. -- g) Resident #12 During an interview with this resident at 9:30 a.m. on 05/04/10, she stated her feet ""constantly hurt and burn"". In addition, the resident stated her legs always hurt. Medical record review, on 05/12/10, revealed this resident had a care plan regarding pain, dated 12/02/09 and updated on 03/03/10. One (1) of the interventions was for nursing staff to ""Provide alternative comfort measures. i.e. heat / cold applications, massage..."" There were no specific directives for the implementation of these comfort measures. (Directives were essential, because the resident had [DIAGNOSES REDACTED]. Based on these diagnoses, some methods of implementation of heat / cold applications and/or massage would be contraindicated for this resident.) Additionally, interview with the resident, at 2:15 p.m. on 05/12/10, revealed nursing staff was not providing hot / cold applications or massage according to the care plan. -- h) Resident #53 Review of this resident's medical record, and interview with the social worker (Employee #30) on 05/12/10 at 10:20 a.m., revealed this resident had experienced declines in mood indicators and activities of daily living (ADL) self-performance since admission on 12/12/09. Review of the resident's current care plan, dated 03/25/10, revealed no changes in the planned interventions for mood, communication, activity involvement, or ADLs since the initial care plan dated 01/01/10, even though staff confirmed the resident had experienced these declines. The interventions for each of these areas were not working for this resident; therefore, different interventions should have been established when the care plan was reviewed on 03/25/10. .",2015-05-01
10314,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,428,E,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure that irregularities noted by the consulting pharmacist for two (2) residents reviewed were reported to a resident's attending physician, and failed to assure that reported irregularities for three (3) residents were acted upon by their attending physician within a reasonable time period. This practice affected five (5) of twenty-one (21) Stage II sample residents. Resident identifiers: #14, #32, #34, #31, and #53. Facility census was 34. Findings include: a) Resident #14 When reviewed on 05/11/10 at 4:00 p.m., the resident's medical record disclosed a ""Chronological Record of Drug Regimen Review"" form dated 03/24/10. The consultant registered pharmacist (RPH) made recommendation to the resident's attending physician and the unit's director of nurses (DON) relevant to an irregularity in the resident's drug regimen. This recommendation could not be found on the medical record. Facility staff was asked to locate the recommendation for surveyor review. On 05/12/10 at 11:55 a.m., a licensed practical nurse (LPN - Employee #28) confirmed the recommendation was not available and there was no evidence it had ever been reported to the DON or attending physician as stated. This employee contacted the RPH, and the report was faxed to the unit for review by the DON and attending physician at that time. -- b) Resident #32 When reviewed on 05/11/10, the resident's medical record disclosed a ""Pharmacy to Physician communication"" document dated 01/26/10, which recommended the physician consider changing a medication, Prilosec (used in the treatment of [REDACTED]. The resident had the medical [DIAGNOSES REDACTED]. This recommendation stated that Prilosec may decrease the effectiveness of another medication, Plavix (a medication used to help prevent harmful blood clots from forming, which given to people who have had a recent heart attack or stroke). Further review revealed the physician did not act upon this recommendation until 04/16/10, when an order was issued to discontinue the Prilosec and to begin Zantac (a medication used to treat heartburn, ulcers, GERD, erosive esophagitis, and other conditions). This finding was confirmed by Employee #28 at 11:30 a.m. on 05/12/10. -- c) Resident #34 When reviewed on 05/11/10, the resident's medical record disclosed a ""Pharmacy to Physician Communication"" document dated 01/26/10, which recommended the physician consider changing the dosage of the medication Zantac. The recommendation stated that related to the resident's CrCl (creatinine clearance), the resident's dosage should be decreased by one-half (1/2) of the current dose he was receiving. (The creatinine clearance test compares the level of creatinine in urine with the creatinine level in the blood. Creatinine is a breakdown product of creatine, which is an important part of muscle. The test helps provide information on kidney function.) The same recommendation was relayed via the communication form to the resident's attending physician on 03/24/10. The physician acted upon the RPH's recommendation by decreasing the dose as recommended on 04/15/10, nearly three (3) months following the original recommendation. -- d) Resident #53 Medical record review, on 05/12/10, revealed the RPH identified an irregularity on 01/26/09. On 05/12/10, a request was made of Employee #28 to locate the written RPH consultant report regarding the irregularity. When Employee #28 was unable to locate the report, she called the RPH. Employee #28 reported the RPH stated to her a written report was not provided, because the RPH directly informed the medication nurse who was passing medications. The RPH stated the change was immediately done. Later that day (05/12/10), the RPH provided a statement regarding the irregularity, which was a need to separate, by two (2) hours, the administration of Cipro (which the resident was ordered at 9:00 a.m. and 9:00 p.m.) with the administration of an iron supplement (at 9:00 a.m.) and a calcium supplement (at 9:00 a.m. and 9:00 p.m.), to prevent absorption problems. Review of the resident's medication administration records (MARs) revealed the irregularity was not corrected and the resident continued to receive the medications together until the course of antibiotics was completed on 01/30/10. -- e) Resident #31 This resident was receiving Zocor. Review of the resident's medical records revealed the facility had not obtained liver function values. The RPH had not identified and reported this irregularity. .",2015-05-01
10315,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,315,G,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview, and staff interview, the facility failed, for two (2) of twenty-one (21) Stage II sample residents who were continent of urine when they entered the facility and became incontinent, to assure timely and appropriate assessment in an effort to possibly regain urinary continence. This resulted in actual harm, as both residents stated a desire to regain normal bladder function and no attempts were made by the facility to assist them with this goal. Resident identifiers: #32 and #31. Facility census: 34. Findings include: a) Resident #32 When reviewed on 05/12/10, the resident's medical record disclosed the resident had been admitted to the Extended Care Unit (ECU) on 12/21/09, following hospitalization for a broken pelvis. At the time of admission to the ECU from acute care, the resident had in place an indwelling Foley urinary catheter. The catheter was removed, according to nurse's notes on 01/12/10. An interview with a licensed practical nurse (LPN - Employee #28), on 05/12/10 at 9:52 a.m., disclosed that facility protocol was typically to remove catheters within twenty-four (24) hours of admission unless there was a [DIAGNOSES REDACTED]. The LPN further stated this resident had a broken pelvis and personally requested that the catheter remain in place. On 01/12/10, the resident agreed to have it removed. The medical record contained no physician's order for the removal of the catheter, no evidence of any attempt by staff to assess the resident's ability to regain continence, and no evidence of any attempt at bladder re-training prior to the removal of the catheter. The resident's minimum data set (MDS) assessments for the previous several months were reviewed. An admission MDS, with an assessment reference date of 10/18/09, stated in Section H that the resident was continent of bowel and bladder (both coded ""0"") with no devices or appliance (such as an indwelling catheter) present. A second admission MDS (with an ARD of 01/05/10) was identical as the above mentioned, although nurse's notes and staff interview stated the resident did have an indwelling catheter present between the dates of 12/21/09 and 01/12/10. A quarterly MDS (with an ARD of 04/05/10) stated the resident was continent of bowel (coded ""0"") and mostly incontinent of bladder (coded ""4""). Although the MDSs inaccurately denied the presence of the indwelling catheter on any assessment, these findings would indicate the resident had been continent of urine prior to her hospitalization and placement of the indwelling catheter and that urinary continence may possibly have been attainable following the removal of the catheter. When interviewed on 05/13/10 at 9:45 am, the resident stated she feels the urge and tries to control it as much as possible. She stated she has ""always had the desire to control it somehow. One thing for sure, I try to avoid the stuff that causes you to urinate. A person that has problems with urine control, they should not drink liquid before they go to bed, especially coffee."" The resident's current care plan, when reviewed, contained no mention of urinary incontinence. The care plan / assessment nurse (Employee #25) confirmed, when interviewed on 05/12/10, that the resident's care plan did not reflect necessary services in the area of urinary incontinence or a plan to assist the resident in restoring as much normal bladder function as possible. b) Resident # 31 Medical record review, on 05/12/10, revealed this resident was incontinent of bladder when admitted on [DATE]. Review of the resident's care plan revealed no plan regarding an attempt at restoring normal bladder function. The resident's care plan regarding bladder incontinence, originating on 02/15/10 and updated on 04/22/10, was: ""Will be clean and dry with use of incontinence products and prompt incontinence care through review date."" The interventions were to check for incontinence and change clothing after incontinence, etc. There were no care plans to assist the resident in regaining bladder continence. This was confirmed by Employee #28 when interviewed at 1:00 p.m. on 05/12/10. At 11:00 a.m. on 05/13/10, the resident was interviewed regarding her incontinence. At that time, the resident stated she could feel the urge to urinate and would like to be continent if at all possible. .",2015-05-01
10316,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,278,D,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, and observation, the facility failed to assure the minimum data set (MDS) assessment accurately reflected the physical status of two (2) of twenty-one (21) Stage II sample residents. Resident identifier: #31 and #33. Facility census: 34. Findings include: a) Resident #31 During an interview with this resident on 05/04/10 at 3:30 p.m., observation made as the resident spoke found broken and carious teeth. The resident described her teeth as being in ""pretty bad shape"" and opened her mouth to display the condition of her teeth. Observation revealed her teeth were in extremely poor condition. The resident's initial minimum data set (MDS), with an assessment reference date (ARD) of 02/07/10, was reviewed. Section L, relative to oral / dental status, did not accurately identify the condition of the resident's teeth. L.1.d ""Broken loose, carious teeth"" was not marked on the MDS, even though this condition had to have existed upon the resident's admission on 01/26/10. -- b) Resident #33 When interviewed on 05/04/10 related to the presence of an indwelling Foley urinary catheter for this resident, Employee #28 (a licensed practical nurse and the medical record coordinator) stated this resident had a Foley catheter due to severe [MEDICAL CONDITION] of the lower legs. The resident was stated to be voiding down her legs, making the skin condition worse. When reviewed on 05/12/10, the resident's medical record revealed the resident was admitted to the Extended Care Unit (ECU) of the facility on 03/18/10. She had been hosptalized on [DATE], when, according to hospital reports, she presented to the emergency department with pain in her right leg. Her provisional [DIAGNOSES REDACTED]. The resident was re-hosptalized on [DATE] and remained hospitalized until 04/26/10, at which time, according to a nursing readmission assessment on this day, the resident returned to the ECU with an indwelling Foley urinary catheter to assist with wound healing. The resident, when observed on numerous occasions during the course of the survey between 05/03/10 and 05/13/10, was noted to have a Foley catheter drainage bag which was suspended on the bottom of her wheelchair and enclosed in a protective cloth bag. Record review revealed the resident's most recent minimum data set assessment (MDS) was a Medicare 5-Day assessment with an assessment reference date (ARD) of 05/02/10. In Section H, the assessor coded the resident as ""3"" in area bladder incontinence, indicating the resident was frequently incontinent of urine. In Section H3, the assessor did not check the item to that would indicated the presence of an indwelling urinary catheter. Employee #28, when asked about the accuracy of this assessment on 05/12/10 at 3:09 p.m., confirmed the resident had had an indwelling Foley urinary catheter in place since readmission to the facility on [DATE] and the MDS was incorrect. .",2015-05-01
10317,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,363,E,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, menu review, recipe review, and staff interview, the facility failed to assure menus were followed for 1200 and 1500 calorie diets, and failed to assure there were menu plans for 2 gram sodium, cardiac, and renal diets. This practice affected fourteen (14) of thirty-three (33) residents who received nourishment from the dietary department. Facility census: 34. Findings include: a) Observation of meal service, on 05/11/10 at 12:05 p.m., revealed all residents were served a 3 ounce portion of meat. Review of the menu plan for this meal revealed the three (3) residents requiring 1200 and 1500 calorie diets were supposed to be served a 2 ounce portion of meat at this meal. At 12:30 p.m., this was brought to the attention of the dietary manager (DM - Employee #90), who confirmed the menu called for 2 ounces, yet 3 ounces were served to these residents. b) Medical record review revealed there were seven (7) residents with a physician's orders [REDACTED]. Review of the menu plan, for the noon meal on 05/11/10, revealed there were no specific menu plans for 2 gram sodium, cardiac, and renal diets. The menu did not indicate which food items were to be salt-free and/or fat-free for these diets. When this was brought to the attention of the DM, the DM stated the specific directives for these diets were on the recipes. The recipes for this meal were reviewed with the DM. There were no special directives for 2 gram sodium, cardiac, or renal diets on the recipes. .",2015-05-01
