rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
8181,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2013-08-01,279,D,1,0,HEN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan reflective of an accurate assessment of the resident. The resident had a deep tissue injury (DTI) to his buttocks. According to the care plan, a contributing factor related to the development of the DTI was incontinence; however, the resident had a suprapubic catheter and a [MEDICAL CONDITION]. This was true for one (1) of four (4) residents whose care plan was reviewed during the complaint investigation. Resident identifier: #82. Facility census: 111. Findings include: a) Resident #82 Medical record review, on 07/30/13, found a care plan for the DTI, initiated on 07/29/13. The care plan addressed a problem of DTI to left buttocks surrounded by incontinence associated [MEDICAL CONDITION] (IAD) related to immobility and incontinence. Further review of the medical record found the resident had a suprapubic catheter and a [MEDICAL CONDITION] before the development of the DTI. At 5:00 p.m. on 07/30/13, the director of nursing verified the care plan was not correct. She stated incontinence was not a contributing factor in the development of the DTI as the resident had a suprapubic catheter and a [MEDICAL CONDITION] before the development of the DTI.",2016-07-01
8182,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2013-08-01,282,D,1,0,HEN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure licensed nursing staff followed the facility's written care plan for Resident #116 related to the maintenance of a Foley catheter. This was true for one (1) of seven (7) residents whose care plans were reviewed during the complaint survey. Resident identifier: #116. Facility census: 111. Findings include: a) Resident #116 Resident #116 was noted to have an indwelling Foley catheter due to [MEDICAL CONDITION] and hypertrophy of the prostate with urinary obstruction. Review of care plan, on 07/30/13 at 11:00 a.m., found an intervention for the nursing staff to Empty catheter drainage bag every shift and record. Review of medical records, on 07/30/13 at 12:00 p.m., found the staff did not consistently record the amount emptied from the catheter bag as directed by the written care plan. In interviews with Employee #56, a licensed practical nurse (LPN), and Employee #47, a registered nurse (RN), on 07/30/13 at 12:30 p.m., both confirmed the catheter bags were emptied every shift and the urine outputs were not recorded routinely. Occasionally the licensed nurse did record the output in the nurses' notes. In an interview conducted on 07/30/13 at 1:30 p.m., Employee #1, the director of nursing, (DON) confirmed the staff did empty catheter bags every shift, but did not record the resident's output every shift as directed in the resident's written care plan.",2016-07-01
8183,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2013-08-01,309,D,1,0,HEN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure consistent assessment, monitoring, and evaluation of a resident who had an indwelling Foley catheter. This practice affected one (1) of five (5) residents reviewed during the complaint survey who had an indwelling Foley catheter. Resident identifier: #116. Facility census: 111. Findings include: a) Resident #116 Review of medical records, on 08/01/13 at 11:30 a.m., noted this resident had been admitted to the facility on [DATE]. The resident had an indwelling Foley catheter due to [MEDICAL CONDITION] and hypertrophy of the prostate with urinary obstruction. Review of nurses' notes found a note written by Employee #66, a licensed practical nurse (LPN), on 07/15/13 at 2:45 p.m. The nurse noted (typed as written), Foley cath changed due to leaking. 24 french 30 cc balloon placed without difficulty. Redness to right and left groin area noted, treatment ordered. The next nurse's note concerning the Foley catheter was written on 07/20/13 at 12:00 p.m. The nurse noted Foley cath to BSD (bedside drainage) intact, no leaking, sediment urine noted. The next nurse's note concerning the Foley was dated 07/25/13 at 10:30 p.m. The nurse documented Foley patent to BSD (bedside drainage) with approx. 300 cc of urine, dark yellow. During an interview with Employee #1, the director of nursing (DON), on 08/01/13 at 1:00 p.m., it was confirmed from review of nurses' notes, the licensed staff had not consistently assessed, monitored, and evaluated the Foley catheter and the nature and amount of the resident's urinary output.",2016-07-01
8184,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2013-08-01,441,D,1,0,HEN111,"Based on observation, medical record review, and staff interview, the facility failed to maintain proper care of a resident's catheter to prevent the spread of infection. Observation found the resident's catheter drainage bag was lying on the floor. This was true for one (1) of four (4) observations of residents with catheters. Resident identifier: #82. Facility census: 111. Findings include: a) Resident #82 During the initial tour of the facility, on 07/30/13, the resident was in bed at 9:45 a.m. on 07/30/13. His catheter drainage bag was lying on the floor beside the bed. Employee #46, the assistant director of nursing (ADON) was in the hallway outside the resident's room at 9:45 a.m. on 07/30/13. She was asked to witness the observation. She entered the room and stated, I will get a new bag and change it because of infection control issues. She verified the catheter bag should not be lying on the floor. At 5:00 p.m. on 07/30/13, the director of nursing (DON) was made aware of the above situation. She stated the resident could have knocked the catheter onto the floor by moving around in bed. Further review of the resident's care plan found a problem, initiated on 07/29/13, related to the resident's deep tissue injury, which stated the resident was immobile. Review of the resident's most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/27/13, found Item G0110, (activities of daily living assistance - bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture,) reflected the resident required the extensive assistance of two (2) staff persons to complete the activity of moving while in bed. .",2016-07-01
8185,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2013-08-01,514,D,1,0,HEN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of facility policy and procedure, the facility failed to ensure a permanent entry in the resident's medical record was not changed after being recorded. This was true for one (1) of seven (7) medical records reviewed during the complaint survey. Resident identifier: #82. Facility census: 111. Findings include: a) Resident #82 Review of the resident's current care plan, located on the medical record, on 07/30/13 at 10:15 a.m. found a handwritten entry to the care plan, Deep tissue injury (DTI) to left buttocks surrounded by IAD (incontinence related [MEDICAL CONDITION]) related to immobility and incontinence, this entry was dated 07/29/13. On 07/30/13 at 10:30 a.m. the unit manager, Employee #47, was asked to make a copy of the resident's care plan. When she returned with the care plan, the original problem was no longer on the care plan. A new care plan problem had been written and dated 07/29/13, Deep tissue injury to left buttocks surrounded by MASD (moisture associated [MEDICAL CONDITION]) related to immobility. The surveyor found Employee #47 and Employee #34, a registered nurse, at the nurses station at 10:35 a.m. on 07/30/13. The surveyor spoke to both employees and asked who had changed the original care plan. Employee #34 stated she had re-written the care plan because it was incorrect. Employee #34 stated she saw the resident's DTI could not be due to incontinence because the resident had a catheter and a [MEDICAL CONDITION]. During the discussion with Employees #47 and #34, the director of nursing (DON) came to the nurses' station. The DON told Employee #34 she should have, yellowed out the problem and corrected it on the original copy. Employee #34 was asked for the original copy of the care plan and she said she could not find it. The DON found the original copy of the care plan in the trash can, torn into pieces. The DON stated she would tape the care plan together and give it to the surveyor. On 08/01/13 at 2:45 p.m. the DON provided a copy of the facility's policy for Clinical Records, Charting and Documentation. The policy directed staff to, . Draw a line through an error, write the correction above it, and date and initial the change. Never remove, use correction fluid or erase documentation. The DON confirmed the original care plan had been removed from the resident's chart on 08/01/13 at 2:45 p.m. ,",2016-07-01
8186,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2012-05-18,156,B,0,1,6XWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate liability notices to one (resident #277) out of four sampled residents reviewed for liability notices and beneficiary appeal rights. Findings Include: Resident #277 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident was notified by the facility that skilled nursing services would end on May 12, 2012. Notice of Medicare Non-Coverage (CMS Form ) was signed by the resident on May 10, 2012. Resident remained in the facility and was not discharged following the end of covered services. However, the resident was not issued the Skilled Nursing Facility Advance Beneficiary Notice (CMS Form ). An interview with employee #76 was conducted on May 16, 2012. Employee #76 stated that she issued the CMS Form and not the CMS Form . A subsequent interview was conducted with employee #76 on May 17, 2012. Employee #76 stated that she misunderstood the training she received regarding the requirements for issuing liability notices.",2016-07-01
8187,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2012-05-18,157,D,0,1,6XWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the responsible party of an administration of intravenous antibiotics for treatment of [REDACTED].#248) out of three sampled for urinary incontinence out of a eight residents identified as having a decline in urinary continence. Findings include: Resident #248 had [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed the resident was always continent. The MDS dated [DATE] revealed the resident had a decline and was occasionally incontinent. The plan of care for incontinence dated 4/3/12 revealed the resident will have incontinence episodes managed without signs and symptoms of urinary tract infection and will have dignity maintained with incontinence care. The plan of care revealed to observe for signs and symptoms of urinary tract infection, monitor labs, and provide perineal care daily and as needed. Observations were made on 5/15/12 at 12:36 p.m. of the resident lying in bed and on 5/16/12 at 6:00 p.m. the resident was ambulating in the halls talking to staff. An interview was done with the resident and she stated she didn't feel well today, but she is a lot better than she used to be. She stated she walks and takes herself to the bathroom and doesn't need any help. During an interview on 5/15/12 with CNA #64 at 12:40 p.m., the CNA stated the resident will ask for help if needed, but very seldom, she stated, she can take herself to the bathroom and doesn't need help from the staff. The CNA stated the resident has been incontinent at times and had been ill awhile back. An interview with RN #32 at 1:45 p.m. was done. The RN stated the resident had a urinary tract infection in March and was started on antibiotic ([MEDICATION NAME]) intravenously (IV) for 10 days on 3/23/12. The RN stated she talks to the daughter all the time, but could not be certain that she notified her when the IV antibiotics was started. She verified there was no documentation anywhere in the chart that the daughter had been notified of the new orders for the IV antibiotics. Review of the clinical record revealed the resident had Escherichia Coli greater than 100,000 on the colony count on 3/21/12 and the physician ordered [MEDICATION NAME] 1.5 mg/kg IV every 8 hours. An interview with the daughter on 5/15/12 at 3:45 p.m. revealed she calls the facility everyday to check on her mother. She stated she was not notified of her mother having a urinary tract infection and receiving IV antibiotics until she called in one day after the resident had been on them (sic) for a few days and RN #32 informed her. Interview with RN #32 at 4:30 p.m. verified that she remembered the daughter calling and being upset that no one had called to tell her that her mother was sick and had to have IV antibiotics. The RN verified the family should have been notified of the resident having a urinary tract infection and of the physician's orders [REDACTED].",2016-07-01
8188,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2012-05-18,166,D,0,1,6XWO11,"Based on record review and interview, the facility failed to resolve a grievance related to missing personal property for one (resident #85) of three sampled residents out of eight residents who complained of having missing personal property during resident interviews. Findings include: During interview with Resident # 85 on 05/14/12 at 3:20 p.m., it was stated he had missing shirts and a pair of jeans missing from his room. Resident #85 also stated during the interview he told someone in the laundry department. Review of the medical record for Resident #85 revealed a form titled Inventory of Personal Effects dated 01/13/12. There are 4 slacks listed and 8 shirts. Review of an undated form titled, Process for Missing Items revealed if an item is identified as missing the resident would need to inform the nurse or staff member regarding the missing items with date and time the item was missing, the staff will check the inventory sheet for the description of the item, the staff will complete a concern form with the item identified and complete an in-house communication slip to notify all departments of missing item and the staff will make every effort to locate or find the missing item. During interview with Social Worker (SW) #43 on 05/15/12 at 1:38 p.m. it was stated she doesn't know much about missing property and the Social Worker Manager would know more. SW #43 then phoned the Laundry Department at the time of the interview and asked if any missing items had been reported by Resident #85. They stated there were none at that time. Licensed Practical Nurse (LPN) #50, identified as the Unit Manager, was made aware of the missing personal property by SW #43. LPN #50 stated she would fill out a form and follow up. LPN #50 also verified laundry personnel had taken the report from Resident #85 and stated nursing staff should also have received notice of the missing items. During interview on 05/17/12 with LPN #47, identified as the Social Worker Manager, it was verified there were no missing items reported for Resident #85. During interview with LPN #50 and LPN #47 on 05/17/12, it was verified a missing items form was not completed per the facility's policy when this surveyor informed them about Resident #85's missing personal property.",2016-07-01
8189,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2012-05-18,224,G,0,1,6XWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures to prohibit neglect for one resident (resident #28) of 3 residents sampled from 8 residents identified by the facility to have had a fall and/or fracture in the last 30 days. Findings Include: Resident #28 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was totally dependent on two or more staff for physical assistance with transfers. Review of the care plan for Transfers dated August 3, 2011 revealed the resident has a potential for injury and impaired ability to self-transfer. The resident requires use of full body mechanical lift and 2 person assistance with transfers to/from bed and chair. The care plan goal was for the resident to be transferred with identified transfer devices/assistance through next review on July 10, 2012. Review of the Resident Care Cardex which outlines relevant resident care needs revealed the resident requires use of a LBGC (Lean Back Geri-Chair). A change of condition form was completed on April 29, 2012 due to increased pain and decreased range of motion. A physician's orders [REDACTED]. Nurse's Notes on April 29, 2012 also document the change of condition. The radiological report, dated April 29, 2012, could not exclude a fracture/dislocation. Recommended were repeat images or a CT (computed tomography). Documented on the report was notification to the physician and his instructions to continue to monitor. A change of condition form was completed on May 2, 2012 due to redness and warmth of the right leg. Physician orders [REDACTED]. [MEDICAL CONDITION] was ruled out. Physician orders [REDACTED]. Nurse's notes on May 3, 2012 documented increased pain to right hip and decreased range of motion. A physician's orders [REDACTED]. The CT report, dated May 4, 2012, revealed the presence of a spiral type fracture involving the distal tibial diaphysis with mild medial angulation distally and an additional oblique fracture involving the distal fibular diaphysis also demonstrating mild medial angulation distally. Following the confirmation of an injury of unknown origin, the facility initiated an investigation. The preliminary investigation revealed on April 27, 2012, a Certified Nursing Assistant (CNA) employee #110 had inappropriately transferred the resident during a shower. Furthermore, it was discovered the employee had failed to assess for correct placement of the right foot and the resident's foot was caught under the footrest of the geri-chair. At the time of the incident, the employee reported to the nurse the resident complained of pain to the foot, yet, but did not report the incident of the foot getting caught in the chair. Observations of the resident on May 14 and 17, 2012 were conducted. The resident was observed in bed with a geri-chair next to the bed. An interview with Certified Nursing Assistant (CNA) employee #110 was conducted on May 17, 2012. Employee #110 stated on April 27, 2012 he gave resident #28 a shower. At the time of the shower, he failed to transfer the resident per her plan of care. Specifically, he failed to use a mechanical lift during transfers. Employee stated he had not verified resident #28's care requirements on her care plan nor on the resident care cardex prior to the transfer. Also, employee #110 stated when he changed the position of the Lean Back Geri-Chair, the resident got her foot caught under the footrest of the geri-chair. Employee #110 stated the resident complained of pain to her boot (understood to mean foot). He reported to the Licensed Practical Nurse (LPN), employee #170, the resident had complained of pain, however, he failed to report the resident had caught her foot under the footrest of the geri-chair. Furthermore, during same interview, employee #110 shared his perception that he failed to provide the necessary care and services the resident required for proper transferring and failed to report to the nurse an accident/incident involving the resident's foot. An interview with LPN employee #170 was conducted on May 17, 2012. She stated on April 27, 2012, employee #110 reported to her resident #28 complained of pain during the shower. She stated she then assessed the resident's foot and it appeared within normal limits. She then medicated the resident with her routine scheduled pain medication. Interviews were conducted with the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) on May 17, 2012. The DON and the ADON summarized the results of the investigation into the injury (fracture) of unknown origin and concluded on April 27, 2012, employee #110 did not use a mechanical lift for transfers as indicated and had not verified placement of the foot prior to changing the position of the Lean Back Geri-Chair. The resident caught her foot in the gap of the footrest which likely resulted in the fracture identified days later. Staff also concluded employee #110 had failed to report the incident to the nurse at the time. Review of the facility's Abuse & Neglect Prohibition policy states each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. Neglect means failure to provide goods and services neccessary to avoid physicial harm, mental anguish, or mental illness.",2016-07-01
