rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
8633,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2013-03-28,371,E,0,1,8VU011,"Based on observation, staff interview, and the facility's Dented Can Policy, the facility failed to ensure proper food storage to prevent possible foodborne illness. This had the potential to affect more than a limited number of residents. Facility census: 109. Findings include: a) On 03/26/13 at 8:50 a.m., during an observation of the kitchen food pantry, a dented #10 can of beef stew was discovered on the shelf. The facility failed to dispose of the dented can of beef stew to eliminate a possible food safety risk. An interview was conducted on 03/26/13 at 8:51 a.m. with Employee #154, the Regional Dietary Manager. She stated the dented #10 can of beef stew should have been pulled from the rack and agreed there was a possibility the dent was severe enough to represent a health issue. On 03/26/13 at 9:17 a.m., Employee #154, the Regional Dietary Manager presented the facility's Dented Can Policy. This policy indicated cans with serious defects or severe dents could compromise the integrity of the can, allowing the contents unsafe for consumption. However, the policy did not provide instructions about what was to be done with a dented can.",2016-04-01
8634,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2013-04-10,201,D,1,0,CZR411,"Based on medical record review, staff interview, and family interview, the facility failed to permit a resident to stay in the facility and not transfer or discharge the resident when she did not meet the discharge requirements. The facility provided information to the resident's responsible party he/she would have to move the resident because the facility did not have long term beds available and her stay there was only temporary. The facility gave a date to the family and they were told they had to come and get the resident on that date. This practice was identified for one (1) of five (5) sampled discharged residents. Resident identifier: 185. Findings include: a) Resident #185 A social service note, dated 01/02/13, reflected the Social Worker (SW) met with Resident #185's Power of Attorney (POA) and the family requested the facility cancel the transfer plans to another nursing home they had been working on for this resident. The note said the SW explained that the transfer was already in progress and there were no long term beds available at this facility and that the resident's stay here was a temporary circumstance. The note indicated this facility had no long term care beds at that point and she was a skilled resident with days left for available service. A note, dated 01/29/12, indicated another nursing home was looking to take the resident and the facility informed the family the resident would either discharge home with the family or transfer to the other facility on Friday 02/01/13. Then the nursing home refused to take the resident. According to the notes, Resident #185 was transferred to another nursing facility on 02/01/13. 04/10/13 at 10:45 a.m., Employee #134 (Social Worker) was interviewed about this resident's discharge. She stated she was not aware all beds could be long term care when she told the resident's family the resident would be discharged after her skilled days were up. She indicated the family wanted to take her out anyway and move her closer to them. A family interview was conducted on 04/15/12 at 7:00 p.m. This family member stated they did not want to move the resident so far away from her sons, but that was what they had to do because the facility told them the resident could not stay at this facility because they did not have a bed available. The family member stated the resident's sons live close and could visit her at this facility. According to the family member, the resident still needed nursing home care, which they could not provide, so they had to move her to another long term care facility a couple hours away that was closer to the resident's sister. The family moved the resident to a location that was inconvenient for the resident's children to visit. According to the family member, they would have left her at this facility. .",2016-04-01
8635,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2013-04-10,203,D,1,0,CZR411,"Based on medical record review, review of a resident's discharge notice, and staff interview, the facility failed to ensure before, or as soon as practicable after, a resident was discharged , a written notice of discharge was provided that included required information, such as the location to which the resident would be transferred and his right to appeal the transfer/discharge. This was identified for one (1) of five (5) discharged residents. Resident identifier: #182. Facility Census: 181. Findings include: a) Resident #182 The discharge letter, dated 03/07/13, was reviewed for Resident #182. This letter stated the resident had become progressively more combative with multiple episodes of hitting other residents. The letter explained multiple interventions had been attempted and that the resident was continuously combative with staff and co-residents. The letter also stated they were giving an immediate discharge notice as of 03/07/13. This letter did not include the physician ordered the resident be discharged to the acute care hospital. The letter included eight (8) State agency names, addresses, and telephone numbers. There was no explanation of what these agencies were, nor was there an explanation the resident had the right to appeal the action to the State. There was no information provide to guide the resident to which agency would be appropriate for the appeal of this discharge. An interview, conducted with the Director of Nursing on 04/10/13 at 10:00 a.m., confirmed Resident #182 did not have the required information provided in his discharge letter. She confirmed this information was provided orally on the phone, but was not included in the letter.",2016-04-01
8636,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2013-04-10,207,D,1,0,CZR411,"Based on medical record review, staff interview, and family interview, the facility failed to allow a resident to remain in the facility regardless of her source of payment. When the skilled services ended for Resident #185, the facility instructed the family that they would have to take her somewhere else or come and get her because they did not have any long term care beds available at the facility. This practice of discharging residents after they were no longer eligible for Medicare benefits, affected one (1) of five (5) sampled closed records reviewed for discharged residents. Resident identifier: #185. Facility Census: 181. Findings include: a) Resident # 185 A social service note, dated 01/02/13, reflected the Social Worker (SW) met with Resident #185's Power of Attorney (POA), and the family requested the facility cancel the transfer plans to another nursing home. The note said the SW explained the transfer was already in progress and there were no long term beds available at this facility and that the stay there was a temporary circumstance. The note indicated this facility had no long term care Medicaid beds at that point. It also noted the resident was a skilled resident with days left for available service. The other home then called and refused to take the resident. A note, dated 01/29/12, indicated yet another nursing home was looking to take the resident and the facility informed the family the resident would either be discharged to home with the family or transferred to the other facility on Friday, 02/01/13. According to the notes, Resident #185 was transferred to another facility on 02/01/13. 04/10/13 at 10:45 a.m. Employee #134 (Social Worker) was interviewed about the Social Service notes. She stated she was not aware all beds could be long term care when she told the resident's family the resident would be discharged after her skilled days were up. A family interview was conducted on 04/15/12 at 7:00 p.m. This family member confirmed the facility told them they had to take the resident out of the facility after her Medicare services ended. It was confirmed the family would have left the resident in this facility because it was closer to her sons and they could visit.",2016-04-01
8637,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2013-04-10,514,D,1,0,CZR411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the clinical record had sufficient information recorded for Resident #186. The medical record was incomplete and there was no documentation recorded during this resident's stay to reflect the resident had exhibited aggressive behaviors. The facility was told in report this resident was alert and oriented and could sign his own papers. When he arrived at the facility, he was confused and combative and was not the same as reported to them earlier. They could not get him to understand or sign any of his documents. The next day, he was sent back to the hospital. There was nothing recorded in his medical record to reflect his condition during the time he was in the facility. This was true for one (1) of five (5) discharged residents whose medical records were reviewed. Resident identifier: #186. Facility Census: 181. Findings Include: a) Resident #181 The medical record revealed Resident #181 arrived at the facility from a hospital at 7:00 p.m. According to the note, he was alert only to person and he had intermittent confusion. It was noted the resident had fallen at 11:00 p.m. He stated he just got up and fell . There was no apparent injury. It was noted on his interdisciplinary note the resident needed to be seen by the doctor to evaluate his capacity status. The resident was sent out to a hospital due to the change in mental status, and was admitted . Review of the nursing notes revealed there was no evidence of any behaviors being exhibited during this resident's stay. He was admitted at 7:00 p.m. 01/28/13 and was discharged [DATE] at 9:00 a.m. His transfer form sent to the hospital with him stated reason for transfer Resistant to care, aggressive behaviors. The back of the transfer form stated resident resistant to care, hitting staff, multiple attempts to self ambulate. There was no evidence of these behaviors recorded in the nursing notes. It was verified, at 5:00 p.m., by the director of nursing, that this resident was not the same as he was when they called report. She stated that when the hospital sent him there, they said he was alert and could sign his own papers. She stated when he arrived, he was confused, combative, and hitting at staff . They thought maybe he was having some kind of withdrawals from his alcohol or something. She stated that they called the hospital the next morning and they told them that was not how he was when he left there and the facility needed to send him back and have the physician look at him again. There was no documentation regarding the resident being combative or anxious. He arrived at the facility and was there less than one day. He was sent to the hospital according to the report sheet at 3:40 p.m. The medical record did not have complete and accurate information recorded about this resident in the medical record.",2016-04-01
8638,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2013-04-18,323,E,1,0,ONJE11,"Based on observation and staff interview, the facility failed to ensure the safety of the residents by leaving an unlocked door into the laundry room, where residents could have access to harmful chemicals. Additionally, signs were not posted outside of the resident room doors for four (4) of fourteen (14) residents who were observed using oxygen. Resident Identifiers: #85, #54, #71, and #44. Facility Census: 96. Findings include: a) During the initial tour of the facility, at 8:35 a.m. on 04/16/13, the laundry room door was found to be unlocked. Just inside of the laundry room door was a wire wall document pocket holder containing the MSDS Manual. Found hanging on the wire pocket holder was a spray bottle of Shout Stain Remover, and a bottle of a cleaning substance called Goo-Gone. The label on the Goo-Gone stated in bold black letters, Harmful or fatal if swallowed. Employee #121, an Environmental Services Aide, was in the laundry room at that time. Employee #121 was asked if the Laundry Room door was always unlocked. Employee #121 stated, Yeah, it's always unlocked. Employee #121, then exited the room. After Employee #121 left, there was no one in attendance in the laundry room. At 9:10 a.m. on 04/16/13, Environmental Services Aide, Employee #92, was asked to go to the laundry room. Again there was no staff in attendance in the laundry room. Employee #92 also stated the door to the Laundry Room was always unlocked. Employee #92 was shown the bottle of Shout Stain Remover and the bottle of Goo Gone hanging on the document pocket holder. She was shown the label on the bottle of Goo Gone. She acknowledged the bottles should not be placed where they were. Employee #92 stated she was going to speak with the Environmental Services Director regarding the issue. After exiting the Laundry Room, a female resident was observed walking with her walker in the hallway near the unlocked, unattended laundry room. b) During the initial tour of the facility, at 8:45 a.m. on 04/16/13, fourteen (14) residents were observed using oxygen. It was noted that four (4) of these residents did not have signs posted on or outside of their room door indicating oxygen usage. These four (4) rooms were, 226A (Resident #85), 231 (Resident #54), 250A (Resident #71), and 125A (Resident #44). Interview with Employees #75, a Licensed Practical Nurse (LPN), and #7, a LPN, was conducted at 8:55 a.m. on 04/16/13. Employees #75 and #7 acknowledged and stated the signs would be placed.",2016-04-01
8639,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2013-04-18,514,D,1,0,ONJE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure clinical records were complete and accurate by failing to appropriately document on the Medication Administration Record [REDACTED]. Resident identifier: #97. Facility census: 96. Findings include: a) Resident #97 Medical record review was conducted for Resident #97 at 11:00 a.m. on 04/16/13. Review of the record revealed the resident had an 'as needed' (PRN) order for oxygen at two (2) liters per minute via nasal cannula, as well as an order for [REDACTED]. On 01/07/13 at 4:00 p.m., Employee #26, a registered nurse (RN), documented in the nurses' notes that Resident #97 complained of shortness of breath. The note went on to say that the resident was wearing her oxygen at two (2) liters per minute per nasal cannula, and her oxygen saturation was 99%. A telephone interview was conducted with Employee #26, at 2:27 p.m. on 04/16/13. Employee #26 was asked why the resident was not offered a nebulizer treatment with her complaint of shortness of breath. Employee #26 replied, I offered her a breathing treatment and she refused. She said the cough syrup helped her, so I gave the cough syrup. Employee #26 was advised there was no documentation on the treatment administration record (TAR) that the resident was wearing her oxygen, or on the MAR indicated [REDACTED]. There was no evidence the resident had refused treatment found in the nursing entries. At that time, Employee #26 stated she did not document on the TAR that the resident was using the oxygen, or on the MAR indicated [REDACTED]. She said she had not documented the refusals in the nursing notes either. The resident was documented in the nurses' notes as wearing her oxygen on 01/08/13 per Employee #38, a Licensed Practical Nurse (LPN), and on 01/09/13 per Employee #107, a LPN. Neither of these uses of the PRN oxygen were documented on the TAR.",2016-04-01
8640,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,152,D,0,1,5VE911,"Based on record review and staff interview, the facility failed to ensure the individuals making financial decisions for two (2) of three (3) sampled residents had the legal authority to do so. Review of Resident #11's financial file found a family member was being permitted to act as the resident's financial power of attorney in the absence of documentation to demonstrate this individual had the legal authority to do so. The physician appointed a health care surrogate (HCS) to make health care decisions on behalf of Resident #2, and the facility permitted this individual to also make financial decisions on behalf of the resident; such authority is not conferred by State law to a HCS. Facility census: 89. Findings include: a) Resident #11 Review of the financial file for Resident #11 revealed there was no documentation to indicate the individual making financial decisions on behalf of this resident who had the legal authority to do so. There was notice in the file by the facility, asking a family member to provide the necessary paperwork to prove they were the resident's financial power of attorney, but no such documentation had been supplied as yet. -- b) Resident #2 Review of the financial file for Resident #2 revealed he had been making his own financial decisions at the time of admission, but his status had changed such that he was no longer able to do so. The physician appointed a HCS to make health care decisions on behalf of the resident, but State law does not confer the authority to a HCS to also make financial decisions. -- c) The above concerns were discussed with Employee #29 (the business office manager) at 1:05 p.m. on 8/10/11.",2016-04-01
8641,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,156,C,0,1,5VE911,"Based on observation and staff interview, the facility failed to post the current address of the State survey agency. This practice has the potential to affect all residents and members of the general, public since all are to have access to this information. Facility census: 89. Findings include: a) On 08/09/11 at mid morning, observation of postings containing the contact information (addresses and telephone numbers) for various State client advocacy groups found the address for the State survey agency was not current. The agency had moved its office to a new location in July 2010, and the address in the posting had not been updated to reflect this change. This was brought to the attention of the facility's administrator (Employee #15) at the time. She verified the information was incorrect and had staff change the information to reflect the new address.",2016-04-01
8642,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,164,D,0,1,5VE911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the facility policy, the facility's staff failed to maintain the confidentiality of clinical records for one (1) of forty-seven (47) Stage II sample residents. Resident identifier: #136. Facility census: 89. Findings include: a) Resident #136 Observation, during medication administration on 08/09/11 at 8:35 a.m., revealed that Employee #86 (a registered nurse - RN) entered room [ROOM NUMBER], leaving the medication cart unattended, in the hallway and out of the employee's line of sight. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. During an interview at the time of the observation, Employee #86 stated the MAR indicated [REDACTED] Review of the facility policy titled 6.0 General Dose Preparation and Medication Administration revealed: 5. During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: . 5.6 Observe each resident's privacy and rights in accordance with Applicable Law. During interviews conducted with the director of nursing (DON) and assistant director of nursing (ADON) on 08/11/11 at 7:50 a.m., the DON voiced the expectation that the nurse was to cover the MAR indicated [REDACTED]. The ADON also stated the MAR indicated [REDACTED]",2016-04-01
8643,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,241,E,0,1,5VE911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of facility policy, and resident and staff interviews, the facility failed to ensure that dignity during dining was maintained for four (4) of forty-seven (47) Stage II sample residents (#13, #23, #24, and #27), and failed to ensure staff knocked on the doors / requested permission prior to entering the rooms of three (3) of forty-seven (47) Stage II sample residents (#21, #56, and #136). Facility census: 89. Findings include: a) Resident #23 Record review revealed Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation in room [ROOM NUMBER], on 08/08/11 at 6:05 p.m., revealed Resident #23 did not have a supper tray for sixteen (16) minutes, while three (3) other residents in the room were eating their meals. Employee #57 (a nursing assistant) delivered Resident #23's supper tray at 6:21 p.m. and fed the resident. An attempt was made to interview Resident #23 at the time of the observation. The resident was awake, alert and able to make eye contact, but the resident was unable to verbally respond. Review of the clinical record revealed an annual assessment dated [DATE] and a quarterly assessment dated [DATE], both of which indicated Resident #23 was cognitively impaired and dependent on staff for eating. Review of the care plan (revised on 07/12/11) revealed an intervention of assist with meals. - During an interview at the time of the observation, Employee #57 stated Resident #23 usually ate in the dining room and that the delay in delivering the tray was because the trays for the dining room were on the second cart, while the trays of the other three (3) residents in the room arrived on the first cart that was delivered. When asked the expectation of serving meal trays to residents at the same time or how a delay in delivery of the tray could have been avoided for a resident who chose to eat in a different location, the employee was not able to answer. - Review of the facility policy titled Nursing Responsibilities at Meal Service revealed the following: Policy - Associates from the nursing services and dietary departments work cooperatively to ensure that each resident has a pleasant dining experience and is served according to regulations. Communication - The nursing service department should communicate to the dietary department (prior to the beginning of the tray line) if a resident will be eating in an area other that the resident's usual dining location. -- b) Residents #136 and #56 Observation during medication administration, on 08/09/11 at 8:35 a.m., revealed Employee #86 (a registered nurse - RN) failed to knock or ask permission prior to entering Resident #136's room. - Observation during medication administration, on 08/09/11 at 8:45 a.m., revealed Employee #86 failed to knock or ask permission prior to entering Resident #56's room. During an interview at the time of the observation, when asked what the expectation was for entering a resident's room, Employee #86 stated she should have knocked before entering. - During an interview on 08/11/11 at 7:50 a.m., the director of nursing (DON) stated her expectation that the nurse should knock or announce and request permission to enter a resident's room. -- c) Resident #13 Random dining observations were made in the main dining room at dinner time on the first day of the survey (08/08/11). This resident was observe to not be well positioned during her meal. She was served on an overbed table that was too high for her to reach comfortably. At 6:20 p.m., she pulled the high-lipped sectioned plate off onto her body as she attempted to reach her salad. The plate rested with one (1) edge against the resident's chest, and the other side rested on the edge of the overbed table. The resident had been unable to reach her salad prior to pulling the plate off onto her chest, because of the manner in which she was positioned. Staff did not notice the plate being positioned on the resident's chest until 6:25 p.m. At that time, a staff member placed the plate back onto the table. The resident, who had previously been attempting to eat her salad, made no further efforts to finish. -- d) Resident #24 On 08/08/11 at 5:45 p.m., this resident was observed in the main dining room awaiting service of her dinner. The resident was leaning to her left. (If upright were 90 degrees, the resident was leaning at approximately 120 degrees.) When asked if she could sit upright without assistance, she attempted to straighten herself unsuccessfully. At 5:55 p.m., she was served her dinner by Employee #21 (an RN). The employee cut the resident's pizza into bite-sized pieces at the table but did not offer to reposition the resident. Resident #24 remained in this position at 6:20 p.m., when the administrator got the resident a clean spoon, as the resident had dropped hers onto the floor. No one offered to assist the resident to sit upright throughout the meal. -- e) Resident #21 On 08/09/11 at 12:59 p.m., this resident was interviewed for Stage I of the survey process. He had the curtain drawn around his bed. He gave permission for this surveyor to enter and agreed to be interviewed. When asked whether staff knocked or asked for permission to enter his space, he replied, No, they just come in. This was in keeping with observations made by another surveyor. -- f) Resident #27 Observation of the evening meal, on 08/08/11, revealed Resident #66 (the roommate of Resident #27) received his evening meal in his room at 5:55 p.m. At 6:30 p.m., Resident #27 had not received a tray, but Resident #66 had already finished eating his meal. The RN (Employee #63) was advised Resident #27 did not have a tray. Employee #63 entered the resident's room and asked the resident if he had eaten. Resident #27 replied, No. Employee #63 stated she would go get a tray for Resident #27. At 6:40 p.m., Resident #27 received his tray. Employee #63, when interviewed at 6:50 p.m. on 08/08/11, and stated, We try to serve the trays at the same time to roommates, but sometimes that is hard to do. Resident #27 was not served a tray until 6:40 p.m. - more than forty-five (45) minutes after the roommate had been served.",2016-04-01
8644,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,246,D,0,1,5VE911,"Based on observations, resident interview, family interview, and staff interview, the facility failed to ensure each resident received reasonable accommodation of individual needs. Three (3) of forty-seven (47) residents on the Stage II sample were found to have call bells / lights that were not accessible to the resident. Resident identifiers: #50, #82, and #107. Facility census: 89. Findings include: a) Resident #50 1. On 08/08/11, in early evening, observation noted this resident had a specialized call light. When asked whether she used the call light, she replied that she did. At that time, the resident was noted to not have access to her call bell. The call light had been placed on the head of the bed above her pillow. The resident, due to her physical limitations, could not reach the call bell. When the resident asked for something to drink, she was advised one (1) of the facility's staff would be needed. A staff member was informed of the resident's request and went to the resident's room. When her room was re-entered, observation noted the call light had been placed within the resident's reach. She used the call light shortly afterward to summon assistance for an episode of incontinence. - 2. On 08/16/11 at 10:30 a.m., observation found the call light was out of the resident's reach. It was sitting on a chair next to the resident's bed, but again, due to her physical limitations, the resident could not access the call bell. Periodic observations noted the call bell remained on the chair. An observation, at 12:45 p.m., found the resident had a visitor. The visitor was seated in the chair, feeding the resident her lunch. The call bell was within the resident's reach. The visitor stated the call bell had been on the chair when she had arrived and she had put it where the resident could have access if needed. -- b) Resident #82 During Stage I of the survey, observation of the resident's room, on 08/09/11 at 10:19 a.m., found the resident was resting in bed and his call cord was on the floor, under the bed. Employee #5 (the central supply clerk) was asked by the surveyor to retrieve the call cord from the floor. The employee retrieved the call light and placed it within reach of the resident. The call light was then checked by Employee #5. She was able to activate the call light, but it would not turn off. Employee #5 stated the end of the call cord was damaged and she would get a new cord for the light. Review of the resident's most recent minimum data set assessment (MDS), with an reference assessment date of 04/21/11, revealed the resident was totally dependant on two (2) staff members for bed mobility; therefore, the resident had no means to retrieve the call cord if he needed assistance. -- c) Resident #107 During observations of the resident and resident rooms on 08/09/11 at 9:32 a.m., this resident was noted to be in bed asleep. There were mats on each side of the bed for her, in case she rolled out. The call bell was found located under the mat on the left side of the bed. This made the call light cord unaccessible for the resident's use, should she need to contact staff for assistance.",2016-04-01
8645,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,278,D,0,1,5VE911,"**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 complete an assessment to accurately reflect a resident's dental status and the presence of a pressure ulcer. This was true for one (1) of forty-seven (47) Stage II sample residents. Resident identifier: #138. Facility census: 89. Findings include: a) Resident #138 1. Observation of the resident, during Stage I of the survey process on the morning of 08/19/11, found the resident's teeth were covered with plaque and several teeth were discolored and missing. Medical record review revealed this [AGE] year old male was admitted to the facility on [DATE], and his current active [DIAGNOSES REDACTED]. A clinical health status report was completed upon admission (07/13/11) by a licensed nurse. This nurse documented the resident had broken, loose or carious teeth. Review of the resident's admission minimum data set assessment (MDS), with an assessment reference date (ARD) of 07/20/11, failed to accurately reflect the resident's dental needs in Section L (oral / dental status), in which the assessor reported the resident had no dental issues. On 08/04/11, a oral health screening tool was completed by a register nurse (RN). Documentation on this tool identified the resident as having teeth that were broken, decayed, and covered with plaque. Recommendations were to refer to a dentist for decayed teeth. Comments on the screening tool included: Front teeth have black decay in center of teeth, unable to see how many teeth are missing due to resident did not open mouth real wide. The director of nursing (DON), when interviewed at 1:55 p.m. on 08/11/11, was unable to present any further information as to why the MDS was incorrectly coded. - 2. Further review of the medical record revealed a wound evaluation flow sheet, completed on 07/13/11 (the day of admission), which stated the resident had a Stage 2 pressure ulcer on his right great toe which measured 0.4 cm in diameter. The wound margins were pink and surrounding tissue was healthy. A care plan was completed on 07/19/11 addressing the pressure ulcer. Review of the resident's MDS, with an ARD of 07/20/11, revealed the resident was coded in Section M as having no pressure ulcers. The wound care nurse (an RN - Employee #21), when interviewed on the afternoon of 08/11/11, verified the resident had a pressure ulcer upon admission and stated she had completed the wound evaluation flow sheet. The DON, when interviewed at 1:55 p.m. on 08/11/11, was unable to present any further information as to why the MDS was incorrectly coded.",2016-04-01
8646,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,279,D,0,1,5VE911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility's interdisciplinary team failed to develop comprehensive care plans to address each resident's care needs and to describe the services to be provided to prevent complications, address therapeutic diet restrictions, address behaviors and maintain a safe environment. The care plans were not complete and/or did not provide instructions to provide care in the areas of dental needs, nutritional status, behaviors, and infection control for three (3) of forty-seven (47) Stage II sampled residents. Resident identifiers: #1, #138, and #20. Facility census: 89. Findings include: a) Resident #1 Review of Resident #1's medical record revealed this [AGE] year old male was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. For Resident #1, the facility failed to develop a comprehensive care plan providing instruction in the following areas: dental care, nutrition, and behaviors. 1. Dental Care Review of the resident's minimum data set assessment (MDS), with an assessment reference date (ARD) of 07/06/11, found the resident triggered for further review in the area of dental care. The Care Area Assessment (CAA) worksheet dated 07/18/11, when reviewed, found the nature of the problem described as follows: Resident has some or all natural teeth lost, potential for dental problems. The care plan considerations were: Will proceed to care plan to minimize risks and avoid complications such as decreased po (oral) intake, weight loss, or pain. The most recent care plan addressing oral care originated on 08/10/09. The care plan problem stated (quoted as typed): Self-care defecit, dependent on staff for all ADL functions of bathing, dressing, toileting and personal hygiene. The goal associated with this problem was (quoted as written): Resident will continue to function at current level thru next review. The only approach associated with dental care was: Staff to assist with oral care daily - 5/11/11. The care plan failed to discuss how the resident's dental needs could affect PO (oral) intake, weight loss, and pain as written on the CAA worksheet. The employee who completed the MDS was no longer employed at the facility; therefore, the care plan addressing dental needs was discussed with the director of nursing on 08/11/11 at 2:45 p.m. and again on the morning of 08/16/11. No further information was provided by this employee. 2. Nutritional status Review of Section K in the most recent MDS, an annual assessment with ARD of 07/06/11, revealed the resident was receiving a mechanically altered diet and had loss of liquids / solids from the mouth when eating or drinking and coughing or choking during meals. Further review of the resident's care plan revealed the following problem, which was initiated on 07/12/11 (quoted as typed): Swallowing Difficulty as evidenced by: Abnormal Swallow Study. Approaches included: Diet as ordered. Educate patient and caregiver on the following safe swallow strategies: (list) (note that no strategies were listed). Monitor of S/Sx (signs and symptoms) of aspiration. Monitor meal consumption. Monthly weights. Proper positioning at meals. Provide thickened liquids as ordered. Provide thickened liquids between meals. Take patient to dining room for meals. Review of the physician's orders [REDACTED]. Special instructions: Do not send rice, corn or hard fruit and vegetables. During an interview with the facility's registered dietician (Employee #101) on 08/15/11 at 12:30 p.m., she was asked why the resident's specific diet was not listed on the care plan with the special instructions. She stated the care plan did state the resident would receive thickened liquids. She also stated, We just list a regular diet in case the diet changes. The care plan failed to include the the type of diet to be served, the consistency of the thickened fluids, and the special instructions for food items that should not be served to the resident. 3. Behaviors Review of the resident's care plan revealed three (3) current problems addressing behaviors (all quoted as written): - 05/22 (no year listed) - History of sexual behavior (resident to resident) sometimes has angry outbursts and may strike out at staff. - 05/14/11 - hit & grabbed other resident in Hallway. - 07/17/10 - Hx (history of) sexual behavior towards female resident. The goal for all three (3) problems was (quoted as typed): Resident to have needs met and have no decline in psychosocial well being / behavior related to cognitive impairment AEB (as evidenced by) staff documentation. This goal was not stated in measurable teems. The DON, when interviewed on 08/11/11 at 2:45 p.m., was unable to explain how the resident's goal was to be measured and was unable to present any further information on the matter. -- b) Resident #138 Medical record review revealed a [AGE] year old male admitted to the facility on [DATE]. Current active [DIAGNOSES REDACTED]. A clinical health status, completed by a licensed nurse upon admission on 07/13/11, identified the resident had broken loose or carious teeth. Review of the resident's admission MDS, with an ARD date of 07/20/11, failed to accurately reflect the resident's dental status; the MDS stated the resident had no dental issues. On 08/04/11, an oral health screening tool was completed by a registered nurse (RN), which noted the resident had teeth that were broken, decayed, and covered with plaque. In the comments section, the RN wrote: Front teeth have black decay in center of teeth, unable to see how many teeth are missing due to resident did not open mouth real wide. Under recommendations, the RN noted the need to were to refer the resident to a dentist for decayed teeth. Review of the care plan revealed the following problem (quoted as typed): (Name of resident) is a new admission to the facilitity and requires staff assistance r/t (related to) self care deficit secondary to [MEDICAL CONDITION], dementia, being HOH (hard of hearing), Ataxia, Depression, Anxiety and [MEDICAL CONDITION]. The only approach addressing dental needs was: Provide oral care qd (every day) in am (morning) and prn (as needed) after meals and at hs (hour of sleep) with toothbrush and toothpaste. This was the only time the resident's oral / dental care needs were addressed in the care plan. The care plan also contained a problem of (quoted as typed): Inadequate Oral Food / Beverage Intake due to: Alcoholism, Food and beverage intake less than required. The care plan did not identify how the facility was going to address his need for a dental consult or how his dental needs could affect his ability to consume meals, cause pain, etc. The DON, when interviewed on 08/11/11 at 2:45 p.m., was unable to provide any further information related to the care plan. On the morning of 08/17/11, the DON stated the facility had scheduled a dental consult. -- c) Resident #20 Observation, on 08/08/11 at approximately 4:00 p.m., found this resident sitting up in a chair in her room. A sign was posted on the wall above the head of her bed for contact precautions. On 08/09/11 at approximately 8:00 a.m., Employee #61 (the assistant director of nursing - ADON) stated the resident had [DIAGNOSES REDACTED] ([MEDICAL CONDITION]). A repeat observation of Resident #20's room, on 08/10/11, found the signage had been removed. On 08/15/11, the resident had once again been placed on contact precautions. On 08/16/11, the resident was observed out and about in the hall in her wheelchair. According to the director of nursing (DON), the resident's last stool culture had come back negative. They were keeping her on precautions a little longer to make sure she did not have any further symptoms. Review of the resident's care plan, established on 07/15/11, found it did not address the isolation needs / limitations. The problem was: Res (resident) has[DIAGNOSES REDACTED] Contact Isolation. The interventions were: 1) Adm (administer) meds as ordered. Encourage as she will refuse. 2) Stool samples as ordered. 3) Notify MD for s/s (signs/symptoms) Dehydration or complications. 4) Contact isolation. The care plan did not address to what extent the contact precautions should or should not limit this individual's activities. For example, there were no instructions to direct caregivers to ensure the resident washed her hands well before leaving her room or whether the resident's movements should be restricted if she was actively having diarrhea, etc.",2016-04-01