10318,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,323,G,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed, for one (1) of twenty-one (21) Stage II sample residents, to provide a resident environment as free of accident hazards as possible, by failing to ensure staff consistently secured and alarmed an exit door leading from the unit to a stairwell. This practice resulted in actual harm for Resident #30 when she exited the door unnoticed and fell down eight (8) steps in her wheelchair, sustaining an acromioclavicular joint separation (separated shoulder). Resident identifier: #30. Facility census: 34. Findings include: a) Resident #30 Review of the facility's incident / accident reports, on 05/11/10, revealed a report stating that, on 03/23/10 at 11:00 a.m., Resident #30 was found in a stairwell off the Extended Care Unit (ECU) at the bottom of eight (8) stairs. Further review of the document disclosed that, following investigation, it was determined a staff member had failed to utilize the proper method of securing the door and re-setting the door alarm after another resident had activated the alarm the day before. This information was confirmed in an interview with vice president of patient care services (Employee #32) on the morning of 05/13/10. The resident's medical record, when reviewed on 05/12/10, disclosed this [AGE] year old female was known to the facility to wander and to be at risk for falling. According to the resident's care plan, which was reviewed on 05/12/10, staff was aware the resident was a high risk for falls related to a history of falls. Interventions to assure the resident was free from falls included measures such as providing activities that minimize the potential for falls while providing diversion and distraction and applying a bed alarm and an EZ release seat belt while in wheelchair. The resident also wore a WanderGuard alarming device / bracelet, but this door was not equipped with the WanderGuard system. Review of the resident's minimum data set (MDS) assessments disclosed an MDS with an assessment reference date of 02/24/10. In Section E (Mood and Behavior), the assessor noted the resident exhibited wandering one (1) to three (3) days in the seven-day assessment reference period. The resident was noted in Section B (Cognitive Skills) to be moderately impaired in cognitive skills for daily decision-making, and in Section G (Physical Functioning), the resident was noted to range from needing extensive assistance to being totally dependent for completing most activities of daily living. When the resident was discovered following the fall, nurses' notes stated she was ""lying on face / left side with wheelchair on back. Had to release EZ release seat belt to get w/c (wheelchair) off resident."" The resident was secured to a back board and transferred to the emergency room (ER). The resident underwent [REDACTED]. There was acromioclavicular joint separation (separated shoulder), the resident returned to the ECU with a sling on the left arm, and the resident's pain medication was increased. .",2015-05-01
10319,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,225,D,1,1,I28Y11,"Based on review of documentation by the facility of self-reported allegations of abuse / neglect and injuries of unknown source and staff interview, the facility failed to immediately report two (2) of five (5) incidents reviewed to the regional ombudsman in accordance with State law. Resident identifiers: #23 and #61. Facility census: 113. Findings include: a) Residents #23 and #61 A review of self-reported allegations of abuse and neglect, on 1 at approximately 1:00 p.m., revealed the facility had not reported two (2) allegations of abuse / neglect to all State officials as required by State law. 1. Resident #23 On 10/15/10, the facility sent an immediate fax reporting of allegations to the nurse aide registry as well as to APS. The allegation stated, ""Family members of resident (name) residing on South Long Hall overheard the alleged perpetrator (employee #78) ask the other CNAs (certified nursing assistants) 'where is mean (resident name)?' The regionial ombudsman did not receive notification of this event in accordance with State law. 2. Resident #61 On 08/07/09, the facility completed an immediate fax reporting to the state survey and certification agency as well as to adult protective services (APS). The allegation information stated, ""daughter yelled at resident to 'get up off her ass and get into the damn chair. Also shoved her in bed. Perpetrator then physically struck the registered nurse (RN) supervisor. The record contained no evidence that the regional ombudsman had been notified in accordance with state law. 3. The facility administrator agreed the regional ombudsman had not been notified of the above allegations. .",2015-05-01
10320,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,253,E,0,1,I28Y11,". Based on observation and staff interview, the facility failed to provide a homelike environment. The bathroom doors in various residents' rooms were in disrepair, and drywall in one (1) resident's room was crumbling around the bottom with debris laying on the floor. This affected more than an isolated number of residents. Facility census: 113. Findings include: a) The doors going into the bathrooms of various residents' rooms, when observed during Stage I and Stage II of the survey beginning on 01/03/11, were found to be in disrepair. The doors were scratched, scraped, and chipped, and one (1) door had a hole in it. The rooms which had doors in disrepair were rooms #6, #8, #5, #9, #14, #13, #19, and #18. Additionally, the drywall at the bottom of the wall entering the bathroom in room #56 was crumbling with debris laying on the floor. These observations were brought to the attention of the administrator (Employee #10) at 11:15 a.m. on 01/12/11. .",2015-05-01
10321,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,272,D,0,1,I28Y11,". Based on comments from a random resident, observation, staff interview, review of facility policy ""1.84 Smoking"", and medical record review, the facility failed to conduct an accurate assessment of a resident's functional capacity as evidenced by failing at accurately assess Resident #53's ability to smoke safely without staff supervision. One (1) of forty (40) Stage I sample residents were affected. Resident identifier: #53. Facility census: 113. Findings include: a) Resident #53 On 01/04/11 at 4:40 p.m., this surveyor was informed by a random resident that another resident, who was in the ""smoker's lounge"", was smoking while wearing oxygen. Observation, at 4:42 p.m., found Resident #53 in the smoker's lounge; he was smoking with his portable oxygen tank present and nasal cannula in place. Two (2) other residents were present in the smoker's lounge at this time. At 4:45 p.m., the administrator accompanied this surveyor into the smoker's lounge to check Resident #53's oxygen tank; the portable oxygen tank was observed by the administrator and surveyor to be turned on. At that time, the administrator removed the nasal cannula from the Resident #53 and submerged it in a cup of water; the water was observed by the administrator and surveyor to bubble vigorously. At that time, three (3) other residents were present in the smoker's lounge. Resident #53 and his oxygen tank were then immediately removed from the smoker's lounge. (See also citation at F323.) - Review of the facility policy titled ""1.84 Smoking"", including the facility-specific addendum dated 06/15/07, revealed: ""Cedar Ridge Center will remain a smoking facility for Independent Smokers Only. If a Resident does not qualify as an Independent Smoker based on the outcome of the Smoking Evaluation the Resident will not be permitted to smoke. ..."" - Review of the facility's Smoking Evaluation tool revealed a series of questions about the resident's medical and cognitive status and behavior. This was followed by a section titled ""Evaluation"", which gave the following direction: ""Supervised smoking is required if 'Yes' answers above."" - Review of Resident #53's smoking evaluations revealed the following: On 04/02/10, the assessor (Employee #125 - a registered nurse) marked ""Yes"" in response to the following questions: ""Does the resident use oxygen?"" and ""Is the resident unable to demonstrate the location of the designated smoking area?"" The assessor noted in the ""Evaluation"" section: ""Supervised smoking is required"". On 07/23/10, the assessor (Employee #100 - a licensed practical nurse) marked ""Yes"" in response to the following question: ""Does the resident use oxygen?"" The assessor noted in the ""Evaluation"" section: ""Resident is not allowed to smoke"", and the reason given was: ""resident (sic) on o2 (sic), states he will not be smoking"". On 10/23/10, the assessor (Employee #38 - a registered nurse) marked ""Yes"" in response to the following questions: ""Does the resident use oxygen?"" and ""Is the resident unable to demonstrate the location of the designated smoking area?"" The assessor noted in the ""Evaluation"" section: ""Independent smoking is allowed"". Under interventions, the assessor recorded, ""resident (sic) turns off oxygen to smoke"". - On 01/04/11 at 6:15 p.m., an interview with the administrator revealed that, according to the Smoking Evaluation tool, Resident #53 should not have been allowed to smoke. .",2015-05-01
10322,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,279,D,0,1,I28Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility's interdisciplinary team failed, for two (2) of forty-two (42) Stage II sample residents, to develop a comprehensive care plan, based on a comprehensive assessment, to ensure the highest practicable levels of well-being for each resident. Resident #72, who had a [DIAGNOSES REDACTED]. The resident's care plan did not address positioning when eating, drinking, or taking medications. Resident #53 was observed smoking a cigarette with the oxygen tank not turned off. No care plan concerning the resident's smoking had been developed even though he was granted the privilege to smoke independently contrary to the facility's Smoking Evaluation tool, which indicated residents who used oxygen were to be supervised while smoking. Facility census: 113. Findings include: a) Resident #72 On 01/04/11 at 1:00 p.m., an interview with the resident was initiated. Observation at this time found he was lying in bed essentially flat with his head elevated no more than 10 degrees. At 1:07 p.m., Employee #100 (a licensed practical nurse - LPN) knocked on the closed door and entered the room to give the resident his medication. The nurse handed the resident the medication cup and a glass of water. The resident flexed his neck just enough to take a drink of water with which to swallow his medication. The nurse did not offer to elevate the head of the bed or assist him to a sitting position. Review of his care plan found a ""Focus"" statement of: ""Resident is at nutritional risk r/t (related to) dx (diagnosis) of dysphagia, currently toleration (sic) regular diet."" The goal included: ""Residetn (sic) will have no s/s (signs / symptoms) of aspiration thru next review."" The interventions were: ""Honor food preferences within meal plan. Encourage 100% consumption of all fluids provided. offer (sic) meal substitutes / alternates as needed to encourage oral intake. regular (sic) diet as ordered. Offer snacks. Supervise / cue / assist as needed with meals. Monitor for signs/symptoms of aspirations."" There was nothing about positioning of the resident to prevent aspiration. - Review of the resident's [DIAGNOSES REDACTED]. -- b) Resident #53 1. On 01/04/11 at 4:40 p.m., this surveyor was informed by a random resident that another resident, who was in the smoker's lounge, was smoking while wearing oxygen. Observation, at 4:42 p.m., found Resident #53 in the smoker's lounge; he was smoking with his portable oxygen tank present and nasal cannula in place. Two (2) other residents were present in the smoker's lounge at this time. At 4:45 p.m., the administrator accompanied this surveyor into the smoker's lounge to check Resident #53's oxygen tank; the portable oxygen tank was observed by the administrator and surveyor to be turned on. At that time, the administrator removed the nasal cannula from the Resident #53 and submerged it in a cup of water; the water was observed by the administrator and surveyor to bubble vigorously. At that time, three (3) other residents were present in the smoker's lounge. Resident #53 and his oxygen tank were then immediately removed from the smoker's lounge. (See also citation at F323.) - 2. On 01/04/11 at 5:28 p.m., an interview with the administrator revealed that, during the ""summer time"", Resident #53 had been observed outside smoking with his oxygen on; the administrator stated he would periodically monitor the resident to be sure his oxygen was turned off. The administrator further stated that Resident #53's care plan was updated, and staff was educated regarding this matter. - 3. Review of the facility policy titled ""1.84 Smoking"", including the facility-specific addendum dated 06/15/07, revealed: ""Cedar Ridge Center will remain a smoking facility for Independent Smokers Only. If a Resident does not qualify as an Independent Smoker based on the outcome of the Smoking Evaluation the Resident will not be permitted to smoke. ..."" Review of the facility's Smoking Evaluation tool revealed a series of questions about the resident's medical and cognitive status and behavior. This was followed by a section titled ""Evaluation"", which gave the following direction: ""Supervised smoking is required if 'Yes' answers above."" - 4. Review of Resident #53's smoking evaluations revealed the following: - On 04/02/10, the assessor (Employee #125 - a registered nurse) marked ""Yes"" in response to the following questions: ""Does the resident use oxygen?"" and ""Is the resident unable to demonstrate the location of the designated smoking area?"" The assessor noted in the ""Evaluation"" section: ""Supervised smoking is required"". - On 07/23/10, the assessor (Employee #100 - a licensed practical nurse) marked ""Yes"" in response to the following question: ""Does the resident use oxygen?"" The assessor noted in the ""Evaluation"" section: ""Resident is not allowed to smoke"", and the reason given was: ""resident (sic) on o2 (sic), states he will not be smoking"". - On 10/23/10, the assessor (Employee #38 - a registered nurse) marked ""Yes"" in response to the following questions: ""Does the resident use oxygen?"" and ""Is the resident unable to demonstrate the location of the designated smoking area?"" The assessor noted in the ""Evaluation"" section: ""Independent smoking is allowed"". Under interventions, the assessor recorded, ""resident (sic) turns off oxygen to smoke"". In an interview on 01/04/11 at 6:15 p.m., the administrator confirmed that, according to the Smoking Evaluation tool, Resident #53 should not have been allowed to smoke. - 5. Review of Resident #53's care plan, on 01/13/11, revealed a revision was made on 01/04/11 to include the following problem statement: ""Resident prefers to smoke however starting this date smoking cessation therapy to assist resident to quit habit due to continued need of oxygen and safety."" The goal associated with this problem statement was: ""Resident will not smoke x 90 days."" The interventions to assist the resident in achieving this goal included: ""Educate the resident / health care decision maker on the facility's smoking policy. Inform resident of the availability of stop smoking material. assess (sic) for adverse behaviors. resident (sic) to receive nicotine patches 21 mg qd (daily) x 4weeks (sic) then nicotine patch 14mg (sic) x 4weeks (sic), then 7mg (sic) x 4weeks (sic) then d/c (discontinue)."" Review of Resident #53's previous care plan, dated 10/27/10, found the interdisciplinary team had not addressed the matter of this resident's smoking, especially in view of the Smoking Evaluation tool dated 10/23/10, in which Employee #38 made an exception by granting this resident the privilege to smoke independently contrary to the directions of the tool. .",2015-05-01