8190,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2012-05-18,248,D,0,1,6XWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide activities for two residents (residents #281 and #120) of three sampled residents out of eight cognitively impaired residents observed not participating in activities. Findings include: 1. Review of the medical record for Resident #281 revealed an admission date of [DATE] and pertinent [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), a comprehensive assessment dated [DATE] revealed Resident #281 has no difficulty hearing, does not speak words, is never or rarely able to make herself understood, rarely or never understands others, has impaired vision and does not have corrective lenses. The MDS also revealed Resident #281 has both long and short term memory problems, is not able to recall the current season, location of her room, staff names or faces and that she is in a nursing home. Resident #281 was also assessed to have moderately impaired decision making skills. The MDS revealed the resident's family members stated it was important for Resident #281 to be around animals such as pets, to keep up with the news, to go outside to get fresh air when the weather is good and to do her favorite activities. Further review of the MDS revealed Resident #281 was assessed by the facility to require extensive physical assistance with bed mobility, transfers, dressing and personal hygiene. Review of an undated activities assessment located in the resident's medical record revealed Resident #281 likes to watch the news everyday and has current interest in watching TV, watching movies, listening to country music, talking and conversing, coloring and enjoys cats. Review of the care plans for Resident #281 revealed a plan of care dated 04/17/12 which identified the resident as being at risk for social isolation due to depression and [MEDICAL CONDITION]. The plan of care also states Resident #281 is aphasic and does not like to be around people she does not know. The documented goals for this plan of care stated the resident will engage in independent self directed activities and will receive social contacts from family visits regularly. The documented interventions for the plan of care stated the facility will provide a calendar of monthly activities, assist with provision of in-room leisure supplies such as television, movies and coloring supplies as requested. The interventions go on to include calling the resident by her preferred name of -----, praise verbally for efforts given, remain sensitive to the resident's comfort levels, provide a listening ear and time to express her thoughts and needs, respect the residents choice of format and setting, do not push the resident to speak if resident ignores staff and visit informally on regular basis to ensure leisure and social needs are being met. The Resident's medical record also contained a document titled Individual Activity Participation Record dated for April 2012. According to this document, the resident has actively participated independently in the activity of watching television, listening to radio and watching movies 14 times from 04/11/12 to 04/30/12. An activity listed as sensory stimulation was documented when the activities staff made eye contact with Resident #281 8 times from 04/11/12 to 04/30/12. Resident #281 was observed in bed, dressed in a hospital gown with her eyes open and the television turned off on 05/15/12 at 9:30 a.m., 11:08 a.m., 12:15 p.m., 1:52 p.m., and 6:24 p.m Resident #281 was also observed in her room, in bed with a hospital gown on with the television turned off, the lights turned off and the curtains drawn on 5/16/12 at 8:17 a.m., 2:23 p.m., 2:37 p.m., and on 05/17/12 at 12:21 p.m Review of a policy provided by the facility dated June 2007 and titled One-to-One Activities revealed the Activity Department provides one-to-one activities to residents who are isolated due to medical reasons or self imposed isolation, individuals who choose not to participate in group activities offered and seldom initiate their own activities or those residents who need staff support and socialization to continue with independent activities of choice. The policy goes on to state any activity that can be presented in a group setting can be provided in a one-to-one activity with adaptations or modifications and one-to-one visits do not have to occur in the resident rooms. They can occur in a lounge area, in the hallway and outdoors. The procedures for this policy include to ensure the frequency and types of activity services provided are reflected in the resident's care plan, vary the time frame of visits according to individual residents, use the comprehensive assessment, the interests and the physical mental and psychosocial needs of the resident as the basis for formatting one-to-one activities. During interview on 05/15/12 at 1:21 p.m., with Activities Assistant #73, who identified herself as the activities assistant for the unit Resident #281 resides on, it was stated the resident likes to watch people walk in the hall, looking out the window and watching television. Activities assistant #73 verified they do nothing else for Resident #281. During interview on 05/15/12 at 1:54 p.m., Certified Nurse Aide (CNA) # 40 stated Resident #281 does not usually have her television on during the day and was not aware of the care planned interventions. On 05/16/12 at 2:37 p.m., the Activities Director verified during interview Resident #281 did not have any coloring material and her television was not on. The Activities Director also stated the plan of care states the coloring material would be provided as requested and did not acknowledge the resident's [DIAGNOSES REDACTED]. 2. Resident #120 had [DIAGNOSES REDACTED]. The most recent Activity assessment dated [DATE] indicated the resident's most current interests in activities included: watching television adventures, listening to country music, talking and conversing, spiritual and religious events, specifically catholic religion, and dogs. The most recent Minimum (MDS) data set [DATE] was documented as a zero on section F for activities. The resident ' s most recent plan of care for activities dated 4/27/11 was reviewed. The care plan revealed the resident was at risk for social isolation with [DIAGNOSES REDACTED]. The goals on the activity plan of care were to maintain the level of activity attendance and participation, engage the resident in independent, self-directed activities and the resident will receive social contacts through visits with peers, family and staff daily. The approach was to assist with the provision of in-room leisure supplies such as movies, music, pet therapy as requested or as available. Call resident by her name, praise verbally for efforts given, remain sensitive to resident's comfort levels, introduce to others for peer support and for socialization with those who have similar interests and cognition with provision of in room leisure activities, i.e. movies, music, pet therapy as requested or as available. Also, to invite and assist the resident to groups of interest like movies, music, outdoors and religious events. The Individual Activity Participation Records were reviewed for the past four months. The activity logs indicated the resident had participated by receiving one piece of mail delivery, one special event and observed one game. The activity logs indicated the resident had a visit with family or friends daily, but the resident was listed as being independent with that activity. The logs also listed the resident as being independent in talking/conversing/telephone. The resident had two one to one visits. Review of activity logs from May 2011 through December 2011 revealed the resident participated in TV/Movies/Radio on a daily basis. An interview with the Activity Director (AD) was done on 5/15/12 at 5:45 p.m She stated the resident was put on Hospice in April. She stated there is a movie played on all residents televisions every Sunday, but stated this resident does not have a television in her room now. She stated the resident also likes to listen to country music, but the resident does not have a radio in her room. She stated the resident likes to have pet visits, but the people who bring dogs to visit only come every other month and only stay for forty-five minutes and don't have the opportunity to see all the residents when they come. Interview with the AD on 5/17/12 at 6:30 p.m., stated she had not contacted the family for a television or radio. She stated the resident likes to stay in bed. When asked to explain the activity logs, she stated the talking/ conversing/ telephone meant the resident could self initiate talking to others and didn't mean she had done all of those things. The visits with friends or family listed on the activity logs included talking to the staff when she codes it as independent (sic). They are not formal activities. They are independent that the resident would have to do on her own. The AD verified the activity logs listed the activities for the resident and if activities were offered to the resident and were refused, the staff should have documented the resident refused if, in fact, the staff offered. The AD could not verify by reviewing the logs whether the staff had offered the resident activities of her choice. The AD verified she had not contacted the family or the facility had not provided in-room supplies for the resident to watch adventure movies or listen to country music on the radio. An interview with Activity Aide #73 on 5/16/12 at 1:15 p.m. revealed, the resident has lived in other rooms and had a television, but she has been moved to this room and has none. She has gone to the Day room on occasion to attend activities, but the aide stated she has had a decline. An interview on 5/17/12 at 12:30 p.m. with CNA #36 stated some days the resident doesn't want to get up and verified the resident did not have a television or radio in her room. On 5/17/12 at 6:10 p.m., an interview was done with RN #32. The RN stated the resident lived in the old building (sic) about a year ago and there were televisions on the wall and she had one there. She then was moved to the third floor in the new building and there was not a television in that room. She was then moved to the fourth floor about two months ago. The RN verified there were only televisions in the day room and the dining room and someone would have to take her in there to watch television. Observations were made on 5/15/12 at 12:35 p.m. of the resident sitting in wheelchair in the hallway. At 1:10 p.m., the resident was in the main dining room eating lunch in her wheelchair with a tray with staff sitting by her side for assistance. On 5/16/12 at 10:50 a.m., the resident was lying in bed. The resident was not observed in any activities on 5/14/12, 5/15/12 or 5/16/12 during the week of the survey. The activity calendars for the past four months were reviewed and revealed multiple days with religious services. There were no pet therapy activities observed on the calendars.",2016-07-01
8191,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2012-05-18,250,D,0,1,6XWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide medically-related social services in the area of discharge planning for one resident (resident #177) of three residents sampled for community discharge. Findings include: Review of the medical record for Resident #177 revealed an admission date of [DATE] and pertinent [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), a comprehensive assessment dated [DATE], revealed the resident has adequate hearing and vision, is able to make himself understood and able to understand others. Resident #177 was also assessed to score a 12 out of 15 on the Brief Interview for Mental Status (BIMS). Section Q of the MDS revealed Resident #177 wishes to return to the community. Review of the care plans for Resident #177 revealed a plan of care dated 01/13/12 which states the resident chooses to be highly involved in daily care decisions regarding suggested or recommended interventions and has specific preferences related to discharge planning. The goal for this plan of care is stated to be Resident #177 will have preferences honored with individual education related to benefits, risks and potential outcomes of choices and preferences. The interventions for this plan of care include to invite the individual to review and discuss suggested or recommended treatments or interventions to allow individual preferences and choices, provide individual education related to individual choices and exercise of preferences relating to standard interventions or treatments, document education provided using Resident Education Record, review potential alternative choices to individual, notify MD of individual's choices and preferences, honor individual choices and preferences as able within parameters of facility and other individual's safety and choices or preferences and observe individual for changes in cognitive and decision making abilities with review of preferences and choices as indicated. Review of the Social Service section of the medical record for Resident #177 revealed an untitled form dated 01/31/12 that states Resident #177 is a resident with a VA contract and the plans are short stay at the facility. A social service note dated 03/28/12 states the facility phoned the VA Medical Center to request a consult order for prosthetics to asses and approve for ramps and safety rails in Resident #177's home. The note states a voice message was left. There is no documentation as to any follow-up phone calls. Resident #177 was observed to ambulate independently with a walker on 05/14/12, 05/15/12, and 05/16/12. During interview on 05/16/12 at 8:57a.m., physical therapist (PT) #96 stated Resident #177 did meet his maximum potential. PT #96 also stated when residents reach their goals with therapy, they communicate with social services and as far as she knew the resident's daughter was very involved and they were waiting on some home renovations from the Veterans Administration (VA). PT #96 added the Resident #177 is ambulating now even better than when he was discharged from therapy services. During telephone interview with Resident #177's daughter on 05/16/12 at 9:14 a.m., it was stated she has had minimal assistance from the facility with items pertaining to her father's pending discharge and verified the resident has recently expressed a desire to go home. The resident's daughter verified they had spoken about the resident's discharge at the last quarterly meeting on 05/01/12 and she has concerns about her father receiving the food he needs while living at home. The Resident's daughter also stated the VA was going to be making some modifications to her father's home, but was not aware of when this would be taking place. During interview on 05/16/12 at 9:23 a.m., social worker (SW) #43 stated she was not familiar with Resident #177's discharge plans and could only speak to what was documented by his assigned social worker who was not available. SW #43 did state she was aware he was a VA resident and had unlimited paid days at the facility. SW #43 verified Resident #177's discharge plan of care was not specific to his individual needs and was not aware of any follow-up to the phone call made to the VA medical center on 03/28/12. On 5/16/12 at 3:55 p.m. during interview with Resident #177, it was stated he wanted to go home 10 days ago, but could not because he didn't have any railings for the steps to his back door. When asked if the facility had spoken to him about the VA assisting with this, Resident #177 stated, they don't tell me nothing. During interview on 05/17/12 with Licensed Practical Nurse (LPN ) # 47 identified as the Social Worker Manager, it was verified there had been no follow-up related to Resident #177's potential discharge. The Administrator verified on 05/17/12, the discharge planning for Resident #177 had not been followed up by the Social Services Department of the facility.",2016-07-01
8192,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2012-05-18,279,D,0,1,6XWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to develop three care plans in the areas of community discharge, [MEDICAL TREATMENT], and pain for three residents (residents 177, 59, 16) of 36 care plans reviewed. Findings include: 1. Review of the medical record for Resident #177 revealed an admission date of [DATE] and pertinent [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), a comprehensive assessment dated [DATE] revealed the resident has adequate hearing and vision, is able to make himself understood and able to understand others. Resident #177 was also assessed to score a 12 out of 15 on the Brief Interview for Mental Status (BIMS). Section Q of the MDS revealed Resident #177 wishes to return to the community. Review of the care plans for Resident #177 revealed a Plan of Care dated 01/13/12 which states the resident chooses to be highly involved in daily care decisions regarding suggested or recommended interventions and has specific preferences related to discharge planning. The goal for this Plan of Care is stated to be Resident #177 will have preferences honored with individual education related to benefits, risks and potential outcomes of choices and preferences. The interventions for this Plan of Care include, to invite the individual to review and discuss suggested or recommended treatments or interventions to allow individual preferences and choices, provide individual education related to individual choices and exercise of preferences relating to standard interventions or treatments, document education provided using Resident Education Record, review potential alternative choices to individual, notify MD of individual's choices and preferences, honor individual choices and preferences as able within parameters of facility and other individual's safety and choices or preferences, and observe individual for changes in cognitive and decision making abilities with review of preferences and choices as indicated. Resident #177 was observed to ambulate independently with a walker on 05/14/12, 05/15/12, and 05/16/12. During interview on 05/16/12 at 8:57 a.m., physical therapist (PT) #96 stated Resident #177 did meet his maximum potential. PT #96 also stated when residents reach their goals with therapy they communicate with social services and as far as she knew the resident's daughter was very involved and they were waiting on some home renovations from the Veterans Administration (VA). PT #96 added the Resident #177 is ambulating now even better than when he was discharged from therapy services. During telephone interview with Resident #177's daughter on 05/16/12 at 9:14 a.m., it was stated she has had minimal assistance from the facility with items pertaining to her father's pending discharge and verified the Resident has recently expressed a desire to go home. The resident's daughter verified they had spoken about the resident's discharge at the last quarterly meeting on 05/01/12 and she has concerns about her father receiving the food he needs while living at home. The Resident's daughter also stated the VA was going to be making some modifications to her father's home, but was not aware of when this would be taking place. During interview on 06/16/12 at 9:23 a.m. with social worker (SW) #43, SW stated she was not familiar with Resident #177's discharge plans and could only speak to what was documented by his assigned social worker who was not available. SW #43 did state she was aware he was a VA resident and had unlimited paid days at the facility. SW #43 verified Resident #177's discharge Plan of Care was not specific to his individual needs. 2. Resident #59 has [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Plan of Care for [MEDICAL TREATMENT] did not indicate anything about the administration of the resident's medications and indicated to provide the diet as ordered. The Plan of Care did not specify on the days of [MEDICAL TREATMENT] if the resident's medications would be given to the resident at the facility or sent with the resident to the [MEDICAL TREATMENT] center. The Plan of Care also did not indicate if the resident would eat meals in the facility on [MEDICAL TREATMENT] days or if they would be sent with the resident to the [MEDICAL TREATMENT] center. An interview was conducted with the RD on 5/16/12 at 4:30 p.m The RD stated the resident eats her meals in the facility before she leaves and when she returns, but has never included it on the Plan of Care. An interview with RN #51 on 5/17/12 at 1:40 p.m., stated the resident gets an early tray for breakfast prior to going to [MEDICAL TREATMENT] and eats lunch when she comes back and verified information was not on the plan of care. A review of the medical record's Medication Administration Records (MARs) for the months of February, March, April and May, 2012 was conducted. The MARs had several days of different medications listed with Out of Facility (OOF) noted. An interview on 5/17/12 at 1:40 p.m. with RN #51 stated the medications were documented as (OOF) because the resident was out of the facility and did not receive her medications at those times of day, she was out for [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. The RN verified there was no instruction on the Plan of Care about how the resident would receive medications on the days the resident went to [MEDICAL TREATMENT]. The RN verified the medications were not given to the resident at 9:00 a.m. on the days of [MEDICAL TREATMENT] by the nurses as ordered by the physician. The RN stated the Plan of Care needed to include instruction for the nursing staff on the administration of the medications on [MEDICAL TREATMENT] days. 3. Resident #16 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident occasionally experiences pain and receives scheduled and PRN (as needed) pain medications as well as non-pharmacological pain interventions. Review of the most recent recapitulation of physician orders, dated May 1, 2012, included orders for [MEDICATION NAME] (a medication used for pain)10 mg to be administered every 6 hours around the clock. Review of the Medication Administration Record [REDACTED]. Review of the clinical record failed to identify a care plan for pain. An interview was conducted with resident #16 on May 14, 2012. He stated he experiences pain with no relief. An interview was conducted on May 16, 2012, with employee #76. Staff confirmed there was no care plan for pain contained within the clinical record and she would expect a resident who receives scheduled pain medication would have a care plan for pain.",2016-07-01