8647,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,281,D,0,1,5VE911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, review of facility policy, and review of professional references, the facility failed to ensure professional practice was maintained during medication administration for one (1) of ten (10) residents. Resident identifier: #84. Facility census: 89. Findings include: a) Resident #84 Record review revealed Resident #84 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During observation of the medication pass on 08/09/11 at 9:10 a.m., Employee #86 (a registered nurse - RN) entered Resident #84's room and placed a medicine cup of pills on the overbed table in preparation to administer the ordered medications. Resident #84's roommate started yelling for help and needing a nurse right away. Employee #86 twice asked the roommate what was wrong and what was needed, but the roommate kept yelling and then indicated a bed pan was needed immediately. Employee #86 left the medicine cup of pills on Resident #84's overbed table and walked over to the roommate's area to look for a bedpan. The employee did not find a bed pan and left the room for a total of three (3) minutes. The pills in the medicine cup remained on Resident #84's overbed table. Employee #86 then returned with a nursing assistant to help the roommate with a bed pan. Medications left at bedside included the following: - [MEDICATION NAME]/APAP ([MEDICATION NAME]) 7.5/500 milligram (mg), 1 tablet - Calcium 600 - D, 1 tablet - Multivitamin, 1 tablet - [MEDICATION NAME] 2.5 mg, 1 tablet - Senna 8.6 mg, 1 tablet - Vitamin D 2000 IU (international units), 1 tablet - [MEDICATION NAME] Antacid Calcium [MEDICATION NAME] 500 mg, 2 tablets During an interview at the time of the observation, when asked what the expectation was for administering medications to a resident, Employee #86 stated she should have taken the medication with her when she left the bedside, if the medication was not administered to the resident. - During an interview on 08/11/11 at 7:50 a.m., the director of nursing (DON) stated that pills should not be left at the bedside when the nurse leaves the room and Employee #86 should have put on the call light to get assistance for the roommate. - Review of the clinical record revealed a quarterly assessment dated [DATE] and an annual assessment dated [DATE], both of which indicated Resident #84 was cognitively impaired. During an interview on 08/11/11 at 12:36 p.m., the RN assessment coordinator (RNAC) revealed that Resident #84 was not assessed for the ability to self-administer medications. - Review of the facility's medication administration policy titled General Dose Preparation and Medication Administration (revision date 05/01/10) found Item #3.9 stated: Facility staff should not leave medications or chemicals unattended. The facility was asked for, but did not have, a professional reference that outlined the fundamental process of medication administration. - Review of RNpedia Internet reference, at http://www.rnpedia.com/home/notes/fundamentals-of-nursing-notes/medication-administration, Medication Administration, Principles of Medication Administration stated: IX. Do not leave the medication at the bedside. Stay with the client until he actually takes the medications.",2016-04-01
8648,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,309,D,0,1,5VE911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, staff interviews, observations, and resident comments, the facility failed to ensure each resident was provided care and services to assist the resident to attain or maintain the highest practicable level of well-being. Two (2) residents were observed to be seated in the main dining room in poor body alignment. Their positioning did not enhance their ability to eat independently. Another resident experienced a hypoglycemic (low blood sugar) episode. There was no evidence of implementation of interventions and reassessment of the blood sugar in accordance with physician's orders [REDACTED].#13, #24, and #52. Facility census: 89. Findings include: a) Resident #13 Observation found this resident had a significant [MEDICATION NAME] curvature of her spine (as in kyphosis). According to her quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 07/08/11, the resident had [MEDICAL CONDITION], dementia, [MEDICAL CONDITION] or [MEDICAL CONDITION], asthma / [MEDICAL CONDITIONS], depression, hypertension, and mild mental [MEDICAL CONDITION]. The MDS also indicated she required limited assistance with eating and had impairment in range of motion of both upper extremities and one (1) side of her lower extremities. The resident required extensive assistance for bed mobility and was totally dependent on staff for transfers. She was nonambulatory. Observation, in the main dining room during dinner time on 08/08/11, found this resident seated in a reclining chair with an overbed table in front of her. The foot of the recliner was elevated. The back of the chair was elevated at approximately 65 degrees. Throughout the meal, she was noted to be leaning to her left and feeding herself with her right hand. As noted above, the resident had a kyphotic deformity of her spine. With the head of her chair elevated to only approximately 65 degrees, the resident had no support for her upper back, neck and head, as she ate. Additionally, she had to raise herself up further when obtaining a bite of food from her plate. The plate was a high-lipped sectioned plate. This had been placed on an overbed table. Even when the resident lifted herself to lean forward, the plate was at the height of her nose. After the resident ate the pizza (which was in the section of the plate closest to her), she raised her body up further off of the back of the chair in an effort to reach the salad (which was in the section of the plate facing away from her). After several bites, her hand hit the rim of the plate, causing it to fall onto her chest. This was at 6:20 p.m. One (1) side of the plate rested against her chest, and the other side was against the overbed table. She continued to eat her salad with the plate in this tilted position. At 6:25 p.m., a staff member noticed the plate and put it back onto the table. The resident made no further attempts to eat her salad. The resident also had a breadstick which was on the table on the far side of the plate. While the plate was on the table, the resident was unable to see the bread stick. Employee #49 (a nursing assistant - NA - who said she was familiar with the resident) was interviewed the morning of 08/16/11. The NA said the resident could help turn herself in bed. She also reported the resident usually slid to the left and could pull herself up - not like we would, but could do some - when in bed. When asked about when the resident was up in her chair, she said the resident got up in a geri chair, but she was not be able to right herself when in the chair. The facility's policy entitled Nursing Responsibilities at Meal Service included: Adapt space and equipment to assist residents in maintaining independent functioning, dignity, well-being and self-determination. -- b) Resident #24 Review of the resident's medical record found she had [DIAGNOSES REDACTED]. Her quarterly MDS assessment, with an ARD of 05/17/11, noted she required extensive assistance for bed mobility, was totally dependent for transfers, was non ambulatory, required supervision for eating, and had impairment in range of motion on one (1) side for both upper and lower extremities. The Quarterly Interdisciplinary Resident Review of 05/10/11 stated the resident's Mobility was Very limited Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. - This resident was observed at dinner time in the main dining room on 08/08/11. At 5:45 p.m., the resident was noted to be leaning to her left. She was using her right hand to drink the beverages that had been served prior to the meal. There were no positioning devices in place to assist the resident in maintaining her position. At this time, the resident was asked whether she could sit up straight in the chair. She made an unsuccessful attempt, then indicated she could not. At 5:55 p.m., she was served her dinner by Employee #21 (a registered nurse - RN). The employee cut the resident's pizza into bite-sized pieces at the table but did not offer to reposition the resident. She remained in this position at 6:20 p.m., when the administrator got the resident a clean spoon, as the resident had dropped hers onto the floor. No one offered to assist the resident to sit upright throughout the meal. On the morning of 08/17/11, the director of nursing (DON) stated therapy was looking at devices to assist the resident in maintaining her position while up in a chair. The facility's policy entitled Nursing Responsible at Meal Service included: Adapt space and equipment to assist residents in maintaining independent functioning, dignity, well-being and self-determination. -- c) Resident #52 On 08/11/11 at 11:25 a.m., review of Resident #52's Medication Administration Record [REDACTED]. According to the resident's MAR, when the blood glucose level falls below 70, the nurse is to administer 15 grams of glucose gel. On 08/11/11 at 11:03 a.m., Resident #52's blood glucose level was 53. The RN (Employee #63) was observed giving 15 grams of glucose gel. Review of the MAR, at 11:25 a.m., found no documentation of the nurse giving the glucose gel. Further review of the MAR found, on 08/06/11, a licensed practical nurse (LPN - Employee #37) recorded Resident #52's glucose level as 51. There was no documented evidence to reflect the LPN followed the physician's orders [REDACTED]. Also, there was no evidence to reflect the nurse rechecked the resident's blood sugar level after discovering the level was below 70. This observation was reported to the DON on 08/11/11 at 11:54 a.m., to which the DON stated, There could be a better system.",2016-04-01
8649,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,312,D,0,1,5VE911,"Based on observations, resident gestures, and review of medical records, the facility failed to ensure a dependent resident who was incontinent of bladder received care and services to ensure good personal hygiene. A resident was observed to an episode of urinary incontinence, wetting her clothing despite wearing an incontinence brief. Her clothing remained wet for over three (3) hours. During this time, the resident's clothing was also noted to be soiled with food / beverage spills. One (1) of forty-seven (47) residents on the sample was affected. Resident identifier: #20. Facility census: 89. Findings include: a) Resident #20 Observation, on 08/15/11 at approximately 10:00 a.m., found Resident #20 sitting in her wheelchair in the doorway to her room. She pointed to her lap / upper leg area, made a gesture of shame on you, pointed to herself, and laughed. The area to which she had pointed, the pubic area and upper inner thigh area of her sweatpants, was wet. By the clear demarcation of the wet and dry areas, the incident had just occurred. She also had bits of food and stains on her clothing. Periodic observations throughout the morning and early afternoon found her clothing had not been changed. The wet area was less clearly defined as her clothing dried. She was last observed in the same clothing at 1:45 p.m., after she had eaten lunch. At that time, a staff member was heard to say the resident needed to be changed, because she had spilled coffee on herself.",2016-04-01
8650,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,323,D,0,1,5VE911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, review of facility policy, and review of professional references, the facility failed to maintain an environment free from accident hazards during medication administration for one (1) of ten (10) residents. Resident identifier: #84. Facility census: 89. Findings include: a) Resident #84 Record review revealed Resident #84 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During observation of the medication pass on 08/09/11 at 9:10 a.m., Employee #86 (a registered nurse - RN) entered Resident #84's room and placed a medicine cup of pills on the overbed table in preparation to administer the ordered medications. Resident #84's roommate started yelling for help and needing a nurse right away. Employee #86 twice asked the roommate what was wrong and what was needed, but the roommate kept yelling and then indicated a bed pan was needed immediately. Employee #86 left the medicine cup of pills on Resident #84's overbed table and walked over to the roommate's area to look for a bedpan. The employee did not find a bed pan and left the room for a total of three (3) minutes. The pills in the medicine cup remained on Resident #84's overbed table. Employee #86 then returned with a nursing assistant to help the roommate with a bed pan. Medications left at bedside included the following: - Hydrocodone/APAP (Acetaminophen) 7.5/500 milligram (mg), 1 tablet - Calcium 600 - D, 1 tablet - Multivitamin, 1 tablet - Lisinopril 2.5 mg, 1 tablet - Senna 8.6 mg, 1 tablet - Vitamin D 2000 IU (international units), 1 tablet - Alkums Antacid Calcium Carbonate 500 mg, 2 tablets During an interview at the time of the observation, when asked what the expectation was for administering medications to a resident, Employee #86 stated she should have taken the medication with her when she left the bedside, if the medication was not administered to the resident. - During an interview on 08/11/11 at 7:50 a.m., the director of nursing (DON) stated that pills should not be left at the bedside when the nurse leaves the room and Employee #86 should have put on the call light to get assistance for the roommate. - Review of the clinical record revealed a quarterly assessment dated [DATE] and an annual assessment dated [DATE], both of which indicated Resident #84 was cognitively impaired. During an interview on 08/11/11 at 12:36 p.m., the RN assessment coordinator (RNAC) revealed that Resident #84 was not assessed for the ability to self-administer medications. - Review of the facility's medication administration policy titled General Dose Preparation and Medication Administration (revision date 05/01/10) found Item #3.9 stated: Facility staff should not leave medications or chemicals unattended. The facility was asked for, but did not have, a professional reference that outlined the fundamental process of medication administration. - Review of RNpedia Internet reference, at http://www.rnpedia.com/home/notes/fundamentals-of-nursing-notes/medication-administration, Medication Administration, Principles of Medication Administration stated: IX. Do not leave the medication at the bedside. Stay with the client until he actually takes the medications.",2016-04-01
8651,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,365,D,0,1,5VE911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident interview, the facility failed to ensure a resident received food in a form to meet her individual needs. The resident had a physician's orders [REDACTED]. She was unable to eat the regular-consistency salad and pepperoni on pizza that was served to her. One (1) of forty-seven (47) residents on the Stage 2 sample was affected. Resident identifier: #32. Facility census: 89. Findings include: a) Resident #32 Observation, during the evening meal in the main dining room on 08/08/11, found this resident eating her dinner. She spat out a piece of pepperoni that had been on a piece of pizza, stating she could not chew that. When asked about her teeth, she said she did not have any - that was why she spat out the pepperoni and why she had not eaten her salad. A list of current diet orders for each resident was requested. The Nutritional Care Plan Summary list, provided by the dietary manager on 08/10/11 at 3:46 p.m., did not include a diet order for this resident. Review of her medical record, the morning of 08/16/11, found the physician had ordered a mechanical soft diet for this resident. The Oral Health Screening Tool, dated 05/19/10, noted: No teeth or dentures. Resident and daughter do not wish to go to dentist or get dentures.",2016-04-01
8652,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,412,D,0,1,5VE911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to assure a follow-up visit for dental services was arranged as recommended after a resident received an emergency dental consult. This was true for one (1) of forty-seven (47) residents sampled in Stage II of the survey. Resident identifier: #1. Facility census: 89. Findings include: a) Resident #1 Observation of the resident, during Stage I of the survey, revealed the resident had teeth that were missing and broken. Medical record review of the resident's dental status revealed a nurses note, dated 03/10/11, stating the resident's physician had started the resident on [MEDICATION NAME] for ten (10) days for an infected tooth; the physician also ordered a dental consult. The director of nursing (DON) was interviewed on the morning of 08/10/11 and was asked about the status of the resident's dental condition. She stated the resident was sent out to a dentist for a consult, but she was unable to produce a copy of the dental consult scheduled for 03/15/11. On 08/10/11 at approximately 1:30 p.m., the DON provided a copy of the dental consult. The resident was seen by a dentist on 03/15/11 for an emergency dental consult. The DON further explained the nurse, who was on duty when the resident returned from the visit, reported the dentist did not want to extract the tooth, so the nurse presumed no follow-up services were needed. After reading the consult on 08/10/11, the DON stated she became aware the dentist wanted to perform a root canal. The DON stated the resident had not been scheduled for a return visit, as she thought the dentist was through with the resident after his initial visit on 03/15/11.",2016-04-01
8653,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,431,E,0,1,5VE911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on inspection of medication storage rooms and medication carts, the facility failed to dispose of expired medical supplies found stored in a medication room and medication cart in a timely manner. Gluco-chlor pads (used to clean glucometers between uses) were found to have been expired in [DATE]. This had the potential to affect all residents receiving blood glucose monitoring. Facility census: 89. Findings include: a) On [DATE] at approximately 3:00 p.m., inspection of the medication storage room on the East wing found one-hundred and two (102) expired Gluco-chlor cleaner pads. The pads are used to clean glucometers prior to testing blood glucose levels on residents. The Gluco-chlor pads expired on ,[DATE]. Seven (7) Gluco-chlor pads were also found in the East wing medication cart with an expiration date of ,[DATE]. These observations were reported to the director of nursing (Employee #58) at 11:57 a.m. on [DATE].",2016-04-01
8654,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,441,E,0,1,5VE911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on observation, staff interviews, and review of the facility policy, the facility failed to administer medication in a sanitary manner for one (1) of forty-seven (47) Stage II sample residents, and failed to maintain sanitary hand washing practices for two (2) of forty-seven (47) Stage II sample residents. Resident identifiers: #13, #52, and #84. Facility census: 89. Findings include: a) Resident #13 Observation, during medication pass on 08/09/11 at 9:30 a.m., found Employee #86 (a registered nurse - RN) failed to wash or sanitize her hands after administering medications to Resident #84 and prior to administering medications to Resident #13. During an interview on 08/11/11 at 7:50 a.m., the director of nursing (DON) stated that hand washing needs to be done between resident contacts. -- b) Resident #84 Observation, during administration of medication on 08/09/11 at 9:10 a.m., found Employee #86 dropped an antacid tablet onto the top of the medication cart while preparing medication for Resident #84. The employee continued to prepare medication for administration to the resident and, after completing the preparation, picked up the tablet that had dropped on the cart and placed it back into the medication bottle with her bare fingers. During an interview at the time of the observation, Employee #86 reported that, in a previous job in a hospital, a pill was thrown away if it dropped on the floor. The employee then stated maybe this pill should have been thrown away. During an interview on 08/11/11 at 7:50 a.m., the DON stated the tablet that was dropped on the cart should have been thrown away. Review of facility's policy titledGeneral Dose Preparation and Medication Administration (revised 05/01/10) found the following: 3.4 Facility staff should not touch the medication . 3.5 If a medication which is not in a protective container is dropped, facility staff should discard it according to facility policy. -- c) Resident #52 During medication pass on 08/11/11 at 11:03 a.m., the RN (Employee #63) failed to wash or sanitize her hands prior to testing a blood glucose level. She entered Resident #52's room, donned gloves, then performed the blood glucose level. She then removed the gloves and left the room without washing her hands. These observations were reported to the DON at 11:57 a.m. on 08/11/11. --- Part II -- Based on observations, review of facility policies, and review of guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff employed practices to prevent the spread of infection. A nursing assistant was observed rendering incontinence care to a resident who was in contact precautions without wearing the appropriate personal protective equipment (PPE). Additionally, the policy and procedure provided by the facility regarding Clostridium difficile (C. diff) did not address the use of PPE. One (1) of forty-seven (47) residents on the Stage 2 sample was affected. Resident identifier: #20. Facility census: 89. Findings include: a) Resident #20 Record review revealed Resident #20 had been diagnosed with [REDACTED]. On 08/15/11, the resident's stool specimen (when tested for [DIAGNOSES REDACTED]) was negative, but she continued to have loose stools. Contact precautions were still in effect at the time of the following observation: On 08/15/11 at 1:45 p.m., Employee #32 (a nursing assistant - NA) was preparing to provide incontinence care to the resident. She asked the resident to go into the bathroom, while she (the NA) gathered needed items. The NA donned gloves, wet some washcloths, then went to the bathroom adjacent to the resident's room. As the NA gathered items, the resident wheeled herself to the bathroom. There, the resident stood up and pulled down her sweatpants and incontinence brief. The brief contained loose stool. The NA did not don a gown, as outlined in the CDC guidelines where contamination due to incontinence may occur, as well as the potential for spores to get onto clothing due to environmental contamination. - The 2007 guidelines by the CDC include: Contact Precautions - Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment. Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission . Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, difficile, noroviruses and other intestinal tract pathogens; RSV). The guidelines also include: II.E.2. Isolation gowns - Isolation gowns are used as specified by Standard and Transmission-Based Precautions, to protect the HCW's arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious material. The need for and type of isolation gown selected is based on the nature of the patient interaction, including the anticipated degree of contact with infectious material and potential for blood and body fluid penetration of the barrier. The wearing of isolation gowns and other protective apparel is mandated by the OSHA Bloodborne Pathogens Standard. Clinical and laboratory coats or jackets worn over personal clothing for comfort and/or purposes of identity are not considered PPE. When applying Standard Precautions, an isolation gown is worn only if contact with blood or body fluid is anticipated. However, when Contact Precautions are used (i.e., to prevent transmission of an infectious agent that is not interrupted by Standard Precautions alone and that is associated with environmental contamination), donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces. - A copy of the facility's policies and procedures for [DIAGNOSES REDACTED] was requested. A document entitled Clostridium Difficile was provided the afternoon of 08/16/11. It included the use of gloves when rendering care and the use of soap and water for handwashing, but it did not include the use of isolation gowns or other PPE. This policy was not consistent with current accepted standards of practice as identified in the CDC guidelines identified above.",2016-04-01
8655,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,463,D,0,1,5VE911,"Based on observation and staff interview, the facility failed to assure resident call lights were functioning properly. This was true for two (2) of forty (40) residents whose call lights were observed in Stage I of the survey. For Resident #1, the call light system failed to engage the light above the door of the room and failed to emit an audible alarm. For Resident #82, the call light could be activated, but it could not be turned off. Resident identifiers: #1 and #82. Facility census: 89. Findings include: a) Resident #1 Observation of this resident's room, on 08/09/11 at 10:33 a.m., found the resident's call light would not work when activated - the light above the door in the corridor did not illuminate, and no audible alarm would sound. Resident #1 was in bed and had no other means to contact caregivers. Employees #41 and #100 (both registered nurses - RNs) also observed the malfunctioning call light. Employee #41 stated she would get the call light fixed immediately. -- b) Resident #82 Observation of this resident's room, on 08/09/11 at 10:19 a.m., found the call light cord was on the floor under the resident's bed. Resident #82 was in bed and had no means to contact caregivers. Employee #5 (the central supply clerk) retrieved the call light and placed it on the resident's bed. When the call light was tested by Employee #5, the light above the door in the corridor illuminated and the audible alarm activated, but the employee could not turn off the call light once activated. Employee #5 stated the end of the activation button appeared to be bent and she would make sure it was fixed.",2016-04-01
8656,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,514,E,0,1,5VE911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to ensure clinical records were maintained for each resident that were complete and contained accurate documentation. Five (5) of forty-seven (47) residents on the Stage II sample were affected. Resident #7 had a physician's orders [REDACTED]. The physician's assistant documented the [MEDICATION NAME] was being given for [MEDICAL CONDITION]; however, no [DIAGNOSES REDACTED]. When the wound care nurse removed Resident #10's [DEVICE]-assisted closure device (vac) dressing, she said someone must have changed it over the weekend, because it was not the one she had last done. No evidence could be found identifying when and by whom, the dressing had been changed. The recapitulation orders for Resident #122 included an unclear order for a [MEDICATION NAME]. Resident #78's medical record included documentation indicating he had been weighed twice before his admitted . Resident #139 was transferred to the hospital, but the nurse failed to document having notified the physician of the resident's acute change in condition record, and failed to record a physician's telephone order to transfer the resident to the hospital. Resident identifiers: #7, #10, #122, #78, and #139. Facility census: 89. Findings include: a) Resident #7 Review of the resident's medical record found a physician's orders [REDACTED]. The progress notes included entries such as: Pt seen (symbol for 'secondary') [MEDICAL CONDITION] (symbol for 'no') reported [MEDICAL CONDITION] since [DATE] but trial (down arrow) in past did prompt [MEDICAL CONDITION]. The notation was undated. Other entries, identified by the director of nursing (DON) as having been written by the physician's assistant, identified a [MEDICAL CONDITION] disorder for this resident. Various documents, such as the front sheet, the physician's orders [REDACTED]. No [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) with an assessment reference date (ARD) of 01/06/11, the annual MDS with an ARD of 04/04/11, and the quarterly MDS with an ARD of 06/23/11 were reviewed. None included an active [DIAGNOSES REDACTED]. All of these assessments were coded 0 for item I5400 [MEDICAL CONDITION]. On 08/16/11 at 10:48 a.m., the registered nurse (RN) assessment coordinator (Employee #18) was asked whether she was aware of Resident #7 having had [MEDICAL CONDITION]. She said she did not recall this having been a problem for this resident. She was asked to see if she could find a [DIAGNOSES REDACTED]. She later reported she had been unable to find anything. The DON also was interviewed. She said she had been the DON of this facility since April 2010. To her knowledge, the resident had not had any [MEDICAL CONDITION] since she had come to work at the facility. She, too, was unable to find any [DIAGNOSES REDACTED]. -- b) Resident #10 At 10:30 a.m. on 08/15/11, Employee #21 (an RN and the wound care nurse) was observed changing the wound vac dressing on this resident. As she finished cleaning the wound, she noted a piece of white foam in the cavity. She commented that someone must have changed the dressing over the weekend. After completing the dressing, the RN was asked to see when the dressing was changed. She checked the treatment record, the nursing entries, the 24-hour report, and medication administration record (MAR). She could find no evidence of the dressing having been changed. Consequently, the reason for the dressing change could not be ascertained. -- c) Resident #122 Review of the resident's current physician orders [REDACTED]. The resident's nurse on duty at 10:05 a.m. on 08/11/11 (Employee #24) was interviewed and asked how she administered the above medication two (2) times a day as directed. The employee viewed the MAR and stated, That order is not correct. I will need to get it clarified. She further stated she had not applied the patch two (2) times a day as directed and explained the patch is put on at 9:00 a.m. and removed at 9:00 p.m. daily The order was then clarified as follows: Nitro-Dur (0.2 MG/-HR) ([MEDICATION NAME]) - [MEDICATION NAME] Dose: 4.8 mg every morning apply at 9 a.m. and remove at 9 p.m. Patch 24 hour. -- d) Resident #78 Review of the resident's weight record in Stage I of the survey disclosed this resident had a recorded weight of 119.1 pounds on 07/01/11 and a recorded weight of 119.1 pounds on 07/04/11. Further review of the medical record revealed the resident was not admitted to the facility until 07/05/11. The DON, when interviewed on the morning of 08/16/11, confirmed the resident was not admitted until 07/05/11; therefore, the resident could not have been weighed on 07/01/11 and 07/04/11. She stated a new employee had been weighing the residents and probably made a mistake. -- e) Resident #139 A review of the medical record for this female resident revealed the resident had a change in medical condition and required hospitalization . Nursing notes reflected this change, but no nursing notes or physician orders [REDACTED]. Nursing notes, on 08/13/11, stated: CNA (certified nursing assistant) called nursing staff LPN (licensed practical nurse) to the room. Resident was lying on bed with HOB (head of bed) up, has non-productive cough, assessment of lung sounds bilat (bilateral) upper lobes, rhonchi, lt. (left) lobe rales, rt. (right) lower lobe diminished . Called LIFE Ambulance for transport. An entry, dated 08/14/11, stated: POA (power of attorney) notified with difficulty d/t (due to) HOH (hard of hearing), secondary person (name) daughter notified. The administrator and the DON informed the surveyor, at 2:25 p.m. on 08/16/11, that the LPN (Employee #47) had called the doctor and remembered giving the notification and getting the order, the LPN had failed to document in the resident's medical record having provided the physician notification and having received the telephone order to transfer the resident to the hospital.",2016-04-01