10323,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,280,D,0,1,I28Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility's interdisciplinary team failed to review and revise a resident's care plan to reflect changes made in her overall plan of care. The physician's orders [REDACTED]. The resident sustained [REDACTED]. Her care plan was updated to reflect the presence of the cast, but the care plan regarding the leg splint was not changed until its use was questioned on 01/11/11. One (1) of forty-two (42) Stage II sample residents was affected. Resident identifier: #1. Facility census: 113. Findings include: a) Resident #1 This resident was identified in Stage I of the survey as having contractures and selected for further review in Stage II. Observations of the resident found she did not have the splint on either leg or on her left hand on 01/04/11 or 01/05/11. She was found to have no splints on when observed on 01/11/11. Review of her current physician's orders [REDACTED]. She also had orders for a cast to her right leg and for: ""Palmar splint to remain on left hand at all times. Remove QD (every day) for hand hygiene and skin care."" There were no order changes regarding the use of the splints after she sustained a fracture to her right leg on 12/22/10. On 01/11/10 at 2:20 p.m., a nursing assistant (Employee #66) was observed rendering care to the resident. When asked about the leg splint, she said the resident did not have one on - she said the resident had a cast on her right leg and she (the nursing assistant) had not put the splint on. A minute later, she said she had been off work and maybe she should have put the splint on the other leg. She said she had not asked. At 2:31 on 01/11/11, Employee #66 reported she had asked and was told the splint had put on hold while the resident had the cast. At 2:10 p.m. on 01/12/11, the resident's medical record was again reviewed. On 01/11/11, an order had been written for: ""(1) Hold until further notice: leg splint (symbol for 'secondary') leg fx (fracture) (2) D/C (discontinue) palmar splint - w/c (washcloth) to hands Dx (diagnosis) contracture."" The care plan in place, until the use of the splints was questioned by the surveyor, included alternating the splint to her legs and applying the splint to her left hand. Although the care plan had been updated regarding the presence of a cast on the resident's right leg, it had not been updated to reflect a change in the use of the splints. .",2015-05-01
10324,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,309,D,0,1,I28Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and medical record review, the facility failed to ensure each resident received necessary care and serviced to maintain the individual's highest practicable level of physical well-being in accordance with the comprehensive assessment and plan of care. A resident, whose [DIAGNOSES REDACTED]. One (1) of forty (40) Stage I sample residents was affected. Resident identifier: #72. Facility census: 113. Findings include: a) Resident #72 On 01/04/11 at 1:00 p.m., an interview with the resident was initiated. Observation at this time found he was lying in bed essentially flat with his head elevated no more than 10 degrees. At 1:07 p.m., Employee #100 (a licensed practical nurse - LPN) knocked on the closed door and entered the room to give the resident his medication. The nurse handed the resident the medication cup and a glass of water. The resident flexed his neck just enough to take a drink of water with which to swallow his medication. The nurse did not offer to elevate the head of the bed or assist him to a sitting position. - Review of the resident's [DIAGNOSES REDACTED]. - According to the Mayo Clinic website, dysphagia comprises problems which usually fall into two (2) categories - one (1) of which is oropharyngeal dysphagia. ""Oropharyngeal dysphagia - Certain problems related to your nerves and muscles can weaken your throat muscles, making it difficult to move food from your mouth into your throat and esophagus (pharyngeal paralysis). You may choke, gag or cough when you attempt to swallow, or have the sensation of food or fluids going down your windpipe (trachea) or up your nose. This may lead to pneumonia. . . ."" (http://www.mayoclinic.com/health/difficulty-swallowing/DS ) - The resident's care plan included a goal of: ""Residetn (sic) will have no s/s (signs / symptoms) of aspiration thru next review."" However, the care plan did not address positioning to prevent aspiration. (See F279.) - Further review of his medical record found occupational therapy had worked with the resident. The baseline, on 10/26/10, noted he required maximal assistance to feed himself; at discharge on 11/12/10, he was noted to need moderate assistance for the goal to feed himself while seated. Another goal was to increase sitting balance, and this goal was noted to have been met. .",2015-05-01
10325,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,312,D,0,1,I28Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, medical record review, care plan review and staff interview, the facility failed to ensure that one (1) of forty-two (42) residents reviewed in stage II of the survey, who was dependent on staff for oral care, received assistance with soaking/cleaning her dentures in order to promote good oral hygiene. Resident identifier: #102. Facility census: 113. Findings include: a) Resident #102 On 01/04/11 at approximately 10:30 a.m. during interview, Resident #102 reported she had not received any assistance with soaking her dentures. She said she would like to have them soaked. Review of Resident #102 ' s current care plan conducted on 1/11/2011 at approximately 10:00 a.m., revealed the facility ' s interdisciplinary team identified: "" Resident exhibits or is at risk for oral health or dental problems as evidenced by ' very poor hygiene, tissues are inflamed ' according to (physician name). "" The goal associated with this problem statement was: "" The resident will maintain intact oral mucous membranes as evidence by the absence of discomfort, gum inflammation/infection, oral [MEDICAL CONDITION] X 90 days. "" The interventions listed to achieve the goal included: "" Brush/clean dentures 2x per day as recommended by (physician ' s name). "" The investigation of the concern voiced by this resident was completed on 1/11/2011 at 11:05 a.m. The nurse aide assigned to resident #102 on this date, employee #59, stated the resident had her own teeth and could brush them with assistance; she had not done denture care for this resident. At approximately 11:10 a.m., this surveyor accompanied the nurse aid (Employee #59) into resident #102 ' s room. The resident then told the nurse aide she wanted her dentures soaked. At that time, the resident received assistance with having her dentures soaked. The following morning, on 1/12/2011 at approximately 11:00 a.m., Employee #129 (registered nurse) reported staff had soaked the resident ' s dentures on this day. She said the facility would monitor this to make sure it occurred on a daily basis. .",2015-05-01
10326,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,318,D,0,1,I28Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of medical records, observations, and staff interview, the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM. Observations of one (1) of forty-two (42) Stage II sample residents found splints were not applied as ordered to the resident's legs and her hand. Resident identifier: #1. Facility census: 113. Findings include: a) Resident #1 In Stage I of the survey, the staff interview revealed the resident had contractures of her legs and one (1) hand. She also was reported in the staff interview to have splinting devices in use for the contractures. The Stage I record review found she had current physician's orders [REDACTED]. The splint was to be change every two (2) hours (alternating legs). There also was an order for [REDACTED]."" Observations, on 01/04/11, found she did not have splints on either leg or her left hand. - During Stage II of the survey process, review of nursing entries revealed the resident had been transferred to the hospital on [DATE], and she was diagnosed with [REDACTED]. - On 01/11/11 at 2:20 p.m., Employee #66 (a nursing assistant) was observed rendering care to the resident. When asked about the splint for the resident's legs, she said the resident did not have one on - she said the resident had a cast on her right leg and she (the nursing assistant) had not put the splint on. The nursing assistant completed providing care and left the resident's bedside. It was noted the resident did not have any device on her left hand. At 2:31 p.m. on 01/11/11, the nursing assistant reported she had asked about the splints and found they were on hold while the resident had the cast on her leg. - The resident's most recent quarterly minimum data set assessment, with an assessment reference date of 11/21/10, indicated the resident had functional limitation in ROM in both upper extremities and both lower extremities. At 2:10 p.m. on 01/12/11, the resident's medical record was further reviewed. The order for the splints to be held had not been written until 01/11/11. On that date, an order was written for: ""(1) Hold until further notice: leg splint (symbol for 'secondary') leg fx (fracture) (2) D/C (discontinue) palmar splint - w/c (washcloth) to hands Dx (diagnosis) contracture."" - On 01/12/11, at approximately 2:15 p.m., the resident was observed lying in bed on her right side. She did not have a washcloth in either hand, nor were any washcloths observed near her hands on her bed. Two (2) additional observations on this date, between 3:00 p.m. and 4:30 p.m., did not find a washcloth in either hand. On 01/13/11 at approximately 2:20 p.m., the resident was again observed. No washcloths were found in the resident's hands, nor were any observed lying on the bed. .",2015-05-01
10327,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,323,K,0,1,I28Y11,". Part I -- Based on comments from a random resident, observation, staff interview, review of facility policy ""1.84 Smoking"", and medical record review, the facility failed to provide a resident environment as free of accident hazards as is possible, as evidenced by allowing Resident #53 to smoke in the ""smoker's lounge"" while using oxygen. Three (3) other residents were also present in the smoker's lounge at this time. This practice placed more than an isolated number of residents in immediate jeopardy of harm or death due to the potential of combustion of the oxygen. The immediate jeopardy situation was removed when Resident #53 was removed from the smoker's lounge after the surveyor and the facility's administrator verified, at 4:45 p.m., that the resident's oxygen tank was turned on and oxygen was actively flowing through his nasal cannula. The administrator was informed of the immediate jeopardy determination at 4:55 p.m. on 01/04/11, after the survey team conferred by telephone with the program manager of the State survey and certification agency. On 01/04/11 at 5:10 p.m., the administrator stated he was going to remove Resident #53's smoking privileges due to the resident not safely smoking independently. At 5:20 p.m., the administrator was observed by another surveyor removing Resident #53's smoking materials. At 5:28 p.m., the administrator reported Resident #53's care plan was updated to address this issue, and staff was educated regarding this matter. The administrator submitted an action plan to address dependent smokers who also use oxygen. The plan outlined suspension of smoking privileges by Resident #53, evaluation of the remaining independent smokers (with no further smokers having been identified as also using portable oxygen tanks), and that, on 01/05/11, the facility's quality assurance (QA) committee would ""hold a special meeting to introduce new policy relating to Independent Smokers who have physician orders that include use of oxygen."" Once Resident #53 and his oxygen tank were removed from the smoker's lounge, the immediate jeopardy was removed, leaving the potential for more than minimal harm to more than an isolated number of residents (until the facility's QA committee convened to complete the steps outlined in the facility's action plan). Facility census: 113. (Please note that, beyond the circumstances described in Part I of this deficiency, additional findings of non-compliance with this overall requirement are outlined below in Parts II and III.) Findings include: a) Resident #53 1. On 01/04/11 at 4:40 p.m., this surveyor was informed by a random resident that another resident, who was in the smoker's lounge, was smoking while wearing oxygen. Observation, at 4:42 p.m., found Resident #53 in the smoker's lounge; he was smoking with his portable oxygen tank present and nasal cannula in place. Two (2) other residents were present in the smoker's lounge at this time. At 4:45 p.m., the administrator accompanied this surveyor into the smoker's lounge to check Resident #53's oxygen tank; the portable oxygen tank was observed by the administrator and surveyor to be turned on. At that time, the administrator removed the nasal cannula from the Resident #53 and submerged it in a cup of water; the water was observed by the administrator and surveyor to bubble vigorously. At that time, three (3) other residents were present in the smoker's lounge. Resident #53 and his oxygen tank were then immediately removed from the smoker's lounge. (This action resulted in removal of the hazard constituting immediate jeopardy.) On 01/04/11 at 4:50 p.m., Resident #53 was in administrator's office with administrator and the surveyor present; at that time the resident stated he was aware that his oxygen must be turned off before smoking. The program manager of the State survey and certification agency, when subsequently informed of the resident's use of oxygen in smoker's lounge, verified this practice constituted immediate jeopardy. The determination of immediate jeopardy, due to the potential of combustion of the oxygen, was conveyed to the administrator at 4:55 p.m. on 01/04/11. On 01/04/11 at 5:10 p.m., the administrator stated the facility was going to remove Resident #53's smoking privileges due to the resident not being able to safely smoke independently. On 01/04/11 at 5:20 p.m., the administrator was observed by another surveyor removing Resident #53's smoking materials. The administrator submitted an action plan to address independent smokers who also use oxygen. The plan outlined suspension of smoking privileges by Resident #53, evaluation of the remaining independent smokers (with no further smokers having been identified as also using portable oxygen tanks), and that, on 01/05/11, the facility's QA committee would ""hold a special meeting to introduce new policy relating to Independent Smokers who have physician orders that include use of oxygen."" 