8193,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2012-05-18,282,D,0,1,6XWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement four care plans in the areas of accidents and activities for three residents (resident #'s 28, 120, 281) out of 36 care plans reviewed. Findings include: 1. Resident #28 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was totally dependent on two or more staff for physical assistance with transfers. Review of the care plan for Transfers dated August 3, 2011, revealed the resident has a potential for injury and impaired ability to self-transfer. The resident requires use of mechanical lift and 2 person assist. The care plan goal was the resident be transferred with identified transfer devices/assistance through next review on July 10, 2012. An interview with Certified Nursing Assistant (CNA) employee #110 was conducted on May 17, 2012. Employee #110 stated on April 27, 2012, he failed to transfer the resident per her plan of care. Specifically, he failed to use a mechanical lift during transfers. Employee #110 stated he had not verified resident #28's care requirements on her care plan nor on the resident care cardex prior to the transfer. 2. Resident #120 had [DIAGNOSES REDACTED]. The most recent Activity assessment dated [DATE] indicated the resident's most current interests in activities included: Watching television adventures, listening to country music, talking and conversing, spiritual and religious events, specifically catholic religion, and dogs. The most recent Minimum (MDS) data set [DATE] was documented as a zero on section F for activities. The resident's most recent plan of care for activities dated 4/27/11 was reviewed. The care plan revealed the resident was at risk for social isolation with [DIAGNOSES REDACTED]. The goals on the activity plan of care were to maintain the level of activity attendance and participation, engage the resident in independent, self directed activities, and the resident will receive social contacts through visits with peers, family and staff daily. The approach was to assist with the provision of in-room leisure supplies such as movies, music, pet therapy as requested or as available, to call resident by her name, praise verbally for efforts given, remain sensitive to resident's comfort levels, introduce to others for peer support and for socialization with those who have similar interests and cognition with provision of in-room leisure activities, i.e. movies, music, pet therapy as requested or as available. Also, to invite and assist the resident to groups of interest like movies, music, outdoors and religious events. During an interview with the Activity Director (AD) on 5/15/12 at 5:45 p.m., she stated the resident was put on Hospice in April (sic). She stated there is a movie played on all residents' televisions every Sunday, but stated this resident does not have a television in her room now. She stated the resident also likes to listen to country music, but the resident does not have a radio in her room. She stated the resident likes to have pet visits, but the people who bring the dogs to visit only come to the facility every other month and only stay for forty-five minutes, and don't have the opportunity to see all the residents when they come. During an interview with the AD on 5/17/12 at 6:30 p.m., she stated the resident likes to stay in bed and verified she had not contacted the family or the facility had not provided in-room supplies for the resident to watch adventure movies or a radio to listen to country music. During an interview with Activity Aide #73 on 5/16/12 at 1:15 p.m., stated the resident has lived in other rooms and had a television, but she has been moved to this room and has none. During an interview on 5/17/12 at 12:30 p.m. with CNA #36, stated some days the resident doesn't want to get up and verified the resident did not have a television or radio in her room. On 5/17/12 at 6:10 p.m., an interview was done with RN #32. The RN stated the resident lived on the old building about a year ago and there were televisions on the wall and she had one there. She then was moved to the third floor in the new building and there was not a television in the room. She was then moved to the fourth floor about two months ago. The RN verified there were only televisions in the day room and the dining room and someone would have to take her in there to watch television. Observations were made on 5/15/12 at 12:35 p.m. of the resident sitting in the hallway in a wheelchair. At 1:10 p.m., the resident was in the main dining room eating lunch in her wheelchair with a tray with staff sitting by her side for assistance. On 5/16/12 at 10:50 a.m., the resident was lying in bed. The resident was not observed to be offered activities of choice on 5/14/12, 5/15/12 or 5/16/12 during the week of the survey. The activity calendars for the past four months were reviewed and revealed multiple days with religious services, but there were no pet therapy activities observed on the calendars. The resident's participation logs for the past four months were reviewed and there was no documentation the resident was offered the religious services, except for one day the resident refused. There were no per therapy offerings and no evidence the resident was offered music or television. 3. Review of the medical record for Resident #281 revealed an admission date of [DATE] and pertinent [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), a comprehensive assessment dated [DATE] revealed Resident #281 has no difficulty hearing, does not speak words, is never or rarely able to make herself understood, rarely or never understands others, has impaired vision and does not have corrective lenses. The MDS also revealed Resident #281 has both long and short term memory problems, is not able to recall the current season, location of her room, staff names and faces or that she is in a nursing home. Resident #281 was also assessed to have moderately impaired decision making skills. Review of the care plans for Resident #281 revealed a plan of care dated 04/17/12 which identified the resident as being at risk for social isolation due to depression and [MEDICAL CONDITION]. The plan of care also states Resident #281 is aphasic and does not like to be around people she does not know. The documented goals for this plan of care stated the resident will engage in independent self directed activities and will receive social contacts from family visits regularly. The documented interventions for the plan of care stated the facility will provide a calendar of monthly activities, assist with provision of in room leisure supplies such as television, movies and coloring supplies as requested. The interventions go on to include calling the resident by her preferred name of -----, praise verbally for efforts given, remain sensitive to the resident's comfort levels, provide a listening ear and time to express her thoughts and needs, respect the residents choice of format and setting, do not push the resident to speak if ignores staff and visit informally on regular basis to ensure leisure and social needs are being met. The Resident's medical record also contained a document titled, Individual Activity Participation Record, dated for April 2012. According to this document the resident has actively participated independently in the activity of watching television, listening to radio and watching movies 14 times from 04/11/12 to 04/30/12. An activity listed as sensory stimulation was documented the activities staff made eye contact with Resident #281 8 times from 04/11/12 to 04/30/12. There was no documentation Resident #281 received or participated in a craft or coloring activity. Resident #281 was observed in bed dressed in a hospital gown with her eyes open and the television turned off on 05/15/12 at 9:30 a.m., 11:08 a.m., 12:15 p.m., 1:52 p.m., and 6:24 p.m Resident #281 was also observed in her room in bed with a hospital gown on with the television turned off, the lights turned off and the curtains drawn on 5/16/12 at 8:17 a.m., 2:23 p.m., 2:37 p.m., and on 05/17/12 at 12:21 p.m., During interview on 05/15/12 at 1:21 p.m. with Activities Assistant #73, who identified herself as the activities assistant for the unit that Resident #281 resides on, it was stated the resident likes to watch people walk in the hall, looking out the window and watching television. Activities Assistant #73 verified they do nothing else for Resident #281. During interview on 05/15/12 at 1:54 p.m., Certified Nurse Aide (CNA) #40 stated Resident #281 does not usually have her television on during the day and was not aware of the care planned interventions. On 05/16/12 at 2:37 p.m., the Activities Director verified during interview Resident #281 did not have any coloring material in her room and the television was not on as the plan of care states. The Activities Director also stated the plan of care states the coloring material would be provided as requested and did not acknowledge the resident's [DIAGNOSES REDACTED].",2016-07-01
8194,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2012-05-18,309,D,0,1,6XWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and resident interview, the facility failed to provide the necessary care and services for the highest practicable well-being in the form of medications for one resident (resident #59) of five residents receiving [MEDICAL TREATMENT] services. Resident #59 has [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The plan of care for [MEDICAL TREATMENT] did not indicate anything about the administration of the resident's medications. The Plan of Care did not state on days of [MEDICAL TREATMENT] whether the resident's medications would be given to the resident at the facility or sent with the resident to the [MEDICAL TREATMENT] center. The resident was interviewed on 5/17/12 at 2:20 p.m The resident stated she does not have any medication sent with her on [MEDICAL TREATMENT] days. A review of the medical record Medication Administration Records (MAR's) for the months of February, March, April and May 2012 was conducted. The MARs had several days of different medications listed with Out of Facility (OOF). During an interview on 5/17/12 at 1:40 p.m. with RN #51, she stated the medications were documented as (OOF) because the resident was out of the facility and did not receive her medications at those times of day because she was out for [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. The RN verified there was no instruction on the Plan of Care about how the resident would receive medications on the days the resident went to [MEDICAL TREATMENT]. The RN verified the medications were not given to the resident at 9:00 A.M. on the days of [MEDICAL TREATMENT] by the nurses as ordered by the physician. The RN stated some type of change needed to be made because the resident did not receive the medication as ordered by the physician and there were many times the resident had not received her medications while out of the facility for [MEDICAL TREATMENT]. The medications ordered at 9:00 a.m. included: [MEDICATION NAME] 20 mg twice a day for hypertension, [MEDICATION NAME] 20 mg one daily for GERD, [MEDICATION NAME] HCL 100 mg once a day due to social isolation secondary to depression, [MEDICATION NAME] 0.5% one drop into both eyes twice a day for [MEDICAL CONDITION], [MEDICATION NAME] 100 mg one a day for gout, Aspirin 81 mg every day for hypertension, Calcium Acetate 667 mg three tablets three times a day for End Stage [MEDICAL CONDITION], [MEDICATION NAME] 100 mg every day for constipation, [MEDICATION NAME] 6.25 mg every day for hypertension, [MEDICATION NAME] 0.5 mg, every day for hormone replacement and [MEDICATION NAME] HCL 25 mg, three times a day for hypertension.",2016-07-01
8195,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2012-05-18,315,D,0,1,6XWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure two (residents #71 and #248) of three residents identified with a decline in urinary continence received care and services to maintain bladder function. Findings include: 1. Review of the medical record for Resident #71 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE], a comprehensive assessment for Resident #71, revealed the resident required limited assistance of one staff member for bed mobility, dressing and walking in the room. Resident #71 was also assessed to require supervision during eating and locomotion on the unit and assessed to require extensive assist from one staff member with transfers, personal hygiene and toilet use. The resident was also assessed to be incontinent of urine occasionally. The comprehensive assessment revealed Resident #71 had both long and short term memory problems, is unable to recall the current season, location of her room, staff names and faces and that she is in a nursing home. Resident #71 was also assessed to have moderately impaired decision making skills. Review of the MDS quarterly assessment dated [DATE] revealed Resident #71 is assessed to now require limited assistance with locomotion on the unit, extensive assist of one staff member for dressing. All other pertinent activities of daily living remained unchanged. Resident #71 was assessed to have declined in the area of urinary incontinence from occasionally to frequently incontinent of urine on this quarterly assessment. Review of the care plans for Resident #71 revealed a plan of care dated 12/30/11 for incontinence related to functional factors and pain. The goal for the plan of care states Resident #71 will have incontinence episodes managed without signs and symptoms of potential complications, including skin breakdown and urinary tract infection [MEDICAL CONDITION] and will have dignity maintained with incontinence care as needed. The interventions include hand-washing before and after delivery of care, have call light within easy reach, provide perineal care daily and as needed, observe for complaints of burning, frequency, noting color, amount and odor of urine, notify physician as needed and observe resident for worsening mental or functional status. Review of a form titled Evaluation for Bowel and Bladder Training and dated 12/29/11 revealed Resident #71 was assessed to be alert with confusion, able to communicate and can see and hear. The resident's functional status was documented as extensive assist. At the time of the assessment Resident #71 was documented to be incontinent and the frequency, amount and pattern varied. The results of the evaluation based on the the above documentation was noted to be marked as unable to participate in B/B (bowel and bladder) program due to dementia. Review of the facility's policy for bowel and bladder management, dated February 2010 revealed Practice Guidelines including the IDT (Interdisciplinary Team) will re-evaluate the bowel and bladder status of the resident quarterly, annually and with significant change through the RAI process and the Care Management Risk Review Meetings. The policy states the IDT will determine who would benefit from a habit training or scheduled toileting program and would include cognitively impaired residents and residents who are assessed to have urinary and or bowel incontinence. The policy states the goal for the program is to increase the periods of continence and to reduce the potential for skin breakdown. Resident #71 was observed on 05/16/12 at 8:26 a.m., seated in a wheelchair in the dining room eating breakfast. There are no signs of incontinence noted. During interview with CNA # 92 on 05/16/12, it was stated Resident #71 was incontinent at times and would take herself to the toilet at times. On 05/17/12, CNA #92 stated Resident #71 was incontinent sometimes once a day and stated she was not on any toileting program that she was aware of. During interview on 05/16/12 at 10:25 a.m. with the MDS coordinator, it was verified Resident #71 had a decline in urinary continence and also stated Resident #71 would not be able to participate in a toileting program due to her cognition. During interview on 05/16/12 at 1:30 p.m., the MDS coordinator verified Resident #71 was not on a toileting program to prevent further decline in urinary continence and a bladder evaluation was not performed with the quarterly assessment. The MDS coordinator could not confirm if Resident #71's decline was discussed during the Interdisciplinary Team (IDT) meeting held for the quarterly review because the documentation was absent for any such meeting. The MDS Coordinator also verified there were no changes made to the resident's plan of care and no consideration of a toileting program for Resident #71. During interview on 05/16/12 at 10:54 a.m. with the Licensed Practical Nurse (LPN) #50, the Unit Manager, it was stated Resident #71 would be able to participate in a toileting program and should be on one because it decreases the risk for infections such as UTI's, falls and skin breakdown. 2. Resident #248 had [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed the resident was always continent. The MDS dated [DATE] revealed the resident had a decline and was occasionally incontinent. The plan of care for Activities of Daily Living(ADL's) dated 1/17/12 revealed the resident requires staff assistance and interventions for completion of ADL needs. The plan of care revealed the resident requires supervision, limited assist, total care utilizing one staff member. The approach was to allow the resident adequate time to complete tasks, and to provide cueing with tasks. The plan of care for incontinence dated 4/3/12 revealed the resident will have incontinence episodes managed without signs and symptoms of urinary tract infection and will have dignity maintained with incontinence care. The plan of care revealed to observe for signs and symptoms of urinary tract infection, monitor labs, and provide perineal care daily and as needed. Observations were made on 5/15/12 at 12:36 p.m. of the resident lying in bed and on 5/16/12 at 6:00 p.m. ambulating in the halls, talking to staff. An interview was conducted with the resident and she stated she didn't feel well today, but she is a lot better than she used to be. She stated she walks and takes herself to the bathroom and doesn't need any help. During an interview on 5/15/12 with CNA #64 at 12:40 p.m., the CNA stated the resident will ask for help if needed, but very seldom. She stated the resident can take herself to the bathroom and doesn't need help from the staff. The CNA stated the resident has been incontinent at times. During an interview with RN #32 at 1:45 p.m., the RN stated the resident had a urinary tract infection and was started on antibiotics on 3/23/12. During an interview with the MDS RN at 1:50 p.m., the MDS RN verified the resident had a decline from the admission MDS on 1/11/12 to the quarterly assessment dated [DATE]. On 5/1616/12 at 1:30 p.m., interviews with MDS Coordinator and RN #32 stated a care planning meeting was done on 4/17/12 and there was no discussion of a bladder re-training program or any type of intervention as a result of the decline. The nurses verified the facility did not follow the policy and procedures to promote continence according to the Bowel and Bladder Management Program. The policy specified the Interdisciplinary Team would determine the appropriate bowel and bladder re-training program for the resident. When the decline was noted the nursing staff failed to determine a plan to promote continence. RN #34 verified there had been no changes with the resident's care in regards to toileting. There had been no bladder function studies or implementation of any new interventions to promote her continence.",2016-07-01
8196,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2012-05-18,323,G,0,1,6XWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review and review of a preliminary investigative report, the facility failed to prevent a fracture and multiple falls for two residents (residents #28 and #120) out of three residents sampled of eight residents identified by the facility for falls/and or fractures in the last 30 days. Findings include: 1. Resident #28 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was totally dependent on two or more staff for physical assistance with transfers. Review of the care plan for Transfers dated August 3, 2011, revealed that the resident has a potential for injury and impaired ability to self-transfer. The resident requires use of full body mechanical lift and 2 person assistance with transfers to/from bed and chair. The care plan goal was that the resident be transferred with identified transfer devices/assistance through next review on July 10, 2012. Review of the Resident Care Cardex which outlines relevant resident care needs revealed that the resident requires use of a LBGC (Lean Back Geri-Chair). A change of condition form was completed on April 29, 2012, due to increased pain and decreased range of motion. A physician's orders [REDACTED]. Nurse's Notes on April 29, 2012 also document the change of condition. The radiological report, dated April 29, 2012, could not exclude a fracture/dislocation. Recommended were repeat images or a CT (computed tomography). Documented on the report was notification to the physician and his instructions to continue to monitor. A change of condition form was completed on May 2, 2012, due to redness and warmth of the right leg. Physician orders [REDACTED]. Deep vein thrombosis was ruled out. Physician orders [REDACTED]. Nurse's notes on May 3, 2012, documented increased pain to right hip and decreased range of motion. A physician's orders [REDACTED]. The CT report, dated May 4, 2012, revealed the presence of a spiral type fracture involving the distal tibial diaphysis with mild medial angulation distally and an additional oblique fracture involving the distal fibular diaphysis also demonstrating mild medial angulation distally. Following the confirmation of an injury of unknown origin, the facility initiated an investigation. The preliminary investigation revealed that on April 27, 2012, a Certified Nursing Assistant (CNA) employee #110 had inappropriately transferred the resident during a shower. Furthermore, it was discovered that the employee had failed to assess for correct placement of the right foot and the resident's foot was caught under the footrest of the geri-chair. At the time of the incident, the employee reported to the nurse the resident complained of pain to the foot, yet, did not report the incident of the foot getting caught in the chair. Observations of the resident on May 14 and 17, 2012 were conducted. The resident was observed in bed with a Geri-Chair next to the bed. An interview with Certified Nursing Assistant (CNA) employee #110 was conducted on May 17, 2012. Employee #110 stated on April 27, 2012, he gave resident #28 a shower. At the time of the shower, he failed to transfer the resident per her plan of care. Specifically, he failed to use a mechanical lift during transfers. Employee stated he had not verified resident #28's care requirements on her care plan nor on the resident care cardex prior to the transfer. Also, employee #110 stated when he changed the position of the Lean Back Geri-Chair, the resident got her foot caught under the footrest of the geri-chair. Employee #110 stated the resident complained of pain to her boot (understood to mean foot). He reported to the Licensed Practical Nurse (LPN) employee #170, the resident had complained of pain. However, he failed to report the resident had caught her foot under the footrest of the geri-chair. An interview with LPN employee #170 was conducted on May 17, 2012. She stated on April 27, 2012, employee #110 reported to her resident #28 complained of pain during the shower. She stated she then assessed the resident's foot and it appeared within normal limits. She then medicated the resident with her routine scheduled pain medication. Interviews were conducted with the Director of Nurses and the Assistant Director of Nurses on May 17, 2012. The DON and the ADON summarized the results of the investigation into the injury (fracture) of unknown origin and concluded on April 27, 2012, employee #110 did not use a mechanical lift for transfers as indicated and had not verified placement of the foot prior to changing the position of the Lean Back Geri-Chair. The resident caught her foot in the gap of the footrest which likely resulted in the fracture identified days later. Staff also concluded that employee #110 had failed to report the incident to the nurse at the time. 2. Resident #120 had [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) on 4/27/12 listed no falls. The MDS indicated the resident was an extensive assist for activities of daily living including locomotion and transfers. The plan of care for falls dated 5/14/12 revealed the resident was at risk for falls related to mental status, history of falls, balance problems, arthritis and the use of psychotropic medications. The plan of care revealed the resident was on a falling star program, therapeutic rest after breakfast, chair alarm, call light within reach and a low bed with floor mats next to the bed. The Interdisciplinary Team (IDT) Post Fall Review dated 5/5/12 with a fall at 9:50 a.m. revealed the resident scooted to middle of room beyond floor mats from bed with no injury. At 12:05 p.m., the resident scooted out of bed again beyond the floor mats into middle of the floor. The fall reviews