8657,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,518,E,0,1,5VE911,"Based on staff interview and review of inservice records, the facility failed to ensure housekeeping personnel (whose services were obtained through an outside contractor) were trained in the emergency procedures to be implemented in the event of a fire or other disaster. This deficient practice has the potential affect more than an isolated number of residents, as these individuals worked throughout the facility. Employee identifiers: #106 and #110. Facility census: 89. Findings include: a) Employees #106 and #110 The surveyor interviewed various staff members, beginning at 11:12 a.m. on 08/15/11, regarding emergency procedures to be implemented in the event of a fire or other disaster. Two (2) housekeepers were included in these interviews: Employee #106, who was working on the East side, and Employee #110, who was working on the West side. When asked how to use the fire extinguisher, Employee #110 was not familiar with the process. She stated, I honestly don't know. I have never had to use one before. Employee #106 responded during the interview but reporting that she was not good at taking tests, and she did not give complete answers on what emergency procedures were to be followed. Further interview revealed the services of Employees #106 and #110 were obtained by the facility through an outside contractor. Review of inservice records supplied by the outside contractor revealed Employee #106 had received some disaster training, but the inservice records did not included a copy of what emergency procedures were taught during this training. These findings were discussed with the administrator on the late afternoon of 08/16/11.",2016-04-01
8658,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2013-04-01,312,D,1,0,KU9T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and medical record review, the facility failed to provide services to maintain good personal hygiene for one (1) of six (6) sampled residents who required staff assistance. Resident #110 had dried blood on his left cheek and left hand for a prolonged period of time. Resident identifier: Resident #110. Facility census: 92. Findings include: a) Resident #110 Review of the medical record, regarding this resident's departure time from [MEDICAL TREATMENT] on 04/02/13, found Resident #110 completed [MEDICAL TREATMENT] at 15:30 (3:30 p.m.). A nursing note, written on 04/02/13 stated, Transport reports [MEDICAL TREATMENT] center stated that resident had scratched his face while at their facility. Observation of Resident #110, in the dining room at 4:30 p.m. on 04/02/13, found the resident had several small scabs on his left cheek and dried blood covering the cheek. Observation of his left index and middle fingers revealed they were almost entirely covered in dried blood. Resident #110 was interviewed, at 4:45 p.m. on 04/02/13, regarding the blood and he said, I know, the girls told me. He verified facility staff members were aware of the dried blood. He was observed as he continued to sit in the dining room and was served his evening meal. No one provided the resident assistance to remove the blood from his face and hand. According to the most recent Minimum Data Set assessment, of 02/09/13, this resident required extensive assistance of one (1) staff member for personal hygiene. His current care plan also stated he required extensive assistance of one (1). This matter was discussed with Employee #82, who was responsible for infection control on 04/10/13 at 8:45 a.m.",2016-04-01
8659,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-04-04,225,D,1,0,Q5Z911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of incident reports, policy review, and staff interviews, the facility failed to report and investigate injuries of unknown origin to the appropriate State agencies as required. This was evident for two (2) of four (4) residents' whose incidents were reviewed. Resident identifiers: #63 and #3. Facility census: 58. Findings include: a) Resident #63 Resident #63's medical records were reviewed on 04/02/13 at 10:00 a.m. She was found to be totally immobile and required to be turned and re-positioned by two (2) staff members and moved from bed to chair using a Hoyer lift and two (2) assistants. She was spoon-fed by staff. The resident was only able to move her right fingers. She was unable to move her upper or lower extremities and was non-verbal. The resident was totally incontinent. She was found to have an incident reported on 01/19/13. The report noted an old bruise, greenish in color, the size of a fifty (50) cent piece on the top of her right foot with no known cause. The follow-up documentation on the incident report (typed as written) was, . Remind staff to be careful when repositioning, transferring or placing resident at table. A second incident of unknown cause was documented on 02/09/13. This report noted when bathing the resident, the staff member had found an abrasion on top of the resident ' s left hand. A third incident of unknown cause occurred on 02/13/13, The resident was noted to have a 2 cm bruised area on her left outer eyebrow area. Although all three (3) incidents were injuries of unknown cause, none of the incidents were reported to the State agencies as required by regulation. The annual comprehensive minimum data set assessment, with an assessment reference date (ARD) of 01/24/13, indicated she had not had any falls. She was coded as having no speech, she was rarely/never understood or able to understand others. She was totally dependent for all activities of daily living (ADLs). She did not walk or wheel herself. She was incontinent of bowel and bladder with intermittent catheterizations required. An interview with Employee # 21, a licensed practical nurse (LPN), on 04/03/13 at 10:00 a.m., revealed the resident was totally immobile, except she could move her right fingers and patted herself on her chest. She was unable to turn or reposition herself in bed or chair. The nurse said the resident was a total assist with all aspects of care. Employee #54, a nursing assistant (NA) was interviewed on 04/03/13 at 10:30 a.m. She also said Resident #63 was unable to turn or re-position herself in bed and chair, was total care for all care, and only moved her right fingers to pat herself. An interview, held with Employee #4, the Director of Nursing (DON), on 04/03/13 at 11:30 a.m., confirmed the resident was unable to move independently and all three (3) incidents of unknown cause should have been reported to the appropriate State agencies in accordance with regulations and thoroughly investigated. No documentation could be found to explain the injuries received on all three (3) occasions. An interview with Employee #53, Social Worker (SW), on 04/03/13 at 12:30 p.m. agreed the three (3) incidents should have been reported and investigated. b) Resident #3 Resident #3's medical records were reviewed on 04/02/13 at 2:00 p.m. She had an incident, on 03/18/13 at 8:00 a.m., which was documented as, When getting pt. (patient) OOB (out of bed) this am, pt. stated 'my leg is broke, ' checked rt (right) outer ankle swollen with bruising. Under contributing factors was (typed as written) Was agitated yesterday & was given [MEDICATION NAME] 1 mg IM (intramuscularly). A radiology report, dated 03/18/13 at 6:57 p.m., was attached to the incident report and included, Impression: Acute lateral malleolus fracture with lateral soft tissue swelling. Diffuse osteopenia. No explanation as to cause of the fractured ankle was found in the nursing progress notes. An incident report, completed by Employee #17, a licensed practical nurse (LPN), on 03/21/13 for 03/17/13 at 10:00 p.m., noted, resident moved to the end of her chair and scooted herself onto floor, a CNA (certified nursing assistant) and myself lifted resident from the floor to her chair, no injuries noted, no swelling or bruising noted, no complaints of pain, resident moves extremities without difficulty. Review of the nurses ' notes for 03/17/13, revealed an entry written by Employee #17, LPN at 10:50 p.m., which stated no behaviors noted. Documentation by Employee #22, NA, on 03/17/13 at 11:15 p.m., noted Changed incontinent pad/brief, resident incontinent of urine. This same information was noted on 03/18/13 at 5:47 a.m. No documentation could be found explaining the injury of the resident ' s right ankle. Observations of Resident #3 were made on 04/02/13 from 10:00 a.m. until 11:45 a.m. The resident put her recliner footrest down twice and scooted to edge of the chair for short periods of time and then scooted back into chair. She was observed cursing and verbally talking to residents, staff and visitors during the whole time. The resident was drinking coffee and when a male resident and a female employee became engaged in conversation and would not include her, she threw her coffee cup at the male resident. The resident continued to curse and laugh at others. In an interview with Employee #4, Director of Nursing (DON), on 04/03/13 at 11:30 a.m., confirmed no documentation could be found to explain the injury to the resident ' s right ankle. She said the incident should have reported to the appropriate State agencies and thoroughly investigated. On 04/03/13 at 12:30 p.m., Employee #53, Social Worker (SW), agreed the incident should have been reported and investigated.",2016-04-01
8660,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,156,C,0,1,46GB11,"Based on interview and review of documentation, the facility was not using the correct Centers for Medicare and Medicaid Services (CMS) form when notifying residents of changes in the services being provided them under the plan. Residents are to be notified when they no longer are going to receive Medicare skilled services using form CMS . The facility was using a a form entitled C-4. This was evident for three (3) of three (3) residents whose records for denial of payment for services were reviewed. This practice had the potential to affect any resident who was discharged from Medicare services. Resident identifiers: #40, #26 and #70. Facility census: 76. Findings include: a) Residents #40, #26, and #70 Review of documentation given these residents, when they no longer qualified for Medicare services, revealed the facility was using a form entitled C-4. This was not the required form as specified by CMS. The form specified by CMS is form CMS . This is the form to be given at the time residents are no longer eligible for skilled services. Such reasons include: when a resident has used all their days, has reached his/her potential, and/or for any reasons, as set forth by CMS, in which Medicare services are discontinued. This was discussed, on 01/09/12 at mid-morning, with the business office manager(Employee #63) who was responsible for providing these notices. Employee #63 stated he was not aware of form CMS , and would begin using it immediately.",2016-04-01
8661,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,157,D,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the responsible party and physician of a resident's continued refusal to allow staff to obtain laboratory specimens. This practice affected one (1) of forty-two (42) sampled residents. Resident identifier: #10. Facility census: 76. Findings include: a) Resident #10 Review of this resident's physician's orders [REDACTED].#10 was ordered a basic metabolic profile (BMP) every four (4) months and a complete blood count (CBC) every six (6) months. Review of the medical record found no laboratory services. Further review of the medical record found the following nursing documentation entries: -- 06/08/11 at 536 -- Resident cont (continues) to refuse to let staff obtain routine schedule labs after several attempts made. Will continue to keep trying to obtain. -- 06/22/11 at 14:20 -- Resident refuses to let staff obtain labs after several attempts made. Will continue to keep trying to obtain. -- 07/22/11 at 12:39 -- Resident refuses to let staff obtain routine labs after several attempts made per staff. Will continue to keep trying to obtain. -- 07/27/11 at 13:27 -- Resident cont to refuse to let staff obtain routine schedule labs after several attempts made per staff. Resident states 'you are not getting any of my blood'. -- 07/29/11 at 09:34 -- Resident cont to refuse to let staff obtain labs after several attempts made. Will continue to keep trying to obtain. -- 08/04/11 at 13:12 -- Resident continues to refuse to let staff obtain labs after several attempts made per staff. will continue to keep trying to obtain. -- 08/12/11 at 12:13 -- Resident continues to refuse to let staff obtain routine labs after several attempt made per staff. Will cont to keep trying to obtain. -- 08/22/11 at 13:56 -- Resident continues to refuse to let staff obtain routine schedule labs after several attempts made per staff. Will continue to keep trying to obtain. -- 09/08/11 at 11:37 -- Resident continues to refuse to let staff obtain routine schedule labs after several attempts made per staff. Will continue to keep trying to obtain. Review of the medical record found no attempts made by the facility to contact Resident #10's responsible party or the physician regarding the resident's refusals to allow blood drawn for ordered lab work. An interview conducted, during the afternoon of 01/09/12, with Employee #74, the minimum data set nurse, confirmed the facility did not notify the responsible party or the physician after Resident #10 refused laboratory services on the dates listed above.",2016-04-01
8662,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,160,B,0,1,46GB11,"Based on review of residents' personal funds and staff interview, the facility failed to convey residents' funds, and to provide a final accounting of those funds, to the individual or probate jurisdiction administering the residents' estates. Instead, the facility paid the residents' funds to the funeral home and did not provide a final accounting of the residents' funds to a legally authorized individual or probate jurisdiction administering the estate. This practice affected three (3) of three (3) sampled residents. Resident identifiers: #2, #9, and #100. Facility census: 76. Findings include: a) Residents #2, #9, and #100 Review of the facility's personal funds accounting records found these three (3) residents' final accounts were paid directly to a funeral home. During an interview, on the afternoon of 01/11/12, a business office manager, Employee #63, confirmed when a resident passed away the facility did provide a final accounting of the residents' funds, and did not send the funds to the individual or probate jurisdiction administering the resident's estate. Employee #63 stated, All funds go directly to the funeral home.",2016-04-01
8663,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,241,D,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to promote care which enhanced the dignity for one (1) of forty-two (42) residents. This resident's fingernails were not groomed as he wanted them groomed. The resident's fingernails were long, jagged and had debris underneath. Resident identifier: #78. Facility census: 76. Findings include: a) Resident #78 On 01/05/12 at 9:30 a.m., observation of Resident #78 revealed he had long, jagged, and dirty fingernails. He said a physician came in to trim his toenails, but no one had trimmed his fingernails lately. The resident had right sided [MEDICAL CONDITION] which affected his right hand and arm. This made him dependent upon staff for things such as nail care. On 01/09/12, at approximately 11:30 a.m., Employee #92 (a licensed practical nurse) was informed the resident's fingernails needed trimmed. On 01/10/12 the resident's fingernails were observed and appeared clean and trimmed.",2016-04-01
8664,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,242,D,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview and staff interview, the facility failed to assure one (1) of forty-two (42) residents was afforded the opportunity to make choices about an aspect of his life that was significant to him. The resident complained about not having any personal spending money to buy things such as soda. He indicated he had informed the facility that he had no money and that this made him upset and angry. The resident had capacity to make decisions and had informed the facility he wanted access to his personal needs allowance which was allotted by Medicaid. The facility did not act upon the resident's request, or provide the resident assistance in getting his money. Resident identifier: #78. Facility census: 76. Findings include: a) Resident #78 Medical record review, conducted on the morning of 01/05/12, revealed this resident was admitted to the facility on [DATE]. On the afternoon of 01/05/12, during an interview with the resident, he indicated his brother handled all of his financial affairs. He said this worked out ok except his brother did not bring any money to him for personal needs. He indicated he had to call his brother and request items such as snacks. He said this bothered him and he would like to have his own money so he did not always have to call and ask his brother for things. On 01/05/12, at approximately 3:00 p.m., the business office manager (Employee #63) verified Resident #78 did not have a trust account set up by the facility. He produced a document showing the resident had declined to have a savings / trust account set up at the time of admission. Employee #63 also provided a copy of the resident's determination of medical capacity. This document, dated 04/21/10, revealed the resident had capacity to make medical decisions. Employee #63 said the facility did not have a copy of the financial power of attorney document. Employee #63 stated the resident had asked him to contact his brother in the past, and have money brought to the facility. He said the resident's brother had never brought any money for the resident's personal spending needs. The resident verified his brother had not brought any money and also said he had asked the office manager for assistance in this matter. On 01/05/12, at approximately 3:30 p.m., Employee #63 went to the resident's room and talked with him about this issue. Resident #78 told Employee #63 he would like to have money to buy things like soda. He wanted Pepsi or orange soda. The office manager told the resident he would personally bring soda to him the next day. On 01/09/12, at approximately 10:00 a.m., a nursing assistant, Employee #42, indicated she had brought Pepsi in for the resident on Sunday. She said he loved soda. On 01/10/12, at approximately 2:00 p.m., Employee #63 provided a copy of the general power of attorney document which listed Resident #78's brother as his general power of attorney. The general power of attorney afforded the brother the right to handle the resident's personal financial affairs. Employee #63 said Resident #78's brother had brought $50 for the resident on 01/10/12, and said he would start doing this on a regular basis. The facility did not provide the resident assistance in having personal spending money, until brought to the attention of the facility during the survey.",2016-04-01
8665,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,246,D,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to assure personal toiletry items were kept within reach for independent use for one (1) of forty-two (42) residents. Resident #78 did not have sufficient oral hygiene supplies for brushing his teeth. Resident identifier: #78. Facility census: 76. Findings include: a) Resident #78 On the morning of 01/04/12, during an interview, Resident #78 said he did not have a toothbrush or toothpaste. He said he had some bottom teeth, but they were not brushed every day. He said staff normally assisted him with oral hygiene about once a week. The resident had [MEDICAL CONDITION] affecting his right side. His night stand was next to his bed on his left side. He was able to access the night stand with his left hand. On 01/10/12, at approximately 2:00 p.m., a nursing assistant (NA), Employee #6, came into the resident's room and looked for his oral hygiene supplies. A tube of unopened toothpaste was in the drawer of the night stand. Employee #6 looked in other areas of the room and could not find any other supplies, such as a toothbrush or an emesis basin. Employee #70, a QA came in later with a toothbrush and emesis basin, and asked where he should put them. The resident requested Employee #70 put the supplies in the night stand drawer. He said he could brush his own teeth if the supplies were kept in the night stand.",2016-04-01
8666,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,253,E,0,1,46GB11,"Based on observations and staff interview, it was determined the facility had not assured the environment and condition of the furnishings were maintained in a sanitary and orderly manner. There were doors to resident bathrooms that had scuffs and scratches, furniture in common dining areas was in need of repair, a bathroom sink leaking, paint was peeling and chipped, and doors to the lounge area and central bath had deep scrapes and gouges in the wood. These environmental issues made the areas unsightly, as well as not easily cleanable. These issues were evident in twenty-two (22) resident rooms, doors to the central bath, and the resident lounge between the 100 and 200 hallways. Room numbers included: 102, 300, 315, 207, 212, 206, 313, 203, 113, 308, 314, 209, 305, 100, 215, 110, 204, 112, 208, 213, 200, and 212. This practice had the potential to affect more than an isolated number of residents. Facility Census: 76 Findings include: a) Rooms 102, 300, 315, 207, 212, 206, 313, 203, 113, 308, 314, 209, 305, 100, 215, 110, 204, 112, 208, 213, 200, and 212 Observations during the stage I interviews and tour of the facility revealed doors to resident rooms and bathrooms had scratches and gouges. Rooms had peeling paint, walls had holes in them, and chipped paint was observed on doorframes. b) Observations, on 01/11/12 at mid-morning, revealed there were chairs in the dining rooms with ripped and / or torn upholstery. The wooden legs of the chairs were scratched and / or in other disrepair. In the central shower area, a shower bed had a vinyl cover that was torn around the button areas. c) Room 308 had a leaking sink and a strong urine odor d) During the afternoon of 01/18/12, these environmental concerns were discussed with the administrator. .",2016-04-01
8667,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,279,E,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to develop a comprehensive care plan to address problems and needs for four (4) of forty-two (42) Stage II sampled residents. Resident #29 did not have a care plan to address her contractures and services needed to prevent further complications. Resident #73 did not have a care plan to address her dental needs. Resident #19 did not have a care plan to address the special care needed for her [DIAGNOSES REDACTED]. (Mayo Clinic April 9, 2011)). Resident #10 did not have a care plan to address her refusal of laboratory services. Failure to identify the needs and services to be furnished through the care planning process had the potential to result in a failure to provide optimum resident care. Resident identifiers: #29, #73, #19, and #10. Facility Census: 76. Findings Include: a) Resident #29 Resident #29 was admitted to the facility on [DATE] with severe joint contractures to all extremities. She received occupational therapy (OT) for management of her contractures. When she was discharged from OT, on 02/25/11, she was referred to the restorative nursing program for bilateral upper extremity and lower extremity passive range of motion exercises for fifteen (15) minutes a day six (6) days a week. This resident was transferred to the hospital, on 04/02/11, and was readmitted to the nursing home on 04/12/11. She was screened by therapy when she returned. It was determined she had an existing deficit, but there had not been a change in function, so she was not treated at that time in therapy. There was no evidence her care plan, which was established prior to her hospitalization , provided for the passive range of motion exercises to be continued after she was readmitted from the hospital. During an interview with the minimum data set (MDS) coordinator, Employee #19, on 01/10/12 at 3:30 p.m., it was verified the resident did not have a care plan to address her positioning or range of motion needs. Employee #19 verified this had been on the resident's care plan prior to her hospitalization in April 2011. However, when she returned on 04/12/2011, the care plan was revised with no plans for treatment or interventions to address the resident's contractures included. b) Resident #73 The comprehensive minimum data set assessment (MDS) assessment, dated 08/26/2011, was reviewed. Section V, in the care area assessment (CAA) note, indicated this resident had dentures. The resident was observed at 10:00 a.m. on 01/05/11. It was noted she did not have dentures in her mouth at that time. She was observed again at meal time, at 12:00 p.m. on 01/05/11. She had a pureed diet and was eating, but again she did not have dentures in her mouth. Resident #73 was observed, on 01/09/11 at 2:30 p.m., having her snack. Employee #32, a nursing assistant, was assisting her and was feeding her a nutritional shake. Employee #32 was questioned, at that time, about the resident's dentures. She stated that she had been off for a few months and the resident wore them before she left, but she had not seen them since she returned to work. An interview was conducted, at 6:00 p.m. on 010/9/11, with a licensed practical nurse, Employee #96. She stated she was the nurse for this resident. The nurse confirmed the resident wore dentures. She searched the resident's drawers in her room and her bedside night stand. There were no dentures located in the resident's room. Employee #96 stated she was not sure what happened to the dentures. She verified the resident did not have them in her mouth and was eating dinner at that time. At 6:15 p.m., the nurse reported she had found the resident's dentures. She stated they did not fit the resident very well. The nurse stated the facility was going to call and have the dentures fixed because they were too large. The medical record contained no evidence this resident's dentures did not fit properly or that her dentures were missing. Her dental CAA note indicated she had dentures, but stated there was no problem. There was no care plan relative to the resident's ill-fitting dentures. c) Resident #19 Review of the facility's care plan for Resident #19 found no identification of the resident's [DIAGNOSES REDACTED].#19 suffered from vision impairment due to the disease. The facility failed to address the [DIAGNOSES REDACTED]. Further review of the medical record found, during a hospital stay on 11/01/11, the physician noted the following: She has had multiple procedures on both lids due to Stevens-Johnso[DIAGNOSES REDACTED] related to cicatricial [MEDICAL CONDITION] (scarring of the conjunctiva), which happened 11 or [AGE] years ago. She is status [REDACTED]. The right eye lid remains affected by chronic Stevens-Johnson related changes. This finding was addressed with Employee #55, at 8:30 a.m. on 01/10/12. She stated, We are looking that up right now. d) Resident #10 Review of this resident's physician's orders [REDACTED].#10 was ordered a basic metabolic profile (BMP) every four (4) months and a complete blood count (CBC) every six (6) months. Review of the medical record found no laboratory services. Further review of the medical record found the following nursing documentation entries: -- 06/08/11 at 536 -- Resident cont (continues) to refuse to let staff obtain routine schedule labs after several attempts made. Will continue to keep trying to obtain. -- 06/22/11 at 14:20 -- Resident refuses to let staff obtain labs after several attempts made. Will continue to keep trying to obtain. -- 07/22/11 at 12:39 -- Resident refuses to let staff obtain routine labs after several attempts made per staff. Will continue to keep trying to obtain. -- 07/27/11 at 13:27 -- Resident cont to refuse to let staff obtain routine schedule labs after several attempts made per staff. Resident states 'you are not getting any of my blood'. -- 07/29/11 at 09:34 -- Resident cont to refuse to let staff obtain labs after several attempts made. Will continue to keep trying to obtain. -- 08/04/11 at 13:12 -- Resident continues to refuse to let staff obtain labs after several attempts made per staff. will continue to keep trying to obtain. -- 08/12/11 at 12:13 -- Resident continues to refuse to let staff obtain routine labs after several attempt made per staff. Will cont to keep trying to obtain. -- schedule labs after several attempts made per staff. Will continue to keep trying to obtain. -- 09/08/11 at 11:37 -- Resident continues to refuse to let staff obtain routine schedule labs after several attempts made per staff. Will continue to keep trying to obtain. Further review of the care plan found no indication of a problem with laboratory refusals for Resident #10. An interview, conducted on the afternoon of 01/09/12, with Employee #74, an MDS employee, confirmed the facility had the refusals care planned the prior year, but failed to identify the problem in the current care plan.",2016-04-01
8668,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,280,D,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on care plan review, medical record review, and staff interview, the facility failed to assure three (3) of forty-two (42) residents had care plans that were evaluated and updated as the residents' needs changed. Resident #78's care plan had not been revised to reflect his ability to remove his personal alarm which was used as a way to alert staff the resident had gotten up and could potentially fall. Resident #47's care plan was not updated after he received dentures. Resident #29's care plan was not updated after a urinary catheter was removed. Resident identifiers: #87, #47, and #29. Facility census: 76. Findings include: a) Resident #87 Care plan review for Resident #87, conducted on 01/09/12 at approximately 1:00 p.m., revealed the following problem, Potential for injury/falls R/T (related to) - History of falls- poor safety awareness - Attempts to transfer without assistance- [MEDICAL CONDITION] drug use. The care plan was initiated on 03/30/11. The interventions listed did not mention the resident's ability to dismantle/turn off his personal tab alarm. The tab alarm was placed on the resident's bed for safety. This intervention section had been revised on 08/05/11. Medical record review revealed Resident #87 sustained a fall, on 12/19/11 at 5:14 p.m. The documentation stated, His alarm was sounding in room, sat on floor on buttocks; hit his head, laceration to back of head. Went out to hospital and they put staples in his head. W/C (wheelchair) alarm noted to not be intact. Resident states he removed the alarm. On 01/10/12 at 10:22 a.m.,. the director of nursing (Employee #55) agreed the resident did have tendencies to remove or turn off his alarm. She agreed this element needed added to the resident's care plan. b) Resident #47 Review of the care plan for Resident #47 revealed the problem, Alteration in nutritional status r/t (related to) edentulous. The interventions included: -Appetite stimulants per orders - Diet: Regular - Mighty shakes 4 ounces/200 cal/ each at 10 am, PM, and PM for nutritional supplement - Monitor for any difficulty chewing, report to MD/Nursing. - Oral care per resident, staff assist as needed. - Weekly weights to monitor weight status-notify MD of significant changes to weight status During an interview with Employee #63, on 01/11/12, the business office manager, related to the resident's dental status, it was identified that Resident #47 had obtained dentures several months ago .Employee #63 stated, That's not true she has dentures because I made the appointment, they just haven't updated her care plan. c) Resident # 29 During a review of Resident #29's plan of care, it was noted there was an intervention that stated, catheter care q (every) shift and PRN (as needed). This resident was observed, on 01/09/2012 at 10:00 a.m. It was noted that she did not have an indwelling catheter. The nursing assistant, Employee #32, verified there was no indwelling catheter present and that it had been removed a few weeks ago. The treatment nurse (Employee # 41) was interviewed, on 1/9/2011 at 2:00 p.m. She verified the catheter had been discontinued on 12/15/2011 because it frequently came out, so the physician ordered to keep it out. At that time, it was verified that the care plan intervention that instructed the staff to provide catheter care should have been revised and removed from the resident's care plan.",2016-04-01
8669,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,313,D,0,1,46GB11,"Based on resident interview, observation, medical record review, and staff interview, the facility failed to assure one (1) of forty-two (42) sampled residents received assistance with her hearing devices. The resident had hearing aids, but staff failed to ensure the hearing aids were operational, and failed to provide the resident assistance in using them. Resident identifier: #19. Facility census: 76. Findings include: a) Resident #19 During an interview with Resident #19, the evening of 01/03/12, it was identified the resident had difficulty hearing the interview questions. Resident #19 stated, I cannot hear anything you are saying. On the morning of 01/04/12, an unidentified nursing assistant (NA) was asked if the resident had hearing aids. The NA stated, She had them, but I think something was wrong with the batteries. Resident #19 was observed on three (3) other occasions, after 01/03/12, without her hearing devices in place. Review of the care plan for Resident #19 found an intervention regarding the hearing aid, Assure resident is wearing hearing aid before engaging in conversation. This intervention was dated 11/23/11. The observation of the resident's difficulty in hearing was reported to the director of nursing, Employee #55, at 8:30 a.m. on 01/10/12. During the afternoon of 01/10/12, the DON reported, She has hearing aids - they were in her drawer.",2016-04-01