2. Review of the facility policy titled ""1.84 Smoking"", including the facility-specific addendum dated 06/15/07, revealed: ""Cedar Ridge Center will remain a smoking facility for Independent Smokers Only. If a Resident does not qualify as an Independent Smoker based on the outcome of the Smoking Evaluation the Resident will not be permitted to smoke. ..."" Review of the facility's Smoking Evaluation tool revealed a series of questions about the resident's medical and cognitive status and behavior. This was followed by a section titled ""Evaluation"", which gave the following direction: ""Supervised smoking is required if 'Yes' answers above."" Review of Resident #53's smoking evaluations revealed the following: - On 04/02/10, the assessor (Employee #125 - a registered nurse) marked ""Yes"" in response to the following questions: ""Does the resident use oxygen?"" and ""Is the resident unable to demonstrate the location of the designated smoking area?"" The assessor noted in the ""Evaluation"" section: ""Supervised smoking is required"". - On 07/23/10, the assessor (Employee #100 - a licensed practical nurse) marked ""Yes"" in response to the following question: ""Does the resident use oxygen?"" The assessor noted in the ""Evaluation"" section: ""Resident is not allowed to smoke "" and the reason given was: ""resident (sic) on o2 (sic), states he will not be smoking"". - On 10/23/10, the assessor (Employee #38 - a registered nurse) marked ""Yes"" in response to the following questions: ""Does the resident use oxygen?"" and ""Is the resident unable to demonstrate the location of the designated smoking area?"" The assessor noted in the ""Evaluation"" section: ""Independent smoking is allowed"". Under interventions, the assessor recorded, ""resident (sic) turns off oxygen to smoke"". In an interview on 01/04/11 at 6:15 p.m., the administrator confirmed that, according to the Smoking Evaluation tool, Resident #53 should not have been allowed to smoke. Review of Resident #53's care plan, on 01/13/11, revealed a revision was made on 01/04/11 to include the following problem statement: ""Resident prefers to smoke however starting this date smoking cessation therapy to assist resident to quit habit due to continued need of oxygen and safety."" The goal associated with this problem statement was: ""Resident will not smoke x 90 days."" The interventions to assist the resident in achieving this goal included: ""Educate the resident / health care decision maker on the facility's smoking policy. Inform resident of the availability of stop smoking material. assess (sic) for adverse behaviors. resident (sic) to receive nicotine patches 21 mg qd (daily) x 4weeks (sic) then nicotine patch 14mg (sic) x 4weeks (sic), then 7mg (sic) x 4weeks (sic) then d/c (discontinue)."" Review of Resident #53's previous care plan, dated 10/27/10, found the interdisciplinary team had not addressed the matter of this resident's smoking, especially in view of the Smoking Evaluation tool dated 10/23/10, in which Employee #38 made an exception by granting this resident the privilege to smoke independently contrary to the directions of the tool. ++++ Part II -- Based on observations, measurement of food temperatures, and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible. The food service supervisor (Employee #12) was observed, beginning at 10:28 a.m. on 01/05/11, carrying steam table pans of hot foods from the facility's kitchen, down halls in which varying numbers of residents and staff were present, to an activities room where the cafe was located. The pans of hot food, which were being transported by hand using pot holders, were covered with foil which would not prevent spillage should the individual transporting the foods lose his balance for any reason. Should a resident attempt to touch the pan or suddenly come in front of the pan, the transporter would not be able to ward off the resident, as both hands were needed to carry the pan. One (1) pan contained meatballs in barbecue sauce measuring 182 degrees Fahrenheit (F), and another pan contained chili measuring 172 degrees F; exposure of skin to a water temperature of 155 degrees F for only 1 second will result in a third degree burn. Because these substances are thicker than water, should these items spill onto skin or clothing, they would cling and prolong the exposure to temperatures sufficient to cause burns. This practice posed an avoidable immediate risk of burns to residents and / or staff who were moving about near the kitchen / dining room, in the South long hall and near the South nursing station. More than an isolated number of residents had the potential to be affected. The administrator was informed of the immediate jeopardy situation at 12:17 p.m. on 01/05/11. At 12:35 p.m. on 01/05/11, the administrator presented an action plan for removal of the immediate jeopardy, which included a policy requiring foods transported to the cafe with the use of a cart. Subsequent observations verified a cart was used for transporting foods from the kitchen to the cafe. The potential for harm was minimized upon implementation of the use of the cart for transporting hot foods from the kitchen to the cafe, with no deficient practice persisting in this matter. (Please note that, beyond the circumstances described in Part II of this deficiency, additional findings of non-compliance with this overall requirement are outlined below in Part III. Facility census: 113. Findings include: a) On 01/05/11 at approximately 10:28 a.m., the facility's food service supervisor was observed walking down the hall carrying a full-size steam table pan; this pan had a capacity of 7 quarts. The employee was using pot holders to carry the pan from the kitchen, through the dining room, down the South long hall past residents and staff, past the South nursing station, to the cafe. The South long hall housed up to thirty-four (34) residents with varying degrees of mobility and cognitive function, and residents from other areas of the building also were present on occasion. At approximately 10:33 a.m., the food service supervisor was observed carrying a half steam table pan through the halls; this pan had a capacity of 10 quarts. It was noted that pot holders were again being used. With the permission of the food service supervisor, this surveyor touched the pan and found the bottom of the pan was hot enough to elicit reflexive withdrawal of the fingers. At 10:35 a.m., the surveyor asked the food service supervisor to take the temperatures of the hot foods in the cafe. He said he would need to get a thermometer. At 10:39 a.m., he returned to the cafe with a thermometer but found the thermometer was not working properly. -- He returned with another thermometer and measured the temperatures of the two (2) items that the surveyor observed him to carry through the hallways using pot holders. - The full-sized steam table pan was approximately half full of meatballs in barbecue sauce. The temperature was measured at 182 degrees Fahrenheit (F). - The half steam table pan was filled with chili to approximately 1-1/2 to 2 inches from the top. The employee measured the temperature of the chili at 172 degrees F. -- The determination of immediate jeopardy was confirmed with the program manager with the State survey and certification agency via telephone and e-mail at 12:02 p.m. on 01/05/11. On 01/05/11 at 12:17 p.m., the administrator was informed of the immediate jeopardy situation in the presence of the survey team. A document was provided with the corrective action described, at 12:35 p.m. on 01/05/11. The document titled ""Immediate Action Plan to Address Method of Transportation of Food"" described an education contact with the Food Service Director, that hot temperature foods would be transported via cart. The plan also noted: ""The Food Service Director will complete an in-service for all dietary employees within 24 hours to ensure all dietary staff members that transport food have been educated to this safety standard."" Subsequent observations, made prior to and during the evening meal on 01/05/11, found a cart being used to transport foods from the kitchen to the cafe. ++++ Part III -- Based on observation and medical record review, the facility failed to ensure a resident with an indwelling urinary catheter received care and services to prevent the potential for traumatic removal of the catheter. A resident was observed moving about in a wheelchair with her catheter tubing dragging on the floor near her feet and the wheels of the chair. The resident used her feet to propel herself. One (1) of forty-two (42) Stage II sample residents was affected. Resident identifier: #16. Facility census: 113. Findings include: a) Resident #16 On 01/13/11, Resident #16 was observed going through the hall to the dining room in her wheelchair for lunch. She said she was supposed to use her feet. The tubing from her indwelling Foley urinary catheter was dragging the floor near her feet and also near the left wheel of the chair. This created a potential for her to place her foot on the tubing or for the tubing to be caught under the wheel of the chair, which may have resulted in traumatic removal of the catheter. Review of the resident's medical record, on 01/13/11 at approximately 2:00 p.m., found the catheter had only recently been inserted. A nursing entry, on 01/11/11 at 15:47 (3:47 p.m.), identified the nurse had talked with the physician about the resident not being able to void on her own for the last five (5) days. The physician had ordered the catheter and an appointment with a urologist. .",2015-05-01
10328,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,329,D,0,1,I28Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. Two (2) of ten (10) residents selected by the ASE-Q software for unnecessary drug review were found to have a lack of documentation of the resident-specific rationale for continuation of the use of psychopharmacological medications. Resident identifiers: #72 and #65. Facility census: 113. Findings include: a) Resident #72 Record review revealed this [AGE] year old male resident had [DIAGNOSES REDACTED]. Review of the medication changes since 01/01/10 to present found the dosage for Klonopin (a benzodiazepine) had remained the same. Review of the current physician's orders [REDACTED]. The medication had been ordered for behaviors manifested by verbal outbursts and / or hitting. He was noted to have dementia with behavioral disturbances. On 03/14/10, the pharmacist had issued a consultation report that included, ""(Resident's name) behavior medications are up for annual review for dosage reduction. He is on: [MEDICATION NAME] 20 mg daily Klonopin 0.5 mg TID (three (3) times a day)."" The recommendation from the pharmacist was: ""Please consider a gradual dose reduction, perhaps decreasing the Klonopin to BID (two (2) times a day) while concurrently monitoring for re-emergence of target and / or withdrawal symptoms. If therapy is to continue at the current dose, please provide rationale describing a dose reduction as clinically contraindicated."" For ""Rationale for Recommendation"", the report had: ""Federal nursing facility regulations require that a gradual dosage reduction (GDR) be attempted in two separate quarters within the first year in which and individual is admitted on a psychopharmacologic medication or after the facility has initiated such medication, and then annually UNLESS CLINICALLY CONTRAINDICATED."" The physician checked that he ""declined"" the recommendation beside the statement ""Continued use is in accordance with the current standard of practice and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder (as outlined below)."" Below the checked statement was: ""Please provide CMS REQUIRED patient-specific rationale why a GDR attempt is likely to impair function or cause psychiatric instability in this individual:"" Nothing was recorded on lines provided on the form for noting this rationale. No additional information was found in review of the physician's progress notes written since 03/14/10. The physician had not provided the requisite documentation regarding why a gradual dose reduction was clinically contraindicated for Resident #72. -- b) Resident #65 Review of this [AGE] year old resident's medical record found she had current physician's orders [REDACTED]. On 02/11/10, the pharmacist had noted the resident was on [MEDICATION NAME] 15 mg at bed time and [MEDICATION NAME] 25 mg daily. It was also noted that the resident was receiving [MEDICATION NAME] 50 mg BID and [MEDICATION NAME] 0.25 mg BID with 0.25 mg daily PRN (as needed). The pharmacist noted the PRN order had been reduced in July. Also in this ""Comment"" section was: ""No other attempts at changing her medications for years."" Review of the resident's current physician orders [REDACTED]. The dosage for [MEDICATION NAME] and [MEDICATION NAME] remained the same. The routine [MEDICATION NAME] dose remained the same, but there was no PRN order currently. The recommendation from the pharmacist was: ""Please consider a gradual dose reduction of one or more of the medications while concurrently monitoring for re-emergence of target and / or withdrawal symptoms. If therapy is to continue at the current dose, please provide rationale describing a dose reduction as clinically contraindicated."" For ""Rationale for Recommendation"" the report had: ""Federal nursing facility regulations require that antipsychotics being used to manage behavior or stabilize mood undergo gradual dose reduction (GDR) attempts in two separate quarters within the first year in which a resident is admitted on one of these medications or after the facility has initiated such medication, and then annually UNLESS CLINICALLY CONTRAINDICATED."" The physician checked: ""I accept the recommendation(s) above WITH THE FOLLOWING MODIFICATION(S):"" and wrote ""D/C (discontinue) [MEDICATION NAME]."" Nothing was written to address the continued use of [MEDICATION NAME], and [MEDICATION NAME]. No additional information was found in review of the physician's progress notes written since 02/11/10. The physician had not provided the requisite documentation regarding why a gradual dose reduction was clinically contraindicated for these medications for Resident #65. -- c) The above was discussed with the director of nursing the afternoon of 01/12/11. She acknowledged the lack of physician documentation in response to the pharmacist's recommendations and noted the documentation should have been made on the pharmacist's consultation forms. .",2015-05-01