indicated the resident had an unassisted fall. There were no new interventions on the first review. The Summary of the Interdisciplinary Team was to continue current interventions for falls and to cleanse under breasts with warm soapy water, rinse, pat dry and apply Nystatin powder under breasts three times a day for seven days. After the second fall on 5/5/12, there were no new interventions for falls, except an order for [REDACTED]. The Intervention Recommendations on the fall reviews (check all that apply) was to do a care plan revision. On 5/7/12 at 5:00 p.m., the resident had another fall. The fall review indicated the resident was up in the Day Room in a wheelchair with a chair alarm. The staff heard the alarm sounding and the resident was found sitting in floor in front of the wheelchair. The Summary of the Interdisciplinary Team was to continue the current interventions of falls and a physician's orders [REDACTED]. The laboratory blood work and urinalysis was not collected until 5/9/12 after the Interdisciplinary Team met to review the falls. There were no nursing staff interventions after the falls. The only new interventions on the review forms after the Interdisciplinary Team met was to do the X-ray and laboratory work. Observations were made of the resident on 5/15/12 at 12:35 p.m The resident was sitting in a wheelchair in the hallway with pommel cushion in the wheelchair with an alarm. On 5/15/12 at 1:10 p.m., the resident was observed in the main dining room sitting in her wheelchair. On 5/16/12 at 10:50 a.m., observations were made of CNA #36 in the resident's room to provide a.m. care. The CNA was knowledgeable of the care plan interventions, such as, allowing the resident to sleep in late and provide a.m. care after breakfast. On 5/17/12 at 7:40 a.m., the resident was observed lying in bed with 1/4 side rails up on both sides of the bed. The CNA #36 stated she has never seen the resident use the side rails to get out of bed, but is able to reposition herself in bed. She stated she tries to push herself up when she wants to get up. During an interview on 5/16/12 at 6:45 p.m. with RN #32 about her falls, the RN stated the resident was on the floor crawling when found on both times on 5/5/12. The RN stated the x-ray was questionable with a fracture of the femoral neck. The family wished for no treatment other than pain medication. The RN stated the resident fell on [DATE] out of the wheelchair and had no injury. The resident had not fallen since January, 2012. She did have labs done on 5/9/12 that revealed a yeast infection in her urine. The DON was interviewed on 5/16/12 at 4:15 p.m. and stated the resident could have been confused when she had the falls on 5/5 and 5/7, but there was no evidence in the chart that he could find to support the resident was having an increase in confusion or any physical symptoms that would have caused the falls. An interview with the physician 5/17/12 at 10:35 a.m. was conducted. The physician stated he could not verify the femoral neck was fractured unless a CT Scan was done and the family declined any invasive procedures since she is on Hospice and they only wanted to keep her comfortable. The physician stated the urinalysis revealed a yeast infection in the urine, but was not a contributing factor for the resident's falls on 5/5 and 5/7. The post fall meeting that was held on 5/9/12 by the IDT team failed to implement any additional interventions to decrease falls.",2016-07-01
8197,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2012-05-18,431,E,0,1,6XWO11,"Based on observation and interview, the facility failed to ensure that expired medications were not available for resident use in two out of three medication storage rooms. Findings include: 1. On 05/14, the medication storage room was observed on the unit identified by the facility as being OB (old building). There was one opened 1000 count bottle of Acetaminophen 325 mg tablets with an expiration date of 03/12 located in the medication storage cabinet. The observation was verified by Licensed Practical Nurse (LPN) #50, identified as the Unit Manager. 2. Observations were made on 5/14/12 at 4:45 p.m. on Unit 3 in the New Building. The Medication Storage room was observed to have a 16 ounce container of fiber powder that had an expiration date of April, 2012. Observations were made in the same Medication Storage room of two 1000 count bottles of Acetaminophen 325 mg tablets with an expiration date of March, 2012 on both bottles. The observations of the expired medications were verified by RN staff #151. The Policy and Procedure for the facility's storage of medications was reviewed. The policy stated the facility should ensure medications and biologicals that have an expired date on the label should be stored separate, away from use from other medications until destroyed or returned to the supplier.",2016-07-01
8198,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,156,E,0,1,JXHC11,"Based on medical record review, staff interview, resident interview, and observation, the facility did not ensure written information was prominently displayed about how to apply for and use Medicaid benefits. The facility also failed to ensure one (1) of forty- six (46) residents had received information regarding how to contact the physician responsible for her care. In addition, the facility failed to ensure two (2) of five (5) residents received the appropriate liability notice after they were discharged from a Medicare Part A service. Resident identifiers: #45, #58, and #114. Facility census: 115. Findings include: a) On 05/15/12, at approximately 9:00 a.m., an observation of the facility revealed they had not posted the necessary information regarding how to apply for and use Medicaid benefits. On 05/16/12, at approximately 9:00 a.m., the administrator (Employee #43) agreed the facility had not posted this information. She indicated the facility had previously posted the information, but people kept taking it down. b) Resident #114 On 05/15/12, at approximately 4:00 p.m., the director of admissions (Employee #68) indicated she gave the residents the consent for treatment and release of information form at the time of admission. Review of Resident #114's medical record, conducted on 05/15/12, at approximately 4:30 p.m., found the consent for treatment and release of information form. The form did list the resident's physician; however, the form did not have contact information listed for the physician. The form had a place to list the physician's telephone number and physician's address, but this information had not been provided on the form. In an interview on 05/22/12, at approximately 8:45 a.m., Resident #114 indicated she did not know how to contact her physician. On 05/22/12, at approximately 5:00 p.m., the director of nursing (Employee #2) asked what type of contact information the facility needed to give the residents regarding how to contact their physician. The director of nursing agreed that the resident's consent for treatment and release of information form required the telephone number and/or address of the resident's physician. c) Liability notices On 05/17/12, at approximately 9:00 a.m., the social workers, Employee #17 and Employee #24, were interviewed regarding the notices given to residents who were discharged from a Medicare Part A service. Resident #45 and Resident #58 were both discharged from Medicare Part A services in April 2012. 1) Resident #58's skilled services ended on 04/30/12 due to the resident reaching his functional ability potential and no longer needing the supervision or skills of a therapist. The facility provided the responsible party with the Notice of Medicare Provider Non-Coverage (CMS form ). They did not provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (CMS form ). The resident remained in the facility and services were terminated prior to the 100-day benefit period per the facility's decision. The facility needed to provide the responsible party with the SNFABN because benefit days remained and there was a potential for financial liability. 2) Resident #45's skilled services ended on 04/02/12 due to the resident having learned to perform the tasks ordered by her physician. The facility provided the responsible party with the Notice of Medicare Provider Non-Coverage (CMS- ). They did not provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (CMS form ). The resident remained in the facility with benefit days. The facility needed to issue the SNFABN because benefit days remained and there was a potential for financial liability. On 05/17/12, at approximately 9:30 a.m., the social workers confirmed they had not sent the SNFABN to Resident #45's and Resident #58's responsible parties.",2016-07-01
8199,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,241,E,0,1,JXHC11,"Based on observations and staff interviews, the facility failed to promote care for residents in a manner that maintained each resident's dignity. During the dining room observations, seven (7) of twenty-two (22) residents were not treated in a dignified manner during the lunch meal. Six (6) of the seven (7) residents were not served their meals although others at the same table were already eating. One (1) of seven (7) residents was not given silverware with which to eat her meal. Facility census: 115. Resident identifiers: #10, #8, #90, #81, #13, #60, and #101. Findings include: a) Resident #10, #8, #90, #13, #60 and #81 During observation of the lunch time meal, on 05/14/12 at 12:00 p.m., these six (6) residents were observed sitting at tables with other residents who had been served and were already eating their meals. Resident #8's was not served until 12:15 p.m. She was seated at a table with two (2) residents who were being fed by staff. When Resident #8 received her meal, she stated her soup was cold. Resident #81 also received her meal at 12:15 p.m., after the other two (2) residents at her table were already eating. Resident #60 did not receive her meal at all during the observation. Resident #60 became very upset and threw her clothing protector across the table. She stated, she had ordered a special lunch while she was in Bingo earlier that morning, but did not receive it. She left the dining room without eating. Resident #13 did not receive her meal. She was seated at a table with two (2) other residents who had already consumed most of their food. Observation of the meal ticket for one (1) of the residents seated at Resident #13's table found Resident #13's meal had been given to the wrong resident. Resident #13 did not receive her meal until 12:25 p.m. Resident #90 received her meal ten (10) minutes after the other resident's at her table obtained their meal trays. Resident #10 was seated at a table with two other residents who were eating. She received her meal fifteen (15) minutes after the other residents were served. b) Resident #101 This resident was served lentil soup, a steak sandwich, and french fries. She was never given silverware through the entire meal. During an interview with the Employee #2 (director of nursing), on the afternoon of 05/15/12, she stated, Staff in the dining room told her it did not go well. She further added, The staff working the dining room on that particular day were not usual people who work that area.",2016-07-01
8200,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,250,D,0,1,JXHC11,"Based on medical record review, staff interview, and resident interview, the facility did not provide medically-related social services for two (2) of forty-six (46) residents. By not providing these essential services, the facility did not ensure the two (2) residents attained/maintained their highest practicable physical, mental, and psychosocial well-being. Resident #114 had disclosed information to nursing staff related to a personal history of abuse by a former spouse. The facility did not provide any social service related interventions to the resident after she disclosed how troubling these past issues were to her. Resident #17 had voiced to nursing staff members both suicidal and homicidal ideations. The facility did not intervene with social service interventions for this resident. Resident identifiers: #114 and #17. Facility census: 115. Findings include: a) Resident #114 On 05/14/12, at approximately 1:00 p.m., Resident #114 indicated she felt sad due to thoughts she had related to the abuse she had endured from her former spouse. She said she struggled with the memories of the abuse she and her children endured. She said she felt she neglected her children and had not protected them as she should have. A nursing note, dated 05/12/12, revealed the resident had expressed to nursing staff her distress over memories associated with spousal abuse and abuse she encountered as a child. The note stated the resident was difficult to redirect. The note also stated the nurse had contacted social services. The medical record review, conducted on 05/17/12 at 9:30 a.m. with Employee #17 (social worker), revealed she knew the resident had talked with nursing staff about the issues of being abused by a former spouse. She said the resident would not open up to her about the issues. She had no progress notes related to her attempts to speak with the resident regarding the issue. She also denied having requested the assistance of nursing or the other social worker regarding the issue. On 05/21/12 at 12:00 p.m., Employee #17 indicated she had revisited the issue with Resident #114 and the resident did open up and talk with her. She told the social worker she had previously received services from a psychiatrist, but did not like the services she received. She told the social worker she would like to see another psychiatrist as soon as possible. b) Resident #17 Review of the medical record found Resident #17 had stated to the staff, on 04/02/12, I wish I had a gun, I'd shoot them both then shoot myself. According to the nursing note, the family nurse practitioner was notified and ordered a urine culture. No evidence was found the facility did anything to address the suicidal ideation expressed by the resident. The following day, on 04/03/12, the attending physician ordered Geodon 20 mg now and then BID (twice a day). During an interview with Employee #2 (director of nursing), on 05/21/12 at 12:45 p.m., she stated, The Geodon was ordered related to the suicidal ideation. Employee #2 further stated, She has said she was going to kill herself before back on 01/31/12. She was sent to the hospital then for psychiatric services. During an interview with Employee 17 (Social Worker), on 05/21/12 at 12:53 p.m., she stated she was unaware Resident #17 had suicidal ideation, she said no one had ever told her. Employee #17 was then asked what the facility normally does when a situation like this occurs. She stated, I would go talk to the resident and do an assessment. Review of the medical record found documentation the resident had expressed suicidal ideations on other occasions. On 02/10/12, Resident #17 told the nurse I don't care if I die. On 01/31/12, the resident told her roommate and daughter with a nursing assistant present, she was going to kill herself. On 05/21/12 at 1:48 p.m., Employee #2 (director of nursing) stated, The family nurse practitioner chose not to do anything about the suicidal threats because the nurse told her the resident was confused. No evidence could be found to demonstrate the facility had addressed the suicidal ideations voiced by the resident on 04/02/12.",2016-07-01
8201,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,253,E,0,1,JXHC11,"Based on observations and staff interview, the facility failed to ensure all essential resident care equipment was maintained in a safe operating condition. Observations were made of unsteady arms on toilet safety frames, inappropriate and cracked toilet tank covers were observed, as well as issues were identified with the surfaces on doors and doorframes. These problems were noted on three (3) of the facility's four (4) hallways. The 100, 300, and 400 hallways had deficits in maintenance identified. Facility census: 115. Findings include: a) Room 114 On 05/15/12, at approximately 6:15 p.m., observations were made of a leaking wax ring around the toilet in Room #114. Resident #55 utilized this toilet. Employee #105 (nurse aide) commented this toilet had leaked for an extended period. On 05/16/12, Employee #97 (maintenance supervisor) indicated he had replaced the wax ring on the toilet in Room #114. b) Rooms #405, #406, #407, and the 100 hall central bath area On 05/16/12, at approximately 11:00 a.m., observations were made of the arms on the toilet safety frames in Room #405, #406, #407 and in the central bath area on the 100 hallway. The arms of the safety frames, which were to assist residents in getting on and off of the toilet, were shaky and unsteady. Employee #97 indicated he knew these safety frames had issues with unsteadiness of the arms and had tried to replace as many as possible. He indicated he wanted to replace them all with a grab-bars/handrails that attached to the wall. c) Rooms #405 and #407 On 05/22/12, at approximately 10:00 a.m., an observation revealed an inappropriate toilet tank covering in Room #405. The facility had utilized a plastic tray to cover the back of the toilet tank. In Room #407, the toilet tank cover was cracked. Employee #97 indicated he would replace these tank coverings and agreed these were not safe. d) Walls, doors, door frames On 05/15/12 at 4:11 p.m., an observation of the door frame going into the bathroom of Room #411 revealed scratched and marred areas. On 05/14/12 at 2:50 p.m., an observation in Room #405 revealed the door facing from this bathroom, that led into the adjacent room, had scratches and areas where the finish had come off. Peeling paint was observed behind the toilet near the baseboard. On 05/14/12 at 2:40 p.m., an observation of the door facing on the bathroom in Room #305 noted scratched areas. On 05/22/12 at 10:30 a.m., the maintenance supervisor indicated the previous administrator had sent him to a local paint store to purchase primer in an effort to repair and repaint the doors. However, he said they did not get to finish the project. He also said they had tried to use wood filler on the scratched areas, but the filler was a darker color than the doors/door frames. He also said the doors would not stain because the plastic coating had come off the doors. On 05/22/12, at approximately 11:00 a.m., the maintenance supervisor said he would report these findings to his property manager.",2016-07-01
8202,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,272,E,0,1,JXHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, family interview, and staff interview, the facility failed to ensure that conditions residents were experiencing were thoroughly and accurately assessed for issues requiring further interventions. There was no evidence Resident #179 and Resident #132 had an accurate assessment completed to reflect their dental status. Residents #184 and #185 did not have their pain thoroughly assessed in order to evaluate the site and severity of the pain, and Resident #73 did not have a thorough range of motion assessment. Failure to properly assess these conditions had the potential to result in the conditions not being properly treated. This practice was true for five (5) of forty-six (46) Stage 2 sampled residents. Resident identifiers: #179, #132, #184, #185, and #73. Facility Census: 115. Findings include: a) Resident # 179 During a resident interview, conducted on 05/14/12 at 1:00 p.m., it was identified this resident was alert and oriented. She was questioned about her oral status and was asked whether she had any pain in her mouth or problems with her dentures. She said she does have pain related to her dentures because they rub her guns and needs new ones. She stated she can hardly eat anything, as her dentures have rubbed her gums sore on the bottom because they are too big. According to the resident, she has lost a lot of weight over the past several months. During a review of the medical record for Resident #179, it was noted her oral assessment was conducted on 04/23/12. This assessment indicated she did not have anything wrong with her teeth at that time. Her Minimum Data Set, dated dated [DATE], also indicated there were no oral or dental problems present. Her nursing notes were reviewed and there were no problems identified with oral status in the nursing notes since her admitted . There was no evidence there had been any complaints of mouth pain The resident was interviewed again on 05/17/12 at 2:00 p.m She stated her mouth was still sore and she had requested some soup for dinner. She stated it had been hurting for at least two weeks or maybe more. She was questioned about her mouth and stated that no one had looked in it, but she knew it was her dentures rubbing her bum because she had lost weight during the last few months and her dentures were too big. She stated she talked with the social worker about them, but she did not want to get anything done until she talked with her husband, because he might want her to use his dentist. She said she told the Social Worker to just wait for any further interventions until she talked to her husband. During medication pass on 05/17/12, Employee #3, a nurse, was observed administering medications to this resident. The resident told him her mouth was hurting and she would like some soup for dinner. The nurse told her that he would let her doctor know her mouth was hurting and get her something to rinse it out with that may make it feel better. He did not look in her mouth or do any type of oral exam. Employee #3 was interviewed at 5/17/12 4:30 p.m. He said he did not know anything about her mouth pain prior to the resident telling him it was hurting. He stated they usually pass this type of information in report. Resident #179 was interviewed again on 05/21/12 at 11:45 a.m. about her mouth. She verified that it was still hurting. She was questioned about an oral assessment and she verified that no one had actually looked inside her mouth, but they did get her some medicine to rinse it out with. She stated she would like the Social Worker to go ahead and make her a dental appointment. It was confirmed that staff members were aware of her mouth pain for at least several days, but there was no evidence an oral assessment was ever completed to further assess this issue. There were no entries in the medical record to reflect she was experiencing mouth pain to ensure this issue was being properly assessed. ====== b) Resident # 132 During a resident interview, on 05/22/12 at 2:30 p.m., Resident #132 was asked, Do you have any chewing or eating problems? This resident stated she does have chewing and eating problems sometimes because she recently had eight (8) teeth pulled and was getting new dentures soon. She stated that she had MS ([MEDICAL CONDITION]) and had muscle spasm sometimes in her throat. The resident's medical record was reviewed and revealed there were no problems identified with her chewing or eating. There was also no evidence found in the medical record this resident had her lower teeth extracted and was getting new dentures. It was noted that on 12/17/11, an oral assessment had been completed. This assessment identified the condition of her teeth as decayed, broken, and greater than three (3) teeth were missing. The minimum data set (MDS), with an assessment reference date (ARD) of 12/23/11, revealed in section L that there were no issues with her oral/dental status. This did not match the original oral assessment. A dental consult in the medical record was dated 01/19/12. According to the dentist, the resident had decayed teeth and needed #21, #22, #23, #24, #25, #26, #27, #28, and #29 extracted. According to the dentist, she also needed new dentures. The MDS assessments did not accurately reflect the resident's oral/dental status. ====== c) Resident #184 During an interview, on 05/22/12 at 2:00 p.m., Resident #184 was asked whether she had discomfort such as pain, heaviness or burning with no relief. She replied Yes. She stated she had pain in her left leg where she had broken her hip. The nurse (Employee #67) was interviewed 05/22/12 at 8:45 a.m. She was questioned about the facility's pain assessments and monitoring. She stated they record the pain information on the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. It was recorded this resident had received this medication a total of five (5) times. There was no evidence on the MAR indicated [REDACTED]. The nursing notes were reviewed since her admission on 05/11/12. It was noted that on 05/14/12 she complained of hip pain and was medicated. There was no evidence of the severity of the pain. A nursing noted dated 05/20/12 stated she had pain in her left leg. The severity of the pain was not assessed. There was no evidence of the location of the pain the other three (3) times the resident received the medication and the severity was never assessed to see whether she was receiving an effective medication. This medication was ordered as needed for severe pain. ====== d) Resident # 185 This resident was interviewed on 05/22/12 at 2:30 p.m. She was asked whether she was having any discomfort now or had she been having discomfort such as pain, heaviness, burning, or hurting with not relief. She stated Yes. She said her left arm was hurting. This resident was interviewed again at 8:15 a.m. on 05/22/12. She stated her chest was hurting and they had just given her something and checked her vital signs. This resident's Medication Administration Record [REDACTED]effective for relieving this resident's pain as soon as the pain medication was administered. The pain location and severity had not been recorded. This resident had voiced she was still experiencing pain and the nurse had just given her some medicine. Employee #67 was interviewed 05/22/12 at 8:45 a.m. She stated she had accidentally initialed the medication was effective and needed to go back and circle it. She verified there was no location or severity included when they assessed for pain and sometimes they record it in nursing notes. The nursing notes were reviewed and there was no evidence that the severity of the pain had been assessed. ====== e) Resident #73 It was identified this resident had contractures present to both legs. During a family interview, on 05/22/12, it was identified that she did not get up in a chair much anymore due to her contractures and chronic pain. Her last minimum data assessment (MDS), dated [DATE], identified in section S that this resident had contractures of both legs. Her last comprehensive assessment, dated 06/14/11, indicated in section S this resident did not have any contractures. Her CAA (care area assessment) did not assess contractures in her knees/ legs and this was not included in her care plan, which was to be based on this assessment. It was identified this resident had contractures present in 2007 when she was admitted to this facility. The Director of Nursing was interviewed at 10:30 a.m. on 05/21/12, She verified the assessment was incorrect and that the contractures were actually present when the resident was admitted and should have been included on the MDS of 06/14/11.",2016-07-01
8203,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,274,D,0,1,JXHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a comprehensive assessment after a significant change for one (1) of forty-six (46) sampled residents. The resident's health status changed, all medications were discontinued, [MEDICATION NAME] was added for pain, and the resident was put on comfort care only. Facility census: 115. Resident identifier: #104. Findings include: a) Resident #104 Review of the medical record for Resident #104 found the resident had been placed on comfort measures only on 04/26/12. Employee #39 (registered nurse) and Employee #16 (social worker) met with the resident's son and discussed his wishes for comfort care. The medical record identified Employee #39 updated the post form to reflect the changes in care. On 05/01/12 the physician discontinued all medications and added [MEDICATION NAME] related to pain. During an interview with Employee #17, on 05/16/12 at 10:15 a.m., it was confirmed she and Employee #39 had discussed with the son his wishes. On 05/17/12, an interview was conducted with Employee #44 related to the comfort measures put in place for Resident #104, the discontinuation of her medications, and the addition of [MEDICATION NAME]. When Employee #44 (MDS nurse) was asked, on 05/17/12 a 1:45 p.m., if a significant change had been completed for Resident #104, she stated, I guess we missed that.",2016-07-01
8204,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,279,E,0,1,JXHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interviews, staff interview, and observations, the facility failed to ensure care plans reflected the care a resident was assessed to need, and the care that was being provided to the residents. The care plans were not accurate and did not reflect the care being provided to the residents. This was found to be true for nine (9) of forty-six (46) sampled residents. Resident identifiers: #145, #179, #132, #73, #35, #104, #7, #3, and #117. Facility Census: 115. Findings include: a) Resident #145 1) This resident was observed on 05/14/12 at 1:00 p.m. in a bed in the high position. She had her bedside table beside her and appeared comfortable. She was interviewed and was alert and oriented answering all of the questions correctly as verified in her record. She was observed in bed multiple times and always had her head elevated in a high position and not in a low bed. During a review of the physician's orders [REDACTED]. It was verified in the medical record this resident had not fallen since she had been at this facility. She had fallen at home and broken her leg. She had been admitted to the facility for therapy. A nursing assistant (Employee # 46) was interviewed, on 05/17/12 at 12:15 p.m., regarding this resident's bed. She stated she had never seen this resident in a low bed and that she did not know she needed one. She also said she had never seen this resident try to get up and did not know of any falls since the resident had been there. The resident's care plan,dated 04/30/12,was reviewed. The care plan identified this resident as a falls risk. The intervention listed in her care plan was utilize low bed. 2) The resident's care plan was further reviewed for the amount of transfer assistance she required. Her care plan addressed that she needed extensive/total assistance for ADL (activity of daily living) care in bathing, grooming, dressing, bed mobility, transfers, locomotion, toileting, due to left distal femoral fracture. The goal was for her to perform transfers with supervision within ninety (90) days. The interventions gave directions for the amount of assistance to be provided with every area except transfers. During an interview with the resident, on 05/15/12 at 1:00 p.m., she stated right now the only way she was allowed to transfer was with the mechanical lift. She stated she had never transferred without the lift yet, she had to wait until her doctor approved other methods of transfer. At 12:15 p.m. on 05/17/12, Employee #46 verified staff always use a mechanical lift to transfer this resident. The care plan did not include any directions of transferring only with a mechanical lift. Her medical record was reviewed further and it was noted on 04/20/12 that she had a transfer evaluation. The evaluation noted she was to use the mechanical lift and two people to help her transfer. This information was not recorded in her comprehensive care plan. ====== b) Resident #179 During a resident interview, conducted on 05/14/12 at 1:00 p.m., it was identified that this resident was alert and oriented. She was questioned about her oral status and was ask whether she had any pain in her mouth or problem with her dentures. She said she does have pain related to her dentures because they were too loose and she needed new ones. She stated she could hardly eat anything because her dentures have rubbed her gums sore on the bottom because they are too big. She stated she has lost a lot of weight over the past several months. During a review of the medical record for Resident #179, it was noted her oral assessment was conducted on 04/23/12. This assessment indicated she did not have anything wrong with her teeth at that time. Her Minimum Data Set, dated dated [DATE], also indicated there were no oral or dental problems present. The resident was interviewed again on 05/17/12 at 2:00 p.m. She stated her mouth was still sore and she had requested some soup for dinner. She stated her mouth had been hurting for at least two weeks or maybe more. She was questioned about her mouth and stated no one had looked in it, but she knew it was her dentures rubbing her gums because she had lost weight during the last few months and her dentures were too big. She stated she went and talked with the social worker about them but she did not want to get anything done until she talked with her husband because he may want her to use his dentist. She said that she told the Social Worker to just wait for any further interventions until she talks to her husband. During medication pass on 05/17/12, this surveyor observed a nurse, Employee #3, administering medications to this resident. She told him that her mouth was hurting and she would like some soup for dinner. The nurse told her that he would let her doctor know her mouth was hurting and get her something to rinse it out with that may make it feel better. He did not look in her mouth or do any type of oral exam. Employee #3 was interviewed at 5/17/12 4:30 p.m. and he said that he did not know anything about her mouth pain prior to the resident telling him it was hurting. He stated that they usually pass this type of information in report. Resident #179 was interviewed again, on 05/21/12 at 11:45 a.m., about her mouth. She said it was still hurting. There was no evidence in this resident's care plan it had been identified the resident was having any dental issues or needed new dentures. ====== c) Resident # 132 During a resident interview, on 05/22/12 at 2:30 p.m., Resident #132 was asked the question Do you have any chewing or eating problems? The resident stated she does have chewing and eating problems sometimes because she recently had eight (8) teeth pulled and was getting new dentures soon. She stated that she has MS ([MEDICAL CONDITION]) and has muscle spasm sometimes in her throat. The resident's medical record was reviewed and revealed there were no problems identified with her chewing or eating. There was also no evidence found in the medical record this resident had her lower teeth extracted and was getting new dentures. It was noted that on 12/17/11, an oral assessment was completed. This assessment revealed that the condition of her teeth was decayed, broken, and greater than three teeth were missing. A dental consult in the medical record was dated 01/19/12. According to the dentist, the resident had decayed teeth and needed #21, #22, #23, #24, #25, #26, #27, #28, #29 extracted. According to the dentist, she also needed new dentures. During an interview with the Social Worker (Employee # 17) on 05/21/12 at 11:00 a.m. it was confirmed this resident was getting her new dentures that day. She stated the resident had her teeth pulled recently and she had new dentures made. The resident's comprehensive care plan did not reflect this resident was having oral issues, that she recently had her teeth pulled, that she had problems chewing, or that she was getting new dentures. ====== d) Resident #73 It was identified this resident had contractures present to both legs. During a family interview, on 05/22/12, it was identified that the resident does not get up in a chair much anymore due to her contractures and chronic pain. Her last minimum data assessment (MDS), dated [DATE], identified in section S that this resident had contractures to both legs. It was identified this resident had contractures present in 2007 when she was admitted to this facility. The Director of Nursing (DON) was interviewed on 05/21/12 at 10:30 a.m. She verified the contractures of the legs were present when the resident was admitted in 2007. She also verified there were no contractures or interventions identified in the interdisciplinary care plan. The DON provided a procedure that she stated was taught to the nursing assistants about providing basic range of motion. This described the process for providing ROM to residents during care. There were no specific directions provided to the amount of ROM specific for this resident. Her contractures were not included in her care plan and specific positioning instructions were not provided. ====== e) Resident #35 Review of the medical record for Resident #35 found she was receiving hospice services. The resident's care plan contained no evidence the resident was receiving hospice services as the facility failed to incorporate goals and interventions related to hospice services. Further review of the medical record found hospice services had created a care plan for their services. No goals or interventions were developed on the care plan. The hospice care plan only gave the facility instructions to notify hospice. An example: Potential for Injury - Notify Hospice., Bowel - Notify Hospice, Impairment of skin integrity - Notify Hospice. No evidence could be found the hospice care plan identified interventions for the facility staff to follow without first notifying hospice. On 05/21/12 at 1:45 p.m., Employee #2 (director of nursing) confirmed there was an issue with the care plans. ====== f) Resident #104 Review the medical record for Resident #104 discovered the minimum data set assessment, with an assessment reference date (ARD) of 04/26/12, indicated she was on a toileting program for being frequently incontinent. No evidence was found in the care plan related to the resident's incontinence and no interventions were put in place. On 05/21/2 at 1:45 p.m., Employee #2 (director of nursing) confirmed there was an issue with the care plans. ====== g) Resident #7 Review of the medical record found the current care plan, with a target date of 06/09/12, identified the resident received a regular diet with magic cups twice-a-day (bid) to maintain a stabilized weight with no significant changes. Further review found the resident's bid magic cups were discontinued on 02/22/12. An interview with a dietary staff member, on 05/21/12 at 2:30 p.m., revealed Resident #7's diet was downgraded to a mechanical soft diet. The staff member provided a copy of the diet order and communication form, signed by licensed practical nurse (LPN), Employee #67, on 05/09/12. This care plan incorrectly instructed staff to provide magic cups bid and failed to identify the change in the resident's diet consistency. h) Resident #3 Review of the minimum data set (MDS), with an assessment reference date (ARD) of 02/26/12, found this resident had been assessed as having contractures of the neck, both shoulders, both elbows, both wrists, both hips and both ankles. Review of the current care plan, with a target date of 05/27/12, found no goals or interventions to ensure Resident #3 sustained no decline in range of motion. ====== i) Resident #117 Resident #117's medical record, reviewed on 05/21/12 at 1:45 p.m. A staff interview, conducted on 05/02/12 at 3:41 p.m., revealed the resident had slid out of bed on 05/02/12. On 05/21/12, at approximately 2:00 p.m., Employee #19 (minimum data set coordinator) provided a copy of the resident's care plan and a copy of a minimum data set assessment, assessment reference date (ARD) 03/20/12. The resident's MDS revealed the resident triggered for falls. The care area assessment (CAA) summary, dated 03/20/12, revealed the facility would address the care area of falls, which triggered on the MDS. The CAA worksheet for falls indicated the assessment items causing falls to trigger were the anti-anxiety and antidepressant medications the resident had received. The CAA worksheet indicated the facility would address falls in the care plan. A review of the resident's care plan revealed the facility did not include the risk of falls. On 05/21/12, at approximately 1:50 p.m., the director of nursing (DON) Employee #2 became aware the care plan for Resident #117 did not address the resident's risk for falls. She indicated she knew the facility had issues with the development and revision of the resident care plans.",2016-07-01
8205,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,280,E,0,1,JXHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to revise the care plans for four (4) of forty-six (46) sampled residents. Residents' care plans were not revised when they were receiving comfort care, [MEDICAL TREATMENT] interventions were not incorporated into the care plan, [MEDICAL CONDITION] were not addressed, interventions for the use of psychoactive medications were not established, and no interventions were put in place for a resident experiencing episodes of pain. Facility census: 115. Resident identifiers: #104, #17, #55, and #185. Findings include: a) Resident #104 Review of the medical record for Resident #104 found, on 04/26/12, the resident was placed on comfort measures only. Employee #39 (registered nurse) and Employee #16 (social worker) met with the resident's son and discussed his wishes for comfort care. The medical record identified Employee #39 as the person who updated the POST (physician's orders [REDACTED]. On 05/01/12, the physician discontinued all medications and added [MEDICATION NAME] related to pain. During an interview with Employee #17, on 05/16/12 at 10:15 a.m., it was confirmed that she and Employee #39 had discussed with the son his wishes and the care plan was not updated to reflect the changes in care. b) Resident #17 1) Suicidal ideation Review of the medical record found Resident #17 had stated to the facility on [DATE], I wish I had a gun, I'd shoot them both then shoot myself. On 05/21/12 at 1:48 p.m., Employee #2 (director of nursing) stated, She has said she was going to kill herself before. Back on 01/31/12, she was sent to the hospital then for psychiatric services. Review of the medical record found further documentation the resident had suicidal ideation on other occasions. On 02/10/12, Resident #17 told the nurse I don't care if I die. On 01/31/12, the resident told her roommate and daughter, with a nursing assistant present, she was going to kill herself. The care plan had not been revised to address the resident's continued expressions of [MEDICAL CONDITION]. On 05/21/12 at 1:48 p.m., Employee #2 confirmed there was a problem with the care plans. 2) [MEDICAL CONDITION] medications On 04/03/12, the attending physician ordered [MEDICATION NAME] 20 mg now and then BID (twice a day). During an interview with Employee #2 (director of nursing), on 05/21/12 at 12:45 p.m., she stated, the [MEDICATION NAME] was ordered related to the suicidal ideation. Review of the care plan for Resident #17 found no interventions put in place for staff to follow for the use of [MEDICATION NAME]. According to Employee #2 on 05/21/12 at 1:48 p.m., she was aware the facility had issues with care plans. c) Resident #185 This resident's care plan, dated 05/21/12, identified a problem with alteration in comfort related to chronic back pain. Her care plan identified measures for relieving pain such as position for comfort and to utilize pillows for positioning. During a review of this resident's medical record, there was no evidence she had exhibited back pain since she had been admitted to this facility on 05/09/12. She had exhibited tightness in her chest in the mid-epigastric area on multiple occasions and had been admitted to the hospital on [DATE], when she experienced chest pain. She returned to the facility on [DATE]. The physician had ordered [MEDICATION NAME] 150 mg twice a day, on 05/21/12, [MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease). Her care plan had not been revised to reflect chest pain and discomfort after she had experienced this multiple times and been sent to the hospital related to this. . d) Resident #55 Resident #55 received [MEDICAL TREATMENT] treatment three (3) times per week due to end stage [MEDICAL CONDITION]. The care plan review, conducted on 05/21/12, at approximately 9:00 a.m., revealed the facility had care planned the following focus area: Resident exhibits or is at risk for impaired renal function and is at risk for complications related to [MEDICAL TREATMENT]. The goal for this focus area stated: [MEDICAL TREATMENT] access will remain patent x 90 days. The interventions to achieve this goal listed the wrong access site. The resident currently had an arteriovenous (AV) graft to his upper right arm. The care plan addressed an old catheter access site to the right groin. The resident indicated, on 05/21/12, at approximately 9:30 a.m., the [MEDICAL TREATMENT] center used the AV graft in his right upper arm. Further care plan review revealed the facility had not included in the plan, monitoring of the positive bruit and thrill in the AV graft.",2016-07-01