8670,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,318,D,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to provide appropriate treatment and services for a resident with severe contractures to prevent further decline in range of motion (ROM). Resident #29 received occupational therapy (OT) services, which included passive range of motion and joint mobility, to her extremities. After she completed her treatment with OT, she was referred to restorative nursing for passive range of motion (PROM). The resident experienced was hospitalized for [REDACTED]. When she returned from the hospital, there was no evidence the resident received range of motion services or treatment for [REDACTED]. Resident identifier: #29. Facility Census: 76. Findings Include: a) Resident # 29 Resident #29 was admitted to the facility on [DATE] with severe joint contractures to all extremities. She was provided OT for management of these contractures. When she was discharged from therapy on 02/25/2011, she was referred to the restorative nursing program for bilateral upper extremity and lower extremity passive range of motion exercises for fifteen (15) minutes a day six (6) days a week. This resident was transferred to the hospital on [DATE], and was readmitted to the facility on [DATE]. She was screened by therapy when she returned. It was determined she had an existing deficit, but there had not been a change in function. She was not treated again at that time by therapy. There was no evidence her care plan, which was established prior to her hospitalization , ensured the passive range of motion exercises were continued after she was readmitted . The restorative nursing assistant (Employee #15) was interviewed at 2:00 p.m. on 01/10/2012. Employee #15 verified she was treating this resident and providing passive range of motion to her extremities prior to the resident's hospitalization . Employee #15 stated when the resident returned from the hospital, on 04/12/2011, she did not receive an order to treat the resident; therefore, the resident was no longer receiving restorative nursing services. An interview was conducted with the occupational therapy (OT) assistant (Employee #100), at 2:30 p.m. on 01/11/2012. She verified this resident had received treatment for [REDACTED]. Employee #100 stated when the resident was transferred to the hospital and returned to the facility, therapy did not pick her up. Since the resident was not picked up by therapy services, there was no order written for restorative nursing services or any therapy related services. Employee #100 was asked if the resident needed range of motion for her contractures and she stated yes. She also said the resident's contractures were severe and would not get better; however she needed range of motion and proper positioning to prevent further complications. An interview with the minimum data set (MDS) nurse (Employee #19), on 01/10/12 at 3:30 p.m., verified the resident did not have a care plan to address her positioning or range of motion needs. Employee #19 verified these services were on the resident's care plan prior to her hospitalization in April 2011. When the resident returned to the facility, on 04/12/2011, the care plan was revised, but no treatment or interventions to address the resident's contractures were incorporated into the revised care plan. Employee #19 verified there was no evidence this resident was receiving range of motion services.",2016-04-01
8671,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,329,D,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** unecessary drug regimen review revealed drug regimen's were missing from the following months (September, October, November and December 2011. The medication review also revealed the resident was suppose to have a lipid panel in 09/12 no communication from pharmacist for drug regimen review conducted on 12/27/11 & 11/28/11. #35 Michale Coleman - Had not recieved a reduction of his [MEDICATION NAME] for a year. #78 Paul Blackburn Pharmacy review not done. No labs could be found related to liver function testing and accurate [MEDICATION NAME] levels. There was only one pharmacy review on [MEDICATION NAME] and that was in January of 2011. labs were not obtained as orderd.",2016-04-01
8672,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,356,B,0,1,46GB11,"Based on observations, review of the nurse staff posting and staff interview, the facility failed to ensure they were in compliance with the requirements set forth by the Center for Medicare and Medicaid Services (CMS) in relation to nurse staffing information. The facility was completing the staff posting in advance, rather than at the beginning of each shift as required. This practice had the potential to affect more than an isolated number of both residents and other interested individuals such as family members or visitors. Facility census: 76. Findings include: a) On 01/03/12, at approximately 4:30 p.m., an observation of the daily staffing sheet revealed the facility had the number of licensed practical nurses and registered nurses for night shift already filled in and counted. On 01/09/12, at approximately 11:00 a.m., a second observation of the daily staffing sheet revealed it had the wrong date listed and had the number of licensed and registered nurses had been filled in for day, evening, and night shifts. On 01/09/12, at approximately 12:00 p.m., the director of nursing (Employee #55) said Employee #89 (licensed practical nurse) took care of the daily staffing post and would answer any questions related to the issue. On 01/09/12, at approximately 1:00 p.m., Employee #89 confirmed she was responsible for the daily staffing posting. She stated she assigned another staff member to fill in the number and hours scheduled for licensed and registered nurses each day. Employee #89 indicated she would discontinue having staff fill out the sheet for the entire day, and instead, fill in the numbers at the beginning of each shift. b) The posting of staff was observed on 01/10/12. Noted on the bottom of this posting was Required staffing is 2.25 hours. This statement was misleading to the public because this is not the required staffing level, but the minimal staffing level required by the State licensure rule. The required staffing is the amount of staff necessary to meet the needs of the residents as described in their plan of care. The administrator was made aware of this statement, at 4:30 p.m. on 01/11/12. It was later verified this erroneous statement was removed from the posting.",2016-04-01
8673,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,371,F,0,1,46GB11,"Based on dietary observations and staff interview, dishware was not stored in a manner that promoted sanitary conditions. Stored plates were discovered to have water between them when food was being served on the tray line. This practice created a medium for bacterial growth resulting in a potential contamination of the dishware. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 76 Findings include: a) While observing meal service, at lunch on 01/09/12, plates were observed stored wet with moisture between them. As these were retrieved from the lowerator for use at the meal, some plates were observed wet. This practice had the potential to allow bacterial grow in the moist environment. The consultant dietitian was present at the time of the observation and verified wet dishes were present. The Food Code, section 4-901.11, requires equipment and utensils, after cleaning and sanitizing, be air dried or used after adequate draining. Wet storage, particularly when items are stacked on top of each other while wet, creates a medium for bacterial growth.",2016-04-01
8674,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,428,D,0,1,46GB11,"Based on record review and staff interview, the facility failed to ensure a drug regimen review was completed monthly by the consultant pharmacist for one (1) of forty-two (42) Stage 2 sampled residents. This resident had a monthly review on 01/24/11, but no reviews for the remaining months in 2011. Resident identifier: #35. Facility census: 76 a) Resident #35 Review of the facility's drug regimen reviews for Resident #35 revealed a drug regimen review dated 01/24/11. No other drug regimen reviews were found for this resident for the eleven (11) other months in 2011. During an interview, on 01/11/12, Employee #74 verified the facility could find no evidence the pharmacist conducted a drug regimen review for this resident after 01/24/11. unecessary drug regimen review revealed drug regimen's were missing from the following months (September, October, November and December 2011. The medication review also revealed the resident was suppose to have a lipid panel in 09/12 no communication from pharmacist for drug regimen review conducted on 12/27/11 & 11/28/11.",2016-04-01
8675,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,441,E,0,1,46GB11,"Based on review of the facility's infection control program, medical record review of residents with Escherichia coli (E-coli), and staff interview, the facility failed to implement an effective infection control program which identified the probable cause of a number of E-coli infections, and failed to develop a plan to prevent the spread of E-coli infections in the facility. This practice had the potential to affect more than a limited number of residents. Facility census: 76. Findings include: a) Review of the facility's infection control tracking form revealed nineteen (19) residents for which E-coli had been identified as the cause of urinary tract infections from 07/2011 through 12/28/11. The list included four (4) residents with indwelling Foley catheters and one (1) resident with a suprapubic catheter. Review of the infection control program found no in-service records related to the prevention of urinary tract infections associated with E-coli. On 01/10/12 at 3:09 p.m., the infection control nurse, Employee #93, stated, I did not focus on E-coli. I was just looking at what I needed to do for isolation measures. She further stated, I did not realize five (5) of the residents had catheters. When asked if she had provided in-services for nursing personnel related to E-coli infections associated with catheters, she stated, No. The facility failed to develop, implement, and maintain an effective infection prevention and control program, regarding the E-coli, to prevent, recognize, and control, to the extent possible, the onset and spread of this infection within the facility.",2016-04-01
8676,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,504,D,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain physician ordered laboratory services for one (1) of forty-two (42) Stage 2 sample residents. A resident was receiving medications for which liver function tests were indicated. The facility had not ensured liver function tests were obtained as ordered by the physician. Resident identifier: #35. Facility census: 76. Findings include: a) Resident #35 Review of this resident's medical record identified Resident #35 was ordered a liver function test every three (3) months. This was because the resident received [MEDICATION NAME] 120 milligrams per day and [MEDICATION NAME] for high cholesterol. Review of the medical record found only one (1) laboratory result for the liver function test, which was obtained on 06/17/11. During an interview with Employee #74, a minimum data set employee, on 01/11/12 at 9:53 a.m., she stated, This is the only one we have. She further stated, It was ordered in September, but we did not obtain it. It was also ordered in November, but we didn't get it then either. A liver function test was obtained for the resident on 01/12/12, after the failure to obtain the ordered test was brought to the facility's attention during the survey.",2016-04-01
8677,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,514,D,0,1,46GB11,"Based on resident interview, medical record review and staff interview, the facility failed to ensure the clinical record for one (1) of forty-two (42) Stage 2 residents was maintained in accordance with accepted professional standards. The medical record did not contain complete and accurate information for activities of daily living (bathing / showering). Resident identifier: #78. Facility census: 76. Findings include: a) Resident #78 On 01/05/12 at 8:52 a.m., Resident #78 said he had gone for several days without a shower, and he wanted a shower every day. Employee #89 (licensed practical nurse) indicated she supervised the restorative nursing program. She provided a copy of the resident's shower / bathing documentation for the month of December 2011. Employee #89 said the facility's computer system did not allow for the nurse aide to document whether a shower or a bath was given. The system the facility used did not allow for accurate documentation, as it did not allow for identification of whether a shower or a bath had been given. This was of particular concern when the resident stated he did not have a shower for days and he wanted a shower daily. There was no means to evaluate whether, and / or when, the resident was provided a shower as opposed to a bath.",2016-04-01
8678,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,520,E,0,1,46GB11,"Based on review of the facility's infection control program, quality assurance committee information, and staff interview, the quality assessment and assurance committee failed to identify and correct infection control problems and environmental issues. This practice had the potential to affect more than a limited number of residents. Facility census: 76. Findings include: a) Infection Control Program Review of the facility's infection control tracking form revealed nineteen (19) residents with E-coli identified as the cause of urinary tract infections from 07/2011 through 12/28/11. The list included four (4) residents with indwelling Foley catheters and one (1) with a suprapubic catheter. Review of the infection control program found no in-service records related to the prevention of urinary tract infections associated with E-coli. On 01/10/12 at 3:09 p.m., the infection control nurse, Employee #93, stated, I did not focus on E-Coli. I was just looking at what I needed to do for isolation measures. She further stated, I did not realize five (5) of the residents had catheters. When asked if she had provided in-services for nursing personnel related to E-Coli infections associated with catheters, she stated, No. On 01/11/12 at 2:30 p.m., the director of nursing (Employee #55) was asked if she had any evidence the quality assurance committee had addressed the more current urinary tract infections in the facility. Employee #55 provided information for 01/24/11. This information noted the committee had discussed, in general, urinary tract infections, but not urinary infections with E-coli and /or the E-coli infections which were associated with catheter use. The findings discussed in the meeting, dated 01/24/11, were issues related to October 2010, November 2010, and December 2010. Employee #55 provided no quality assurance information which verified the committee was aware and / or had an action plan regarding the facility's most current nineteen (19) urinary tract infections as described above. b) Environment The facility had not ensured the environment and condition of the furnishings were maintained in a sanitary and orderly manner. There were doors to resident bathrooms that had scuffs and scratches, furniture in common dining areas was in need of repair, a bathroom sink was leaking, paint was peeling and chipped, doors to the lounge area and central bath had deep scrapes and gouges in the wood. These environmental issues made the areas unsightly, as well as not easily cleanable. These issues were evident in twenty-two (22) resident rooms ( Room numbers included: 300, 102, 315, 207, 212, 206, 313, 203, 113, 308, 314, 209, 305, 100, 215, 110, 204, 112, 208, 213, 200, and 212), doors to the central bath, and the resident lounge between the 100 and 200 hallways. A discussion was held with the consultant maintenance / housekeeping staff from a sister facility, at 2:25 p.m. on 01/11/12. At that time, it was revealed there had not been a specific time planned to implement environmental repairs. She indicated environmental issues were discussed at quality assurance meetings, but no action plan regarding timetables for repairs and / or replacement of damaged furnishings had been established.",2016-04-01
8679,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2012-07-24,279,D,0,1,C5CK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to develop a comprehensive care plan for one (1) of twenty-six (26) sampled residents. This resident was receiving an anti-anxiety medication on a regular basis; however, the resident's care plan made no mention of the anxious behaviors. Resident identifier: Resident #72. Facility census 38. Findings include: a) Resident #72 When reviewed on 07/18/12, the medical record of Resident #72 revealed the resident had received [MEDICATION NAME] 1 mg PO (by mouth) every morning for anxiety. The resident's care plan was reviewed and it included no mention of anxious behaviors. Employee #22, a facility nurse, was interviewed on 07/23/12 at 2:30 p.m., and confirmed there was no care plan for anxious behaviors.",2016-04-01
8680,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2012-07-24,323,E,0,1,C5CK11,"Based on observation, review of labels on items in the store room, and staff interview, the facility failed to ensure the environment remained as free of accident and hazards as possible by allowing the doors to the supply room to remain unlocked. In the supply room were chemicals and supplies that could cause harm to residents. This practice had the potential to affect more than a minimal number of residents who were mobile. Facility census: 38. Findings include: a) During a random tour of the unit, on 07/17/12 at 10:25 a.m., a room labeled Supply Room was observed unlocked. This room had doors on each side leading into separate hallways. Each door was outfitted with a lock which required a key for entry, but both doors were unlocked at the time of this observation. Upon entering the room, many potentially hazardous items were observed, including disposable razors and items which had warning labels which stated, Contact medical care immediately or contact poison control center. These items were observed in the room and/or on a cart. These included, but were not limited to: - Pain relieving rub ointment - SSD 1% Silver Sulfadiazine Cream - Granulex Spray - Hydrogen Peroxide - Razors - Shaving Cream Employee #22, a facility nurse, was interviewed on 07/17/12 at 10:48 a.m., and the director of nursing (Employee #7) was interviewed on 07/17/12 at 11:20 a.m. Both confirmed the doors had locks that used keys and were unlocked, as well as the items in the room and cart were accessible to residents that were mobile.",2016-04-01
8681,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2012-07-24,329,E,0,1,C5CK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and observations, the facility failed to ensure the medication regimens for four (4) of twenty-six (26) sampled residents were free from unnecessary medications. Resident #71 received anti-anxiety medication with no evidence of anxious behavior. Resident #14 remained on an antipsychotic medication without evidence of an attempted dose reduction. Resident #31 was receiving medication for [DIAGNOSES REDACTED]. Resident #72 was receiving an anti-anxiety medication with no evidence of anxiety. Resident identifiers: #71, #14, #31, and #72. Facility census: 38. Findings include: a) Resident #71 When reviewed on 07/16/12, the medical record revealed a physician's orders [REDACTED]. Further review divulged staff were administering the medication every day and sometimes twice daily. At the time this medication was administered, there was no evidence of associated behaviors to justify the need. Also, there was no evidence non-pharmacological interventions had been attempted to relieve any anxiety the resident was experiencing prior to the use of medication. When interviewed, on 07/18/12 at 2:42 p.m., Employee # 22 (Nurse) was asked to provide evidence of the need for the anti-anxiety medication. This employee confirmed there was no anxiety documented for this resident, and no monitoring of behaviors. b) Resident #14 Review of the medical record on 07/16/12, found Resident #14 had been receiving the antipsychotic [MEDICATION NAME] since 08/11/11. Further review of the medical record found no evidence the facility had attempted a gradual dose reduction. According to the regulation, the drug regimen of each resident must be reviewed at least once a month. No evidence was found to indicate a review and recommendation for this medication had been completed for Resident #14. On 07/19/12, at approximately 8:58 a.m., Employee #7 (DON) provided a copy of consultation provided by the pharmacist that was completed 07/18/12. The director of nursing confirmed she could find no evidence the [MEDICATION NAME] had been reviewed before that time. c) Resident #31 Record review revealed Resident #31 was receiving the medications [MEDICATION NAME], and [MEDICATION NAME] Sprinkles for dementia with behaviors. There was no evidence of monitoring for the behaviors that might have warranted the use of these medications. Interview with Employee #7 (DON), on 07/18/12 at 9:17 a.m., confirmed there was no evidence of any monitoring in place for the medications. She agreed there should have been a monitoring sheet to assess the frequency of the behaviors and the effectiveness of the medication for the behaviors. The comprehensive assessment, dated 04/05/12, revealed Section E (E200), Behavioral Symptoms-Presence and Frequency was coded as no behaviors having occurred during the look back period d) Resident #72 Review of the medical record, on 07/18/12, revealed a behavior monitoring sheet for anxiety with no behaviors, interventions, or side effects noted. The monitoring sheet displayed 0 in all areas. The Medication Administration Record [REDACTED]. On the nurse's medication notes (on the reverse side of the medication administration record), nurses documentation was noted for seven (7) of the fifteen (15) days the medication was administered. This documentation did not describe a specific behavior for which the medication was given, stating only restless. Furthermore, there was no outcome of the medication administration described, stating only eff (effective). Staff interview, with Employee #22 (a nurse), on 07/23/12 at 2:30 p.m., confirmed the lack of evidence necessary to justify the use of a PRN anti-anxiety medication.",2016-04-01
8682,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2012-07-24,371,F,0,1,C5CK11,"Based on observation and staff interview, the facility failed to properly store food items in the resident's pantry area and failed to served items from the kitchen in a sanitary manner. Food items were found in the residents' refrigerator open and not dated. Additionally, the refrigerator in the pantry where residents' items were kept was unclean. Food items were also served from the kitchen to the unit with no covering over the dessert. This had the potential to affect more than an isolated number of residents. Facility census: 38. a) Resident pantry area. Observation of the resident pantry was conducted with Employee #7 (the director of nursing) on 07/19/12, at approximately 8:30 a.m. Food items were found open and contained no date. A carton of milk was open with no date, a jar of pumpkin butter contained no date, a bottle of salad dressing was open and was not dated, one container of cucumbers with vinegar was observed with no resident's name and contained no date. Employee #7 (DON) immediately disposed of the undated food items, and confirmed the items should have been labeled and dated. b) Observation of the residents' pantry, on 07/19/12, found the refrigerator to be unclean and crusty food was adhered to the shelving in the refrigerator. Employee #7 (the director of nursing) was present during the observation. She immediately called housekeeping to clean the refrigerator. According to the facility's policy and procedure for cleaning the refrigerator, the area was to be cleaned once a week. On 07/19/12, at approximately 8:30 a.m., Employee #7 (DON) confirmed the refrigerator needed to be cleaned. b) Kitchen observations Observation of the kitchen area, on 07/17/12 at 11:40 a.m., revealed the dietary department did not store and serve items in a sanitary manner as evidenced by small bowls containing pears and some containing gelatin were observed on trays near the tray line as the meal service was about to begin and were not covered. Once tray service was complete, the cart was followed to the second floor. The trays were removed from the cart and taken into resident rooms with the items remaining to be uncovered. All residents received small bowls that were served uncovered. This observation in the kitchen area was confirmed with the dietary staff that were present at lunch time on 07/17/12.",2016-04-01
8683,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2012-07-24,428,D,0,1,C5CK11,"Based on record review and staff interview, the pharmacist failed to identify and address the need for a dose reduction for one (1) of twenty-six (26) residents on the sample. Resident identifier: #14. Facility census: 38. Findings include: a) Resident #14 Review of the medical record on 07/16/12, found Resident #14 had been receiving the antipsychotic Seroquel since 08/11/11. Further review of the medical record found no evidence the pharmacisit had recommended a gradual dose reduction be attempted. According to regulation the drug regimen of each resident must be reviewed at least once a month. No evidence was found to indicate this had been completed for Resident #14. On 07/19/12 at approximately 8:58 a.m., Employee #7 provided a copy of consultation provided by the pharmacist that was completed 07/18/12. The director of nursing confirmed she could find no evidence the Seroquel had been reviewed before this time. .",2016-04-01
8684,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2012-07-24,431,D,0,1,C5CK11,"Based on observation and staff interview, the facility failed to dispose of expired medications. The facility had two (2) bottles of expired medications in the medication storage room available for use. This practice had the potential to affect more than an isolated number of residents. Facility census: 38. Findings include: a) Observation of the medication storage room with Employee #7 (director of nursing), on 07/19/12, at approximately 8:45 a.m., found a bottle of Fortical nasal spray with an expiration date of 05/12/12. Further observation found Brovana Inhalant solution with an expiration date of 04/12/12. Employee #7 (DON) immediately disposed of the expired medications. .",2016-04-01
8685,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2012-07-24,441,E,0,1,C5CK11,"Based on staff interview and review of the facility's policy and procedure for tracking infections, the facility failed to implement an effective infection control program to identify infections and prevent their spread to other residents. The facility's policy and procedure identified no plan for tracking and trending infections and prevention of the spread of infections. This had the potential to affect more than an isolated number of residents. Facility census: 38. Findings include: a) Infection control policy and procedure Review of the infection control policy and procedure found it did not describe a means of tracking and trending infections. On 07/23/12, at approximately 3:35 p.m., Employee #31 (infection control nurse) provided a copy of a resident order list containing a list of antibiotics ordered for residents. She confirmed she had no forms which included the resident room number, the antibiotic and the exact type of infection the resident had. Employee #31 also provided a quarterly list which contained the number of urinary tract infections for the quarter, the number of upper respiratory infections. The list provided failed to list the resident, the room number, and the type of infection. She was asked if she had anything on a monthly basis to identify infections. She stated, this is all I have. On 07/24/12, at approximately 1:15 p.m., Employee #31 confirmed she had no other information related to infections. No evidence could be found the facility had developed a method for tracking and trending infections in order to identify whether infections were being spread, and, if indicated, to develop interventions to prevent the spread of infections. The facility failed to develop a policy on how they were going to monitor and track infections.",2016-04-01
8686,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2013-04-10,323,E,1,0,X3C911,"Based on observation and staff interview, the facility failed to provide an environment that was free from accident hazards over which the facility had control. The housekeeping closets on the first and second floor were not locked. Both housekeeping closets contained bleach, floor cleaner, and hand soap. This practice had the potential to affect all cognitively impaired residents who wandered into the unlocked closets and had access to the chemicals contained within. Facility census: 96. Findings include: a) An observation, on 04/09/13 at 08:40 a.m., revealed the first floor housekeeping closet across from the nursing station was not locked. This closet contained bleach, floor cleaner, and hand soap. An observation on 04/09/13 at 12:15 p.m. revealed the second floor housekeeping closet across from the nursing station was not locked. This closet contained bleach, odor eliminator, floor cleaner, and hand soap. An interview with Employee #39-Housekeeper, on 04/09/13 at 08:45 a.m., revealed the first floor housekeeping closet was to be locked at all times. Employee #39 verified the closet was unlocked. This staff member stated I only walked away for just a few minutes while the door was unlocked. Employee #39 verbalized she understood that leaving the door unlocked could allow residents to have access to the chemicals within. An interview with Employee #66-Housekeeper, on 04/09/13 at 12:20 p.m., verified the second floor housekeeping closet was not locked. This staff member stated I thought I had locked the door behind me. Employee #66 verbalized she understood residents could enter the closet and have access to the chemicals inside if the door isn't locked. Interview with Employee #97-Environmental Services Director, on 04/09/13 at 1:45 p.m., revealed the housekeeping closets on the first and second floors should be locked at all times. This staff member verbalized the facility did not have a policy stating the doors should be locked, however all staff was trained on keeping these doors locked at all times. He also verbalized all staff was trained on hazardous chemicals and the dangers they impose to all residents.",2016-04-01
8687,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2012-04-26,253,B,0,1,S35H11,"Based on observation and staff interview, it was determined maintenance and housekeeping services had not ensured doors to resident bathrooms were free from scratches and gouges, walls were not marred and scuffed, and doorframes did not have chipped paint. This affected nine (9) resident rooms in the facility. Room numbers: 99, 110, 111, 112, 113, 221, 224, 226 and 227. Census: 64. Findings include: a) Resident room #s 99, 110, 111, 112, 113, 221, 224, 226 and 227 Observations of the facility, during Stage I of the quality indicator survey process, revealed doors and walls that were scratched, marred, and/or scuffed. Door frames to bathrooms and to the hallways had paint chipped off of the door frames. This was discussed with the maintenance director, Employee #63, as part of the environmental component of the survey process. It was also made known to the administrator, Employee #55, on the afternoon of 04/25/12.",2016-04-01
8688,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2012-04-26,312,D,0,1,S35H11,"Based on observation, staff interview, and medical record review, the facility failed to ensure one (1) of thirty (30) Stage 2 sampled residents, dependent on staff for grooming needs, received necessary care and services to ensure the residents' hands and fingernails were cleaned prior to dining. Resident identifier: #70. Facility census: 64. Findings include: a) Resident #70 During random observations of the noon meal service in the main dining room, on 04/24/12 at 12:30 p.m., Resident #70 sat and ate her lunch at a table with other residents. It was noted a brownish colored substance was packed beneath all the resident's fingernails. The director of nursing (DON), Employee #57 was notified of the condition of the resident's fingernails. Employee #57 assisted the resident to a restroom and cleaned Resident #70's hands and fingernails. The brownish colored substance was no longer present beneath the resident's fingernails following the hand hygiene assistance provided by the DON. Review of the medical record found the minimum data set (MDS), with an assessment reference date (ARD) of 02/29/12, identified the resident required the extensive assistance of one (1) staff member for grooming needs, including washing of hands. Review of the current care plan, with a target date of 05/31/12, found nursing staff were to, Ensure and assist with grooming needs, comb hair, wash face, hands, and oral hygiene as needed.",2016-04-01
8689,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2012-04-26,323,G,0,1,S35H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, review of facility documents, medical record review, and mechanical lift manufacturer representative interview, the facility failed to ensure one (1) of thirty (30) Stage 2 sampled residents was transferred in a manner to prevent injury. Facility staff utilized a lift pad (sling) not designed for use with the facility's mechanical lift to transfer Resident #77 from a wheelchair to her bed. The resident fell out of the lift pad (sling) while suspended in the air and struck the floor. The resident sustained [REDACTED]. The facility failed to ensure lift pads (slings), not intended for use with their current mechanical lifts, were removed from the facility's inventory. The facility failed to ensure facility staff were adequately trained in the use and operation of mechanical lifts and lift slings. These deficient practices resulted in harm to Resident #77, and placed all residents who required transfers with a mechanical lift at risk of injury. Resident identifier: #77. Facility census: 64. Findings include: a) Resident #77 - Licensed practical nurse (LPN), Employee #15, was interviewed on 04/23/12 at 2:13 p.m. as part of the Stage 1 Quality Indicator Survey (QIS). When asked whether Resident #77 had any falls or fractures in the previous 30 days, Employee #15 stated the resident fell from a mechanical lift on 04/18/12 and sustained a fracture of her left humerus. - Review of facility documents found at 7:30 p.m. on 04/18/12, nursing assistants (NA), Employees #35 and #33 were transferring Resident #77 from the wheelchair to the bed using a mechanical lift. The report documented, Resident in Hoyer lift & (and) fell out. The report documented the resident complained of pain to her left shoulder, left hip, and right foot. - Review of the medical record found the minimum data set (MDS), with an assessment reference date (ARD) of 02/01/12, Section G, found the resident required the total assistance of two (2) or more staff members for transfers. Review of the current care plan with a target date of 05/04/12 found staff were to, Assist resident getting in and out bed using mechanical lift with two staff members. The care plan did not specify what type of lift sling to utilize for this resident. - Further review of the medical record found the resident was transported to an acute care facility following her fall on 04/18/12. She was returned to the facility from the emergency room in the early morning hours of 04/19/12 with [DIAGNOSES REDACTED]. An x-ray report, dated 04/18/12, documented acute fractures of the right third through fifth metatarsal necks (toes). an order for [REDACTED]. On 04/21/12 at 8:00 a.m., a nursing note documented the resident complained of pain to the left shoulder with yellowish discoloration to her left upper extremity, just above the elbow. A physician's orders [REDACTED]. Review of the x-ray results, dated 04/22/12, found the following, .There is a large effusion at the elbow. This is secondary to a nondisplaced supracondylar fracture with very slight posterior angulation. There may be a subtle fracture of the radial head as well . -- An interview was conducted with the director of maintenance, Employee #63 at 9:00 a.m. on 04/25/12. He was asked whether he inspected the mechanical lift following Resident #77 falling from the lift on 04/18/12. Employee #63 stated he attended a meeting concerning the fall and learned the type of sling utilized to transfer the resident was not intended for use with the lifts they currently utilized. He stated the white sling was to be used with a different model of mechanical lift which had been placed out of commission. -- An interview was conducted with the administrator, Employee #55, at 9:00 a.m. on 04/25/12. She stated the white lift pad was removed from use following the resident's fall on 04/18/12. She stated the lift pad had not been removed from inventory when the model of mechanical lift intended for use with the white slings was placed out of commission. -- The staff development nurse, Employee #1 was asked, at 9:00 a.m. on 04/25/12, to provide evidence of NAs #35 and #33 competency related to the use of mechanical lifts. She provided an in-service document dated 03/09/12 on the proper use of the mechanical lift and lift pads (slings). Both NA #35 and #33 were listed. --Employee #1 was asked to demonstrate the use of the different slings and her training methods related to mechanical lifts at 11:15 a.m. on 04/25/12. She stated the NAs watched a video, and then she takes them two-at-a-time and watches them demonstrate lifting individuals using the mechanical lift. She was asked to demonstrate which color and type of lift pad (sling) to utilize for residents of different sizes and different body types. Employee #1 was unable to demonstrate what pads (slings) to utilize in differing situations. She was asked how she taught aides the proper lift pad (sling) to utilize if she could not determine it herself. She stated that she relies heavily on the senior aides. She was asked whether she was aware the facility had a white lift pad present in the building prior to Resident #77's fall. Employee #1 stated she was aware the facility had white lift pads, but had not evaluated the use of this lift pad during the training she provided. -- A NA, Employee #36, was asked at 11:30 a.m. on 04/25/12, about the use of mechanical lift pads. She stated, There are some white ones (slings) from the old lift that we can still use. Employee #1 agreed this information was not accurate. -- Another NA, Employee #47, was asked at 11:45 a.m. on 04/25/12, how aides determined which color and type of sling to use with a mechanical lift. She stated in the presence of the DON that aides use their own judgement when choosing a sling to utilize. -- An interview was conducted, on 04/30/12 at 9:58 a.m., with a representative from the manufacturer of the mechanical lifts currently utilized by the facility. The representative was asked if it was appropriate to utilize a sling from a different manufacturer with the lifts currently utilized by the facility. The representative stated when facilities called and ask that question, they are told no. The manufacturer recommends only use of the slings intended for the model utilized by the facility to ensure safety.",2016-04-01