10329,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,371,F,0,1,I28Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's policies regarding food handling, review of portions of the 2005 USDA Food Code (as adopted by the State of West Virginia), staff interview, and resident interview, the facility failed to ensure foods were procured from approved sources and were stored, prepared, and distributed under sanitary conditions. Outdated items were found stored in refrigerators. Staff did not properly restrain their hair. Raw, unpasteurized goose eggs were found stored improperly and were not obtained from an approved source. Food items were not labeled and dated to ensure usage within acceptable time frames. The freezer door would not close properly, allowing the build-up of ice and frost, and so on. Additionally, dietary staff did not utilize appropriate hand hygiene techniques when indicated. Observation of the refrigerator in the pantry on the nursing unit found unlabeled and/or undated food items and plastic containers which, when opened, were noted to contain mold growing on top of unrecognizable food items. Additionally, Resident #36 was found to have a bottle of ranch dressing in her room that was open and unrefrigerated. These practices had a potential to affect all residents who consumed oral nutrition prepared in this central kitchen. Facility census: 113. Findings include: a) During the initial tour of the kitchen at approximately 5:30 p.m. on 01/03/11, the following were noted: 1. Observation of the reach-in refrigerator located in the kitchen found the following: - Raw, unpasteurized goose eggs On the top shelf, on the left hand side of the reach-in refrigerator, were at least ten (10) uncooked goose eggs. The eggs were contained in an unsealed bread wrapper, except for one (1) that had rolled out of the wrapper. Inspection of the eggs found they had not been cleaned. The 2005 Food Code requires that eggs shall be received clean (3-202.13) and that ""Eggs that have not been treated to destroy all viable Salmonellae shall be labeled to include safe handling instruction as specified in law, including 21 CFR 101.17(h)."" Additionally, these eggs were stored over meats in a steam table pan covered with plastic wrap and other items that were on the shelves below; had the egg shells cracked open, their contents would have contaminated the food items stored below them. On 01/12/11, during the lunch preparation, the reach-in refrigerator was checked. The goose eggs were not seen. When asked about the eggs, a dietary staff member (Employee #22) said they had been for a resident, but they had gotten rid of them. - Two (2) small steam table pans covered with plastic wrap containing salad dressings. Neither container had been labeled as to its contents nor dated. - A Ziploc bag containing sliced ham and another with cooked bacon. There were no labels or dates on these bags to ensure the food items were used timely. - A full steam table pan with sliced corn beef covered with plastic wrap. There was no date or label found on the covering or pan. - Behind some other items, in the back of the refrigerator, was a Ziploc bag labeled ""Chicken to puree on 12-30-10."" The bag had a ""pasty"" looking material adhering to the sides and, when opened, an unpleasant odor was detected. - A container labeled ""Cuke salad"" and dated 12/29/10. - A plastic container (not the original container) containing at least one (1) quart of sauerkraut dated 12/27/10. - 2. Observation of the walk-in freezer found the following: The door to the walk-in freezer (which was accessed by walking through the walk-in refrigerator) was icy and would not shut. Ice had accumulated around the bottom of the door inside of the refrigerator area. There was a build-up of frost on the inside of the door and items in the freezer. - 3. Observation of the walk-in refrigerator found the following: - There were five (5) plastic crates of milk sitting directly on the floor. - Prepared cheese sandwiches were on a tray on a shelf. There was no date to indicate when the sandwiches had been prepared or by when they should be used. - A plastic container (not the original container) was covered loosely with plastic wrap. It was dated ""31 [DATE]"" and labeled as being Ketchup. - An open box of Lyons cranberry juice dated 12-21-10 - 4. By the coffee machine, food crumbs and dust were observed on the bottom an inverted plastic pitcher and on the lid of another pitcher. - 5. The large stand type Univex mixer was stored in an area off of the kitchen where staff stored personal items on the wall/shelf across the room. When a male employee was asked whether the mixer was used, he said, ""Once in a great while."" The bowl of the mixer was not covered. The mixer's attachments were stored in the mixing bowl. There was dried food readily apparent on the head of the mixer. - 6. In the dry storage room, plastic food molds were stored directly on floor. A dried brownish substance was noted in some of the molds. This could attract pests as well as inhibiting cleaning of the floor. - 7. Empty cardboard boxes were on the floor of the dry storage area. One (1) box contained boxes of Lyons cranberry juice cocktail. - 8. Red rubber mats that were visibly soiled were rolled up and had been put under the sink and storage shelving in the kitchen. In an interview at approximately 10:30 a.m. on 01/13/11, the food service supervisor said the mats should have been taken outside, not left rolled up in the kitchen. - 9. A 3-quart plastic container was observed on a shelf with trapped moisture inside. -- b) Observations at lunch time in the kitchen on 01/12/11 found the following: 1. A wet cloth was retrieved from the sink where it had been lying atop some cookware. The cloth was used to wipe the top shelf of the sneeze guard off, then it was put back in sink on top of the cookware. The cloth was not been maintained in a sanitizing solution. On 01/13/11 at approximately 10:30 a.m., the food service supervisor stated the cloths should have been placed in the containers by the sink, and he pointed to the designated containers. The containers had been sitting in the same place at lunch time on 01/12/11, but had not been utilized. - 2. Utensils to be used for serving lunch were placed face down on the top shelf of the steam table sneeze guard. There were assorted non-food and non-food service items on the end of the counter (a notebook, papers, menus, a box of gloves, etc.) in close proximity to the utensils. Additionally, staff had been observed to place their bare hands on the shelf as they went about their duties. - 3. The door to the walk-in refrigerator was found unlatched, and the freezer door was also unlatched. - 4. Dietary staff did not ensure their hair was restrained in accordance with 2-402.11 of the 2005 Food Code. The code requires that employees wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean utensils, etc. During lunch preparation and service, Employees #20 and #22 did not have effective hair restraints. - 5. Employee #22 was observed checking the temperature of a pan of small sausages. She put the thermometer through a sausage. When she removed the thermometer, she used her bare finger to push a sausage off of the end of the thermometer, back into the pan. - 6. Employee #19 was observed washing dishes in the dishwasher. At times, Employee #21 would remove the clean dishes from the dishwasher and Employee #19 would put another rack of soiled dishes into the machine. However, on more than three (3) occasions, Employee #19 pushed the rack of clean dishes out with a rack of soiled ones. - 7. Employee #22 was observed to have four (4) rings on her fingers. The rings had wide bands. The 2005 Food Code includes ""2-303.11 Prohibition. 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."" - 8. On 01/12/11 at 1:41 p.m., Employee #22 was asked how foods in the refrigerator were to be dated. She said they try to date items with the date each is put in the refrigerator and the date by which it is to be used. However, if there was only one (1) date, it was the date the item was put in the refrigerator. The facility's policy ""'Use By' Dating Guideline"" includes: ""Foods that have been mixed with other ingredients, prepared in any way, or portioned out include, but are not limited to: Juices, thickened beverages, canned fruit, unused portions, prepared salads, cut fruits / vegetables, roasted / slice meats. Use by date three (3) days after preparation."" The document includes: ""Day of preparation or opening is considered Day 1 in the 'use by' date. Example: Tuna salad made on Monday would have a use by date of Wednesday."" - 9. On 01/13/11 at approximately 10:30 a.m., the issues observed on the day of the tour and during lunch observations were discussed with the facility's food service supervisor (Employee #12) as he had not been present on those occasions. The walk-in refrigerator and freezer were again observed. The food service supervisor acknowledged there was a problem with the freezer door and said they have to chip ice off every couple of days. He also said there were plans to replace the unit. During this observation, mold was noted on the walk-in refrigerator door seal. This had the potential to affect the effectiveness of the seal. According to the food service supervisor, the steam tables and movable equipment were taken out into the dining room at night so the kitchen floor could be cleaned. However, it was noted the floor around the bottoms of fixed equipment was in need of cleaning. It was also noted that, when items were being prepared for meal service, the carts with foods that required refrigeration that were needed for the upcoming meal were placed in the walk-in freezer. This effectively blocked access to the freezer unless the carts were moved. During observations, there were times when the carts had to be removed from the refrigerated area. This had a potential to affect the temperature of items on the carts, as well as the temperature in the refrigerator. -- c) On 01/04/11, as the food service supervisor was preparing to serve lunch in the Cafe, he was observed to wash his hands. He performed the procedure in an acceptable manner until he turned the water off with paper towels, then continued to handle the paper towels with both hands. On 01/12/11, during lunch preparation in the kitchen, a dietary staff member (Employee #20) completed the handwashing procedure properly, but she, too, handled the paper towels with both hands after having turned off the water. Employees #12 and #20 recontaminated their hands after having performed acceptable hand hygiene, by wiping their hands with the paper towels they used to turn off the contaminated surfaces of the water faucets at the hand sinks. -- d) Observation of the refrigerator in the nutrition pantry on the North Hall, at 2:00 p.m. on 01/12/11, found plastic containers which, when opened, were noted to contain mold growing on top of unrecognizable food items. Some of the containers were labeled with residents' names but no dates. A Subway sandwich was found without a date and no name. Another sandwich was found with a resident's name but no date. The refrigerator also contained three (3) half gallons of milk for resident consumption which were opened with no dates. Yogurt was found with a resident's name, but the yogurt container had expire date of 12/04/10. These observations were made in the company of a registered nurse (Employee #129). -- e) Resident #36 On 01/04/11 at approximately 11:05 a.m., observation found Resident #36 had an opened bottle of ranch salad dressing sitting on her overbed table. She indicated she used the salad dressing whenever she wanted and denied having a refrigerator to store the dressing. The bottle felt warm to touch and had instructions for refrigeration after opening. On 01/04/11 at approximately 2:00 p.m., a licensed practical nurse (Employee #115) was made aware of the bottle of salad dressing. She indicated she would take care of the situation. On 01/11/11 at approximately 10:00 a.m., an observation revealed the resident still had a bottle of opened ranch salad dressing sitting on her overbed table. A registered nurse (Employee #125) was made aware of the resident having the opened bottle of ranch salad dressing on her overbed table. She indicated she would take care of the situation and agreed the resident should not have the opened bottle of ranch dressing in her room without it being refrigerated. .",2015-05-01
10330,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,431,D,0,1,I28Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to identify and dispose of two (2) bags of intravenous medication which had expired, for one (1) resident of random opportunity. Resident identifier: #148. Facility census: 113. Findings include: a) Resident #148 Observation of the facility's medication storage room on North Hall, at 12:51 p.m. on [DATE], found the medication refrigerator contained two (2) bags of Vancomycin 1250 mg for intravenous use. The bags of medication were labeled with Resident #113's name. One (1) bag had an expiration date of [DATE], and the second bag had an expiration date of [DATE]. The findings were shared with a registered nurse (Employee #129) at the time of the observation. .",2015-05-01
10331,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,441,E,0,1,I28Y11,". Based on observations and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to establish and maintain an infection control program designed to provide a prevent the transmission of disease and infection. Facility staff did not practice handwashing in accordance with standards of practice. Two (2) dietary staff members were observed to handle paper towels after they used them to turn off the faucet. A nursing assistant was observed to remove her gloves after providing care to a resident, then she provided assistance to another resident. She did not wash her hands after removing her gloves and before assisting the second resident. Additionally, a resident was observed maneuvering her wheelchair in the hallway with the tubing of her indwelling catheter dragging the floor. These practices had the potential to cause more than minimal harm to more than a limited number of residents. Resident identifiers: #1 and her roommate, and #16. Facility census: 113. Findings include: a) Hand Hygiene 1. On 01/04/11, as the food service supervisor (Employee #12) was preparing to serve lunch in the Cafe, he was observed to wash his hands. He performed the procedure in an acceptable manner until he turned the water off with paper towels, then continued to handle the paper towels with both hands. - 2. On 01/11/11 at 2:20 p.m., Employee #66, a nursing assistant, was observed rendering care to Resident #1. After providing mouth care to the resident, the employee removed her gloves and went into the resident's bathroom. Resident #1's roommate called for assistance in getting dressed, and nursing assistant went to help her. The employee did not wash her hands after removing her gloves and before going to assist the roommate. - 3. On 01/12/11, during lunch preparation in the kitchen, a dietary staff member (Employee #20) completed the handwashing procedure properly, but she, too, handled the paper towels with both hands after having turned off the water. - 4. According to CDC's ""Guideline for Hand Hygiene in Health-Care Settings"" (dated 10/25/02): ""Indications for handwashing and hand antisepsis: ""... I. Decontaminate hands after contact with inanimate objects ... ""J. Decontaminate hands after removing gloves ..."" Employees #12 and #20 recontaminated their hands after having performed acceptable hand hygiene, by wiping their hands with the paper towels they used to turn off the contaminated surfaces of the water faucets at the hand sinks. Employee #66 failed to wash her hands after removing her gloves and before caring for Resident #1's roommate. -- b) Resident #16 On 01/13/11, the resident was observed going through the hall in her wheelchair for lunch in the dining room. Her Foley urinary catheter tubing was dragging the floor near her feet and also near the left wheel of the chair. Review of the resident's medical record, on 01/13/11 at approximately 2:00 p.m., found the catheter had only recently been inserted. A nursing entry, on 01/11/11 at 15:47, identified the nurse had talked with the physician about the resident not being able to void on her own for the last five (5) days. The physician had ordered the catheter and an appointment with a urologist. .",2015-05-01