8206,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,309,D,0,1,JXHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure Resident #185 was provided services to attain her highest practicable level of comfort from pain. She did not receive her medication as ordered by the physician to treat her chest discomfort. The resident had a [DIAGNOSES REDACTED]. A medication was ordered by the physician for treatment of [REDACTED]. Additionally, a pain medication given this resident was noted effective on the Medication Administration Record [REDACTED]. Resident identifier: #185. Facility Census: 115 Findings Include: a) Resident #185 During an interview with this resident, on 05/22/12 at 8:15 a.m., she stated her left chest was hurting. She said that they had just given her some medication, but it was still hurting. Her Medication Administration Record [REDACTED]. This was just fifteen (15) minutes prior to the resident expressing she was having pain. It was also recorded, on the MAR, that this medication was effective. This was fifteen (15) minutes after it was administered. In addition, the MAR indicated [REDACTED]. The resident's medical record was reviewed. It was noted this medication had been ordered at 1:40 p.m. on 05/21/12. The medication was scheduled on the MAR indicated [REDACTED] The dose for 05/21/12 at 9:00 p.m. was circled, meaning it was not given. At 8:15 a.m. on 05/22/12, the dose to be given at 9:00 a.m. on 05/22/12 was circled. The nurse (Employee #67) was interviewed on 05/22/12 at 8:45 a.m. She was questioned about the record stating the resident's pain medication was effective. She stated she must have circled that by accident. Employee #67 was then asked why the medication [MEDICATION NAME] 150 mg, that was ordered the day prior to this observation, had been circled as unavailable two (2) times. She stated that it had not yet come in from the pharmacy. The nurse was questioned about the availability of medications in the facility. She stated, They have meds in the Pyxis (an automated machine for dispensing medications), but she would have to go up and check if that is in there. (It was verified that when she referred to the Pyxis, she was actually referring to the facility's in-house medication system which was called the Omni-Cell.) At 8:55 a.m., Employee #67 reported she looked in the facility's Pyxis and the [MEDICATION NAME] was available there so she went ahead and gave the medication. The resident was interviewed again on 05/22/12 at 9:15 a.m. She confirmed that her pain was better after she took her medicine (the [MEDICATION NAME]). This medication had been ordered for eighteen (18) hours and was in the facility to administer, but had not been administered. . II Based on medical record review and staff interview, the facility failed to ensure one (1) of forty-six (46) Stage 2 sampled residents was appropriately monitored for mouth pain in accordance with physician's instructions. Resident identifier: #7. Facility census: 115. Findings include: a) Resident #7 Review of the medical record found a 05/15/12 physician's progress note documenting the resident was examined for complaints of mouth pain. The physical examination documented the examiner found inflammation present, tenderness elicited, Patient with redness and tenderness to tongue, palate, and [MEDICATION NAME] areas. Further review of the progress note found, Assessment: Patient with inflamed (sic) taste buds and oral mucosa. ; decline in status requiring intervention; Plan Add new medication(s); monitor for signs of worsening symptoms; [MEDICATION NAME] swish and swallow QID (four-times-a-day) x 7d (for seven days). Monitor status. Review of the nursing notes found no evidence nursing staff monitored or assessed the resident's oral status in accordance with the instructions and plan of care. This issue was brought to the attention of the director of nursing (DON), Employee #2, on the afternoon of 05/21/12. She was unable to provide evidence of assessment or monitoring of this resident's oral status.",2016-07-01
8207,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,323,D,0,1,JXHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and resident interview, the facility failed to ensure safety interventions ordered by the physician were implemented in an attempt to lessen the risk of injury. The residents had physician's orders [REDACTED]. Observations found these measures were not being employed. Two (2) of forty-six (46) sampled residents were affected. Facility census: 115. Resident identifiers: #17 and #145. Findings include: a) Resident #17 During the resident interview, on 05/15/12 at 10:30 a.m., Resident #17 was observed in bed. The bed was not in a low position and no floor mats were present. Review of the medical record revealed the resident had an order in place for floor mats and a low bed related to accidents. During an interview with Employee #2 (director of nursing), on 05/16/12 at 4:46 p.m., it was learned the mats should be in position except when the resident was eating or being bathed. At 4:48 p.m. on 05/16/12, the resident was again observed while in bed. There were no mats in place and the bed was not in the low position as ordered. This information was immediately conveyed to Employee #2. The facility discontinued the mats and low bed on 05/16/12 at 6:15 p.m.; however, at the time of the observations, the orders for the mats and low bed were in effect. b) Resident #145 This resident was observed on 05/14/12 at 1:00 p.m. in a bed in the high position. She had her bedside table beside her and appeared comfortable. She was interviewed and found to be alert and oriented. She answered all of the questions correctly as verified by review of her medical record. She was observed in bed multiple times. Her head was always elevated and the bed was in a high position. During a review of the physician's orders [REDACTED]. It was verified in the medical record this resident had not fallen since she had been at this facility. She had fallen at home, broken her leg, and had come to the facility for therapy. A nursing assistant (Employee #46) was interviewed, on 05/17/12 at 12:15 p.m., regarding this resident's bed. She stated she had never seen this resident in a low bed and that she did not know she needed one. She also said she had never seen this resident try to get up or known of any falls since she had been here. The resident's care plan, dated 04/30/12, was reviewed and identified this resident as a falls risk. The intervention listed in her care plan stated utilize low bed.",2016-07-01
8208,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,329,D,0,1,JXHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the medication regimen for one (1) of forty-six (46) Stage 2 sample residents was not free from unnecessary medications. The facility failed to provide non-pharmacological interventions for a resident expressing [MEDICAL CONDITION], and failed to review the resident for falls related to the use of [MEDICAL CONDITION] medications for one (1) of forty-six (46) sampled residents. Facility census: 115. Resident identifier: #17. Findings include: a) Resident #17 1) Review of the medical record found Resident #17 had stated to the staff, on 04/02/12, I wish I had a gun, I'd shoot them both then shoot myself. On 05/21/12 at 1:48 p.m., Employee #2 (director of nursing) stated, She has said she was going to kill herself before back on 01/31/12. She was sent to the hospital then for psychiatric services. Review of the medical record found further documentation the resident had [MEDICAL CONDITION] on other occasions. On 02/10/12, Resident #17 told the nurse I don't care if I die. On 01/31/12, the resident told her roommate and daughter with a nursing assistant present, she was going to kill herself. On 04/03/12, the attending physician ordered [MEDICATION NAME] 20 mg now and then BID (twice a day). On 05/01/12, the [MEDICATION NAME] was increased to 40 mg twice a day. During an interview with Employee #2 (director of nursing), on 05/21/12 at 12:45 p.m., she was asked why the [MEDICATION NAME] had been started on 04/03/12. She stated, The [MEDICATION NAME] was ordered related to the suicidal ideation on the day before. Review of the care plan for Resident #17 found no interventions put in place for staff to follow for the use of [MEDICATION NAME]. The use of [MEDICATION NAME] could not be found listed on the care plan. During an interview with Employee 17 (Social Worker) on 05/21/12 at 12:53 p.m., she stated, She was unaware Resident #17 had suicidal ideation, she said no one had ever told her. Employee #17 was then asked what the facility normally did when a situation like this occurred. She stated, I would go talk to the resident and do an assessment. On 05/21/12 at 1:48 p.m., Employee #2 (director of nursing) stated, The family nurse practitioner chose not to do anything about the suicidal threats because the nurse told her the resident was confused. No evidence could be found the facility attempted any non-pharmacological interventions when the resident voiced homicidal and suicidal thoughts. 2) Review of the falls investigation forms found Resident #17 had nine (9) falls between 02/14/12 and 04/12/12. During an interview with Employee #2 (director of nursing), on 05/21/12 at 12:45 p.m., she was asked if the facility had the pharmacist review the [MEDICAL CONDITION] medications related to falls. She stated, We discussed it in IDT (interdisciplinary team). Review of the medical found on 02/21/12, the facility held a meeting and discussed the resident's falls. The note included, Discussed with IDT r/t fall on 02/20/12: cont (continue) with current POC treatment for [REDACTED]. During an interview, on 05/21/12 at 4:10 p.m., with Employee #43 (administrator), Employee #30 (assistant director of nursing), and Employee #130 (pharmacist/via telephone conference) the pharmacist was asked if the facility had asked her to review Resident #17's [MEDICAL CONDITION] medications related to falls. Employee #130 stated, No. No evidence could be found the facility followed up on contacting the pharmacist related to Resident #17's falls.",2016-07-01
8209,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,364,D,0,1,JXHC11,"Based on resident interview, observation, measurement of food temperatures, and staff interview, the facility failed to serve hot food for two (2) of one hundred fifteen (115) residents. These residents were served cold lentil soup during the lunch meal. Resident identifiers: #8 and #81. Facility census: 115 Findings include: a) Resident #8 During observation of the lunch meal on 05/14/12, Resident #8 received her lunch meal fifteen (15) minutes after other residents seated at her table received theirs. When her tray arrived, she stated her soup was cold. b) Resident #81 During observation of the lunch meal on 05/14/12, Resident #81 received her lunch meal after other residents seated at the same table had already been served. The facility provided a thermometer to Employee #87. When Employee #87 checked the temperature of the soup, the thermometer showed the soup was 100 degrees Fahrenheit (F). To ensure palatability, the professionally accepted temperature for hot foods at the point of service is a minimum of 120 degrees F.",2016-07-01
8210,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,367,D,0,1,JXHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure the therapeutic diet for one (1) of forty-six (46) Stage 2 sampled residents was prescribed by the attending physician. The resident was ordered a regular diet, but was provided a mechanical soft diet. Resident identifier: #7. Facility census: 115. Findings include: a) Resident #7 Review of the medical record found a discrepancy between the diet ordered by the physician and the diet the resident was receiving. According to the current physician's orders [REDACTED]. Observation of the noon meal, on 05/21/12, noted the resident received a mechanical soft diet. An interview with a dietary staff member, on 05/21/12 at 2:30 p.m., revealed the resident's diet was changed from a regular diet to a mechanical soft diet on 05/09/12. The dietary staff member provided a copy of a diet order and communication form, dated 05/09/12, which changed the resident's diet texture from regular to mechanical soft. The form was signed by a licensed practical nurse (LPN), Employee #67. Review of the medical record found no order by the attending physician changing the resident's diet. An interview with an LPN, Employee #67, on 05/21/12 at 3:20 p.m., revealed the nurse was feeding the resident breakfast on 05/09/12 when she noted the resident was having difficulty eating a piece of sausage. Employee #67 stated she filled out a form to change the resident's diet texture to mechanical soft and sent it to the dietary department. The nurse could provide no evidence the attending physician was consulted prior to making this change to the resident's diet. The nurse stated it was her understanding they did not require an order to downgrade a resident's diet, only to upgrade one. An interview with a corporate nursing consultant, on 05/21/12 at 4:30 p.m., elicited the facility had no standing orders or facility policy which would allow an LPN to change a resident's diet without a physician's orders [REDACTED].>",2016-07-01
8211,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,371,F,0,1,JXHC11,"Based on observation, facility policy review, and staff interview, the facility failed to ensure foods were served and stored under sanitary conditions. Observations were made in the cafe area of staff members touching nonfood items, then food items without changing gloves. In addition, observations were also made of undated/unlabeled food, and expired/out dated food items, stored in the nourishment pantry refrigerators at both nursing stations. This practice had the potential to affect more than an isolated number of residents. Facility census: 115. Findings include: a) 100/200 hall On 05/16/12, at approximately 6:00 p.m., observations on the 100/200 hall nourishment pantry revealed: -- Peanut butter sandwiches with a date of 05/11/12. Employee #101 (registered nurse) indicated she would throw away these sandwiches. b) 300/400 hall On 05/16/12, at approximately 6:15 p.m., Employee #28 (licensed practical nurse) assisted with the observations of the refrigerator on the 300/400 hall. The following were noted: -- A carton of Activia yogurt did not have a date or any resident's name on the package. -- A carton of Yoplait yogurt in the freezer did not have a date or resident's name labeled on the package. The LPN stated a family had probably brought these items in for a resident. -- A carton of eggs had a manufacturer's date of 2010. The egg carton had eggs in it and contained no one's name. -- There were several sandwiches with no date or label in the refrigerator. -- A plastic container of fruit had spoiled. The fruit had no date or label and appeared to be container brought in from a resident or family, not a container provided by the facility. -- A Subway salad had no date or label and when the LPN opened the salad the contents were spoiled. The dietary manager (Employee #130) provided a copy of the facility's Use By dating guideline. The guideline stated Foods that have been mixed with other ingredients, prepared in any way, or portioned out include but are not limited to: Juices, thickened beverages, canned fruit, unused portions, prepared salads, cut fruits/vegetables, roasted/sliced meats, are used within three (3) days after preparation. Ready-to-eat potentially hazardous foods, including but not limited to: Milk, yogurt, cottage cheese, cooked foods, hard cooked eggs, produce, use by date seven (7) days after opening. b) Dining Observation in the Cafe During an observation of the Cafe, at 11:40 a.m. on 5/22/12, Employee #13 was observed preparing meals and serving them to residents. She was the only staff member preparing and serving in the cafe at that time. She put on gloves and was preparing chicken sandwiches. Employee #13 was observed to touch the food with her gloved hands, and then touch non-food items. This contaminated her gloves. After handling the plates and the lids to the steam table, she touched a food item while wearing the same gloves. She put lettuce on the sandwiches with her contaminated gloves. No tongs were used to handle the lettuce or buns after she had touched non-food items with her gloved hands. Employee #13 was interviewed about the process of serving the foods and touching both food and non-food items with the gloves. She verified she could have used tongs to handle the food or could have used only one hand to prepare the food and the other for handling non-food items. .",2016-07-01
8212,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,425,D,0,1,JXHC11,"Based on record review, resident interview, and staff interview, the facility failed to administer a medication to one (1) of forty-six (46) Stage 2 sample residents in a timely manner. Resident #185 did not receive the medication Zantac, as ordered by the physician to treat her chest discomfort related to gastroesophageal reflux disease (GERD), for eighteen (18) hours after it was ordered. Resident identifier: #185. Facility Census: 115 Findings Include: a) Resident #185 During an interview with this resident, on 05/22/12 at 8:15 a.m., she stated her left chest was hurting. She said that they had just given her some medication, but it was still hurting. Her Medication Administration Record [REDACTED]. It was also noted, on the MAR, that the resident had a new medication order dated 05/21/12 for Zantac 150 mg twice a day (BID). Further review of the medical record found this medication had been ordered at 1:40 p.m. on 5/21/12. It was scheduled on the MAR indicated [REDACTED] The dose for 05/21/12 at 9:00 p.m. was circled, meaning it was not given. At 8:15 a.m. on 05/22/12, observation revealed the dose to be given at 9:00 a.m. on 05/22/12 was circled. The nurse (Employee #67) was interviewed on 05/22/12 at 8:45 a.m. When asked why the medication Zantac 150 mg, that was ordered the day prior to this observation, had been circled unavailable two (2) times, she stated it had not yet come in from the pharmacy. She was questioned about the availability of medications in the facility and she stated, They have meds in the Pyxis but I would have to go up and check if that is in there. (It was verified that when she referred to the Pyxis she was actually referring to the facility's in house medication system which was the Omni-Cell. Employee #67 reported, at 8:55 a.m., that she looked in the facility's Pyxis and the Zantac was available there, so she went ahead and gave it. The resident was interviewed again, at 9:15 a.m. on 05/22/12. She confirmed her pain was better after she took her medicine (Zantac). This medication had been ordered for eighteen (18) hours and was in the facility to administer, but had not been administered. .",2016-07-01
8213,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,428,D,0,1,JXHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, pharmacist interview, and staff interview, the facility failed to report, and the pharmacist did not identify, repeated falls for one (1) of forty-six (46) sampled residents. The resident had repeated falls and was on psychotropic medications. Facility census: 115. Resident identifier: #17. Findings include: Resident #17 Review of the falls investigation forms found Resident #17 had nine (9) falls between 02/14/12 and 04/12/12. During an interview with Employee #2 (director of nursing) on 05/21/12 at 12:45 p.m., she was asked whether the facility had the pharmacist review the psychotropic medications related to falls. She stated, We discussed it in IDT (interdisciplinary team). Review of the medical record found on 02/21/12, the facility held a meeting and discussed the resident for falls. The note included, Discussed with IDT r/t (related to)fall on 02/20/12: cont (continue) with current POC (plan of care) treatment for [REDACTED]. During an interview, on 05/21/12 at 4:10 p.m., with Employee #43 (administrator), Employee #30 (assistant director of nursing), and Employee #130 (pharmacist/via telephone conference), the pharmacist was asked whether the facility had asked her to review Resident #17's psychotropic medications related to falls. Employee #130 stated, No. No evidence could be found of the facility having followed up on notifying the pharmacist on the falls Resident #17 was experiencing. Additionally, the pharmacist had not identified this potential adverse consequence of the psychotropic medication.",2016-07-01
8214,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,431,F,0,1,JXHC11,"Based on observations and staff interview, the facility failed to ensure medications were properly stored and safely label. The facility's front medication room did not provide a sanitary environment to store medications. The sink was dirty and sink and walls had dried spills on them. There were medications stored in the refrigerator that were not properly labeled and were in a package with different medications. The package stated Pneumovax and there was a vial of the medication Acetylcysteine mixed in with the Pneumovax vials. There were vials of vitamin B12 (cobalamin) injectable laying in the bottom of the refrigerator that had no box or label. The back medication room also had containers of Tobramycin for inhalation laying in the refrigerator with no name or label. There was an opened half empty bottle of orange soda on the medication cart with no name or date. The practice of not providing safe labeling and safe storage of medications had the potential to affect more than a limited number of residents. Facility Census: 115. Findings include: a) Front Medication Room 1) The front medication room was observed with Employee #39 (a nurse), at 11:45 a.m. on 05/16/12. The sink was soiled with dried spills and the walls also had dried spills on them creating an unclean environment for the storage of medications. 2) Observations of the storage of the medications found a plastic bag with a label from the pharmacy that read Pneumovax. Inside the plastic bag were several vials of Pneumovax for injection and there was one vial that was not the same This vial was labeled 4 ml of Acetylcysteine 10% 100 mg per ml. (Pneumovax in a pneumonia vaccine. Acetylcysteine is for inhalation treatments.) The Acetylcysteine vial instructed the medication was not for injection, yet it was stored in the same plastic bag with the Pneumovax vials for injection. 3) There were two (2) vials of B 12 (cobalamin) injection in the bottom of the refrigerator. These vials did not have a label or box and it could not be determined for which resident the medications were intended. Employee #39 verified the Acetylcysteine did not belong with the vials of Pneumovax. She also verified that medications should not be laying in the refrigerator with no label. b) Rear Medication Storage Room An observation of the rear medication storage room was conducted with Employee #84 (a nurse) at 12:15 p.m. on 05/17/12. There were clear plastic containers that read Tobramycin 300 mg per 5 mls laying in the bottom of the refrigerator. These were not labeled and the box with the label was not present. The nurse verified these medications should not be in there. He stated he was not sure where they had come from. c) Medication Cart During medication administration pass observations, with Employee #84, on 05/17/12 at 4:30 p.m., a half empty bottle of orange soda was noted stored in the drawer of the medication cart. There was no name written on this bottle. Employee #84 verified the bottle should not be in the cart. He said it was not his and he did not know from where it had come.",2016-07-01