8690,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2012-04-26,441,F,0,1,S35H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, record review, and staff interview, it was determined the facility's Infection Control Program had not ensured five (5) of ten (10) sampled employees were free of communicable disease prior to direct resident contact, which could potentially expose more than a limited number of residents, and had not ensured an employee washed her hands and donned gloves prior to the instillation of eye drops to one (1) of thirty (30) sampled residents. Employee identifiers: #13, #5, #41, #54, and #38. Resident identifier: #38. Facility census: 64. Findings include: a) Employees During the review of personnel files, at 11:30 a.m. on 04/25/12, it was determined by the absence of a completed physical form signed by the appropriate medical professional, that two (2) employees hired in 2012 (Nurses' Aides #38 and #54) had not had their pre-employment physicals prior to performing direct resident care. This was confirmed by the Employee Health Nurse (Employee #1) at 1:30 p.m. the same day, when she reviewed the blank forms in the personnel files. Further, there was no evidence in the files of three (3) long - term employees (Registered Nurse #13, Dietary aide #5, and Nurses' Aide #41) to indicate they had obtained their annual physical in the previous 12 months. This was confirmed by the Employee Health Nurse (Employee #1), at 1:30 p.m. the same day, when she reviewed the blank forms in the personnel files. During an interview with the Administrator, at 2:45 p.m. on 04/25/12, she acknowledged the facility does require these physicals. b) Resident #38 During random observations of the medication administration pass, on 04/25/12 at 8:04 a.m., licensed practical nurse (LPN), Employee #15 gave Resident #38 oral medications while the resident was seated in a wheelchair in the resident hallway. Employee #15 removed a hand wipe from a container on her medication cart and wiped her hands. She then picked up a bottle of [MEDICATION NAME] eye drops, and placed one drop in Resident #38's left eye. The nurse did not wear gloves during this procedure. The director of nursing (DON), Employee #57, was informed of this observation and was asked to provide the facility's policy related to the instillation of eye drops. Review of the facility policy provided by Employee #57, on 04/25/12 at 9:15 a.m., found staff were to perform hand hygiene, and apply clean gloves prior to instilling eye drops. Employee #57 was interviewed, on 04/25/12 at 9:30 a.m., concerning the use of hand wipes for hand hygiene prior to instilling eye drops. She stated she did not give permission for sanitizing wipes to be utilized.",2016-04-01
8691,ST. MARY'S HOSPITAL,515113,2900 FIRST STREET,HUNTINGTON,WV,25702,2012-03-22,156,E,0,1,GA6A11,"Based on the liability notice and beneficiary appeal review and staff interview, the facility failed to ensure three (3) of three (3) residents who were discharged from a Medicare Part A skilled service received the appropriate notice. In addition, the facility did not ensure the residents were informed of the reason they were discharged from a skilled service. Resident identifiers: #5, #15, and #9. Facility census: 13. Findings include: a) Residents #5, #15, and #9 On 03/21/12, at approximately 3:00 p.m., the social worker (Employee #30) provided a copy of the notices that were given to three (3) residents who were discharged from a skilled service. Resident #5 received the notice of Medicare Provider Non-Coverage (CMS ) on 10/18/11. The form did not state why the facility had discharged the resident from the skilled service. According to the social worker the resident had reached her maximum potential in therapy. She was discharged from the facility on 10/19/11. Resident #15 received the notice of Medicare Provider Non-Coverage (CMS ) on 11/29/11. He was discharged from the facility on 12/02/11. The notice did not contain the reason the resident was discharged from the skilled service. According to the social worker this resident had reached his maximum potential in therapy. Resident #9 received the notice of Medicare Provider Non-Coverage (CMS ) on 10/28/11. She was discharged from the facility on 10/29/11. The notice did not contain the reason why the resident was discharged from the skilled service. According to the social worker this resident had reached her maximum potential in therapy. According to the Center for Medicare and Medicaid Services Survey and Certification letter (S&C-09-20) the facility has the obligation to not only issue the CMS- , but also the SNFABN (skilled nursing facility advanced beneficiary notice) or a denial letter to address liability for payment. The SNFABN is given because benefit days remain to inform the patient of potential financial liability. The generic notice (CMS ) is given to notify the resident of their right to an expedited review by the QIO (quality improvement organization.) The social worker stated Resident #15, #9, and #5 were all discharged from Part A services. She said the unit normally did not keep residents more than twenty (20) days, if that long. She did comment that these residents did have skilled nursing days left and also could have chosen to pay privately for a continued stay on the unit.",2016-04-01
8692,ST. MARY'S HOSPITAL,515113,2900 FIRST STREET,HUNTINGTON,WV,25702,2012-03-22,272,E,0,1,GA6A11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policy and procedures for pressure ulcers, and staff interview, the facility failed to assess pressure ulcers for three (3) of twenty-one (21) stage II sample residents. The pressure ulcers were not measured or described in accordance with the facility's policy and procedures. Resident identifiers: #63, #46, and #64. Facility census: 13. Findings include: a) Resident #63 Resident #63 was admitted to the facility on [DATE]. She remained in the facility from 09/20/11 to 10/07/11. Measurements for the wound were obtained on 09/20/11 and 09/25/11. No evidence could be found the facility had measured the wound with the exception of 09/20/11 and 09/25/11. The facility's policy and procedure manual for pressure ulcer prevention and management stated, wound assessments will be completed with descriptive documentation at every dressing change. During an interview with the clinical care manager (Employee #1), on 03/20/12, at approximately 1:57 p.m., she confirmed the wound should have been measured once a week. b) Resident #46 Resident #46 was admitted to the facility on [DATE]. Review of the medical record found she had soft heels bilaterally. No evidence could be found the facility had measured the areas. The comprehensive assessments for 11/20/11 and 12/01/11 identified Resident #46 as having two (2) stage I pressure ulcers. Record review found no measurements for the areas. During an interview with Employee #1 on 03/20/12, at approximately 1:57 p.m., it was confirmed the wounds should have been measured once a week. c) Resident #64 Resident #64 was admitted to the facility on [DATE]. Review of the wound assessment sheet found she had a 9 x 5 centimeter red area to the sacrum. On 03/10/12, the wound was treated, but no measurements were found for this day. According to the facility's policy and procedures, wounds are to be measured once a week or at dressing changes. On 03/20/12, at approximately 1:57 p.m., Employee #1 confirmed the wound should have been measured once a week.",2016-04-01
8693,ST. MARY'S HOSPITAL,515113,2900 FIRST STREET,HUNTINGTON,WV,25702,2012-03-22,279,E,0,1,GA6A11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to develop a comprehensive care plan to address pressure ulcers for two (2) residents, for four (4) residents prescribed psychoactive medications, and for one (1) resident with a urinary catheter. Residents #63 and #46 did not have a care plan to address pressure ulcers and the care and treatment to prevent worsening of the pressure ulcers. Residents #107, #104, #108, and #106 did not have care plans to address the use of psychoactive medications and complications related to the use of those medications. Resident #63 did not have a care plan to address the care and use of a urinary catheter. Failure to identify the needs and services to be furnished through the care planning process had the potential to result in a failure to provide optimal resident care. Resident identifiers: #63, #46, #107, #104, #108, and #106. Facility census: 13. Findings include: a) Resident #63 Resident #63 was admitted to the facility on [DATE]. Review of the medical record identified she had a 4 x 4 centimeter Stage I pressure ulcer to the sacrum. Review of the care plan found no evidence the facility had developed a care plan for the pressure ulcer. During an interview with the clinical care manager, Employee #1, on 03/20/12, at approximately 1:57 p.m., she stated she could find no care plan for the pressure ulcers for Resident #63. b) Resident #46 Resident #46 was admitted to the facility on [DATE]. Review of the medical record found she had two (2) pressure ulcers to her heels upon admission. The care plan did not contain interventions to prevent worsening of the pressure ulcers. The clinical care manager, Employee #1, on 03/20/12, at approximately 1:57 p.m., confirmed the pressure ulcers to Resident #46's heels were not in her care plan. According to the facility's policy and procedure manual, Assessed risk is communicated to caregivers for immediate implementation of risk reduction strategies through the Kardex, intershift report, and the interdisciplinary plan of care (IPOC). c) Resident #107 Resident #107 was admitted to the skilled nursing unit on 03/16/12. She was on the antipsychotic medication [MEDICATION NAME] 0.25 mg at bedtime. Review of the care plan found no interventions and no adverse side effects listed for the use of [MEDICATION NAME]. On 03/20/12, at approximately 1:57 p.m., Employee #1 also reviewed the care plan and could find no mention of the use of [MEDICATION NAME] on the care plan. d) Resident #63 Resident #63 was admitted to the skilled nursing unit on 09/20/11. Review of the medical record identified the use of a urinary catheter. The use and care of the urinary catheter was not found on the care plan. During an interview with Employee #1, on 03/20/12, at approximately 1:57 p.m., she confirmed the catheter was not listed on the care plan. e) Residents #104, #108, and #106 A review of the care plans for Residents #104, #108, and #106, on 03/21/12, at approximately 2:30 p.m., revealed the care plans did not address the potential adverse side affects associated with the use of benzodiazapines (a class of agents used for a variety of reasons, including the treatment of [REDACTED]. The care plans also did not address the anxiety [DIAGNOSES REDACTED]. In addition, no plans had been developed to provide guidance to staff for non-pharmacologic interventions to be attempted prior to and/or instead of medications when the residents experienced anxiety. 1) Resident #104 The medical record review for Resident #104, conducted on 03/20/12, at approximately 1:00 p.m., revealed the resident received [MEDICATION NAME] 0.25 mg po (by mouth) 3 times a day and HS (at night) prn (as needed) for anxiety. 2) Resident #108 The medical record for Resident #108, conducted on 03/20/12, at approximately 12:00 p.m., revealed the resident received [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg tablet one tablet twice per day for anxiety. 3) Resident #106 The medical record review for Resident #106 conducted, on 03/21/12, at approximately 2:00 p.m., revealed the resident received [MEDICATION NAME] ([MEDICATION NAME]) .25 mg po every 8 hours if needed for anxiety. On 03/20/12, at approximately 1:57 p.m., the director of nursing, Employee #1, verified the care plans did not address the potential adverse side affects associated with the use of the medications these residents received.",2016-04-01
8694,ST. MARY'S HOSPITAL,515113,2900 FIRST STREET,HUNTINGTON,WV,25702,2012-03-22,314,E,0,1,GA6A11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policy and procedures for pressure ulcers, and staff interview, the facility failed to provide care and services to assess, implement preventative measures and/or treat existing pressure ulcers to promote healing for for three (3) of twenty-one (21) stage II sample residents who were admitted with pressure ulcers. The pressure ulcers were not assessed, measured, described, and/or treated in accordance with the facility's policy and procedures. Resident identifiers: #63, #46, and #64. Facility census: 13. Findings include: a) Resident #63 Resident #63 was admitted to the facility on [DATE]. According to the wound assessment, she was admitted with a 4 x 4 cm non-blanchable red area to the sacrum. The medical record review found no treatment started for the Stage I pressure ulcer until 09/25/11. The facility's skin care protocol stated for prevention measures [MEDICATION NAME] sacral dressing was to be applied to non-blanchable [DIAGNOSES REDACTED] to the sacral area. The facility did not begin treatment of [REDACTED]. Resident #63 remained in the facility from 09/20/11 to 10/07/11. Measurements for the wound were obtained on 09/20/11 and 09/25/11. No evidence could be found the facility had measured the wound with the exception of 09/20/11 and 09/25/11. The facility's policy and procedure manual for pressure ulcer prevention and management stated, wound assessments will be completed with descriptive documentation at every dressing change. The skin assessment sheet stated, if a patient has a skin impairment upon admission, the skin care protocol is to be initiated. During an interview with the clinical care manager (Employee #1), on 03/20/12, at approximately 1:57 p.m., she confirmed the wound should have been measured once a week, and treatment for [REDACTED]. b) Resident #46 Resident #46 was admitted to the facility on [DATE]. Review of the medical record found she had soft heels bilaterally. No evidence could be found the facility had measured the areas. The comprehensive assessments for 11/20/11 and 12/01/11 identified Resident #46 as having two (2) stage I pressure ulcers. Record review found no measurements for the areas. During an interview with Employee #1 on 03/20/12, at approximately 1:57 p.m., it was confirmed the wounds should have been measured once a week. c) Resident #64 Resident #64 was admitted to the facility on [DATE]. Review of the wound assessment sheet found she had a 9 x 5 centimeter red area to the sacrum. On 03/10/12, the wound was described as a reddened blanchable area on the coccyx and [MEDICATION NAME] sacral dressing was applied, no measurements were found for this day. According to the facility's policy and procedure for wound prevention and management of pressure areas wounds are to be measured once a week or at dressing changes. On 03/20/12, at approximately 1:57 p.m., Employee #1 confirmed the wound should have been measured once a week.",2016-04-01
8695,ST. MARY'S HOSPITAL,515113,2900 FIRST STREET,HUNTINGTON,WV,25702,2012-03-22,329,E,0,1,GA6A11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure four (4) of twenty-one (21) residents on the stage II sample were free from unnecessary medications. These residents received psychopharmacological medications such as [MEDICATION NAME], or [MEDICATION NAME] without adequate monitoring for efficacy, behaviors and/or clinically significant adverse consequences associated with the use of these medications. Additionally, the facility failed to provide non-pharmacological interventions instead of, or in addition to, medications. Resident identifiers: #104, #106, #108, and #64. Facility census: 13. Findings include: a) Resident #104 The medical record review for Resident #104, conducted on 03/20/12, at approximately 1:00 p.m., revealed the resident received [MEDICATION NAME] 0.25 mg po (by mouth) 3 times a day and HS (at night) prn (as needed) for anxiety. There was no evidence of monitoring for efficacy or adverse side effects. Additionally, there was no evidence of the use of non-pharmacological interventions instead of, or in addition to to use of the medication. b) Resident #106 The medical record review for Resident #106, conducted on 03/21/12, at approximately 2:00 p.m., revealed the resident received [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg po every 8 hours if needed for anxiety. There was no evidence of monitoring for efficacy or adverse side effects. Additionally, there was no evidence of the use of non-pharmacological interventions instead of, or in addition to to use of the medication. c) Resident #108 The medical record review for Resident #108, conducted on 03/20/12, at approximately 12:00 p.m., revealed the resident received [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg tablet one tablet twice per day for anxiety. There was no evidence of monitoring for efficacy or adverse side effects. Additionally, there was no evidence of the use of non-pharmacological interventions instead of, or in addition to to use of the medication. d) On 03/21/12, at approximately 8:21 p.m., an interview was conducted with the director of nursing (Employee #1). She indicated the facility had not monitored for the potential negative side effects associated with the psychoactive medications for residents #104, #106, and #108. Employee #1 also indicated the facility had not monitored the effectiveness of the medications based on an assessment of the increase or decrease in mood indicators that created the need for the psychoactive medications. e) Resident #64 Resident #64 was admitted to the skilled nursing unit on 03/16/12. She was receiving [MEDICATION NAME] in the hospital prior to admission to the skilled nursing unit. Review of the medical record found no evidence the facility was monitoring Resident #64 for adverse side effects or behaviors. The antipsychotic medication, [MEDICATION NAME], was noted as an anti-anxiety medication. During an interview with the clinical care manager (Employee #1), on 03/21/12 at 8:21 a.m., she stated we do not monitor the behaviors. She further stated she could not find anything in the medical record related to behaviors or the monitoring for adverse effects associated with the use of [MEDICATION NAME].",2016-04-01
8696,ST. MARY'S HOSPITAL,515113,2900 FIRST STREET,HUNTINGTON,WV,25702,2012-03-22,371,F,0,1,GA6A11,"Based on observation, review of the Food and Drug Administration (FDA) Food Code, and staff interview, the facility failed to ensure food items were stored, prepared, and distributed under sanitary conditions. Various issues related to overall cleanliness of the physical environment, equipment, and storage of food items created potential for contamination of foods and food service items. Thirteen (13) of thirteen (13) residents who resided on the skilled nursing unit (SNU) received an oral diet from the kitchen and had the potential to be affected. Facility census: 13. Findings include: a) On 03/19/12, at approximately 11:00 a.m., and on 03/21/12, at approximately 3:00 p.m., Employee #40 (assistant food service director) accompanied the tour of the kitchen/food service area, and confirmed the following sanitation infractions affected the overall sanitary distribution of food: 1) On 03/19/12, a cardboard box was sitting in the sink in the salad preparation area. 2) On 03/20/12, the scoop for sugar was found down inside the container. The container contained a small amount of sugar and the scoop was inside the sugar. The container did not have a label which indicated the container held sugar. According to the food and drug administration (FDA) 2009 code section 3-304.12 In food that is not potentially hazardous handles should be stored above the top of the food. According to the FDA 2009 code section 3-302.12 Food storage containers should contain the common name of the food item. 3) On 03/20/12, the drain under the Jello cooler contained dirt and debris. 4) On 03/20/12, a fan located on the floor near the food service tray line area had dirt and debris on the outer casing as well as the fan blades. A string was also coming out of the metal pieces of the fan. 5) On 03/20/12, a seal on one of the facility's hot boxes was found coming loose. According to the FDA 2009 code section 4-501.11 Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturers instructions. 6) On 03/20/12 the bottom area of a hot box was dirty. This hot box contained food items that were going to be served 7) On 03/20/12, the floor located behind the hot boxes contained crumbs and dirt. Employee #40 said these boxes had to be pulled from against the wall due to the fire marshal's requirements. She agreed the floor needed cleaned. According to the FDA 2009 code section 6-501.12 Physical facilities should be cleaned as often as necessary to keep them clean. 8) On 03/20/12, the specialty foods reach-in refrigerator contained a water bottle that did not have a proper label. Employee #40 verified the bottle contained a plastic piece of tape with a name that the assistant food service director did not recognize. She immediately discarded this water bottle",2016-04-01
8697,ST. MARY'S HOSPITAL,515113,2900 FIRST STREET,HUNTINGTON,WV,25702,2012-03-22,502,D,0,1,GA6A11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a laboratory test for one (1) of twenty-one stage II sample residents was obtained as ordered. The resident had a physician's orders [REDACTED]. Resident identifier: #108. Facility census: 13. Findings include: a) Resident #108 On 03/21/12 at 9:00 a.m., review of the medical record for Resident #108 revealed a physician's orders [REDACTED]. The physician ordered the test on 03/09/12. It was scheduled for Monday, Wednesday, and Friday. The record revealed the facility obtained the test on 03/12/12, 03/14/12, and on 03/19/12. The test was not obtained on 03/16/12. Employee #10 (registered nurse) reviewed the medical record and concluded the facility had not obtained the test on 03/16/12.",2016-04-01
8698,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-11-03,156,C,0,1,S3DJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to prominently display in the facility, written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. The information could not be located in the area of the facility to which residents and visitors members were directed on the facility's information board. This practice had the potential to affect all residents and visitors wishing to review this information. Facility census: 57. Findings include: a) Upon initial entrance to the facility on [DATE] at approximately 10:45 a.m., a notice was observed in the entrance hallway on a board with other mandatory posting, stating survey results and information related to applying for Medicaid and Medicare could be found in the white binder in the front lobby. Employee #59 (front office personnel), when questioned, confirmed the front lobby was considered to be an area by the front door where two (2) chairs and a table were located. This area was searched, and no white binder was located. Employee #59, when subsequently approached about the inability of the surveyor to locate the binder of information, confirmed it was not in the designated location. This employee further stated residents sometimes carried the notebook off. In approximately fifteen (15) minutes, Employee #59 returned and had located the white binder. The necessary information was included, as stated in the posting on the information board.",2016-04-01
8699,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-11-03,167,C,0,1,S3DJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to make available for examination and post in a readily accessible place a notice of their availability, the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. This practice had the potential to affect all residents and visitors wishing to review this information. Facility census: 57. Findings include: a) Upon initial entrance to the facility on [DATE] at approximately 10:45 a.m., a notice was observed in the entrance hallway on a board with other mandatory posting, stating survey results and information related to applying for Medicaid and Medicare could be found in the white binder in the front lobby. Employee #59 (front office personnel), when questioned, confirmed the front lobby was considered to be an area by the front door where two (2) chairs and a table were located. This area was searched, and no white binder was located. Employee #59, when subsequently approached about the inability of the surveyor to locate the binder of information, confirmed it was not in the designated location. This employee further stated residents sometimes carried the notebook off. In approximately fifteen (15) minutes, Employee #59 returned and had located the white binder. The necessary information was included, as stated in the posting on the information board.",2016-04-01
8700,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-11-03,170,B,0,1,S3DJ11,"Based on resident council representative interview and staff interview, the facility failed to ensure residents received prompt delivery of mail. The facility elected not to have mail delivered on Saturdays. Therefore, residents had to wait until Monday to receive mail when the postal service would normally deliver mail to persons living in the community on Saturdays. This practice had the potential to affect more than an isolated number of residents. Facility census: 57. Findings include: a) During an interview on 11/02/11 at approximately 9:00 a.m., Resident #29 (who represents the resident council as president) reported that residents at this facility did not receive mail on Saturdays. When interviewed on 11/02/11 at approximately 9:30 a.m., Employee #60 (administrative assistant) acknowledged the facility had the mail delivery stopped on Saturday due to the mail box being broken into and mail being stolen. On 11/03/11 at approximately 1:00 p.m., the director of nursing (DON) reported an activity assistant would start getting the mail out of the box after the facility resumed Saturday delivery. According to the guidance to surveyors for determining a nursing facility's compliance with this requirement: 'Promptly' means delivery of mail or other materials to the resident within 24 hours of delivery by the postal service (including a post office box) and delivery of outgoing mail to the postal service within 24 hours, except when there is no regularly scheduled postal delivery and pick-up service.",2016-04-01
8701,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-11-03,226,E,0,1,S3DJ11,"Based on review of the facility's abuse prohibition policy and staff interview, the facility failed to ensure the implementation of policies and procedures that included protection of residents after allegations of neglect were made. One (1) of five (5) supervisors indicated an employee would not need to be suspended from direct care duties after an allegation of neglect were made against them, contrary to the facility's policy addressing protection of residents during investigations into allegations of abuse. This practice had the potential to affect more than an isolated number of residents. Employee identifier: #15. Facility census: 57. Findings include: a) Employee #15 On 11/01/11 at approximately 1:00 p.m., during review of the facility's compliance with the abuse prohibition requirements, an interview with Employee #15 (assistant director of nursing - ADON) revealed she did not believe an employee would need to be suspended after an allegation of abuse was made against him or her. Employee #15 reported that the facility could reassign the employee, not allowing the employee to work with the resident who was considered the alleged victim in the situation. On 11/01/11 at approximately 2:00 p.m., an interview with the director of nursing (DON - Employee #9) revealed she completed the investigations of allegations of abuse and neglect at the facility. She said employees who were accused of abusing residents would be suspended pending completion of the facility's investigation into the allegation(s) made against the employee. The facility's abuse policy, reviewed on 11/01/11 at approximately 3:00 p.m., revealed the following in Section 5.1.2: The employee alleged to have committed the act of abuse will be removed from duty pending an investigation.",2016-04-01
8702,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-11-03,252,E,0,1,S3DJ11,"Based on observation and staff interview, the facility failed to provide a comfortable, homelike environment in the main dining area at lunch time on 10/31/11. While residents were trying to eat their lunch, five (5) to seven (7) staff members were emptying food carts and conversing loudly in direct proximity of the residents' dining space. This practice had the potential to affect more than a minimal number of residents who eat meals in the main dining area of the facility. Facility census: 57. Findings include: a) On 10/31/11 at 12:15 p.m., observations of the noon meal in the main dining area were made. The dining room was noted to be very full, with minimal space for staff and residents to move around. As the meal progressed, observation found that, rather than serving the resident meal trays directly from the kitchen area, the trays were put onto food carts which were left in the already crowded room, and the carts were unloaded by staff members who were serving the residents. At that time, three (3) large enclosed food carts were situated in the area closest to the kitchen door and directly adjacent to dining tables where residents were seated and trying to eat. Serving staff was clustered around the carts, attempting to locate individual residents' meal trays. The cart doors were constantly opening and closing, and staff was continuously discussing which tray should go where. At the dining table closest to the carts, three (3) residents (#43, #14 and #2) were noticed to be making no attempt to eat. These resident remained at this table throughout the meal, and although staff occasionally prompted them to eat, none of the three (3) ate more than a few bites of food. At approximately 12:45 p.m., the dietary manager (Employee #1) was made aware of the confusion and chaos observed in the dining room. Employee #1 stated this was the manner in which all trays were served in the dining room at all meals, and Employee #1 agreed that the process did make the dining environment very chaotic while residents were trying to eat.",2016-04-01
8703,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-11-03,258,E,0,1,S3DJ11,"Based on observation, confidential resident interview, and staff interview, the facility failed to provide for the maintenance of comfortable sound levels for the residents. Doors were noted to be slamming loudly in resident living areas. This practice had the potential to affect more than a minimum number of residents. Facility census: 57. Findings include: a) On the afternoon of 10/31/11, the sound of frequently slamming doors was noted from the nurse's station of the facility. When investigated, the outside door entering the Autumn unit was very loud when it closed. This was considered by staff to be the ambulance door, but traffic through this door was noted several times between 1:30 p.m. and 6:00 p.m. on 10/31/11. While seated at the nurse's station and observing medication administration on 11/01/11, this surveyor noted the door on the central bath was also slamming each time it closed. Between the hours of 7:50 a.m. and 9:30 a.m., this door was noted to slam loudly twelve (12) times. Many residents were noted to be still in bed during this time. Restorative staff was obtaining weights on this date (the first day of the new month) and staff was frequently entering and exiting the central bath through this door with residents. Both of these doors were located in areas of close proximity to resident living space. On the morning of 11/01/11, two (2) residents who resided on the Autumn unit (who wished to remain anonymous) stated the sound of slamming doors did bother them on occasion. One (1) of the two (2) residents stated staff used the outside door at the end of the hallway when entering the facility early in the morning and that he/she was frequently awakened by the noise of the slamming door. At approximately 1:00 p.m. on 11/01/11, the door to the central bath was determined to have a device installed that was intended to prevent the door from slamming when shut. This device did not appear to be functioning properly and did not prevent the slamming. At 1:30 p.m. on 11/01/11, the facility's maintenance director (Employee #62) was asked to observe the doors in question. This employee stated nothing could be done about the noise of either door. The central bath door closure could not be adjusted, according to this employee, because then it would not shut. This employee further stated the outside entrance door to Autumn unit was slamming against a hollow metal door facing, and it too could not be made more quiet when shutting. When asked how he would like to be awakened by the sound of these slamming doors, he stated, I can see what you mean. He further stated he had never had complaints. Many residents of this and any long term care facility are not able to voice complaints. Some forty-five (45) minutes later, at approximately 2:15 p.m. on 11/01/11, Employee #62 asked this surveyor to come and observe the central bath door again. The door, at that time, was noted to shut slowly and not slam. This employee stated, It's been like this for fifteen (15) years. On the morning of 11/03/11, Employee #62 asked this surveyor to observe the outside entrance door on Autumn wing. The door had been adjusted in some manner that made the closing much quieter. This door did retain a loud noise associated with the actual latching device that Employee #62 again stated could not be lessened due to the hollow metal door facing that the device latched to.",2016-04-01