10332,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,502,D,0,1,I28Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to obtain laboratory service to meet the needs of residents in a timely manner. The facility failed to obtain laboratory services as ordered by the physician for one (1) of forty-two (42) Stage II sample residents. The physician had ordered laboratory services on 12/20/10, to be obtained in one (1) week following the receipt of an abnormal lab for Resident #32, and the follow-up lab services were not obtained until after surveyor intervention on 01/06/11. Resident identifier: #32. Facility census: 113. Findings include: a) Resident #32 Medical record review, on 01/06/11, revealed this resident was ordered laboratory services on 12/20/10 related to a [DIAGNOSES REDACTED]. According to the medical record for Resident #32, when reviewed on 01/06/11, no additional lab results could be found. Employee #116, a licensed practical nurse, was asked if she could locate the results of the follow-up lab. During an interview on 01/11/11 at 11:51 a.m., Employee #116 confirmed that the follow-up lab had not been obtained as ordered, stating the physician was notified on 01/06/11, and laboratory services were obtained on that day. .",2015-05-01
10333,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,520,K,0,1,I28Y11,". Based on comments from a random resident, observation, staff interview, review of facility policy ""1.84 Smoking"", and medical record review, the facility's quality assessment and assurance (QAA) committee failed to identify quality deficiencies of which it was - or should have been - aware which were reflective of system failures in the area of accident hazards, and failed to develop and implement appropriate plans of action to correct these quality deficiencies. On 04/02/10 and 07/23/10, Resident #53 had been assessed as being unsafe to smoke independently due, in part, to his use of oxygen. On 10/23/10, the assessor (Employee #38, a registered nurse) determined he was permitted to smoke independently even though he continued to use oxygen, which was contrary to the directions on the Smoking Evaluation tool, noting that ""resident turns off oxygen to smoke"". This Smoking Evaluation also was marked by the assessor to indicate that Resident #53's care plan had been updated to address this; however, review of the care plan in effect for Resident #53 at the time of the immediate jeopardy found no mention of smoking. On the afternoon of 01/04/11, Resident #53 was found to be smoking in the facility's ""smoker's lounge"" with his oxygen tank turned on and oxygen actively flowing through his nasal cannula. This practice placed Resident #53 and three (3) other residents who were present in the smoker's lounge in immediate jeopardy of harm or death due to the potential of combustion of the oxygen. The immediate jeopardy situation was removed when Resident #53 was removed from the smoker's lounge after the surveyor and the facility's administrator verified, at 4:45 p.m., that the resident's oxygen tank was turned on and oxygen was actively flowing through his nasal cannula. In subsequent interviews, the administrator reported having been aware that Resident #53 had been observed outside smoking with his oxygen on and that he (the administrator) would periodically monitor the resident to be sure his oxygen was turned off. The administrator also confirmed that, based on the results of his Smoking Evaluation, Resident #53 should not have been permitted to smoke. An interview with the director of nursing (DON) revealed that smoking issues frequently came up in the facility's QAA committee meetings, but specific issues regarding Resident #53 had never been discussed. Facility census: 113. Findings include: a) Resident #53 1. On 01/04/11 at 4:40 p.m., this surveyor was informed by a random resident that another resident, who was in the smoker's lounge, was smoking while wearing oxygen. Observation, at 4:42 p.m., found Resident #53 in the smoker's lounge; he was smoking with his portable oxygen tank present and nasal cannula in place. Two (2) other residents were present in the smoker's lounge at this time. At 4:45 p.m., the administrator accompanied this surveyor into the smoker's lounge to check Resident #53's oxygen tank; the portable oxygen tank was observed by the administrator and surveyor to be turned on. At that time, the administrator removed the nasal cannula from the Resident #53 and submerged it in a cup of water; the water was observed by the administrator and surveyor to bubble vigorously. At that time, three (3) other residents were present in the smoker's lounge. Resident #53 and his oxygen tank were then immediately removed from the smoker's lounge. (This action resulted in removal of the hazard constituting immediate jeopardy.) On 01/04/11 at 4:50 p.m., Resident #53 was in administrator's office with administrator and the surveyor present; at that time the resident stated he was aware that his oxygen must be turned off before smoking. The program manager of the State survey and certification agency, when subsequently informed of the resident's use of oxygen in smoker's lounge, verified this practice constituted immediate jeopardy. The determination of immediate jeopardy, due to the potential of combustion of the oxygen, was conveyed to the administrator at 4:55 p.m. on 01/04/11. On 01/04/11 at 5:10 p.m., the administrator stated that facility was going to remove Resident #53's smoking privileges due to the resident not being able to safely smoke independently. On 01/04/11 at 5:20 p.m., the administrator was observed by another surveyor removing Resident #53's smoking materials. On 01/04/11 at 5:28 p.m., an interview with the administrator revealed that, during the ""summer time"", Resident #53 had been observed outside smoking with his oxygen on; the administrator stated he would periodically monitor the resident to be sure his oxygen was turned off. The administrator further stated that Resident #53's care plan was updated, and staff was educated regarding this matter. -- 2. Review of the facility policy titled ""1.84 Smoking"", including the facility-specific addendum dated 06/15/07, revealed: ""Cedar Ridge Center will remain a smoking facility for Independent Smokers Only. If a Resident does not qualify as an Independent Smoker based on the outcome of the Smoking Evaluation the Resident will not be permitted to smoke. ..."" Review of the facility's Smoking Evaluation tool revealed a series of questions about the resident's medical and cognitive status and behavior. This was followed by a section titled ""Evaluation"", which gave the following direction: ""Supervised smoking is required if 'Yes' answers above."" Review of Resident #53's smoking evaluations revealed the following: - On 04/02/10, the assessor (Employee #125 - a registered nurse) marked ""Yes"" in response to the following questions: ""Does the resident use oxygen?"" and ""Is the resident unable to demonstrate the location of the designated smoking area?"" The assessor noted in the ""Evaluation"" section: ""Supervised smoking is required"". - On 07/23/10, the assessor (Employee #100 - a licensed practical nurse) marked ""Yes"" in response to the following question: ""Does the resident use oxygen?"" The assessor noted in the ""Evaluation"" section: ""Resident is not allowed to smoke"", and the reason given was: ""resident (sic) on o2 (sic), states he will not be smoking"". - On 10/23/10, the assessor (Employee #38 - a registered nurse) marked ""Yes"" in response to the following questions: ""Does the resident use oxygen?"" and ""Is the resident unable to demonstrate the location of the designated smoking area?"" The assessor noted in the ""Evaluation"" section: ""Independent smoking is allowed"". Under interventions, the assessor recorded, ""resident (sic) turns off oxygen to smoke"". - In an interview on 01/04/11 at 6:15 p.m., the administrator confirmed that, according to the Smoking Evaluation tool, Resident #53 should not have been allowed to smoke. - Review of Resident #53's care plan, on 01/13/11, revealed a revision was made on 01/04/11 to include the following problem statement: ""Resident prefers to smoke however starting this date smoking cessation therapy to assist resident to quit habit due to continued need of oxygen and safety."" The goal associated with this problem statement was: ""Resident will not smoke x 90 days."" The interventions to assist the resident in achieving this goal included: ""Educate the resident / health care decision maker on the facility's smoking policy. Inform resident of the availability of stop smoking material. assess (sic) for adverse behaviors. resident (sic) to receive nicotine patches 21 mg qd (daily) x 4weeks (sic) then nicotine patch 14mg (sic) x 4weeks (sic), then 7mg (sic) x 4weeks (sic) then d/c (discontinue)."" - Review of Resident #53's previous care plan, dated 10/27/10, found the interdisciplinary team had not addressed the matter of this resident's smoking, especially in view of the Smoking Evaluation tool dated 10/23/10, in which Employee #38 made an exception by granting this resident the privilege to smoke independently contrary to the directions of the tool. -- 3. On 01/13/11 at 2:05 p.m., an interview with the DON (Employee #46) revealed that smoking issues frequently come up in QAA committee meetings, but specific issues regarding Resident #53 had never been discussed.",2015-05-01
10334,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-01-13,362,F,0,1,I28Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's policies regarding food handling, review of portions of the 2005 USDA Food Code (as adopted by the State of West Virginia), and staff interview, the facility failed to employ sufficient support personnel competent to ensure proper sanitary techniques were being utilized when storing and/or preparing food. Outdated items were found stored in refrigerators. Dietary staff did not properly restrain their hair. Raw, unpasteurized goose eggs were found stored improperly and were not obtained from an approved source. Food items were not labeled and dated to ensure usage within acceptable time frames. The freezer door would not close properly, allowing the build-up of ice and frost, and so on. Observation of the refrigerator in the pantry on the nursing unit found unlabeled and/or undated food items and plastic containers which, when opened, were noted to contain mold growing on top of unrecognizable food items. Additionally, dietary staff did not utilize appropriate hand hygiene techniques when indicated. These practices had a potential to affect all residents who consumed oral nutrition prepared in this central kitchen. Facility census: 113. Findings include: a) During the initial tour of the kitchen at approximately 5:30 p.m. on 01/03/11, the following were noted: 1. Observation of the reach-in refrigerator located in the kitchen found the following: - Raw, unpasteurized goose eggs On the top shelf, on the left hand side of the reach-in refrigerator, were at least ten (10) uncooked goose eggs. The eggs were contained in an unsealed bread wrapper, except for one (1) that had rolled out of the wrapper. Inspection of the eggs found they had not been cleaned. The 2005 Food Code requires that eggs shall be received clean (3-202.13) and that ""Eggs that have not been treated to destroy all viable Salmonellae shall be labeled to include safe handling instruction as specified in law, including 21 CFR 101.17(h)."" Additionally, these eggs were stored over meats in a steam table pan covered with plastic wrap and other items that were on the shelves below; had the egg shells cracked open, their contents would have contaminated the food items stored below them. On 01/12/11, during the lunch preparation, the reach-in refrigerator was checked. The goose eggs were not seen. When asked about the eggs, a dietary staff member (Employee #22) said they had been for a resident, but they had gotten rid of them. - Two (2) small steam table pans covered with plastic wrap containing salad dressings. Neither container had been labeled as to its contents nor dated. - A Ziploc bag containing sliced ham and another with cooked bacon. There were no labels or dates on these bags to ensure the food items were used timely. - A full steam table pan with sliced corn beef covered with plastic wrap. There was no date or label found on the covering or pan. - Behind some other items, in the back of the refrigerator, was a Ziploc bag labeled ""Chicken to puree on 12-30-10."" The bag had a ""pasty"" looking material adhering to the sides and, when opened, an unpleasant odor was detected. - A container labeled ""Cuke salad"" and dated 12/29/10. - A plastic container (not the original container) containing at least one (1) quart of sauerkraut dated 12/27/10. - 2. Observation of the walk-in freezer found the following: The door to the walk-in freezer (which was accessed by walking through the walk-in refrigerator) was icy and would not shut. Ice had accumulated around the bottom of the door inside of the refrigerator area. There was a build-up of frost on the inside of the door and items in the freezer. - 3. Observation of the walk-in refrigerator found the following: - There were five (5) plastic crates of milk sitting directly on the floor. - Prepared cheese sandwiches were on a tray on a shelf. There was no date to indicate when the sandwiches had been prepared or by when they should be used. - A plastic container (not the original container) was covered loosely with plastic wrap. It was dated ""31 [DATE]"" and labeled as being Ketchup. - An open box of Lyons cranberry juice dated 12-21-10 - 4. By the coffee machine, food crumbs and dust were observed on the bottom an inverted plastic pitcher and on the lid of another pitcher. - 5. The large stand type Univex mixer was stored in an area off of the kitchen where staff stored personal items on the wall/shelf across the room. When a male employee was asked whether the mixer was used, he said, ""Once in a great while."" The bowl of the mixer was not covered. The mixer's attachments were stored in the mixing bowl. There was dried food readily apparent on the head of the mixer. - 6. In the dry storage room, plastic food molds were stored directly on floor. A dried brownish substance was noted in some of the molds. This could attract pests as well as inhibiting cleaning of the floor. - 7. Empty cardboard boxes were on the floor of the dry storage area. One (1) box contained boxes of Lyons cranberry juice cocktail. - 8. Red rubber mats that were visibly soiled were rolled up and had been put under the sink and storage shelving in the kitchen. In an interview at approximately 10:30 a.m. on 01/13/11, the food service supervisor said the mats should have been taken outside, not left rolled up in the kitchen. - 9. A 3-quart plastic container was observed on a shelf with trapped moisture inside. -- b) Observations at lunch time in the kitchen on 01/12/11 found the following: 1. A wet cloth was retrieved from the sink where it had been lying atop some cookware. The cloth was used to wipe the top shelf of the sneeze guard off, then it was put back in sink on top of the cookware. The cloth was not been maintained in a sanitizing solution. On 01/13/11 at approximately 10:30 a.m., the food service supervisor stated the cloths should have been placed in the containers by the sink, and he pointed to the designated containers. The containers had been sitting in the same place at lunch time on 01/12/11, but had not been utilized. - 2. Utensils to be used for serving lunch were placed face down on the top shelf of the steam table sneeze guard. There were assorted non-food and non-food service items on the end of the counter (a notebook, papers, menus, a box of gloves, etc.) in close proximity to the utensils. Additionally, staff had been observed to place their bare hands on the shelf as they went about their duties. - 3. The door to the walk-in refrigerator was found unlatched, and the freezer door was also unlatched. - 4. Dietary staff did not ensure their hair was restrained in accordance with 2-402.11 of the 2005 Food Code. The code requires that employees wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean utensils, etc. During lunch preparation and service, Employees #20 and #22 did not have effective hair restraints. - 5. Employee #22 was observed checking the temperature of a pan of small sausages. She put the thermometer through a sausage. When she removed the thermometer, she used her bare finger to push a sausage off of the end of the thermometer, back into the pan. - 6. Employee #19 was observed washing dishes in the dishwasher. At times, Employee #21 would remove the clean dishes from the dishwasher and Employee #19 would put another rack of soiled dishes into the machine. However, on more than three (3) occasions, Employee #19 pushed the rack of clean dishes out with a rack of soiled ones. - 7. Employee #22 was observed to have four (4) rings on her fingers. The rings had wide bands. The 2005 Food Code includes ""2-303.11 Prohibition. 