8215,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,441,E,0,1,JXHC11,"Based on observation and staff interview, the facility failed to maintain a safe, sanitary environment to help prevent the development and transmission of disease and infection. It was the facility's practice to leave opened carts of partially consumed foods, soiled plates, soiled bowls, soiled glasses, and soiled cups in the resident hallway outside the dietary department for extended periods of time. This deficient practice affected one (1) of forty-six (46) Stage 2 sampled residents, and provided access to contaminated food-related items by any resident present in the hallway. Resident identifier: #109. Facility census: 115. Findings include: a) Resident #109 Observation throughout this survey event found open three-shelf metal carts left in the resident hallway outside the dietary department for extended periods of time. It was noted the carts contained partially eaten food items, soiled plates, cups, bowls and glasses. This practice was observed following the morning snack pass, following the noon meal service, following the afternoon snack pass, and following the evening meal service. On 05/21/12 at 2:30 p.m., Resident #109 was observed in his wheelchair adjacent to the dietary department door. It was noted he was looking at the cart parked outside the dietary department which contained partially consumed food items from the afternoon snack pass. Resident #109 approached the cart and removed a Styrofoam cup of an ice cream-like substance from the top of the cart. He removed the paper covering from the cup exposing the contents. It was noted the rim of the cup was broken, and spoon marks were trailing along the top. The resident stuck his tongue into the cup and began licking and sucking at the contents. The facility placed Resident #109 and other residents at risk of disease and/or infection by this unsafe and unsanitary practice.",2016-07-01
8216,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,514,D,0,1,JXHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, and staff interview, the facility failed to document the correct area of injury and treatment and failed to document the correct medication ordered by the physician. Two (2) of forty-six (46) sampled residents were affected. Facility census: 115. Resident identifiers: #17 and #22. Findings include: a) Resident #17 Observation of Resident #17, on 05/15/12, found a dressing to the left knee. The resident stated she had a fall in the bathroom and had hurt her knee. Review of the incident and accident form, dated 04/04/12, identified the resident had an injury to the right knee from her fall in the bathroom. The physician's orders [REDACTED]. During an interview with Employee #2, on 05/16/12 at 12:45 p.m., it was confirmed the injury was to the left knee. b) During an observation of the medication administration for Resident #22, on 05/16/12 at 10:00 a.m., Employee #36 was observed to administer a medication from a bottle that read [MEDICATION NAME] Sodium 100 mg . A review of Resident #22's Medication Administration Record [REDACTED]. The nurse was interviewed about this medication and it was noted that the [MEDICATION NAME] in the medication cart was 10 mg. She stated that had to be wrong because it would take 10 (ten) of the [MEDICATION NAME] to made 100 mg. She stated they had always given the resident [MEDICATION NAME] and that this must be a transcription error. The nurse called the physician and had the order clarified. She stated they had been giving the correct medication, but it had been transcribed incorrectly.",2016-07-01
8217,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-07-25,154,D,1,0,1LKT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to accurately inform the family and resident of the total health status related to antibiotic use for one (1) of three (3) residents reviewed for the use of antibiotics. The facility notified the resident and family member the resident was receiving the antibiotic [MEDICATION NAME] for a urinary tract infection. The resident was actually receiving the antibiotic for another diagnosis. He did not have a urinary tract infection at the time this antibiotic was ordered. Resident identifier: #114. Facility census: 112. Findings include: a) Resident #114 Review of the medical record, on 07/24/13, identified a physician's orders [REDACTED].#90 (licensed practical nurse - LPN) dated 06/29/13. The physician's orders [REDACTED]. Further review of the medical record found a general note written by Employee #90 (LPN), on 06/29/13 at 19:12, stating the family was notified this resident was ordered [MEDICATION NAME] for a urinary tract infection. During an interview conducted on 07/24/13 at 3:11 p.m., Employee #137 (family nurse practitioner), revealed she did not order [MEDICATION NAME] for a urinary tract infection. She stated, The [MEDICATION NAME] was ordered for results of a chest-x-ray called to me on 06/29/13, by the facility. Employee #137 also stated, I wouldn't have ordered [MEDICATION NAME] for a urinary tract infection. Review of the medical record identified a chest x-ray, dated 06/29/13, with the following impression: Under ventilated lungs, mild cardiomegaly, ill-defined densities left lung base could represent atelectasis or mild consolidation, recommend follow up.",2016-07-01
8218,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-07-25,160,D,1,0,1LKT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of discharged residents' financial account balances, medical record review, and staff interview, the facility failed to provide a final accounting and a refund of the balance of a resident's personal funds to the individual or probate administering the individual's estate within thirty (30) days of death. This was true for one (1) of three (3) discharged records reviewed for personal funds. Resident identifier: #122. Facility census: 112. Findings include: a) Resident #122 Medical record review found the resident expired at the facility on [DATE]. The resident's financial account was reviewed with Employee #59, the business office assistant, at 3:35 p.m. on [DATE]. Employee #59 verified a check was not issued for the balance of the resident's funds ($1,065.13) until [DATE]. At 5:00 p.m. on [DATE], the administrator stated the facility had to wait until the account was settled before issuing the funds and this was not always possible to refund a residents money within 30 days of death.",2016-07-01
8219,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-07-25,205,E,1,0,1LKT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to provide a discharge/transfer bed-hold policy notice that included the contact names and information should the resident wish to appeal the discharge/transfer from the facility. This was found for three (3) of three (3) residents reviewed for notice of the bed-hold policy at the time of transfer. This had the potential to affect all residents discharged /transferred from the facility. Resident identifiers: #116, #44, and #123. Facility census: 112. Findings include: a) Resident #116 Medical record review, on 07/23/13 at 11:00 a.m., revealed the resident was originally admitted to the facility on [DATE]. The resident was transferred to an acute care facility on 06/27/13. The resident was readmitted to the facility on [DATE], then transferred again on 07/04/13. No evidence was found in the resident's medical records that the resident or family was given a transfer/discharge bed-hold policy at the time of either transfer from the facility. During an interview on 07/24/13 at 3:00 p.m., with Employee #123, the director of nursing (DON), she was unable to provide evidence the bed-hold policy, either verbal or written notice, was provided to the resident/family. In addition, a copy of the written notice of transfer was not included in the resident's medical record as required by facility policy. b) Resident #44 Medical record review on 07/23/13 at 1:00 p.m., found the resident was originally admitted to the facility on [DATE]. The resident was transferred to an acute care facility on 07/18/13. No evidence was found in the resident's medical records that the resident/family was given a transfer/discharge bed-hold policy upon transfer from the facility. During an interview, on 07/24/13 at 3:00 p.m., with the DON, she was unable to provide evidence the bed-hold policy notice, either verbal or written, was provided to the resident/family. In addition, a copy of the written notice of transfer was not included in the resident's medical record as required by facility policy. c) Resident #123 Review of the resident's medical record, on 07/24/13 at 2:00 p.m., revealed the resident was originally admitted to the facility on [DATE]. A physician's orders [REDACTED].Transfer to ER for evaluation d/t irregular heartbeat and HTN. No other documentation of resident's condition or transfer could be located. During an interview, on 07/24/13 at 3:00 p.m., the DON, she was unable to provide evidence notice the bed-hold policy, either verbal or written, was provided to the resident/family. In addition, a copy of the written notice of transfer was not included in the resident's medical record as required by facility policy. d) Review of the facility's policy on Discharge and Transfers found, 5.1. For unplanned, acute transfers, patients, family, and legal guardian will be notified verbally. 5.1.1 Written notice will follow verbal notification per state requirements. 5.1.2 A copy of the written notices of transfer will be placed in the patient's medical records.",2016-07-01
8220,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-07-25,225,D,1,0,1LKT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of information reported by the facility, review of medical records, resident interview, and staff interview, the facility failed to conduct a thorough investigation to determine whether or not an injury of unknown origin was the result of abuse or neglect for one (1) of twenty-seven (27) reportable allegations/incidents reviewed. The resident was found with an avulsion [MEDICAL CONDITION] shoulder. The source of the injury was unknown, There was no evidence the facility conducted a thorough investigation to rule out abuse or neglect. Resident identifier: #62. Facility census: 112. Findings include: a) Resident #62 Review of the facility documentation of reportable allegations of abuse/neglect on 07/23/13 at 2:15 p.m., revealed a reported injury of unknown origin regarding this resident. An incident report was written by Employee #32, a licensed practical nurse (LPN) on 06/05/13 at 2:00 p.m. The report noted the incident was not witnessed and the resident's activity prior to the incident was unknown. The resident's mental status prior to the incident was documented as alert and disoriented. The mobility status prior to the incident indicated the resident required assistance, as she had paralysis on the right side. According to the report, the resident complained of shoulder pain to someone and this was reported to the nurse practitioner (NP). An x-ray was ordered. The x-ray of the right shoulder showed an avulsion fracture of the right shoulder. The physician and the responsible party were both notified of the results of the x-ray on 06/05/13. This injury of unknown origin was faxed to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Ombudsman on 06/05/13. Review of the nurses' notes revealed nothing regarding an investigation regarding the [MEDICAL CONDITION] shoulder. The facility's investigation contained a statement by the social worker dated 06/05/13 and one by the NP dated 06/18/13. There were no witness statements from nursing staff who worked on or around the date the resident complained of shoulder pain. The facility was unable to provide evidence of an investigation to determine causal factors and/or to rule out abuse or neglect. During an interview with Employee #24, the assistant director of nursing, on 07/25/13 at 11:00 a.m., she stated she asked the NP for a statement concerning the fracture. She said the NP had written a statement prior to 06/18/13, but it had been misplaced. No additional information regarding this missing statement was provided prior to exit. Several discussions were held with Employee #68, the nursing home administrator (NHA), during the survey. He stated, We talked to multiple staff members. No evidence and/or information regarding these staff inquiries was provided prior to exit. An interview was conducted with Resident #62, on 07/25/13 at 12:45 p.m. Upon inquiry about what happened to her shoulder, the resident stated, I don't remember.",2016-07-01
8221,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-07-25,250,D,1,0,1LKT11,"Based on medical record review and staff interview the facility failed to ensure a resident received medically-related social services when the resident became visibly upset after being taunted and verbally abused by another resident. This was a random finding for one (1) resident. Resident identifier: #52. Facility census: 112. Findings include: a) Resident #52 While reviewing the medical record of Resident #91 a nurses' note, written on 06/27/13 at 15:02, was discovered. The note was, Resident pulling foods off another elderly residents table, intentionally doing it, moved her drinks from her then poured her drink on the other resident, laughing, called her retard, this other resident was visible upset and crying pointing at (name of Resident #91.) This other resident has a hx (history) of being quiet, smiles a lot and not known to bother other residents. 2 residents on this hall and 1 staff member told me what (Resident #91) was doing, one resident said she was just being mean to her picking at her. I did intervene at that time and asked (Resident #91) to remove herself from the area, (Resident #91) denied it but was laughing and did not move. The resident who was upset did agree to move, as being transferred from area, (Resident #91) told her bye retard An interview was conducted with Employee #35, the social service director, at 12:58 p.m. on 07/24/13. Employee #35 identified the resident who was verbally abused and taunted, as Resident #52. She verified Resident #52 was the resident referred to in the note as being quiet and was not know to bother others. Employee #35 stated Resident #91 was sent to the hospital for her behaviors. Employee #35 agreed she should have spoken to Resident #52 when the incident occurred. Employee #35 further verified Resident #52 was alert and oriented and even though the resident was unable to speak after her stroke, she would have know and understood what Resident #91 had said to her. At approximately 2:00 p.m. Employee #35 returned to the surveyor and stated she was unable to find any nursing notes or any evidence of any interventions provided to Resident #52 on the day of the incident.",2016-07-01
8222,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-07-25,279,D,1,0,1LKT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to to develop a care plan for one (1) of seven (7) residents related to multiple health conditions and psychosocial needs for the resident. The care plan did not include information related to the care and use of a PICC line, Foley catheter, [MEDICAL CONDITION], and the use of pain medications. The care plan was also incomplete, as it did not address the identified distressed mood symptoms of this resident. Resident identifier: #114. Facility census: 112. Findings include: a) Resident #114 During a review of the medical record for Resident #114 on 07/23/13, it was found the resident entered the facility on 06/10/13. Further review identified this resident had a [MEDICAL CONDITION] in place, a peripheral inserted central catheter (PICC), a Foley catheter, and was also receiving Oxy-fast liquid and Oxy IR for pain. Review of the care plan found nothing relative to the Foley catheter, PICC line, [MEDICAL CONDITION], or the use of pain medication. This review of the care plan revealed the facility identified the resident exhibited distressed mood systems; however, the facility did not develop goals and interventions for the identified distressed mood symptoms. On 07/23/13 at 2:12 p.m. Employee #123 (director of nursing) confirmed the care plan did not identify the use of a Foley catheter, pain medications, [MEDICAL CONDITION] and PICC line. Employee #123 also confirmed the care plan for distressed mood symptoms was incomplete, in that it had no goals and interventions for the identified problem.",2016-07-01
8223,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-07-25,280,D,1,0,1LKT11,"Based on medical record review, observation of the resident's meal tray, and staff interview, the facility failed to update a resident's care plan to reflect a requested food item for one (1) of seven (7) residents reviewed. Yogurt was to be served with all meals, for this resident identified by the facility with significant weight loss. Resident identifier: #27. Facility census: 112. Findings include: a) Resident #27 Observation of the resident's breakfast tray, served in her room on 07/22/13 at 10:00 a.m., found a meal ticket which listed plain yogurt for a meal preference. The yogurt was not served to the resident. The resident's husband was at her bedside during the observation. He stated his wife had not been eating well and had lost some weight since her arrival at the facility. He said he requested plain yogurt be served with all her meals because, she will eat that when she doesn't eat anything else. He further added she ate yogurt prior to admission to the facility, and they made several special dishes at home which included yogurt as an ingredient. He said he was not sure why the facility could not comply with his request for yogurt. He stated sometimes it's there and sometimes it's not there. Employee #62, a licensed practice nurse, entered the resident's room for medication pass during the interview. This employee was asked why the yogurt was not on the resident's tray. She stated she thought the yogurt was served as a snack at 10:00 a.m., 2:00 p.m. and 8:00 p.m. but she was not sure. Further review of the resident's medical record found the resident's weight was recorded as 144.4 pounds on the date of her admission, 10/30/12. The resident's most current weight, recorded on 07/17/13 was 112.6 pounds. An interview conducted with the dietary manager, Employee #6, on 07/23/13 at 10:05 confirmed the yogurt should have been served with the resident's meal, as she received a dietary supplement (a magic cup) twice a day at 10:00 a.m. and 2:00 p.m. Observation of the kitchen refrigerator revealed the facility did have the plain yogurt available. Further review of the resident's care plan found a problem, initiated on 01/10/13, Resident is at nutritional risk. Therapeutic and mech alt. (mechanically altered) diet. Dys (dysphasia) puree NAS (no added salt), ice cream w/ (with) meals, magic cups bid (two times a day), significant weight loss x (times) six months. An approach to this problem was to honor food preferences within meal plan. On 07/24/13 at 10:00 a.m., the dietary manager, Employee #6 provided the copy of the resident's current care plan and verified the care plan should have been updated to include serving the plan yogurt with meals instead of the ice cream as listed on the current plan of care.",2016-07-01