8704,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-11-03,279,D,0,1,S3DJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed, for one (1) of seventeen (17) sampled residents, to develop a comprehensive care plan that included measurable objectives and timetables to meet each resident's identified needs and that described services to be furnished to assure the resident's highest level of well being. Resident #75, who entered the facility with a need for therapy services, had no care plan to assure optimal well-being once therapy services were no longer needed. Facility census: 57. Findings include: a) Resident #75 The medical record of Resident #75, when reviewed on 11/02/11, disclosed the resident was admitted to the facility on [DATE] following hospitalization where she had been admitted from home for [MEDICAL CONDITION], a metabolic condition in which there is not enough sodium (salt) in the body fluids. The resident also had medical [DIAGNOSES REDACTED]. At the time of admission, the history and physical completed by the resident's physician at the facility stated, Admit, fluid restriction, PT/OT (physical therapy and occupational therapy). The resident's record disclosed she had been discharged from PT and OT services in late August. The resident's current care plan, which was dated to have been implemented on 08/17/11, made no mention of any needs the resident had related to discharge from the facility (should that time come) or any plan related to staying in the facility, once she no longer needed the services of OT/PT. The facility's physical therapist assistant (PTA - Employee #11), when interviewed on the morning of 11/02/11, confirmed Resident #75 had met her established goals related to these therapies. A consulting social worker (Employee #47), when interviewed on the afternoon of 11/02/11, following review of the resident's record, confirmed there was no evidence of discharge planning for this resident, either at the time of admission to the facility, or following the completion of her established PT/OT goals.",2016-04-01
8705,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-11-03,280,D,0,1,S3DJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, care plan review, and staff interview, the facility failed to ensure two (2) of thirty-nine (39) sampled residents' care plans were updated to reflect changes significant to their care. One resident (Resident #28) had a [DIAGNOSES REDACTED]. One (1) resident (Resident #73) had continued weight loss, and the care plan did not reflect this issue. Resident identifiers: #28 and #73. Facility census: 57. Findings include: a) Resident #28 On 11/02/11 at approximately 9:30 a.m., medical record review for Resident #28 revealed this resident had a [DIAGNOSES REDACTED]. The nursing notes for the time period of 10/09/11 through 11/02/11 contained documentation that the resident's urine was having a strong, foul odor for seventeen (17) days. On 11/02/11 at approximately 10:30 a.m., an interview with Employee #23 (a licensed practical nurse - LPN) revealed she had taken care of Resident #28 on several occasions. She said the resident normally had a strong urine odor. She also said the resident had not had any other symptoms associated with a urinary tract infection. The medical record showed the resident's temperature to be within normal range, and she had not complained of any pain which would have indicated a possible urinary tract infection. On 11/03/11 at approximately 8:00 a.m., the director of nursing (DON - Employee #9) had documentation from 09/08/04 regarding Resident #28's issues with urine odors. On 09/08/11, a nurse contacted the physician regarding the resident's strong urine odor. At that time, the physician directed staff to contact him if the resident began to run a temperature. On 11/03/11 at approximately 10:00 a.m., the registered nurse who completed all minimum data set assessments and care plans (Employee #16) reviewed Resident #28's care plan. She indicated she could revise the care plan to include the issue regarding the resident's strong urine odor. She said she would incorporate this into the section that included other related issues such as the resident's risk of urinary tract infections and [MEDICATION NAME] use. -- b) Resident #73 The medical record of Resident #73, when reviewed on 11/02/11, revealed the resident had been admitted to the facility on [DATE] following hospitalization where she underwent a thoracotomy (surgery to remove all or part of a lung) and resection for a lung mass. The resident was noted by her physician to be admitted with deconditioning related to this hospitalization , with the hopes that she could be strengthened and return home. The resident also had surgical wounds requiring daily care. At the time of admission to the facility on [DATE], she weighed 146# and was 5 feet, 5 inches tall. Admission medication orders included [MEDICATION NAME] daily for a supplement. ([MEDICATION NAME] is a vitamin and mineral supplement.) A progress note, recorded by the dietary manager on 08/10/11, recognized the resident's weight was 137# and that she had experienced a 9# weight loss in two (2) weeks. The note further stated, RD (registered dietician) will assess. The resident was not assessed by the RD for an additional six (6) days. Her weight at that time had declined an additional 2#. The care plan for this resident, when reviewed, contained interventions related to the resident's risk for weight loss that were recognized as necessary upon admission, but the interventions had not been reviewed / revised when the resident experienced continued weight loss. The dietary manager (Employee #1), when interviewed at 1:45 p.m. on 11/02/11, confirmed the resident's care plan had not been revised following the original determinations of need.",2016-04-01
8706,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-11-03,325,D,0,1,S3DJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed, for one (1) of seventeen (17) sampled residents, to assure the resident maintained acceptable parameters of nutritional status, by failing to intervene in an appropriate and timely manner when a resident experienced ongoing significant weight loss. Resident identifier: #73. Facility census: 57. Findings include: a) Resident #73 The medical record of Resident #73, when reviewed on 11/02/11, revealed the resident had been admitted to the facility on [DATE] following hospitalization where she underwent a thoracotomy (surgery to remove all or part of a lung) and resection for a lung mass. The resident was noted by her physician to be admitted with deconditioning related to this hospitalization , with the hopes that she could be strengthened and return home. The resident also had surgical wounds requiring daily care. At the time of admission to the facility on [DATE], she weighed 146# and was 5 feet, 5 inches tall. Admission medication orders included [MEDICATION NAME] daily for a supplement. ([MEDICATION NAME] is a vitamin and mineral supplement.) A progress note, recorded by the dietary manager on 08/10/11, recognized the resident's weight was 137# and that she had experienced a 9# weight loss in two (2) weeks. The note further stated, RD (registered dietician) will assess. The resident was not assessed by the RD for an additional six (6) days. Her weight at that time had declined an additional 2#. When assessed on 08/16/11, the RD recommended the resident receive the dietary supplement Resource 2.0 two (2) times a day. Although the resident remained within her determined ideal body weight range of 112# to 138#, the resident had experienced a 12# weight loss in twenty (20) days, after having been admitted to the facility for recovery following extensive surgery. The resident was hospitalized the following day with a medical [DIAGNOSES REDACTED]. Review of the medical record disclosed that, although the dietary manager noted the resident's weight loss, no intervention was undertaken until the resident had experienced significant loss. The care plan for this resident, when reviewed, contained interventions related to the resident's risk for weight loss that were recognized as necessary upon admission, but the interventions had not been reviewed / revised when the resident experienced continued weight loss. Although the resident experienced a substantial weight loss, she remained within her estimated ideal body weight range. Upon return from the hospital, the resident did receive the recommended nutritional supplement, her body weight began to rebound, and a 2# weight gain was realized by the time she was weighed on 08/25/11. The resident's condition improved, and she was able to be discharged from the nursing facility to a lesser level of care (an assisted living facility) on 09/02/11. When interviewed on 11/02/11 at 1:45 p.m., the dietary manager confirmed the above findings.",2016-04-01
8707,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-11-03,327,D,0,1,S3DJ11,"Based on resident interview, observation, review the facility's resident council meeting minutes, and staff interview, the facility failed to provide fresh water to two (2) of forty-nine (49) Stage II sampled residents. Resident identifiers: #44 and #45. Facility census: 57. Findings include: a) Residents #44 and #45 Residents, when interviewed during Stage I of the survey, were asked if the facility provided sufficient water for hydration. Resident #45 stated, They always give us cola, but when we ask for water, we never get it. Sometimes, we have to go get it ourselves. Resident #44 stated, There is no sense in checking my water pitcher, because they never give us water. Observations were made on 11/01/11, 11/02/11, and 11/03/11 to check for fresh water for residents in the facility. Residents #44 and #45, on each observation, had only approximately 60 cc of water in their pitchers; the water was warm, and the pitchers contained no ice. Review of the resident council minutes found residents had complained, on 08/05/11, that they do not get fresh ice water. On 10/07/11, residents again complained of not receiving fresh ice water. This concern was discussed with the director of nursing (Employee #9) at 2:25 p.m. on 11/03/11.",2016-04-01
8708,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-11-03,371,F,0,1,S3DJ11,"Based on observation, staff interview, and service report review, the facility failed to ensure proper sanitation, storage, and food handling practices were in place to prevent the outbreak of foodborne illness. The facility did not ensure they had appropriate test kits available to verify the concentration of sanitizer solutions for the 3-compartment sink and the rinse water of the low temperature dish machine. In addition, the facility did not ensure proper labeling, storage, and disposal of food items in the pantry area located near the facility's nursing station. These practices had the potential to affect all residents. Facility census: 57. Findings include: a) On 10/31/11 at approximately 11:00 a.m., a tour of the kitchen and an interview with the dietary manager (Employee #1) revealed the facility had a low temperature dishwasher that used chemical sanitation. The dietary manager took a test strip from the cylinder and tested the sanitizing solution that ran through the dish machine. The test strip turned a shade of purple. The cylinder had different colors associated with different ppm (parts per million). None of the colors on the cylinder were purple. The dietary manager said the facility had recently selected a new food distributor, and he did not know if this had anything to do with the test strips not coinciding with the colors on the cylinder. He said the test strip should show the color associated with 50 ppm. However, the test strip did not correlate with the color on the cylinder that indicated 50 ppm. An observation of the 3-compartment sink, also located in the dish room, revealed there were no test strips available to test the chemical sanitation in this sink. The dietary manager said they must have ran out, and he went to get more sanitation strips for the 3-compartment sink. The 3-compartment sink and the dish machine both used a sanitizing agent. There were no postings of information to inform dietary staff what type or concentration of chemical sanitation needed to be used for the dish machine and 3-compartment sink. Without any information regarding the type of sanitizer and amounts needed for effective sanitization, staff would not know whether or not the proper concentration of sanitizing solution was in use. Sanitizer solutions test strips are essential in the food service industry to ensure that sanitizers are at proper concentrations. On 11/02/11 at approximately 1:00 p.m., the dietary manager reported the food vendor had provided a chart to put in the dishroom showing what type of sanitizer needed to be used and what concentrations they needed to look for to ensure proper sanitation. The dietary manger said he would mark the chart to show the staff which section applied to the dish machine (which used a chlorine sanitizer) and which applied to the 3-compartment sink (which used a QT 10 sanitizer). -- b) On 11/02/11 at approximately 7:30 a.m., during the breakfast meal an observation of the cook (Employee #3) used the same gloves to handle bowls of cream of wheat, the utensils to portion the cream of wheat in the bowls, as well as the utensils to put sausage links on the plate. She then used the same gloves to pick up pancakes and place them on residents' plates. At approximately 8:00 a.m., the dietary manager arrived in the kitchen area and gave the employee a utensil to pick up the pancakes rather than using her gloved hands. -- c) On 11/03/11 at approximately 9:00 a.m., during an interview with the dietary manager, he agreed Employee #3 should not have used her gloved hands to pick up the pancakes after she had handled other non-food items, such as bowls and utensils. He also agreed the test strips did not correspond with the color on the cylinder for 50 ppm chemical sanitation. He confirmed that a chart in the dish room would help staff identify the type and amount of sanitation needed for the 3-compartment sink and dish machine. -- d) On 10/31/11, during tour of the facility, observation of the resident's nourishment pantry revealed open containers of food in the refrigerator with no dates and no names. The follow items were found in the refrigerator: a Dairy Queen Blizzard with no date and no name, opened butter with no date, opened bologna with no date, opened jar of vanilla peaches with no date and no name. Under the sink in the pantry were cups of drinks, opened cheddar crackers, an open box of Lucky Charms cereal, and an open bag of fudge sticks cookies. Employee #23 accompanied this surveyor on the observation at 10:51 a.m.",2016-04-01
8709,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2013-04-25,157,D,1,0,0C5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the responsible party of a resident's change in condition. The resident was ordered antibiotics for a [DIAGNOSES REDACTED]. The facility failed to notify the responsible party related to the refusals of taking the antibiotics, and the refusals of therapy services. One (1) of three (3) residents reviewed was affected. Resident identifier: #71. Facility census: 70. Findings include: a) Resident #71 Resident #71 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 04/03/13, she was ordered antibiotics to treat a left lung infiltrate. The physician ordered [MEDICATION NAME] 500 mg twice a day for ten (10) days, [MEDICATION NAME] 500 mg three (3) times a day for ten (10) days, and [MEDICATION NAME] 600 mg twice a day for ten (10) days. The Medication Administration Record [REDACTED]. Further review of the medical record identified the facility had failed to notify the responsible party of the resident's refusal to take the medications as ordered, and of her refusal to participate in therapy services. Review of the therapy notes for 04/05/13 found the resident had been refusing to participate. The notes included She spends most of her time in the bed. She is being transferred to a personal care home on 04/07/13. Resident was educated on the need to get out of bed more. Discussed discharge plan to personal care home and resident became mildly agitated. The resident was seen four (4) days from 03/30/13 to 04/05/13. Therapy progress note for 03/13/13 through 03/29/13 included Resident was seen ten (10) days during therapy progress period. Patient has been educated on need to participate with rehabilitation services and the effects of bed rest. Potential for achieving goals: Resident has poor potential to achieve goals due to refusals. Resident would benefit from continued physical therapy services, but refuses to participate. On 03/22/13, resident refused to participate with therapy with multiple attempts made to get resident to participate. A therapy progress note, dated 03/16/13 was, Attempted twice to get resident to participate with therapy. Resident stated, I just want to lay in bed and I do not want to be bothered. Nursing also attempted to to get resident to participate, stating to resident the importance of therapy to get her back home. Resident stated, nursing can not make her do something she didn't want to. Nursing staff continued to encourage her so she could get stronger to return to home with family. Resident continued to refuse. During an interview with Employee #42 (director of nursing), on 04/24/13, at 1:50 p.m., she confirmed the facility failed to notify the responsible party related to the resident refusing to take medications, and refusing to participate in therapy services.",2016-04-01
8710,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-04-29,225,D,1,0,LRUF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, were reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency) for one (1) of twelve (12) residents reviewed. The facility failed to immediately report an alleged misappropriation of a resident's controlled medications. In addition, the facility failed to report another registered nurse (RN), who had knowledge of the alleged misappropriation of controlled medications, to the RN Licensing Board. This was found for one (1) of twelve (12) residents reviewed. Resident identifier: #96. Facility census: 95. Findings include: a) Resident #96 As part of a complaint investigation, a list of licensed nurses leaving employment with the facility during the past three (3) months was requested on 04/22/13 at 1:00 p.m. The files of all licensed staff leaving employment in March and April 2013 were reviewed on 04/22/13 at 2:10 p.m. A file was found for registered nurse (RN), Employee #195, who was listed as terminated for gross misconduct/falsification of records. The file showed she was let go on 03/07/13 for misappropriation of narcotics. There was an investigation conducted by the facility in March 2013 which resulted in the nurse's termination. She was also reported to the RN licensing board on 03/11/13. According to the cover letter to the RN Board, written by the director of nursing, Employee #133, the incident had taken place a month earlier, on 02/09/13. The cover letter stated (typed as written): I am filing this complaint related to a nurse who worked for me. Her name is (Employee #195) RN, license #*****. On February 9th 2013 (Employee #195) was working as a staff nurse for the (facility name). That night at the end of her shift she left the facility without completing the required end-of-shift narcotic count/verification process. The nurse who was coming on duty to relieve (Employee #195) RN was (Employee #71) RN. She was left to do the count with a fell ow nurse (Employee #129) LPN who was also on duty at that time. These two staff nurses counted the narcotic drawer that was left without the outgoing nurses' verification secondary to (Employee #195)'s departure from the facility. Subsequent count of narcotics showed that there were six (6), missing narcotics from a resident's medication card. Witness statements report that (Employee #71) RN called (Employee #195) RN to inform her about the narcotic discrepancy. (Employee #195) RN then returned to the facility and filled in six (6) narcotic entries on a resident's narcotic count sheet. Investigation shows that this person was not a current resident at our facility and therefore could not have received the missing doses in question on that date. During my initial interview with (Employee #195) RN she acknowledged not doing the required narcotic count. (Employee #195) also did not have a reason as to why she would leave the facility before doing the required narcotic verification process. (Employee #195)'s employment was suspended upon discovery of the incident. After interviewing (Employee #195) and obtaining written witness statements her employment was terminated. b) As part of the facility's investigation, five (5) witness statements were obtained, from four (4) nurses and the director of nursing. These included: 1) Statement dated 03/05/13 from RN #71 (typed as written): Arrived to work and received report from (#195). She then proceeded up the hall. I reminded her we needed to count. She said 'I'm back in the morning if there is any problem I'll fix it then.' She then left the building. I proceeded to count with (#129) present. There were six prn (as needed) pain pills missing for (former Resident #96) room [ROOM NUMBER]-1. I immediately called (#195) and informed her. She said 'I gave them to (former resident #96) on the day he was sent out for a G.I. bleed.' She arrived back at the facility to correct the narc book. 2) Statement from LPN #129 (typed as written): I worked A wing the weekend of [DATE]th & 10th on 230 hall. (#195) worked 220 hall from 7AM - 7pm. (#71) relieved (#195) at 7pm. They didn't count the narc drawer because (#195) was in a hurry to leave. When (#71) sat down to count, there were six [MEDICATION NAME] missing from (former resident #96)'s card. (#71) was very upset and showed it to me. We then counted her cart together. The count was right, except for six missing [MEDICATION NAME]. (former Resident #96) was out to the hospital and had been since the 6th of February. (#71) called (#195) and (#195) returned to the building and signed the pills out and took a urine test and told me that (RN #65) made her. I don't think (#65) even knew what was going on. I did not report this to anyone because it wasn't my narc drawer and I have reported to nursing supervisors several times for previous months that I believe (#195) is impaired. I was told by the prior DON that I was picking on her and that I should not make allegations. I did tell (#71) that if that had happened to me, I would not have accepted narc keys and I would have reported it immediately. Friendship or no friendship, it ends with my license being in jeopardy. On 3-2-13 and 3-3-13, I worked 220 hall. I noticed several narcotics discrepancies that were very obvious in the narc book. I called and reported it to (former RN #196), RN on call. I believe that this needs dealt with immediately. (#196) made copies of the narc book and (administrator #45) called facility and said she would investigate it. These residents deserve better. 3) Statement from LPN #93 (typed as written): To whom it may concern, I was a nurse on A wing on midnight shift. When I left Sat. AM, (former Resident #96) had a full card (30) of [MEDICATION NAME] - he had left the facility for a number of days and went to hospital. A couple of days after he was gone, 6 pills came up missing. I was not working when this happened. However (#71) and another nurse (#129) both called me @ home and said what happened. Apparently, (#195) was called back in by (#71) to sign out the pills. I was told by (#71) that the pills were given to a different resident. A couple of the aides were told what happened also. I told both (#195) and (#71) that I would never lie for either of them. 4) Statement dated 03/04/13 from former RN #195 (typed as written): (Former Resident #96) On 2/8/13 narc count was not done nurse coming on shift was late & I had something to do - 4 pills was not signed out on him from that day - nurse called me & made me aware - so I came back in & signed med out - 5) Statement dated 03/04/13 from director of nursing, #133 (typed as written): On 3/4/13 I called (#93) LPN related to a possible narcotic issue that happened in early February involving (former Resident #96). (#93) knew immediately what I was speaking of. (#93) stated to me that, (#71) RN called her on that day (2/9/13), and stated that, (#195) left without doing the required end-of-shift narcotic count with her. (#93) also mentioned that (#71) told her that after the narc count was not done that a resident (former Resident #96) was several pills (6) short on the count. (#93) stated that (#71) called (#195) to come back in to fix the omission. (#93) stated that she cautioned (#71) against Covering for (#195), and that if this incident ever came to light that she (#93) would not risk her license in this type of issue. (#93) stated that during this time of the 'missing narcotics' the resident was not even actually a resident in this facility. Medical records show that resident was discharged on [DATE] and re-admitted on [DATE]. c) An interview was conducted with the administrator, Employee #45, on 04/26/13 at 10:00 a.m. She was advised the facility's own investigation revealed licensed staff failed to immediately report a known misappropriation of a former resident's property, which was also a controlled medication. Although former Resident #96 was no longer at the facility on 03/05/13, he was a resident of the facility when the misappropriation took place. In addition to all licensed staff being mandatory reporters for abuse, neglect, and misappropriation, Legislative rule title 19, WV Code ? 30-1-4 and ? 30-7-4 Disciplinary Action states, A registered professional nurse required to file a complaint with the board in accordance with this rule or any other state law or rule shall do so within thirty (30) days after their knowledge of the alleged violation. The facility's investigation found that an RN (Employee #71) was aware of the possible misappropriation of controlled medication belonging to former Resident #96. Employee #71 failed to report this knowledge to the facility, as misappropriation to the State agency, and to the RN Board. In addition, the facility failed to report the misappropriation of resident's property immediately upon discovery. The facility also failed to report Employee #71 to the RN Licensing Board, so a determination could be made as to whether disciplinary action was indicated for her failure to report the possible misappropriation of controlled medications. The administrator, Employee #45, voiced understanding of these issues.",2016-04-01
8711,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-04-29,241,D,1,0,LRUF12,"Based on observation and staff interview, the facility failed to maintain the dignity of a resident with an indwelling Foley catheter. This was found for one (1) of three (3) residents observed who had Foley catheters, in a survey sample of (9) residents. Resident identifier: #71. Facility census: 93. Findings include: a) Resident #71 On 07/03/13 at 8:35 a.m., Resident #71 was observed lying on his bed. Observation revealed the resident had an indwelling Foley catheter. The catheter bag, containing clear yellow urine, was hanging on the bed frame. This could be seen by anyone passing in the hallway. At 8:40 a.m. on 07/03/13, an interview was conducted with Employee #63, the unit manager. She stated all residents with an indwelling Foley catheter should have the catheter bag enclosed within a privacy bag. Employee #63 observed the resident at 8:45 a.m. She agreed the resident's catheter bag should be enclosed in a privacy bag. She further commented a privacy bag was necessary for the resident's dignity since anyone passing his room could see his catheter bag with visible urine. Employee #63 stated she knew the resident had a privacy bag and began searching his room. Resident #71's privacy bag for his indwelling Foley catheter was located by Employee #63, hanging on his wheelchair in the corner of his room.",2016-04-01
8712,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-04-29,252,D,1,0,LRUF11,"Based on observation, maintenance record review, and staff interview, the facility failed to provide a safe, clean, comfortable and homelike environment for (1) of nine (9) current residents reviewed. The wall next to this resident's bed was in poor repair. The facility was aware of the condition of the wall, but had made no effort to correct the situation. Resident identifier: #42. Facility census: 95. Findings include: a) Resident #42 Observations of Resident #42 were made on 04/22/13 at 1:00 p.m., 04/22/13 at 4:30 p.m., 04/23/13 at 9:10 a.m., 04/23/13 at 2:00 p.m., and 04/23/13 at 3:00 p.m. Resident #42's bed was placed with one side against the wall of the room. He was always found lying on his right side with his face within a foot of the wall. There were two (2) main areas where the wall was damaged. Those areas were around four (4) inches in diameter, and the outer finished layer of the wall was gone. Toward the center, the depth of the damage increased, to include the inside of the wall itself. There were several, eighteen (18) to twenty (20) small areas where small pieces of the outer finish layer of the wall were missing and the inside of the wall material was exposed. These were roughly circular and ranged from around one fourth inch (?) to one inch (1) in width. Also noted were many marks on the wall around and through these damaged areas, that appeared to be linear scratches. These were jagged in appearance, not perfectly straight marks. All of this damage was adjacent to the area where Resident #42's face and hands were observed. He appeared debilitated, perhaps contracted nearly in a fetal position, but was seen to be restless and moving about in his bed. A registered nurse (RN), Employee #148, was interviewed on 04/23/13 at 3:15 p.m. She was asked to observe the damage to the wall in Resident #42's room. She was asked if she knew how the damage occurred. Employee #148 stated Resident #42 picked at the wall all the time. She also said the resident had been observed putting some of the pieces in his mouth. When asked if any other staff members were aware of this, she said she had spoken to the unit manager about it, and she said the two (2) of them went to the director of nursing (DON), Employee #133, either the beginning of last week, or the end of the week before and informed him of this situation. According to Employee #148, the DON said he would take care of it. A nursing assistant (NA), Employee #51, was interviewed on 04/23/13 at 4:13 p.m. She was asked to observe the damage to the wall in Resident #42's room. She was asked if she knew how the damage occurred. She said the resident gets mad and hits the wall. Employee #51 stated the resident made the two (2) big places hitting it. According to Employee #51, the resident picked at the wall a lot. She was asked if the nursing assistants had told anyone about this. She said she had told the nurses and that all the afternoon shift nurses knew about it. Maintenance work orders were requested from the maintenance supervisor, Employee #134, on 4/22/13 at 1:00 p.m. Review of these work orders found no work orders for March or April 2013 involving the wall in Resident #42's room. The director of nursing, Employee #133, was interviewed on 04/24/13 at 9:30 a.m. He was asked about the wall damage, and the concern that Resident #42 may be placing debris from the wall in his mouth. He said he had no knowledge of the situation; that if he did, he would have taken care of it immediately. He denied any meeting with any nursing staff had ever taken place on the subject. During the day, on 04/24/13, after the condition of the wall was brought to the facility's attention during the survey, the facility placed a wall covering on the affected wall and rearranged the layout of the furniture in the resident's room.",2016-04-01