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."" - 8. On 01/12/11 at 1:41 p.m., Employee #22 was asked how foods in the refrigerator were to be dated. She said they try to date items with the date each is put in the refrigerator and the date by which it is to be used. However, if there was only one (1) date, it was the date the item was put in the refrigerator. The facility's policy ""'Use By' Dating Guideline"" includes: ""Foods that have been mixed with other ingredients, prepared in any way, or portioned out include, but are not limited to: Juices, thickened beverages, canned fruit, unused portions, prepared salads, cut fruits / vegetables, roasted / slice meats. Use by date three (3) days after preparation."" The document includes: ""Day of preparation or opening is considered Day 1 in the 'use by' date. Example: Tuna salad made on Monday would have a use by date of Wednesday."" - 9. On 01/13/11 at approximately 10:30 a.m., the issues observed on the day of the tour and during lunch observations were discussed with the facility's food service supervisor (Employee #12) as he had not been present on those occasions. The walk-in refrigerator and freezer were again observed. The food service supervisor acknowledged there was a problem with the freezer door and said they have to chip ice off every couple of days. He also said there were plans to replace the unit. During this observation, mold was noted on the walk-in refrigerator door seal. This had the potential to affect the effectiveness of the seal. According to the food service supervisor, the steam tables and movable equipment were taken out into the dining room at night so the kitchen floor could be cleaned. However, it was noted the floor around the bottoms of fixed equipment was in need of cleaning. It was also noted that, when items were being prepared for meal service, the carts with foods that required refrigeration that were needed for the upcoming meal were placed in the walk-in freezer. This effectively blocked access to the freezer unless the carts were moved. During observations, there were times when the carts had to be removed from the refrigerated area. This had a potential to affect the temperature of items on the carts, as well as the temperature in the refrigerator. -- c) Observation of the refrigerator in the nutrition pantry on the North Hall, at 2:00 p.m. on 01/12/11, found plastic containers which, when opened, were noted to contain mold growing on top of unrecognizable food items. Some of the containers were labeled with residents' names but no dates. A Subway sandwich was found without a date and no name. Another sandwich was found with a resident's name but no date. The refrigerator also contained three (3) half gallons of milk for resident consumption which were opened with no dates. Yogurt was found with a resident's name, but the yogurt container had expire date of 12/04/10. These observations were made in the company of a registered nurse (Employee #129). -- d) On 01/04/11, as the food service supervisor was preparing to serve lunch in the Cafe, he was observed to wash his hands. He performed the procedure in an acceptable manner until he turned the water off with paper towels, then continued to handle the paper towels with both hands. On 01/12/11, during lunch preparation in the kitchen, a dietary staff member (Employee #20) completed the handwashing procedure properly, but she, too, handled the paper towels with both hands after having turned off the water. Employees #12 and #20 recontaminated their hands after having performed acceptable hand hygiene, by wiping their hands with the paper towels they used to turn off the contaminated surfaces of the water faucets at the hand sinks. .",2015-05-01
10335,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-03-18,205,D,1,1,I28Y12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide to the resident (and a family member or legal representative) a written notice which specified the duration of the facility's bed-hold policy when one (1) of sixteen (16) sample residents was transferred to the hospital due to urgent medical needs. Resident identifier: #102. Facility census: 116. Findings include: a) Resident #102 Medical record review, on 03/16/11, revealed this resident was admitted to the facility on [DATE]. On 03/14/11, the resident was transferred to the hospital due to an acute change in condition. The medical record contained no evidence the resident was provided a written notice which specified the duration of the facility's bed-hold policy. At 1:45 p.m. on 03/16/11, an interview was conducted with the director of nursing (DON - Employee #45). When asked for evidence the required information was provided to the resident and a family member or legal representative, the DON stated the information was included in a packet of information which the facility sent to the hospital with Emergency Medical Services (EMS) upon transfer. Further interview revealed the facility was unable to provide evidence this information was sent with the resident; and there was no evidence a family member or legal representative was also provided the written bed-hold policy when Resident #102 was transferred to the hospital. In addition, the facility had no means of assuring the resident and a family member or legal representative got this information, since it was included in a packet of medical information intended for the hospital. On 03/17/11 at 9:00 a.m., a discussion was held with the facility's administrator (ADM - Employee #10), regarding the provision of a written bed-hold policy to the resident and a family member or legal representative upon transfer to the hospital. At that time, the ADM confirmed the facility had not been providing the information to a family member or legal representative, and confirmed he was unable to provide evidence the information was sent with the resident at the time of transfer. The ADM also confirmed the information was not actually provided to the resident; therefore, there was no assurance the resident received the information, from the packet sent to the receiving hospital. .",2015-05-01
10336,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2012-01-13,323,D,1,0,GWX811,". Based on observation, staff interview, medical record review, and facility policy review, the facility failed to provide adequate staff supervision to assist a confused and wandering resident during a large activity held in the main first floor dining room. This practice affected one (1) of five (5) sampled residents. Resident identifier: #41. Facility census: 119. Findings include: a) Resident #41 This facility was entered on 01/12/12 at 3:15 p.m. to conduct an unannounced complaint investigation. During the entrance conference with the administrator in the hallway leading from the main dining room, a male voice could be heard from the main dining room stating, ""(Resident's first name) sit down, sit down (Resident's first name)"". An immediate observation from the doorway of the main dining room noted twenty-three (23) facility residents seated in geriatric chairs and wheelchairs arranged in semicircles in front of a gentleman playing music and telling jokes. The administrator approached and was asked if any staff members were present in the dining room to oversee the residents during this activity. The administrator stated he had two (2) activity aides but did not see any of them in the dining room. He stated he could not imagine where they were and expected someone to be present. He then left the area. Resident #41 was observed to stand up from her wheelchair and approach a female resident reclined in a geriatric chair with a leopard-print blanket covering her. Resident #41 grasped the resident's blanket and was attempting to cover the female resident's feet. This female resident and another female resident seated in a wheelchair beside her began slapping at Resident #41 and telling her to stop. The male volunteer spoke into the microphone, stated Resident #41's first name and again told her to sit down. A female staff member dressed in a business suit entered the dining room and attempted to assist the resident. The administrator identified the staff member as his human resources person. A telephone interview was conducted with the acting activity director (Employee #166) on 01/13/12 at 9:44 a.m. She stated the former activity director had quit without notice and she was filling in as interim. She stated it was ""unacceptable"" for the activity aides to leave the residents unsupervised during an activity and ""they know better than that"". An interview was conducted with an activity aide, Employee #39, on 01/13/12 at 10:14 a.m., with the director of nursing present. Employee #39 stated she left the activity area to relay two (2) resident's dietary requests to the kitchen staff. She stated she entered the kitchen and could not find any dietary staff members. Employee #39 stated she exited the back of the kitchen and looked in the break room and up the service hallway. She stated she could not see the residents after exiting the kitchen and did not hear the volunteer telling Resident #41 to sit down. Review of the medical record found the current care plan with a target date of 02/10/12. Review of the portion of the care plan addressing activities found the following language, ""Resdient (sic) activity particpation is a strenght (sic), she participates in most activities of her choice. She is confused often and requires encoruagment (sic) and redirection"". The interventions included ""redirects as neede (sic)"". Review of the activity manual, dated 01/07/05, in the section entitled Components of Program Provision-Presentation, found the following language, ""Invite the resident to an area outside the activity that may be more restful and seek assistance if a resident becomes anxious and, or agitated during the activity"". .",2015-05-01
10337,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2012-01-31,279,D,1,0,X6UI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview, staff interview, and family interview, the facility failed to develop an interim care plan upon admission related to anticoagulant use for one (1) of sixteen (16) sampled residents. This resident was known to be on anticoagulants, and was allowed to be shaved by facility staff with a disposable razor. The resident was nicked several times one day while being shaved, yet the care plan was still not developed until two (2) days later when the family requested the resident to be shaved only with an electric razor. Resident identifier. #79. Facility census: 105. Findings include: a) Resident #79 Resident #79 was admitted to the facility, on 01/16/12, with a history of [MEDICAL CONDITION] and embolism, history of old [MEDICAL CONDITION] infarction, and history of a stroke resulting in hemipalegia affecting his non-dominant side. Record review revealed his [DIAGNOSES REDACTED]. During an interview with this resident, on 01/31/12 in the early afternoon, he stated an employee had shaved him with a disposable razor on 01/29/12. The employee had nicked him several times on his face. Observation revealed four (4) small dried scabs on his face. During an interview with a family member, on 01/31/12 in the early afternoon, it was found the family had voiced a complaint to the facility earlier that day about his having been nicked while being shaved on 01/29/12. They requested that a family member come in to shave him on 02/02/12. The family would bring in an electric razor for the resident's use. In an interview, on 01/31/12 in the early afternoon, the director of nursing stated the facility had no policy prohibiting a resident who was on anticoagulant therapy from being shaved by staff with a disposable razor, as long as their PT/INR lab work was normal. However, those residents were not allowed to have disposable razors in their rooms for their own personal use. When asked, she said they had no policy prohibiting aides from trimming the nails of residents who were on anticoagulant therapy. Review of the resident's care plan revealed it was updated on 01/31/12 to include a new focus on anticoagulant therapy for [MEDICATION NAME], and being at risk for adverse effects. A new intervention included nursing staff were not to shave the resident, and the family would obtain an electric shaver for family members to use on him. Another new intervention was to report adverse effects such as blood in the urine or stool, bleeding of the gums or nose, and bruising. Other interventions included to administer (anticoagulant therapy) per physician orders, obtain labs as ordered and notify the physician, obtain vital signs as necessary. Review of the medical record found an abnormal PT blood level on 01/31/12 of 78.4, with the normal reference range being 9.1 - 11.5. The INR was also abnormally elevated at 8.1, with the normal reference range between 0.8 and 1.2. For conventional anticoagulation, the range is between 2.5 and 3.0. For intensive anticoagulation, the range is between 2.5 to 3.5. During interviews with nurses, Employees #12, #52, and #104, in the late afternoon on 01/31/12, they reported the aide (Employee #111) who shaved Resident #79 on 01/29/12, had over [AGE] years experience. They provided a copy of the patient information worksheet the aides used daily, and stated it was updated that day for the resident to not be shaved by staff, and the family would shave him with an electric razor. .",2015-05-01