8713,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-04-29,309,G,1,0,LRUF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for eight (8) of fourteen (14) residents reviewed. Resident #98 was admitted with a history of an identified reaction/allergy to [MEDICATION NAME] and [MEDICATION NAME]. The facility flushed the resident's percutaneous intravenous central line (PICC) with [MEDICATION NAME] on three (3) separate occasions. This resulted in harm to Resident #98, as the resident had a reaction and was taken to the emergency room for treatment. Residents #20, #35, #71, and #84 did not have blood pressures taken as ordered. The facility failed to obtain necessary information to ensure pacemaker checks were completed as required for Residents #69 and #83. Wound treatments for Resident #27 were not completed as ordered. Resident identifiers: #98, #20, #35, #71, #84, #69, #83, and #27. Facility census: 95 Findings include: a) Resident #98 This [AGE] year old male was admitted on [DATE] after a recent hospital stay for an acute illness and surgery. During his stay at the acute care facility, he experienced an acute reaction to [MEDICATION NAME] and [MEDICATION NAME] (anticoagulants) . Because of this reaction, the medical records sent with the resident on admission clearly identified the resident's allergy to [MEDICATION NAME] and [MEDICATION NAME]. The records specifically stated, Consult hematology prior to future [MEDICATION NAME] or [MEDICATION NAME] (a low molecular form of [MEDICATION NAME]) and Would avoid all [MEDICATION NAME] products in the immediate future. The resident's admission orders [REDACTED]. The central line catheter protocol form was completed on 03/21/13, and signed at 5:50 p.m., by Employee #22, a registered nurse (RN). Despite the notation in the allergy box, of an allergy to [MEDICATION NAME] and [MEDICATION NAME], the nurse marked the flushing protocol section to . flush unused lumens of the percutaneous intravenous central line (PICC) with 5 milliliters (ml) of normal saline and 5 mls of [MEDICATION NAME]. Review of the medical record, on 04/24/13 at 9:00 a.m., verified the resident received three (3) doses of [MEDICATION NAME] flush through the red port of his central line catheter. The first dose was on 03/20/13 at 9:00 p.m., the second dose was given on 03/21/13 at 09:00 a.m. and the last dose was at 9:00 p.m. on 03/21/13. An order was written to discontinue the [MEDICATION NAME] flush, on 03/23/13 at 4:00 p.m., by Employee #22. A note written by a licensed practical nurse (LPN), Employee #129, stated the resident was transferred out by ambulance, on 03/23/13, for an unplanned evaluation and treatment. Medical record review revealed the resident had been spiking fevers of 99.1 to 104.1., and had two (2) critical lab values: hemoglobin (Hgb) 8.6 (the reference range 12.5 - 16.3) and platelet (plt) count of 63 (reference range 140 - 450) on 03/21/13. Review of the care plan, on 04/24/13, identified the facility had added the notation of the [MEDICATION NAME] allergy to the care plan on 03/26/13, three (3) days after the resident was discharged from the facility. This information was not a part of the care plan when the resident was given [MEDICATION NAME] flushes. During an interview with a registered nurse, Employee #78, on 04/24/13, she acknowledged the care plan was changed on 03/26/13 after the resident was discharged . She stated she had added it because, It had not been care planned. Copies of medical records were obtained from the tertiary care center on 04/24/13 at 9:00 a.m. According to these records, the physicians at the tertiary center were unable to completely rule out a [DIAGNOSES REDACTED]. Due to this, the resident was treated with Argatroban, a direct [MEDICATION NAME] inhibitor. b) Thirteen (13) residents' medical records were reviewed, on 4/23/13 at 9:00 a.m., related to physician's orders [REDACTED]. The orders were not all the same. The review found four (4) of the thirteen (13) residents did not have their blood pressure checks done as ordered. The facility's policy on vital signs, when reviewed on 04/23/13 at 2:55 p.m., revealed vital signs included blood pressure, pulse, respiration, and temperature. The four (4) residents whose blood pressure checks and/or vital signs were not completed as ordered included: 1) Resident #20 A seventy (70) year old woman, was admitted to the facility on [DATE]. She had an active physician's orders [REDACTED]. As of 04/23/13, there was no evidence vital signs (including blood pressure checks) had been taken since 03/04/13. 2) Resident #35 This resident had an active physician's orders [REDACTED]. As of 04/23/13, the only evidence vital signs (including blood pressure checks) were taken were on 03/14/13, 04/17/13, and 04/19/13. 3) Resident #71 This resident had an active physician's orders [REDACTED]. As of 04/23/13, there was no evidence vital signs (including blood pressure checks) had been taken since 02/13/13. 4) Resident #84 A fifty-three (53) year old woman, was admitted to the facility on [DATE]. She had a physician's orders [REDACTED]. As of 04/23/13, the only evidence vital signs (including blood pressure checks) had been taken were on 03/28/13 at 5:05 p.m., 03/28/13 at 10:10 p.m., 03/29/13 at 5:17 a.m., and 03/31/13 at 3:19 a.m. 5) An interview was conducted with the director of nursing, Employee #133, on 04/23/13 at 2:45 p.m. He reviewed the documentation related to blood pressures for Residents #20, #35, #71, and #84, and agreed blood pressures had not been taken as ordered by the physician. c) Two (2) current residents at the facility had pacemakers, Resident #69 and Resident #83. Their medical records were reviewed on 4/23/13 at 10:38 a.m. 1) Resident #69 This resident was admitted to the facility on [DATE]. She had a cardiac pacemaker. There was an active physician's orders [REDACTED]. No cardiologist recommendations or documentation were found in the medical record, and there was no evidence pacemaker checks were done since admission. 2) Resident #83 This resident had a cardiac pacemaker. She had an active physician's orders [REDACTED]. There were notes under the orders that stated last check 3/12/12. There was also a handwritten note that stated, next scheduled pacer check 5/7/13. The care plan stated pacemaker checks were to be done according to cardiologist recommendations; however, no cardiologist recommendations or other details were found in the medical record. 3) The facility policy and procedure for pacemakers was requested. It was reviewed on 04/23/13 at 1:00 p.m. The document, Procedure: Pacemaker Effective Date: 06/01/96 Revision Date: 10/01/12 stated in part: 1.1 Identify type and identification number of pacemaker and document in medical record. 1.2 Review instruction booklet or contact cardiologist for specifics regarding patient's pacemaker. 1.2 Contact pacemaker clinic/physician to schedule regular pacemaker checks. 1.4 Document schedule/instructions for patient's pacemaker checks in patient's care plan and on Treatment Administration Record (TAR) 5. Monitor for function of pacemaker. 5.1 Perform pacemaker checks according to schedule and instructions of pacemaker clinic/physician. 4) The director of nursing, Employee #133, was interviewed on 04/23/13 at 2:45 p.m. He reviewed the documentation and agreed that neither resident's record contained the type, identification number, instructions or specifics regarding the pacemaker. He acknowledged the type of pacemaker determined how often it must be checked. Employee #133 confirmed the facility did not know the type of either resident's pacemaker. He also agreed there was no evidence of pacemaker checks in the Treatment Administration Record (TAR) of either resident. d) Resident #27 This seventy-five (75) year old woman was admitted to the facility on [DATE]. She was admitted for rehabilitation procedures following traumatic fracture of a bone. Her brief interview for mental status (BIMS) score,assessed on 03/13/13 was 15, indicating she was cognitively intact. She was also indicated as interviewable by the facility, on the resident roster they completed. Her medical record was reviewed on 04/24/13 at 8:30 a.m. Resident #27 suffered a fall at home, fracturing her left leg. There were pins in place to secure the fracture. She had a physician's orders [REDACTED].? peroxide and ? normal saline, apply gauze around the pins, and secure them with Kling (gauze bandages that cling to themselves and stretch to conform to body contours) twice each day and more often if needed. The order was written on 02/26/13, and was still active. On 04/24/13, the resident's TARs for March and April 2013 were reviewed: - During March 2013, the treatments were not completed during day shift on March 1, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 23, and 24. The record also showed treatments were not completed during the afternoon shift on March 5, 21, and 25. - During April 2013, the record showed the treatments were not completed during the day shift on April 1, 7, 8, 9, 17, and 22. T he record also showed treatments were not completed during the afternoon shift on April 6, 9, 13, 14, 17, 18, 19, and 21. Resident #27 was interviewed on 04/24/13 at 10:30 a.m. She was asked about her injury and about the treatments that were ordered for her twice each day, and more often as needed. She replied they don't always do it every day. They miss a few days at times. The director of nursing, Employee #133, was interviewed on 04/24/13 at 11:00 a.m. He was shown the physician's orders [REDACTED]. Employee #133 confirmed the evidence indicated Resident #27 did not consistently receive the physician ordered wound care treatments.",2016-04-01
8714,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-04-29,318,D,1,0,LRUF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon medical record review, staff interview, and resident interview, the facility failed to ensure one (1) resident reviewed with a limited range of motion (ROM), in a facility sample of fourteen (14), received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM. This resident was admitted to the facility after a traumatic fracture of her left leg. She was not provided ROM as ordered by the physician. Resident identifier: #27. Facility census: 95. Findings include: a) Resident #27 This seventy-five (75) year old woman was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her brief interview for mental status (BIMS) score, assessed on 03/13/13 was 15, indicating she was cognitively intact. She was indicated as interviewable by the facility, on the resident roster they completed. Medical record review, on 04/24/13 at 8:30 a.m., revealed Resident #27 suffered a fall at home, fracturing her left leg. There were pins in place to secure the fracture. Further review of her physician's orders [REDACTED]. These seated/supine exercise protocols were to be completed with the resident five (5) times a week for fifteen (15) minutes a session. On 04/26/13 at 10:15 a.m., the restorative nursing record for Resident #27 was reviewed. This review revealed the range of motion exercises, which were ordered on [DATE], had been provided only once (on 04/08/13) between 03/28/13 and 04/22/13. The records indicated the facility began providing the services again, on 04/22/13, after the onset of this complaint investigation/survey. The resident received the ordered services during the survey on 04/22/13, 04/24/13 and 04/25/13. During an interview, on 04/26/13 at 11:00 a.m., Employee #133, the director of nursing, confirmed the services were not provided the resident as ordered by the physician. Resident #27 was originally interviewed on 04/24/13 regarding a different matter. On 04/26/13, she asked the surveyor to return and talk with her. She was again interviewed on 04/26/13 at 10:02 a.m. Resident #27 stated, Things really changed here since you talked to me. She was asked how things had changed. She replied, They came in and did some exercises with my leg. Resident #27 said, You know, if they had been doing that all along, I might be further along than I am now. When asked if she was supposed to have been receiving the exercises all along, or if this was something new, she said she did not know.",2016-04-01
8715,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-04-29,323,G,1,0,LRUF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, medical record review, review of the facility's abuse and reporting information, review of staff in-services, and staff interview, the facility failed to ensure the resident environment remained as free from accident hazards as possible for two (2) of two (2) residents reviewed for safety issues, in a facility sample of fourteen (14). The facility failed to ensure Resident #98 received adequate supervision and assistance devices to prevent accidents. The facility failed to monitor this resident who eloped, and sustained injuries during the elopement. His whereabouts were unknown for an hour, until notified by emergency responders, that he was found and was undergoing emergency treatment. In addition, the facility failed to repair a damaged wall which Resident #42 may have been ingesting. Resident identifiers: #98 and #42. Facility census: 95. Findings include: a) Resident #98 Medical record review revealed Resident #98 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. According to the facility's abuse/neglect reporting information, reviewed on 04/22/13 at 10:07 a.m., this resident eloped from the facility on 04/09/13. During the survey, an investigation of exit doors was conducted as to their design, their function, the types in use, and their maintenance and testing. Review of maintenance logs and tests, on 04/23/13 at 2:30 p.m., found no documented concerns to suggest there was a malfunction on the afternoon of 04/09/13. There were three (3) doors designed to automatically lock when approached by a resident wearing a WanderGuard device, such as the one ordered for Resident #98. In addition, if a resident wearing a WanderGuard followed someone out an already opened door, an audible alarm sounded. These doors were at the main entrance, a door leading outside from the main dining room, and a door that was located on the hallway toward the assisted living unit, where staff exited to the outside to smoke. If the WanderGuard was not in place, was not functioning, and/or the doors were disarmed, Resident #98 could have exited, without being noticed, any of the three (3) doors designed for automatic locking. All the remaining doors, when armed, were of the type that required one to push the panic bar type of release, wait fifteen (15) seconds, and the door would open, whether or not one was wearing a WanderGuard. A loud audible alarm sounded as soon as the bar was touched, and did not stop until reset by a key pad. If one went out these doors, he/she could not get back inside unless someone reset the door from the inside. The resident's closed medical record was reviewed, beginning on 04/23/13 at 4:10 p.m. Prior to the elopement incident, Resident #98's care plan included a focus item for the risk of elopement due to dementia and cognitive loss. One of the interventions was to utilize and monitor the resident's security bracelet according to protocol. His care plan indicated he could ambulate independently. Review of physician's orders [REDACTED]. The treatment administration record (TAR) indicated the placement of his WanderGuard was not checked by the assigned nurse on the day shift or the afternoon shift of 04/09/13, the date of the elopement. Restorative nursing documentation contained documentation of weekly checks to ensure the units were operating and batteries were sufficiently charged. Such a check was documented for Resident #98 on 04/09/13. Also contained in this restorative information was a hand written note stating (as written): (Resident #98) document on cutting wander guards off. A second handwritten note stated (as written): Cuts wander guard off Hosp 3/14 Multiple recordings in the incident report, the facility's investigation, and nurses' notes concerning the elopement stated the WanderGuard was in place. The incident report completed by a former registered nurse (RN), Employee #196, stated (typed as written): (local rescue squad) called to inform us that the resident was discovered. Wanderguard was in place to left ankle. A nurse's note, also by Employee #196, dated 04/09/13 at 4:54 p.m., stated (typed as written): Resident exited the facility by himself, UTD time of elopement. He was discovered at (local country club). Facility was called at 1500 by (local rescue squad). Was informed by staff at the field club that the resident had fallen and was found in the golfing area by two golfers. the golfers placed the resident on their golf cart and took him to the office. This nurse went to visualize the resident and his current status. Resident was noted to be lying on the stretcher, verbal and confused. Emergency treatment was provided by (local rescue squad). Transported to (local acute care hospital) by (local rescue squad). (Name) MPOA, was called at 15:15. Wanderguard was noted to be in place to the left ankle. Medical record review revealed a summary of the situation completed by the social worker, Employee #37 (typed as written): At approximately 3:00 pm on 4/9/13, it was reported that (Resident #98) had eloped from the facility and was found by golfers at the (local golf club) down the road. He was found lying on the ground, and (Local Rescue Squad) was called and notified the facility upon recognizing the resident. It was reported that his wander guard was in place on his left ankle. The resident was noted as having a superficial laceration to his face and low blood sugar, but he was not seriously injured. According to staff statements, the resident was last seen at approximately 2:00 p.m. that afternoon attending an activity in the assisted living area of the facility. A band was playing from 2-3:00 pm, the time during which the resident eloped. Since his wander guard was in place and working, we can only assume that the door alarm was not heard. b) The facility's investigation regarding the resident's elopement included two (2) pertinent statements: 1) A statement from an activities staff member, Employee #56 (typed as written) included: Resident 320 Bed 2. Had come to the 2 oclock activitie music in Chessey (the assisted living unit within the facility). He stayed about 5, maybe 10 mins. Then came up back to the front 2) A statement from a registered nurse (RN), Employee #148 (typed as written) included: On April 9th 2013 at approximately 2pm, I saw and spoke with (Resident #98). He stated he was going to go take a nap because his roommate was quiet (Resident #98) walked towards his room and I went to lunch He was in his room. I did not hear any door alarms other than the aide going out for oxygen. Statement #1 and #2 call into question the social worker's conclusion that the resident exited from the assisted living unit while the band was playing and therefore, staff may not have heard the alarm. It appears just as likely the last place any staff saw the resident was in his hallway. The acute care medical record of Resident #98's emergency room visit was reviewed at the hospital on [DATE] at 8:15 a.m. These hospital medical records revealed the resident sustained [REDACTED]. During the investigation, a visit was made to the local rescue squad, on 04/25/13 at 10:30 a.m. The two (2) emergency medical technicians (EMTs) who had responded to the call were interviewed. They said Resident #98 was found lying face down on a putting area of the golf course. They said the location was about a half mile from the facility. When asked if the resident had on a Wander Guard, EMT #1 said they cut the resident's pants off, as he was wet and covered in mud, to determine the extent of his injuries. EMT #1 said he knew what a wander guard was, and Resident #98 definitely did not have one on his leg. Other information obtained during the complaint investigation gave rise to additional questions about the actual circumstances which may have provided the opportunity for Resident #98 to elope undetected by facility staff: Review of the facility's in-servicing of staff in elopement procedures and one-on-one care for Resident #98 following his elopement led to the discovery of in-servicing of staff related to the disarming and propping open of doors. An interview with the RN staff educator, Employee #59, on 04/24/13 at 1:48 p.m., found there had been concerns with staff disarming and propping open doors so they could go outside to procure portable oxygen and get back in on their own without sounding any alarms. A document was presented that showed nineteen (19) staff members still had not been in-serviced as of 04/24/13. A trip around the building confirmed there were two (2) doors used by staff to obtain oxygen. One (1) was at the end of one of the hallways in assisted living. The other was at the end of the hallway on the unit where Resident #98 resided. This doorway lead in the general direction of the country club. The elopement and the investigation were discussed with the administrator, Employee #45, on 04/26/13 at 9:40 a.m. She confirmed adequate supervision was not provided, and the resident was injured as a result. She confirmed the facility did not know where the resident was, how he eloped, or what exit was used. It was verified no one saw the resident for approximately an hour and the facility was unaware he was not in the building until called by rescue personnel. At the close of the complaint investigation, there was still no conclusive evidence regarding what happened; however, several questions were raised during the investigation as to the presence of the wander guard and the consistent, correct use of the doors in the facility. b) Resident #42 Observations of Resident #42 were made on 04/22/13 at 1:00 p.m., 04/22/13 at 4:30 p.m., 04/23/13 at 9:10 a.m., 04/23/13 at 2:00 p.m., and 04/23/13 at 3:00 p.m. Resident #42's bed was placed with one side against the wall of the room. He was always found lying on his right side with his face within a foot of the wall. There were two (2) main areas where the wall was damaged. Those areas were around four (4) inches in diameter, and the outer finished layer of the wall was gone. Toward the center, the depth of the damage increased, to include the inside of the wall itself. There were several, eighteen (18) to twenty (20) small areas where small pieces of the outer finish layer of the wall were missing and the inside of the wall material was exposed. These were roughly circular and ranged from around one fourth inch (?) to one inch (1) in width. Also noted were many marks on the wall around and through these damaged areas, that appeared to be linear scratches. These were jagged in appearance, not perfectly straight marks. All of this damage was adjacent to the area where Resident #42's face and hands were observed. He appeared debilitated, perhaps contracted, nearly in a fetal position, but was seen to be restless and moving about in his bed. Resident #42's medical record was reviewed on 04/23/13 at 9:12 a.m. He was admitted to the facility on [DATE]. He had a [DIAGNOSES REDACTED]. A goal was in place for no episodes of choking or aspiration. He was to be kept at a ninety (90) degree upright position when swallowing food or drink. The resident was also at risk for respiratory infections due to respiratory infiltrate. A registered nurse (RN), Employee #148, was interviewed on 04/23/13 at 3:15 p.m. She was asked to observe the damage to the wall in Resident #42's room. She was asked if she knew how the damage occurred. Employee #148 stated Resident #42 picked at the wall all the time. She also said the resident had been observed putting some of the pieces in his mouth. When asked if any other staff members were aware of this, she said she had spoken to the unit manager about it, and she said the two (2) of them went to the director of nursing (DON), Employee #133, either the beginning of last week, or the end of the week before and informed him of this situation. According to Employee #148, the DON said he would take care of it. A nursing assistant (NA), Employee #51, was interviewed on 04/23/13 at 4:13 p.m. She was asked to observe the damage to the wall in Resident #42's room. She was asked if she knew how the damage occurred. She said the resident gets mad and hits the wall. Employee #51 stated the resident made the two (2) big places hitting it. According to Employee #51, the resident picked at the wall a lot. She was asked if the nursing assistants had told anyone about this. She said she had told the nurses, and that all the afternoon shift nurses knew about it. Maintenance work orders were requested from the maintenance supervisor, Employee #134, on 4/22/13 at 1:00 p.m. Review of these work orders found no work orders for March or April 2013 involving the wall in Resident #42's room. The director of nursing, Employee #133, was interviewed on 04/24/13 at 9:30 a.m. He was asked about the wall damage, and the concern that Resident #42 may be placing debris from the wall in his mouth. He said he had no knowledge of the situation; that if he did, he would have taken care of it immediately. He denied any meeting with any nursing staff had ever taken place on the subject. During the day, on 04/24/13, after the condition of the wall was brought to the facility's attention during the survey, the facility placed a wall covering on the affected wall and rearranged the layout of the furniture in the resident's room, in an attempt to ensure a safe, comfortable sanitary environment for Resident #42, and to ensure Resident #42 did not ingest non-food items.",2016-04-01
8716,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-04-29,431,D,1,0,LRUF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, medical record review, policy review, review of personnel files, and staff interview, the facility failed, in coordination with the licensed pharmacist, to maintain a system of accurate accounting of the receipt and disposition of controlled medications for two (2) of two (2) residents reviewed for controlled medications, in a facility sample of fourteen (14). There was no system in place to account for the receipt, usage, disposition, and reconciliation of controlled medications. The lack of a process for reconciliation prevented the prompt identification of loss and/or diversion of controlled medications. This resulted in an inability to minimize the time between the actual loss or diversion and the time of detection and follow-up to determine the extent of loss. In addition, there was no evidence the pharmacist evaluated the facility's procedures and made recommendations for improvements after the facility determined there had been a misappropriation of controlled medications at the facility. The controlled medications of Resident #96 were misappropriated by licensed staff. This was not discovered for approximately one (1) month, when it was reported by another nurse. Resident #99's controlled medications were found in the medication cart over a month after he was discharged from the facility, and over two (2) months after the physician's orders [REDACTED]. Resident identifiers: #96 and #99. Facility census: 95. Findings include: a) Resident #96 Review of the personnel file for a registered nurse (RN), Employee #195, revealed she was terminated from employment on 03/07/13 for gross misconduct/falsification of records. Her personnel file showed she misappropriated controlled medications which were ordered and available for Resident #96. The facility investigated this situation in March 2013. According to the cover letter to the RN Board, written by the director of nursing, Employee #133, the incident had taken place a month earlier, on 02/09/13. The cover letter stated (typed as written): I am filing this complaint related to a nurse who worked for me. Her name is (Employee #195) RN, license #*****. On February 9th 2013 (Employee #195) was working as a staff nurse for the (facility name). That night at the end of her shift she left the facility without completing the required end-of-shift narcotic count/verification process. The nurse who was coming on duty to relieve (Employee #195) RN was (Employee #71) RN. She was left to do the count with a fell ow nurse (Employee #129) LPN who was also on duty at that time. These two staff nurses counted the narcotic drawer that was left without the outgoing nurses' verification secondary to (Employee #195)'s departure from the facility. Subsequent count of narcotics showed that there were six (6), missing narcotics from a resident's medication card. Witness statements report that (Employee #71) RN called (Employee #195) RN to inform her about the narcotic discrepancy. (Employee #195) RN then returned to the facility and filled in six (6) narcotic entries on a resident's narcotic count sheet. Investigation shows that this person was not a current resident at our facility and therefore could not have received the missing doses in question on that date. During my initial interview with (Employee #195) RN she acknowledged not doing the required narcotic count. (Employee #195) also did not have a reason as to why she would leave the facility before doing the required narcotic verification process. (Employee #195)'s employment was suspended upon discovery of the incident. After interviewing (Employee #195) and obtaining written witness statements her employment was terminated. As part of the facility's investigation, five (5) witness statements were obtained, from four (4) nurses and the director of nursing. These included: - Statement dated 03/05/13 from RN #71 (typed as written): Arrived to work and received report from (#195). She then proceeded up the hall. I reminded her we needed to count. She said 'I'm back in the morning if there is any problem I'll fix it then.' She then left the building. I proceeded to count with (#129) present. There were six prn (as needed) pain pills missing for (former Resident #96) room [ROOM NUMBER]-1. I immediately called (#195) and informed her. She said 'I gave them to (former resident #96) on the day he was sent out for a G.I. bleed.' She arrived back at the facility to correct the narc book. - Statement from LPN #129 (typed as written): I worked A wing the weekend of [DATE]th & 10th on 230 hall. (#195) worked 220 hall from 7AM - 7pm. (#71) relieved (#195) at 7pm. They didn't count the narc drawer because (#195) was in a hurry to leave. When (#71) sat down to count, there were six hydrocodone missing from (former resident #96)'s card. (#71) was very upset and showed it to me. We then counted her cart together. The count was right, except for six missing hydrocodone. (former Resident #96) was out to the hospital and had been since the 6th of February. (#71) called (#195) and (#195) returned to the building and signed the pills out and took a urine test and told me that (RN #65) made her. I don't think (#65) even knew what was going on. I did not report this to anyone because it wasn't my narc drawer and I have reported to nursing supervisors several times for previous months that I believe (#195) is impaired. I was told by the prior DON that I was picking on her and that I should not make allegations. I did tell (#71) that if that had happened to me, I would not have accepted narc keys and I would have reported it immediately. Friendship or no friendship, it ends with my license being in jeopardy. On 3-2-13 and 3-3-13, I worked 220 hall. I noticed several narcotics discrepancies that were very obvious in the narc book. I called and reported it to (former RN #196), RN on call. I believe that this needs dealt with immediately. (#196) made copies of the narc book and (administrator #45) called facility and said she would investigate it. These residents deserve better. - Statement from LPN #93 (typed as written): To whom it may concern, I was a nurse on A wing on midnight shift. When I left Sat. AM, (former Resident #96) had a full card (30) of hydrocodone - he had left the facility for a number of days and went to hospital. A couple of days after he was gone, 6 pills came up missing. I was not working when this happened. However (#71) and another nurse (#129) both called me @ home and said what happened. Apparently, (#195) was called back in by (#71) to sign out the pills. I was told by (#71) that the pills were given to a different resident. A couple of the aides were told what happened also. I told both (#195) and (#71) that I would never lie for either of them. - Statement dated 03/04/13 from former RN #195 (typed as written): (Former Resident #96) On 2/8/13 narc count was not done nurse coming on shift was late & I had something to do - 4 pills was not signed out on him from that day - nurse called me & made me aware - so I came back in & signed med out - - Statement dated 03/04/13 from director of nursing, #133 (typed as written): On 3/4/13 I called (#93) LPN related to a possible narcotic issue that happened in early February involving (former Resident #96). (#93) knew immediately what I was speaking of. (#93) stated to me that, (#71) RN called her on that day (2/9/13), and stated that, (#195) left without doing the required end-of-shift narcotic count with her. (#93) also mentioned that (#71) told her that after the narc count was not done that a resident (former Resident #96) was several pills (6) short on the count. (#93) stated that (#71) called (#195) to come back in to fix the omission. (#93) stated that she cautioned (#71) against Covering for (#195), and that if this incident ever came to light that she (#93) would not risk her license in this type of issue. (#93) stated that during this time of the 'missing narcotics' the resident was not even actually a resident in this facility. Medical records show that resident was discharged on [DATE] and re-admitted on [DATE]. - There was no evidence the facility evaluated the circumstances regarding the misappropriation of these controlled medications to determine if procedures were implemented and/or to determine necessary procedural changes. In addition, there were no recommendations from the pharmacist as the result of the identification of the misappropriation, to prevent the situation from occurring again. b) Resident #99 The narcotics book on A wing, 220 hall, was reviewed at 12:20 p.m. on 04/29/13. On page 112, there was an entry for Resident #99, which indicated the facility received a full card of thirty (30) hydrocodone 5/325 tablets. The resident had an order for [REDACTED].#99 was admitted to the facility on [DATE] and was discharged to his home on 03/22/13. Review of medication administration records for his entire stay indicated the hydrocodone was never given. On 04/29/13 at 12:30 p.m., the director of nursing (DON), Employee #133, was asked to account for the hydrocodone and to determine the eventual disposition of the narcotic. Employee #133 did so, and stated the card contained all thirty (30) doses of the hydrocodone. He stated the hydrocodone was still in the narcotics drawer of the medication cart. This was found to be the case, during an observation with Employee #133 on 04/29/13 at 12:35 p.m. There was no evidence the narcotic was ever counted at each shift from the date it was ordered (on 02/11/13) until 04/29/13, when the DON completed the count himself. The resident went home on 03/22/13, yet the medication was still on the medication cart on 04/29/13. It was subsequently determined, at 2:10 p.m. on 04/29/13, by a registered nurse, Employee #59, that the hydrocodone was ordered for Resident #99 on 02/11/13, and the resident went out to the hospital the same day. He returned to the facility on [DATE]. Upon his return, the medication was not renewed/reordered. The observation of the narcotic records also revealed several pages of the nurses' narcotics book had entries which appeared to have been altered by being overwritten with a black permanent marker. These obscured entries were noted on pages 42, 62, 65, 102, 112, and 128. On 04/29/13 at 12:40 p.m., the policy and procedures for disposition of medications was requested. Also, a request was made for any auditing procedures in place to ensure the required narcotics counts were being done each shift and that discrepancies would be detected by the facility. At that time, a discussion was held with the DON regarding the fact that both the misappropriation of narcotics on 02/09/13 and the failure to count, or even recognize the continued presence of a full card of thirty (30) narcotics in the medication cart since 02/11/13, were only discovered by being reported months later by Employee #129 in the first instance, and by a surveyor in the second. At 1:53 p.m. on 04/29/13, the DON was interviewed about the requested policies and procedures, and about his expectations as to what should have transpired with the medication. He said his expectation was that the narcotic should have been sent for destruction immediately upon the resident's return to the facility on [DATE] when the order was not renewed. He stated he had a scanner in his office. He said the medication should have been scanned for destruction, and then placed in a lock box in the closet in his office until the pharmacist could come and destroy the medication. The DON also confirmed the medication should have been counted each shift for the entire time it was in the nurses' medication cart, up to 04/29/13. The DON said the pages that appeared to have been marked on with a permanent marker were discovered when the licensed professional nurse, Employee #129 reported the registered nurse, Employee #195, for misappropriation of medications on or about 03/05/13. According to the DON, this discovery contributed to the decision to terminate the employment of Employee #195. He also attributed all the disfigurement of the records to Employee #195. Finally, on 04/29/13 at 2:20, the DON stated there was no policy and procedure in place for destruction of medications, except for Policy #8.2. This policy, entitled Disposal/Destruction of Refused, Discontinued, and Expired Medications dated 03/01/11, stated: If destruction cannot occur immediately, outdated or discontinued medications in packaging from the pharmacy are stored in a double-locked cabinet/drawer/area until such time as destruction can occur. The DON was unable to provide a written procedure that detailed the process he described as his expectation to scan and place medications in a lock box in his office. He further said there was no audit tool available that would assist him in discovering irregularities in the safeguarding of narcotics, except his expectation that the nurses would report them to him in a timely manner. This situation with Resident #99 was indicative of a failure to maintain a system of accurate accounting of the receipt and disposition of controlled medications in coordination with the licensed pharmacist. For over two (2) months, the controlled medications were not accounted for through reconciliation or any other means. The facility already experienced a misappropriation of controlled medications with Resident #96. The controlled medications for Resident #99, which were not used, not ordered, and left on a medication cart created a great potential for additional misappropriation. F431 S/S-D Based on observation, record review, staff interview and policy/procedure, the facility failed to maintain accurate and timely medication records of controlled substances for one (1) of two (2) medication carts on the 300 hallway. Findings include: On 07/01/13 at 11:55 a.m. reviewed the narcotic count with Employee #129 a Licensed Practical Nurse (LPN) for the medication cart on the 330 hall. During the narcotic count at 12:05 p.m., the narcotic book was documented to have fourteen (14) tablets of the controlled substance medication Ambien 10 mg for Resident # 35. While counting the actual medication package, it contained thirteen (13) tablets ' for the resident. Employee #129 a LPN verified the count was not correct for the medication Ambien and she explained that an end of shift narcotic count had been performed this morning with the night shift nurse when she came on duty. She further explained that she has only been employed at this facility for two (2) weeks and would notify her Supervisor of the narcotic count having a discrepancy. Employee #126 a LPN informed Employee #146 the Manager of Clinical Operations (MCO) and the acting Director of Nursing (DON) of an inaccurate narcotic count for two (2) end of shift counts, one at 7:00 a.m. and one at 11:30 a.m. as documented on the shift count sheet. An interview was conducted with Employee # 41 the administrator and Employee #146 the MCO and acting DON at 12:30 p.m., informed during their investigation it was found that Employee #18 a LPN had given the medication Ambien to the resident at 2000 (8:00 p.m.). They had phoned and texted Employee #18 and were awaiting a return phone call from her. Also informed employee #18 had worked a double shift and had just forgot to sign out the medication on the narcotic sheet, but had signed she had given it on the Medication Administration Record [REDACTED]. Received from employee #146 the MCO and acting DON on 07/01/13 at 1:45 p.m., a copy of the facility policy/procedure for management of controlled drugs that had been read and signed by employee #129, resident #35 ' s MAR, the narcotic sheet from 330 hall and the shift count sheet. Also informed Employee #129 had been counseled to ensure the narcotic count is correct at the end of shift. Received and reviewed an incident report that was completed by employee #129 a LPN for the medication error regarding the incorrect narcotic count of the medication Ambien. On 07/02/13 at 8:00 a.m. received a copy of the facility policy/procedure for management of controlled drugs that had is correct at the end of the shift count been read and signed by Employee #18 a LPN. Also informed the employee had been counseled to ensure the narcotic count is correct at the end of her shift.",2016-04-01
8717,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-04-29,490,F,1,0,LRUF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that administration utilized its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by repeating the same deficient practice. During the survey ending on April 29, 2013, the facility received citations F252 and F431. The survey ending on 5/22/13 resulted in citation F428. On the most recent survey ending on July 3, 2013 the facility received repeat citations on all three citations F252, F431, and F428. Findings include: a.) F252 Eight (8) of sixty-four (64) resident rooms within the facility were in disrepair and one (1) of sixty-four (64) resident rooms had a strong urine odor that extended into the main hallway. Resident rooms: #230, 301, 302, 308, 328, 332, 334, and 338. b.) F431 The facility failed to maintain accurate and timely medication records of controlled substances for one (1) of two (2) medication carts on the 300 hallway. c.) F428 The facility failed to ensure the narcotic count was accurate for one (1) of two (2) medication carts on the 300 hallway. [MEDICATION NAME] was one (1) less in the medication package than what the narcotic log had documented.",2016-04-01
8718,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-04-29,492,D,1,0,LRUF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to operate and provide services in compliance with accepted professional standards and principles that apply to professionals providing services in a nursing facility. The facility failed to report a registered professional nurse (RN) to the RN Licensing Board so a determination could be made to determine whether or not appropriate disciplinary action was required. This was found for one (1) RN who was aware of a possible misappropriation of a controlled medication for Resident #96. Facility census: 95. Findings include: a) Resident #96 As part of a complaint investigation, a list of licensed nurses leaving employment with the facility during the past three (3) months was requested on 04/22/13 at 1:00 p.m. The files of all licensed staff leaving employment in March and April 2013 were reviewed on 04/22/13 at 2:10 p.m. A file was found for registered nurse (RN), Employee #195, who was listed as terminated for gross misconduct/falsification of records. The file showed she was let go on 03/07/13 for misappropriation of narcotics related to this resident. There was an investigation conducted by the facility in March 2013 which resulted in the nurse's termination. She was also reported to the RN licensing board on 03/11/13. According to the cover letter to the RN Board, written by the director of nursing, Employee #133, the incident had taken place a month earlier, on 02/09/13. During the facility's investigation, a statement, dated 03/05/13, was provided by an RN, Employee #71 (typed as written): Arrived to work and received report from (#195). She then proceeded up the hall. I reminded her we needed to count. She said 'I'm back in the morning if there is any problem I'll fix it then.' She then left the building. I proceeded to count with (#129) present. There were six prn (as needed) pain pills missing for (former Resident #96) room [ROOM NUMBER]-1. I immediately called (#195) and informed her. She said 'I gave them to (former resident #96) on the day he was sent out for a G.I. bleed.' She arrived back at the facility to correct the narc book. The facility's investigation revealed Employee #71 was aware of the possible misappropriation of controlled medication belonging to former Resident #96. The facility failed to report Employee #71 to the RN Licensing Board, so a determination could be made as to whether disciplinary action was indicated for her failure to report the possible misappropriation of controlled medications. During an interview with the administrator, Employee #45, on 04/26/13 at 10:00 a.m , Employee #45 voiced understanding the facility had a responsibility to report Employee #71 to the RN board.",2016-04-01
8719,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-04-29,520,F,1,0,LRUF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that a quality assessment and assurance committee identified issues and developed and implemented appropriate plans of action to correct identified quality deficiencies During the survey ending on April 29, 2013, the facility received citations F252 and F431. The survey ending on 5/22/13 resulted in citation F428. On the most recent survey ending on July 3, 2013 the facility received repeat citations on all three citations F252, F431, and F428. Findings include: a.) F252 Eight (8) of sixty-four (64) resident rooms within the facility were in disrepair and one (1) of sixty-four (64) resident rooms had a strong urine odor that extended into the main hallway. Resident rooms: #230, 301, 302, 308, 328, 332, 334, and 338. b.) F431 The facility failed to maintain accurate and timely medication records of controlled substances for one (1) of two (2) medication carts on the 300 hallway. c.) F428 The facility failed to ensure the narcotic count was accurate for one (1) of two (2) medication carts on the 300 hallway. [MEDICATION NAME] was one (1) less in the medication package than what the narcotic log had documented.",2016-04-01
8720,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-04-30,246,D,1,0,DD6111,"Based on observations, resident interview, and review of the resident council meeting minutes, the facility failed to provide reasonable accommodations to meet the individual needs and preferences of a resident by failing to ensure the resident's call system was maintained within reach for one (1) of twenty (20) sampled residents. Resident identifier: #80. Census: 95. Findings include: a) Resident #80 This resident was observed in bed, on 04/24/13 at 1:10 p.m., with her call bell on the floor and out of reach. During the interview, she reported she could not always reach her call bell and has had to call her daughter in the past in order to obtain assistance. Her daughter then calls the facility and informs them the resident is unable to reach her call bell and is in need of assistance. The Resident Council Meeting Minutes were reviewed on 04/25/13 at 8:00 a.m. for the past three (3) months. During the meeting on 01/28/13, four (4) of the fourteen (14) residents present stated they were having a problem reaching their call bells. The plan was for the Director of Nursing (DON), Employee #133, to complete call bell audits. The DON confirmed, on 04/30/13, the facility was currently doing multiple staff audits including checking if the residents could reach their call bells. .",2016-04-01
8721,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-04-30,252,E,1,0,DD6111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, and review of the residents' council minutes, the facility failed to provide a safe, clean, comfortable and homelike environment for the residents. Identified concerns included: resident council meeting minutes for the past three (3) months contained complaints from the residents regarding their rooms not being cleaned daily; random observations of two (2) separate occupied rooms found them to be in an unsanitary condition; and a resident reported her room was not routinely cleaned. Resident identifiers: #80, #34, and #16. Facility census: 95. Findings include: a) Resident #80 Resident #80 was interviewed on [DATE] at 1:10 p.m. She reported her room was not kept clean. According to the resident, housekeeping might come in every other day, but there was no routine cleaning schedule. Review of the concern log, on [DATE], found a documented complaint dated [DATE]. Resident #80's daughter had expressed concerns regarding the resident's bathroom having a terrible odor and being unclean. The administrative action plan included housekeeping was instructed to thoroughly clean the restroom. b) Resident #16 During a random observation of the facility, on [DATE] at 3:15 p.m., Resident #16's room was found with the bed by the window without a mattress, the floor was visibly dirty and sticky, a used toothbrush and respiratory aerosol machine were on the floor along with several small pieces of paper, two (2) dirty trash cans - one with dirty gauze inside, a partially used mouthwash bottle sat on the window ledge, and seven (7) open boxes of gloves were in the room. In an interview at 3:17 p.m. with nursing assistants (NA), Employees #30 and #87, they confirmed the room was dirty. Employee #30 reported it had not been cleaned since the other resident in that room had died a few days ago. In a follow-up interview, on [DATE] at 3:30 p.m., the director of nursing (DON), Employee #133, and Employee #3, the director of housekeeping, verified the room was dirty and in an unsafe condition for Resident #16 who currently resided in the room in the bed by the door. Housekeeping immediately began to clean the room. b) Resident #34 On [DATE] at 3:16 p.m., it was observed bed B had no mattress. Resident #34's possessions were laying on the bed frame per her request. An interview on [DATE] at 3:30 p.m., with the DON, Employee #133, and Employee #3, the director of housekeeping, verified the bed frame was lacking a mattress and needed to be covered. The DON agreed this was a safety concern for Resident #34. c) Resident council meeting minutes were reviewed on [DATE] at 8:00 a.m. for the past three (3) months. During the meeting on [DATE], three (3) of fourteen (14) residents stated their rooms were not being cleaned on a daily basis. The facility reported they were auditing the situation and were actively recruiting two (2) new housekeepers. The minutes for the meeting on [DATE] identified three (3) of twelve (12) residents reported their rooms were not being cleaned daily. Administration again reported they were doing random audits and recruiting housekeepers. The minutes for the meeting conducted on [DATE] reported three (3) of eleven (11) residents still had an issue with their rooms not being cleaned on a daily basis. Administration planned to continue the audits.",2016-04-01
8722,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-04-30,309,D,1,0,DD6111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide treatments to a resident's wounds as ordered by the physician. Resident #13 had wounds on his feet and hands for which he had been seeing a physician outside the facility in consultation for wound care. Observation of the treatment to the resident's feet identified the nurse applied Bag Balm rather than the ordered [MEDICATION NAME] ointment. One (1) of two (2) residents observed for wound care did not receive the treatment as ordered by the physician. Resident identifier: #13. Facility Census: 96. Findings include: a) Resident #13 During observations on 04/29/13 at 2:00 p.m., the dressing change and treatments were observed to the arterial wounds on this resident's feet. Employee #99 was observed to remove the resident's dressings and clean the wounds. She applied Bag Balm ointment directly to the bottom of his feet. She then covered his feet with Xeroform and covered this with Kerlix dressing. The treatment record was reviewed and compared to the physician's orders [REDACTED]. The nurse was interviewed on 04/29/13 at 2:30 p.m. about the treatment she provided. She verified the Bag Balm was not what was on the physician's orders [REDACTED]. The nurse agreed she should not have changed this physician's orders [REDACTED].",2016-04-01
8723,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-04-30,441,D,1,0,DD6111,"Based on observation, policy review, and staff interview, the facility failed to provide care to wounds in a sanitary manner to prevent wound contamination during dressing changes. The nurse failed to change her gloves during wound care after she removed the soiled dressing and before applying a clean dressing. In addition, hand hygiene was not performed in accordance with the facility's policies to reduce transmission of pathogenic microorganisms. These practices were observed during two (2) of two (2) dressing changes completed by the treatment nurse who did skin care and treatments for the entire facility. This had the potential affect all residents receiving treatments. Resident identifiers: #13 and #4. Facility census: 96. Findings include: a) Resident #13 During a treatment observation on 04/29/13 at 4:00 p.m., the registered nurse, Employee #99 (treatment nurse), was observed providing treatments to Resident #13. He had extensive wounds on his feet and hands. During this observation, the nurse put on her gloves and removed the soiled dressing from the resident's right foot. She applied Bag Balm ointment to the area and a clean Xeroform dressing, then wrapped it with Kerlix. She was then observed to remove her gloves and go in the bathroom to wash her hands. This surveyor counted one thousand one, one thousand two (two seconds) that the water was on while she washed her hands. She turned off the water with her bare hand and got a paper towel from the holder. She dried her hands and put on another pair of gloves. She then proceeded to the resident's left foot. She removed the dressing and cleaned the wound. She then applied Bag Balm to the area and a clean Xeroform dressing and wrapped it with Kerlix. She did this procedure with the same gloves she had worn to remove the soiled dressing. She then removed her gloves and washed her hands. This surveyor again counted one thousand one, one thousand two (two seconds) as she washed her hands. She again turned off the water and got a paper towel to dry her hands (after turning off the water without a paper towel) . After putting on a clean pair of gloves, she removed the dressing on the resident's left hand. The the area had bloody drainage. She cleaned the necrotic bloody area with cleaner and gauze and applied Bag Balm as ordered. She applied 4 x 4 dressings between the resident's necrotic fingers. She then proceeded to put a clean dressing on his right hand as ordered. After she completed the dressing change, she washed her hands again for two (2) seconds and turned off the water with her bare hands, then obtained a paper towel to dry her hands. The facility's policy entitled 14.1 Dressing: Aseptic was reviewed. This policy was last revised on 06/01/09. The policy instructed after the area was exposed to be treated, clean gloves were to be applied to remove the soiled dressing. The policy then instructed to discard the dressing and gloves according to infection control policy. The policy stated to then cleanse your hands and apply clean gloves. You were then to cleanse the wound and apply the treatment as ordered. The facility's policy on Hand Hygiene, last revised on 03/01/08, instructed in Section 3.1 to wash hands with warm (not hot) water, put soap in hands and rub hands vigorously for fifteen (15) seconds covering all surfaces of the hands and fingers. Rinse hands with warm water and dry thoroughly with paper towel. Use paper towel to turn off water. During an interview with Employee # 133 (director of nursing) and Employee #99 (treatment nurse) on 4/30/13 at 3:00 p.m., the facility's policy for dressing changes was discussed. The nurse was made aware of the observation and verified she was aware you needed to change gloves after removing the soiled dressing, but she was nervous and did not change her gloves properly. The hand washing policy was also discussed and it was confirmed she did not follow proper technique for hand hygiene practices. b) Resident #4 Employee #99, the wound care nurse, was observed performing Resident #4's dressing change on 04/30/13 at 10:40 a.m. Employee #99 was observed washing her hands three (3) times - before starting the dressing change, after removing the old dressing, and at the end of the dressing change after bagging her garbage. All three (3) times the hand washing was completed in less than four (4) seconds. In addition, the employee turned the faucet off with her bare hands. The facility policy titled 2.2 Hand Hygiene states under process 3.1 To wash hands with soap and water: Wet hands with warm (not hot) water, apply soap to hands and rub hands vigorously for at least 15 seconds covering all surfaces of the hands and fingers. Rinse hands with warm water and dry thoroughly with a disposable towel. Use towel to turn off faucet. An interview was conducted on 04/30/13 with the director of nursing, Employee #133, and the wound care nurse, Employee #99. During the interview, Employee #99 acknowledged she had not washed her hands for fifteen (15) seconds at any time during Resident #4's dressing change.",2016-04-01
8724,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-04-03,241,E,1,0,GJF111,"Based on observation and staff interview, the facility failed to ensure dignity for the residents by not removing dirty dishes and old food from breakfast from the dining room area prior to the lunch meal. This had the potential to affect more than a limited number of residents. Facility Census: 126. Findings include: a) Upon observation of the dining room located at the end of 300 Hall, on 04/01/13 at 12:05 p.m., it was observed that a rolling dining cart was sitting along the side wall, with the door open. On this cart were four (4) trays which contained old food from breakfast and dirty breakfast dishes. At that time, the dining room had twelve (12) residents seated and waiting for lunch. It was observed the food that had been prepared for lunch was already out in the serving area. Interview with a cook, Employee #73, was conducted at that time. He was asked why the breakfast trays were still sitting in an open cart in the dining area when lunch was ready to be served. He stated the trays should have been taken to the back already. Resident #19 was observed seated at a table with his spouse within arms length of this cart containing the old food and dirty dishes. The resident was not able to answer questions. It was only after the issue was brought to the attention of the cook, did he advise kitchen staff to take the trays to the kitchen. The Nursing Home Administrator (NHA), Employee #109, as well as the Director of Nursing (DON), Employee #6, were advised of the findings at 12:15 p.m. on 04/01/13.",2016-04-01
8725,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-04-03,309,D,1,0,GJF111,"Based on record review and staff interview, the facility failed to ensure the highest practicable well-being of the resident by failing to initiate neuro checks on a resident who sustained a fall. This was found for one (1) of four (4) residents sampled. Resident Identifier: #127. Facility Census: 126. Findings include: a) Resident #127 Review of the residents' Falls Investigation Reports was conducted at 8:38 a.m. on 04/02/13. No injuries were noted with the exception of a fall which occurred on 01/29/13. That fall was unwitnessed, and the falls report included, Abrasion to the center of forehead measuring 3 cm x 1 cm. Laceration with swelling to left side of forehead measuring 0.1 x 0.1, and that neuro checks were initiated. However, there was no evidence to show the resident was followed up with neuro checks or sent to the hospital for evaluation. An interview was conducted with the Director of Nursing (DON), Employee #6, at 9:30 a.m. on 04/02/13 regarding the resident's fall on 01/29/13. The DON was shown the falls report for that fall. She was advised there was no neuro check sheet found in the chart, and the resident was not sent out to the hospital. She looked through the resident's chart and was unable to locate a neurocheck sheet dated for 01/29/13. At 11:55 a.m. on 04/02/13 the DON confirmed that she could not locate evidence that neurochecks had been initiated on the resident after the fall on 01/29/13.",2016-04-01
8726,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-04-03,323,E,1,0,GJF111,"Based on observation and staff interview, the facility failed to ensure the safety of residents by not storing items that had a potential to cause harm to residents, in a secure area. This had the potential to affect more than a limited number of residents. Facility Census: 126. Finding include. a) During the initial tour of the facility, at 11:40 a.m. on 04/01/13, the shower room on 300 Hall was observed. The door to the shower room had no lock and potentially hazardous items were unsecured. The door could be easily opened by lightly pulling on a handle on the outside of the door. These items were observed in the shower room on a shelf: 1) a container of Clorox Bleach wipes, with the lid loosened, 2) an individual razor, as well as a pack of unopened razors, 3) a can of shaving cream, 4) deodorant, 5) body wash, and 6) a large jug of body wash, 3/4 of the way full, with no lid was sitting on the floor of a shower stall. Interview with a registered nurse, (RN), Assistant Director of Nursing (ADON), Employee #52 was conducted at 11:52 a.m Employee #52 was observed the 300 Hall shower room. She confirmed they were not supposed to be there. When Employee #52 returned to the hallway, she was asked if there were any residents on the hallway who wandered. Employee #52 pointed out three (3) residents who wandered on the hall. These were residents #100, #93, and #98. All three (3) of these residents' rooms were in close proximity to the shower room. Interview with Nursing Home Administrator (NHA), Employee #109, and RN, Director of Nursing (DON), Employee #6, was conducted at 12:15 p.m. on 04/01/13. They are advised at that time of the items found in the shower room, as well as the issue with the residents who wandered. Both Employee #109 and Employee #6 were in agreement that this was a safety hazard.",2016-04-01
8727,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2012-05-10,272,D,0,1,B5IX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interviews, the facility failed to ensure the minimum data sets (MDS) for two (2) of twenty-six (26) residents were completed accurately. Resident #21's assessment did not accurately reflect the resident's dental status, and Resident #77's weight loss was not reflected on her assessment. Resident identifiers: #21 and #77. Facility census: 68. Findings include: a) Resident #21 Observation of the resident's oral cavity during Stage I of the quality indicator survey (QIS) found the resident had some broken natural teeth. Review of the minimum data set (MDS), with an assessment reference date (ARD) of 09/24/11, Section (L) - Oral/dental status, item (d) found the facility documented the resident had no Obvious or likely cavity or broken natural teeth. Observation of the resident's oral cavity with Employee #75, a licensed practical nurse, at 2:30 p.m. on 05/08/12, found the resident had at least one broken tooth on the top upper right side of her gum. Further review of the medical record found the facility had referred the resident for a dental consult on 11/04/11 for, . two teeth decayed and broke off on the upper right side leaving a snag. The results of the dental consult found documentation from the dentist, Resident's (#6) tooth was broken to gingival margin, patient said the tooth was not hurting and she did not want an extraction at this time. That is ok as long as it does not hurt. Review of oral assessments, completed by the nursing staff, found only one assessment completed on 02/08/11, before the 09/24/11 MDS. The oral assessment indicated, Has several own teeth. A few small caries maybe present but no large areas. During an interview with the with dietary manager, on 05/08/12 at 3:20 p.m., she verified the resident's diet was changed from a regular diet to a mechanically soft diet on 11/02/11 due to, loosing some teeth. The dietary manager was unsure of any further details regarding the resident's dental issues. An interview with Employee #8, the registered nurse unit manager, at 3:30 p.m. on 05/08/12, revealed the resident did not received any dental consults between 02/08/11 (the completion of the oral assessment), and the completion of the 09/24/11 annual MDS. Employee #8 verified the 09/24/11 MDS was incorrectly coded under Section (L) question (d). Employee #29, a registered nurse, was also interviewed with Employee #8. Employee #29 stated she had completed the oral assessment. She verified the resident had a few small caries when she examined the oral cavity. She said she should have written a nursing note so the dental issues were identified before completion of the 09/24/12 MDS. b) Resident #77 This resident was admitted to the facility on [DATE]. Her weight was listed as 361 lbs. (pounds) on the five (5) day Medicare admission MDS assessment, with an ARD of 04/03/12. The next MDS assessment, with an ARD of 04/13/12, which was a Medicare 14 day assessment, indicated the weight was 328 lbs. This was a loss of 33 lbs in ten (10) days. If a resident loses more than than 5% in 30 days, the MDS should have been coded as a significant weight change having occurred. A 5% weight change for this resident would have been 18 lbs. The weight was coded as a 0 which indicated no change. The next MDS significant change assessment, with an ARD of 04/27/12, revealed the resident's weight was now 312 pounds. This assessment had been coded as a significant change for other areas, but not the weight loss. The weight on this assessment represented an additional loss of 16 pounds in 14 days. This was also a significant weight loss. Again the MDS assessment was coded as a 0 which meant no weight change or none known. Interview with Employee #8, the RN (registered nurse) unit charge nurse, on 05/08/12 in the afternoon, revealed she had reviewed the definition of the weight loss. According to the MDS criteria it should have been coded as a Yes or 1 (one) which would indicate a significant weight loss on both MDS assessments. She stated it was a human error in coding. The MDS had been coded as a 0 which meant there was no weight loss or gain or it was unknown.",2016-04-01
8728,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2012-05-10,280,D,0,1,B5IX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, it was determined the facility had not revised the care plan for one (1) of twenty-six (26) sampled residents. Upon admission to the facility, Resident #73 had planned to return home after discharge from the facility. Her plans later changed and she decided to become a long-term resident of the facility. Her care plan was not revised to reflect the change in her discharge plans. Resident identifier: #73. Facility census: 68. Findings include: a) Resident #73 Resident #73 was admitted to the facility on [DATE]. Her initial discharge plans were to return home. Review of the medical record found, on 04/13/12 at 9:25 a.m., Resident #73 told Employee #54 (social worker) her plans had changed, and she wanted to reside in the facility long term. Review of the care plan, on 05/08/12, identified the care plan had not been revised to reflect the resident's change in discharge plans. During an interview with Employee #54, on 05/09/12, she confirmed she had not made revisions to the care plan to reflect the changes in Resident #73's discharge plans.",2016-04-01
8729,PINE VIEW NURSING AND REHABILITATION CENTER,515184,400 MCKINLEY STREET,HARRISVILLE,WV,26362,2012-04-12,161,E,0,1,QOYO11,"Based on review of facility documents and staff interview, the facility failed to provide a surety bond sufficient to ensure compensation of the resident for any loss of residents' funds managed by the facility. This had the potential to affect all residents with funds managed by the facility. Facility census: 54. Findings include: a) A review of facility documents, at 1:00 p.m. on 04/11/12, revealed the surety bond on file for protection of the residents' funds being managed by the facility was in the amount of $5000.00. The trial balance of the resident fund account, provided by Employee #31, reflected a balance of $5830.66 as of 04/09/12. The administrator (Employee #1) and Employee #31, who was responsible for handling the residents' funds, were interviewed at 3:00 p.m. on 04/11/12. They acknowledged the statement was correct. The administrator agreed the total account balance exceeded the coverage amount of the current surety bond.",2016-04-01
8730,PINE VIEW NURSING AND REHABILITATION CENTER,515184,400 MCKINLEY STREET,HARRISVILLE,WV,26362,2012-04-12,225,D,0,1,QOYO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel file review and staff interview, the facility failed to make reasonable efforts to ensure they did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law; or had a finding against their professional license concerning abuse, neglect, mistreatment of [REDACTED]. This was found for one (1) of ten (10) employees whose personnel records were reviewed. Facility census: 54. Findings include: a) Employee #73 Personnel files of ten (10) staff were reviewed at 3:00 p.m. on 04/11/12. Review of the file of a registered nurse (RN), Employee #73, found she held active professional licenses in this state and a neighboring state. She was hired on 10/12/11. She had been criminal background checks conducted in both states, however, a check of her professional license status, to determine whether there were any actions taken or pending against it, was not completed until after it was requested by the surveyor on the evening of 04/11/12. The license verification presented was dated 04/12/12. When interviewed, on 04/12/12 at 11:00 a.m., the bookkeeper, Employee #31, confirmed the current status of the Employee #73's nursing license had not been completed until requested by surveyors.",2016-04-01
8731,PINE VIEW NURSING AND REHABILITATION CENTER,515184,400 MCKINLEY STREET,HARRISVILLE,WV,26362,2012-04-12,253,D,0,1,QOYO11,"Based on resident interview, observation, and staff interview, the facility failed, for one (1) of 31 Stage II sample residents, to provide housekeeping services necessary to ensure cleanliness of adaptive equipment (side rail). The side rail had debris and a dried yellow substance on the cross bar and down the vertical length of the side rail. Resident identifier: #24. Facility census: 62. Findings include: a) Resident #24 In an interview, conducted on 04/10/12 at 11:02 a.m., Resident #24 responded to the question Is the facility clean with a no. The resident stated just look at that. Inspection of the side rail found a urinal hanging on the cross bar of the side rail. The cross bar was covered in a brown substance. A dried yellow substance was found on the vertical bars below the cross bar. On 04/11/12 at 11:00 a.m., the director of nursing (Employee #15) was shown the side rail and agreed the side rail needed to be cleaned. On this same day, at 1:00 p.m., a second observation found no substances on the side rail from the top of the rail to the mattress level. Resident #24 stated it (side rail) was still dirty. Upon closer inspection, a dried yellow substance was noted to still be present on the lower half of the rail. At 1:30 p.m., this was discussed with the director of housekeeping (Employee #41). She stated she would take care of this. Observation of the side rail at 1:40 p.m. revealed no soiling remained on the entire side rail.",2016-04-01
8732,PINE VIEW NURSING AND REHABILITATION CENTER,515184,400 MCKINLEY STREET,HARRISVILLE,WV,26362,2012-04-12,323,D,0,1,QOYO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, resident interview, and staff interview, the facility failed to provide adequate supervision to prevent accidents for one (1) of thirty-one (31) sampled residents. Staff failed to respond to a request for assistance by a dependent resident in a timely manner. Resident identifier: #42. Facility census: 54. Findings include: a) Resident #42 A review of the medical record revealed Resident #42 weighed 344.2 pounds. The resident's [DIAGNOSES REDACTED]. This resident had an over-sized wheelchair and relied on it for ambulation. The resident could only ambulate for short distances (approximately 48 feet) with a walker and assistance. This individual was alert, oriented, conversed freely, and could make needs known. During an interview with a licensed practical nurse (Employee #21), at 10:15 a.m. on 04/12/12, she stated Resident #42 required at least one person to assist with transfers from bed to wheelchair or wheelchair to toilet. She added that the resident was ever-conscious of falling and requested assistance. At 11:22 a.m. on 04/12/12, while standing at the nurses' station, an announcement over the intercom was heard, Emergency assistance - men's restroom. This surveyor proceeded down the hall. When the corner toward the dining room was turned, a flashing light could be seen outside of the men's bathroom located at the entryway to the dining room. No staff members were seen proceeding in this direction. At 11:26 a.m., the same announcement was made a second time. A nurses' aide (Employee #54) came down the hall, passed by the flashing light and went into a room further down the hall. Then the dietitian (Employee #85) also walked by the flashing light and entered a room further down the hall. At 11:30 a.m., the assistant administrator (Employee #84) exited a nearby office, proceeded to the bathroom, knocked on the door, and entered. Resident #42 was in the bathroom and needed assistance. Employee #84 provided the needed assistance and started out of the room with the resident in a wheelchair. At that point, Employee #54 came out of the room up the hall and proceeded to stop to assist. Employee #85 also stopped on her way back down the hall and a third unidentified aide came out of the dining room and proceeded to push the resident to his / her room. When asked about this occurrence, the assistant administrator stated all staff were instructed to answer lights, but there had not been an emergency really, the resident just needed assistance. She did acknowledge that when she answered the light she did not know who was in the bathroom or what the need was. The charge nurse (Employee # 22) agreed that all staff were responsible for answering lights and intercom directed needs for assistance. The facility policy regarding Call lights states, 1. When light comes on over doorway or sounds at nursing station panel, go to the resident's room.",2016-04-01