10338,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-01-13,167,B,1,0,VNEB11,". Based on observation and staff interview, the facility failed to ensure the results of all surveys were readily accessible for resident or visitor viewing. Review of the survey book, located in the lobby of the facility, found the absence of the two (2) most recent complaint investigation surveys. Findings include: a) On 01/12/12, review of the survey book, located in the lobby at the entrance of the facility, revealed the most recent survey result posted was a complaint investigation survey completed in February 2011. During an interview with the director of nursing (DON), on 01/12/12 at 8:45 a.m., she stated she thought there was a complaint survey in December 2011. She was uncertain whether there were any others between February and December 2011. The DON stated the administrator would have copies of any surveys in his office. Interview with the administrator, on 01/12/12 at 9:00 a.m., revealed he had two (2) complaint surveys with deficiencies in his office that were not posted in the survey book in the lobby. One (1) missing complaint survey with citations was conducted in April 2011, and the other missing complaint survey with citations was conducted in October 2011. .",2015-05-01
10339,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-01-13,272,D,1,0,VNEB11,". Based on record review and staff interview, the facility failed, for one of ten (10) sampled residents, to ensure the accuracy of a comprehensive assessment. Review of a discharge minimum data set (MDS) assessment, found it was coded incorrectly. The assessment indicated the resident had no pressure ulcers at the time of discharge. However, there was documented evidence in the resident's medical record to establish the resident had a decubitus ulcer on her buttocks. Resident identifier: #103. Facility census: 102. Findings include: a) Resident #103 Review of Section M of the discharge MDS for Resident #103, dated 12/06/11, revealed it was coded as the resident having no pressure ulcers at the time of discharge. Review of the discharge summary note, dated 12/06/11, found a notation signed by the physician which stated in part ""Upon discharge she did have decubitus on buttocks"". A skin integrity report noted the initial recording of a Stage II pressure ulcer on Resident #103's coccyx was on 11/06/11. Review of weekly measurements found it remained a Stage II ulcer until 12/06/11, when it was then described as unstageable. In an interview with the director of nursing (DON), on 01/12/11, at approximately 5:30 p.m., she said she would have to check with her MDS nurse to see if the discharge MDS for Resident #103 was coded incorrectly related to skin conditions at discharge. On 01/13/11, at approximately 11:00 a.m., the DON agreed Section M of the 12/06/11 discharge MDS had been coded incorrectly. The resident had had a decubitus ulcer at the time discharge. .",2015-05-01
10340,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-01-13,441,D,1,0,VNEB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to ensure residents were free from the potential for transmission of organisms via inanimate objects. Observation of treatments found one instance of a key, which hung from the nurse's neck, touching a resident's foot and towel, then came in contact with the lift sheet of another resident. Also, observation of another treatment found the name tag of an employee rested on the bare hip of a resident as she helped position the resident during a dressing and wound vac change. Resident identifiers: #81 and #13. Facility census: 102. Findings include: a) Resident #81 Observation of a treatment for [REDACTED].#22, touched the resident's bare foot and a towel that was lying on the bed during the treatment. Observation of a treatment to Resident #81 on 01/11/12 at 12:30 p.m., revealed the same key touched the lift sheet on which the resident had been lying. He had multiple small, slightly opened areas on the posterior left thigh surrounded by areas of reddened skin. Immediately after the treatment was completed, the nurse, Employee #22, was asked about the key touching items in both residents' beds. She stated she does not typically wear the key, but had been in a hurry when a resident became ill unexpectedly a short while before. She had forgotten to remove the key from her neck. She did not realize the key had touched anything in either bed. b) Resident #13 Observation, on 01/11/12 at 5:00 p.m., of a decubitus ulcer on the coccyx of Resident #13, and changing of the wound vac, revealed a malodorous wound. During observation of this treatment, the name tag of Employee #1 (a nursing assistant) was seen lying on the bare left hip of Resident #13 as she helped hold and position the resident on her right side as nurse Employee #22 changed the wound vac. This was brought to Employee #1's attention immediately after the treatment was completed. She removed her name badge and washed and sanitized it. She did not realize her name badge had been lying on the resident's hip. c) Findings for the above two (2) incidents were relayed to the director of nursing on 01/11/12, at approximately 5:30 p.m., with no further information or comments provided. .",2015-05-01
10341,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-01-13,514,D,1,0,VNEB11,". Based on record review and staff interview, the facility failed to ensure all documents in a resident's medical records were complete. Review of medical records found incomplete entries for the amount of food and fluids consumed at all meals for one (1) of ten (10) sampled residents. Additionally, there were incomplete entries on the intake and output record for the same resident. Resident identifier: #13. Facility census: 102. Findings include: a) Resident #13 Review of activities of daily living (ADL) books found spaces to record the percentages of breakfast, lunch, and dinner, and for the amount of liquids the resident had consumed at each meal. Spaces were also provided for staff to record the intake and output of each resident for each shift. Review of the ADL book for Resident #13 found blank spaces for the consumption of food and fluids for the noon meal on 01/03/12, 01/05/12, 01/08/12, 01/10/12, and the evening meal on 01/08/12. The intake and output record had blank spaces also. The resident's oral intake was not recorded as follows: 11-7 and 3-11 on 01/02/12; 11-7 and 3-11 on 01/03/12; 7-3 on 01/04/12 and 01/05/12; 7-3 and 3-11 on 01/06/12; all shifts on 01/08/12, 7-3 on 01/09/12 and 01/10/12. The following dates had blank spaces, indicating the Foley catheter output for Resident #13 was not recorded as follows: 11-7 and 3-11 on 01/02/12, 7-3 on 01/03/12 and 01/04/12, 11-7 and 7-3 on 01/05/12, all shifts on 01/08/12, 7-3 on 01/09/12 and 01/10/12. Further review of the ADL books found instructions signed by the director of nursing stating that, beginning July 01, nursing assistants ""are not allowed to leave at the end of the shift until the nurse's have checked that all of your books are done. The nurses will be held accountable."" During interview with the director of nursing on 01/11/12 at 10:20 a.m., when asked where to find meal and fluid percentages that residents' consume, and the intake and output measurements, she said the ADL books had that information. When informed of the missing meal and fluid recordings, and missing intake and output recordings for Resident #13, she stated she would look for the missing information. No further information was provided prior to exit. .",2015-05-01
10342,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-01-17,309,D,1,0,9VUN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, review of a residents' hospital discharge summaries, and review of the facility's pharmacy services policies and procedures, it was determined the facility failed to provide the necessary care to maintain the highest practicable physical well-being in accordance with physician orders [REDACTED]. This resident, who had [MEDICAL CONDITION] (MS), was admitted on [DATE], with a physician's orders [REDACTED]. The resident did not receive a dose of this medication until 12/14/11, due to the pharmacy's inability to supply the medication. Additionally, there were three (3) additional missed doses when the facility ran out of the original two (2) week supply from the pharmacy. There also was no evidence the resident's attending physician was notified of the delay in the resident's treatment, or the additional missed doses. Resident identifier: #72. Facility census: 71. Findings include: a) Resident #72 This resident was admitted to the facility on [DATE]. The resident was admitted from the hospital, where this [AGE] year-old had been treated for [REDACTED]. Medical record review revealed the resident's admission orders [REDACTED]. This medication was for treatment of [REDACTED]. During a review of the Medication Administration Record [REDACTED]. The start of the treatment was delayed due to the pharmacy's inability to supply the medication. A review of the December 2011 and January 2012 MARs revealed there was another delay of three (3) doses of Interferon beta, when the facility ran out of the initial two (2) week supply which had been provided by the pharmacy. Interviews were conducted with three (3) licensed nurses (LPNs), Employees #01, #08, and #81, from 11:05 a.m. to 11:20 a.m. on 01/17/12, These LPNs stated they had provided care and medications for this resident. During the interview, the LPNs stated the facility could not get the Interferon from the pharmacy. During an interview with a regional nurse (Employee #91), on 01/17/12 at 12:15 p.m., Employee #91 stated the facility's pharmacy did not have Interferon beta in stock when this resident was admitted to the facility. The regional nurse indicated the facility eventually received a two (2) week supply, and when that was gone, there was another omission of three (3) doses before it became available again. Review of the facility's policy ""7.0 Medication Shortages / Drugs Not Available, process #3 3.3"" indicated if an emergency delivery was unavailable, a licensed nurse was to contact the attending physician to obtain orders or instructions. There was no evidence this was done. Item 5.1 of the policy, regarding when a missed dose was unavoidable, stated the staff was to document missed doses on the MAR, with an explanation in the nurses' notes. Review of the hospital discharge summary revealed documentation which stated, ""If there are any additional questions, our staff is very familiar with this patient and we can help in any way possible."" The discharge summary also provided the name and telephone numbers of the attending physician at the hospital, the nursing unit where the resident was treated, and an invitation to contact the hospital social worker . The discharge summary also stated, ""We really want the patient to succeed and are wishing her the best."" During a review of progress notes, no evidence was found indicating the attending physician had been notified of the problem with getting the ordered medication for the resident. Further interview with the regional nurse (Employee #91), on 01/17/12 at 12:15 p.m., information was requested as evidence the attending physician was notified of the delay in treatment. No further information was provided. .",2015-05-01
10343,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-01-17,425,D,1,0,9VUN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and review of the hospital discharge summary, it was determined the facility failed to provide routine drugs in a timely manner for one (1) of eight (8) sampled residents. Resident #72 was admitted to the facility on [DATE], from the hospital, where she had been treated for [REDACTED]. Upon admission, the resident had a physician's orders [REDACTED]. The resident did not receive a dose of this medication until 12/14/11, due to the pharmacy's inability to supply the medication. Additionally, there were three (3) additional missed doses when the facility ran out of the original two (2) week supply from the pharmacy. Resident identifier: #72. Facility census: 71. Findings include: a) Resident #72 This resident was admitted to the facility on [DATE]. The resident was admitted from the hospital, where this [AGE] year-old had been treated for [REDACTED]. Medical record review revealed the resident's admission orders [REDACTED]. This medication was for treatment of [REDACTED]. During a review of the medication administration records (MAR), for the months of December 2011 and January 2012, it was discovered the resident did not receive a dose of Interferon beta until 12/14/11, although it was ordered on [DATE]. The start of the treatment was delayed due to the pharmacy's inability to supply the medication. The start of the treatment was delayed for several days while the facility's pharmacy attempted to obtain the medication. A review of the December 2011 and January 2012 MARs revealed there was another delay of three (3) doses of Interferon beta, when the facility ran out of the initial two (2) week supply which had been provided by the pharmacy. Interviews were conducted with three (3) licensed nurses (LPNs), Employees #01, #08, and #81, on 01/17/12 from 11:05 a.m. to 11:20 a.m. These LPNs stated they had provided care and medications for this resident. During the interview, the LPNs stated the facility could not get the Interferon from the pharmacy. During an interview with a regional nurse (Employee #91), on 01/17/12 at 12:15 p.m., the nurse stated the facility's pharmacy did not have Interferon beta in stock when this resident was admitted to the facility. The nurse indicated the facility eventually received a two (2) week supply, and when that was gone, there was another omission of three (3) doses before it became available again. The regional nurse confirmed the Interferon had not been provided timely to the resident, or as as ordered by the physician. .",2015-05-01
10344,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2009-07-16,371,F,0,1,KV9O11,"Based on an observation and staff interview, the facility did not ensure employees do not store food and beverages in the refrigerator used to store resident food. This has the potential to affect all residents. Facility census: 64. Findings include: a) On 07/13/09 at 4:10 p.m., observation revealed a plastic bottle with fluid was stored in the refrigerator used to store food for the residents. An interview with dietary staff revealed the bottle of juice belonged to one (1) of the dietary workers. The dietary staff member told the owner of the bottle of juice to remove the bottle and that they were not permitted to have their personal items in the resident refrigerator.",2015-05-01
10345,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2009-07-16,241,D,0,1,KV9O11,"Based on an observation and staff interview, the facility did not ensure one (1) resident of a sample of fifteen (15) was provided care in a manner that maintained or enhanced the resident's dignity. Resident #42 was observed out in the hallway with a facility night gown open, exposing the resident's entire back. Facility census: 64. Findings include: a) Resident #42 On 07/14/09 at 8:30 a.m., observation found Resident #42 self-propelling down the B hallway dressed in a facility night gown with the resident's back fully exposed. An interview with the administrator revealed the resident was to be dressed before staff removed the resident from his room to the hallway. .",2015-05-01