8224,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-07-25,309,D,1,0,1LKT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure three (3) of five (5) residents, in a facility sample of thirty-one (31), received care and services necessary to promote their highest level of well-being. The facility failed to provide antibiotic medication and total parental nutrition (TPN) via Resident #116's peripherally inserted central catheter (PICC). Resident #44 had no follow-up after a laxative was administered. The facility failed to assess and treat Resident #114's complaints of stomach upset/abdominal pain. Resident identifiers: #116, #44, and #114. Facility census:112. Findings include: a) Resident # 116 1) Medical record review on 07/24/13 at 10 a.m., found the resident was originally admitted to the facility on [DATE]. Review of the admission orders [REDACTED]. All three (3) were to be given via a PICC line. According to the Medication Administration Record [REDACTED]. It was also not administered on 06/27/13 during the 11:00 p.m. through 7:00 a.m. shift. [MEDICATION NAME] was not administered at 6:00 p.m. on 06/26/13 or at 6:00 a.m. on 06/27/13. [MEDICATION NAME] was not administered on 06/26/13 and 06/27/13 at 9:00 p.m. An interview was held with Employee #123, the director of nursing (DON), on 07/24/13 at 3:00 p.m. She verified the MAR indicated [REDACTED]. No further evidence this medication was administered was provided prior to exit. 2) Further medical record review, on 07/24/13 at 11:00 a.m., found the resident was discharged on [DATE] at 22:45 (10:45 p.m.) and re-admitted to the facility on [DATE] 19:08 (7:00 p.m.) and was discharged again on 07/04/13 at 2:00 p.m. Review of the 07/01/13 admission orders [REDACTED]., 6 a.m., 12 p.m., and 6 p.m.) and Meropenem 500 milligrams (mg) every twelve (12) hours (9 a.m. and 9 p.m.) Both medications were to be given via the PICC line for the treatment of [REDACTED]. Review of the MAR for the resident's stay at the facility from 07/01/13 through 07/04/13 revealed the resident did not receive [MEDICATION NAME] on 07/02/13 and 07/03/13 at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. On 07/04/13, the resident did not receive the [MEDICATION NAME] at 12:00 p.m. The resident did not receive Meropenem on 07/02/13 and 07/03/13 at 9:00 a.m. or on 07/02/13 at 9:00 p.m. Review of the nurses' notes found no evidence the medication was given. An interview was held with Employee #123, the director of nursing (DON) on 07/24/13 at 3:00 p.m. She verified the MAR indicated [REDACTED]. She further stated, She was out for an appointment in Charleston on 07/02/13. There was no evidence the resident received the medications as ordered. By the time of exit, the facility provided no evidence the resident was out of the facility on 07/02/13. b) Resident #44 Medical records, reviewed on 07/24/13 at 2:00 p.m., found the resident received 30 milliliters (ML) of Milk of Magnesium (MOM) on 07/18/13 at 2:12 a.m. The resident had requested something to help her bowels move. Review of the MAR found no follow up on the laxative (MOM). Review of the nurse's notes found the following note, Resident complained of feeling full stated she felt uncomfortable and sore. As of 07/24/13, there were no other notes concerning bowel movements and/or efficacy of the laxative which was given on 07/18/13. During an interview with the DON on 07/24/13 at 3:00 p.m., the DON was asked to provide information related to follow up of the laxative given on 07/18/13 at 2:12 a.m. No further information was provided prior to the conclusion of the survey. c) Resident #114 1) Review of this resident's medical record on 07/22/13 at 1:59 p.m. identified this resident complained of an unrelieved upset stomach on 06/28/13. On 06/28/13 at 6:10 p.m., a nurse's note, written by a registered nurse, Employee #19 included the following, Resident continues to report unrelieved upset stomach, has PRN (as needed) medication which did not help with the symptoms nor did his scheduled stomach medication, spoke to FNP (family nurse practitioner) new order noted for [MEDICATION NAME] 30 cc every 8 hours PRN to be tried first if no relief then give [MEDICATION NAME] 4 mg every 6 hours PRN, his wife also state that he had a fever of 100.3 and wanted Tylenol to be given, new order noted for Tylenol 325 mg give 2 tablets PO every 6 hours PRN for fever, patient and wife verbalized understanding. There was no evidence Employee #19, or any nurse, checked back with Resident #114 on 06/28/13 to see if the orders obtained for [MEDICATION NAME] helped his unrelieved upset stomach. There was no evidence the resident's abdominal pain was reassessed after the [MEDICATION NAME] was administered on 06/28/13 until 06/30/13. On 06/30/13 at 01:27 (1:27 a.m.) a nurse's note said Resident resting at short intervals. Complaining of abdominal pain. Abdomen soft. Bowel sounds active x 4 quads. GT site red, cleansed with soap and h20. Drain sponge applied. Foley catheter draining dark yellow urine. Tube feeding going at 65 ml/hr. Denies nausea. Pain med given per order. Temp 08.0 pulse 78, Resp 18 even non labored. BP 132/78. A nurse's note dated 06/30/13 at 09:00 (9:00 a.m.) included, Resident reports abdominal pain. PEG tube accessed, tube in correct area, no residue noted, bowel sounds noted in all 4 quadrands (sic), resident was tender to touch on abdomen, talked to family nurse practitioner, new order noted to obtain a STAT KUB (x-ray of the kidneys, ureter, and bladder) order called to mobile imaging and resident aware. Another nurse's note, written on 06/30/13 at 16:00 (4:00 p.m.) included, Spoke to family nurse practitioner concerning resident's KUB impression showed mildly increased gas in the bowel suspicious for mild ileus and featureless loop of bowel in the left abdomen, new order was given to send resident to ER of choice for expanded GI work up since medication given not helping with the pain, went to talk to resident and his wife was present, accepted order to go to ER of choice. Resident stated that he was in pain and wanted some pain medication before he left; resident was medicated for pain and given his 4 p medication prior to leaving. Ambulance called for transport, and hospital emergency room called and nurse given report. The resident was discharged from the facility on 06/30/13, and sent to the emergency room for evaluation. On 07/24/13 at 3:11 p.m., with the administrator, DON, and FNP present, an interview was conducted with Employee #19. Employee #19 was shown the nurse's note written by her on 06/28/13. She was asked if she checked back with Resident #114 to assess the effects of the [MEDICATION NAME]? Employee #19 stated, I don't remember, I would have passed it on to the next nurse, it was the end of my shift, I may have peeked my head in there. I didn't write a note, nothing was working even after I tried the [MEDICATION NAME] first as the nurse practitioner ordered and then the [MEDICATION NAME]. On 07/24/13, the facility provided a form referred to as an S-Bar. The S-Bar was a form to note a condition change in a resident. During an interview with the DON, on 07/24/13 at 9:58 a.m., she stated, The S-Bar was started by Employee #19 on 06/28/13. On 07/24/13 at 3:11 p.m., Employee #19 was asked when she started the S-Bar on Resident #114. She stated, I did not start the S-Bar until 06/30/13 when he was sent to the hospital. On the 28th, it was at the end of my shift. When I came back on the 30th he was still complaining. That's when I called the nurse practitioner again. When asked if she felt this resident needed a change of condition form filled out at the time of her note, she stated, Not really, when I came back on the 30th and he was still hurting I talked to the nurse practitioner and we tried to treat him in house. 2) During a review of this medical record it was discovered Employee #138 (respiratory therapist) completed a respiratory assessment scale/pulmonary index v3 for Resident #114 on 07/01/13. There were several questions to answer about the resident in the performance of this assessment. The following assessment questions were answered by Employee #138: 1. Level of consciousness - alert, oriented, cooperative 2. Activity - non-ambulatory up in chair w/assist 3. Dyspnea Index - SOB w/strenuous exercise 4. Breath Sounds - unilaterally/bilaterally diminished and clear 5. Secretions - moderate, thick 6. Cough - strong/productive 7. Sp 02 - 92-95% 8. Oxygenation - Fi02 less than or equal to 35% 9. Ventilation/Respiration - increased respiratory rate = 20-25 10. Chest X-Ray - unavailable > 7-14 days 11. Respiratory History - past history of smoking and/or his of [MEDICAL CONDITION] disease The respiratory therapist was interviewed on 07/24/13 at 2:00 p.m., with her manager present. During this interview Employee #138 was asked on what date this assessment was completed? She stated, On 07/01/13. She was then asked if this was an accurate assessment of this resident's condition on 07/01/13. She replied, No, because he was not here. She further stated, The information I used to complete this assessment was from a previous assessment on 06/28/13. He was out to the hospital and I could not have seen him that day. She was then asked why she would do an assessment when the resident was not in the facility. She stated, Because I am required to do a respiratory assessment. A copy of the respiratory assessment Scale/Pulmonary Index v3 was given to Employee #138 for review. She was asked if there was any information on this assessment which indicated the assessment information was taken from a previous assessment. She replied, No, it does not say this information was from 06/28/13. She was also asked on 07/24/13 at 2:00 p.m., if this was an accurate assessment of Resident #114 on 07/01/13. She stated, No, it would not be.",2016-07-01
8225,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-07-25,314,D,1,0,1LKT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and medical record review, the facility failed to provide care and services to promote the healing of pressure ulcers for one (1) of four (4) residents reviewed for pressure ulcers. Resident #41 had three (3) pressure ulcers for which treatments were not provided as ordered. Resident Identifier: #41. Facility census: 112. Findings include: a) Resident #41 During a review of the medical record for Resident #41, it was found this resident had three (3) pressure ulcers. Further review of this resident's treatment administration record (TAR)identified the facility was not providing treatments as ordered. The TAR indicated numerous times for which there was no evidence the dressing was changed as ordered. The facility provided no evidence the physician's orders [REDACTED]. On 07/23/13 at 3:36 p.m., Employee #123 (director of nursing), provided copies of the TARs for Resident #41 for the months of June 2013 and July 2013. At this time, Employee #123 confirmed the facility was not changing the dressing as ordered by the physician. During an interview with Resident #41 on 07/25/13, at 8:24 a.m., he also confirmed the facility was not changing the dressings as ordered by the physician. .",2016-07-01
8226,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-07-25,363,F,1,0,1LKT11,"Based on observation of meals served, preparation of food items, recipes, resident interview, and staff interview, the facility failed to ensure menus were followed. Daily planned menus were posted throughout the facility for resident observation. These menus were not followed. The facility also failed to ensure recipes were followed during food preparation. This practice had the potential to affect all residents who received food from the facility's kitchen. Facility census: 112. Findings include: a) Confidential interviews were conducted with nine (9) residents who complained about the food served at the facility, including the taste. b) Observation of the posted planned menu for the noon meal on 07/22/13 found the facility's main kitchen, was serving, Italian sub sandwich with ham, salami, and American cheese, accompanied by tomatoes, lettuce and onion on a steak roll. Residents were also were to be served a cucumber and tomato salad. Numerous observations of the noon meal received by the residents, who were eating in their rooms, found not all sandwiches included ham, salami and bologna. The sandwiches served varied from bologna and cheese to salami, bologna, and cheese. Tomatoes, lettuce and onions were not served on these resident's trays. At 1:30 p.m. on 07/22/13, Employee #136, the regional food services director, was interviewed regarding the variety of sandwiches served. Employee #136 also accompanied the surveyor to view the various sandwiches served to residents and the cucumber salad. Employee #136 asked the cook, Employee #134, if she had made the sandwiches according to the posted menu. She stated she ran out of ham. On 07/23/13 at 2:00 p.m. Employee #136 was asked for a copy of the recipe for the cucumber salad that was served for lunch on 07/22/13. The recipe required the cucumbers be peeled and the salad was to be made with white vinegar. Employee #136 acknowledged the salad was not made with white vinegar because the facility did not have this ingredient available and the cucumbers were not peeled. c) Observation of the posted breakfast meal on 07/23/13 found the facility was serving orange juice, oatmeal and a cinnamon raisin biscuit. Further observation of the tray line found the facility was serving what appeared to be a piece of white cake with raisins. The surveyor asked to sample the cake. The cake was dry, tasteless and hard on the bottom. At 9:30 a.m., Employee #136 was asked if the facility was following their posted menu. He stated the cook had not made the biscuits as directed by the menu. He stated she used the ingredients from the biscuit recipe and made a cake instead of a biscuit. The biscuit recipe called for ground cinnamon and icing. Employee #136 acknowledged the cake did not have icing or 1/4 cup and 1 3/4 teaspoons of ground cinnamon as called for in the recipe. He stated the cook told him she had used 1 teaspoon of cinnamon for the cake. Employee #136 said the cake should have been made in smaller pans so the bottom of the care would not have been hard. d) At 11:50 a.m. on 07/23/13, the surveyor entered the kitchen to observe the tray line. Employee #137 was observed making a dessert, which appeared to be the gelatin dessert for lunch. When questioned about what he was preparing, Employee #137 stated the cook had not made enough dessert so he was making more. Observation of the dessert that was made prior to try line service was compared to the dessert being made by Employee #137. The surveyor asked for a sample of each dessert. Employee #6, the dietary manager, was also asked to taste the desserts with the surveyor. Employee #6 verified the gelatin, just made by Employee #137 was grainy and warm. The surveyor then ask for a copy of the recipe for the Jello. Employee #6 provided a copy of a recipe for, gelatin swirl. This recipe required the gelatin be chilled for 45 minutes after mixing. Further instructions required the cook to used a chilled mixer bowl and mix whipped topping for 4-6 minutes before adding the thickened gelatin. The gelatin was to be chilled at least 2-4 hours before service. Observation of the facility's meal service times found the first lunch cart was to be served to unit 3 at 11:40 a.m. Employee #137 was just finishing the dessert at 11:50 a.m. Employee #6 verified the gelatin did not have time to chill and was not made according to the recipe.",2016-07-01
8227,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-07-25,364,F,1,0,1LKT11,"Based on observation, temperature measurement, resident interview, and staff interview, the facility failed to ensure food items were served to residents at acceptable temperatures. This practice had the potential to affect all residents who received meals from the kitchen. Facility census: 112. Findings include: a) Confidential interviews with five (5) residents, who received meals in their rooms. found complaints of cold food. b) At 9:30 a.m. on 07/25/13, Employee #6, the dietary manager was asked to obtain temperatures of the last tray served for breakfast on the Unit 3 tray cart. Employee #6, verified the temperatures of the following items served for breakfast: -eggs - 93.9 degrees -oatmeal 107.4 degrees The dietary manager stated the items were too cold and were not served at the proper temperatures.",2016-07-01
8228,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-07-25,366,D,1,0,1LKT11,"Based on observation of the resident's meal tray, medical record review, family interview and staff interview, the facility failed to ensure a resident, with a known weight loss, was provided a requested food item to be served with each meal. This was true for one (1) of three (3) dependent residents observed during meal times. Resident identifier #27. Facility census: 112. Findings include: a) Resident #27 Observation of the resident's breakfast tray, served in her room, on 07/22/13 at 10:00 a.m., found a meal ticket which listed plain yogurt for a meal preference. The yogurt was not served to the resident. The resident's husband was at her bedside during the observation. He stated his wife had not been eating well and had lost some weight since her arrival at the facility. He had requested plain yogurt be served with all her meals because, she will eat that when she doesn't eat anything else. He further added she ate the yogurt prior to admission to the facility and they made several special dishes at home which included yogurt as an ingredient. He was not sure why the facility could not comply with his request for yogurt. He stated sometimes it's there and sometimes it's not there. Employee #62, a licensed practice nurse, entered the resident's room for medication pass during the interview. This employee was asked why the yogurt was not on the resident's tray. She stated she thought the yogurt was served as a snack at 10:00 a.m., 2:00 p.m. and 8:00 p.m. but she was not sure. Further review of the resident's medical record found the resident's weight was recorded as 144.4 pounds on the date of her admission, 10/30/12. The resident's most current weight, recorded on 07/17/13 was 112.6 pounds. An interview conducted with the dietary manager, Employee #6, on 07/24/13 at 9:30 a.m. confirmed the yogurt should have been served with the resident's meal, as she receives a dietary supplement (a magic cup) at 10:00 a.m., 2:00 p.m. and 8:00 p.m. Observation of the kitchen refrigerator revealed the facility did have the plain yogurt available.",2016-07-01
8229,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-07-25,371,F,1,0,1LKT11,"Based on staff interview, review of the facility's temperature logs, and review of facility policy and procedure, the facility failed to ensure food items were cooked to the the proper temperatures to prevent the rapid and progressive growth of infectious organisms resulting in the potential of foodborne illnesses. This practice had the potential to affect all residents receiving meals from the kitchen. Facility census: 112. Findings include: a) Confidential interviews with eight (8) residents who receive meals in their rooms found complaints of receiving cold food. b) On 07/23/13 at 2:00 p.m., Employee #136, the regional food service director and Employee #6 the dietary manager were asked to provide evidence of food temperatures taken prior to meal service for the past three (3) days. The facility served food from the kitchen and also served meals in the cafe. Temperatures of foods prior to service were requested for items served in the kitchen as well as temperatures from items served in the cafe. Employees #136 and #6 verified the following information: -On 07/20/13 tuna salad sandwiches were served in the cafe. The temperature of the tuna was recorded as 42 degrees before service. Employee #6 verified the temperature should not have exceeded 40 degrees. -The breakfast meal on 07/21/13 consisted of orange juice, oatmeal, scrambled eggs, muffin, milk and coffee. There was no evidence temperatures were obtained. -The hot meal served for lunch on 07/21/13 which consisted of a fish fillet on a roll, rissole potatoes and vegetable or minestrone soup had no record of temperatures being obtained. -The breakfast meal served on 07/22/13, which consisted of orange juice, cream of wheat french toast milk and coffee had no record of temperatures being recorded before service. -The noon meal served from the kitchen on 07/22/13, consisted of an Italian sub sandwich, cucumber salad, cheddar cheese soup, milk and coffee. The facility had no evidence temperatures taken before service. -Employee #6 stated at 2:00 p.m. on 07/23/13, staff are required to take the temperatures of each food item served and record the temperatures on the production work sheet or the cafe temperature log. Employee #6 verified the facility had no means to verify food was cooked to the proper temperature before leaving the kitchen. c) Review of the facility policy and procedure, entitled Food and Nutrition Services Policies and Procedures found the following: Foods are to be cooked to the internal temperatures specified in the recipe directions. Tray line holding temperatures are taken and recorded on the Production Worksheets at the beginning of each meal service.",2016-07-01
8230,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-07-25,514,E,1,0,1LKT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, resident interview, and staff interview, the facility failed to ensure medical records were complete and accurate for six (6) of ten (10) residents reviewed. Resident #49's treatment administration records for pressure ulcers could not be found by the facility. Resident #114's respiratory assessment was completed on 07/01/13 while the resident was not in the facility. In addition, documentation was incorrect regarding the reason an antibiotic was ordered for Resident #114. The allergies [REDACTED]. Residents #116, #123, and #44's medical records did not contain a transfer form. Resident identifiers: #49, #114, #115, #123, #116, and #44. Facility census: 112 Resident findings: a) Resident #49 Resident #49 was admitted to the facility with pressure ulcers. During an interview held with this resident on 07/22/13 at 1:00 p.m., he stated, I had to have surgery on my wounds because they were not changing my dressings. On 0723/13 the treatment administration record was requested for Resident #49. On 07/25/13, Employee #123 (director of nursing) confirmed the treatment administration records for Resident #49 could not be located. On 07/22/13 at 1:00 p.m., Resident #49 alleged the facility did not take care of his wounds and he had to undergo debridement of his wounds. The treatment administration records since admission were requested from the facility on 07/24/13. On 07/25/13 at 8:25 a.m., Employee #123 (director of nursing) with Employee #68 (administrator) present confirmed the treatment administration records from 06/13/13 thru 06/26/13 could not be located. Further review of the medical record for Resident #49 confirmed this resident was sent to the hospital for wound care on 06/26/13. On 07/25/13 at 8:25 a.m., Employee #123 confirmed the facility could not locate the treatment administration records for 06/13/13 thru 06/26/13. b) Resident #114 1) Resident #114 was discharged from the facility on 06/30/13, and sent to the emergency room for evaluation. During a review of the medical record it was discovered Employee #138 (respiratory therapist) completed a respiratory assessment Scale/Pulmonary Index v3 for Resident #114 on 07/01/13. There were several questions to answer about the resident in the performance of this assessment. The following assessment questions were answered by Employee #138: 1. Level of consciousness - alert, oriented, cooperative 2. Activity - non-ambulatory up in chair w/assist 3. Dyspnea Index - SOB w/strenuous exercise 4. Breath Sounds - unilaterally/bilaterally diminished and clear 5. Secretions - moderate, thick 6. Cough - strong/productive 7. Sp 02 - 92-95% 8. Oxygenation - Fi02 less than or equal to 35% 9. Ventilation/Respiration - increased respiratory rate = 20-25 10. Chest X-Ray - unavailable > 7-14 days 11. Respiratory History - past history of smoking and/or his of [MEDICAL CONDITION] disease The respiratory therapist was interviewed on 07/24/13 at 2:00 p.m., with her manager present. During this interview Employee #138 was asked on what date this assessment was completed? She stated, On 07/01/13. She was then asked if this was an accurate assessment of this resident's condition on 07/01/13. She replied, No, because he was not here. She further stated, The information I used to complete this assessment was from a previous assessment on 06/28/13. He was out to the hospital and I could not have seen him that day. She was then asked why she would do an assessment when the resident was not in the facility. She stated, Because I am required to do a respiratory assessment. A copy of the respiratory assessment Scale/Pulmonary Index v3 was given to Employee #138 for review. She was asked if there was any information on this assessment which indicated the assessment information was taken from a previous assessment. She replied, No, it does not say this information was from 06/28/13. She was also asked on 07/24/13 at 2:00 p.m., if this was an accurate assessment of Resident #114 on 07/01/13. She stated, No, it would not be. 2) Review of the medical record on 07/24/13, identified a physician's orders [REDACTED].#90 (licensed practical nurse - LPN) dated 06/29/13. The physician's orders [REDACTED]. Further review of the medical record found a general note written by Employee #90 (LPN), which noted on 06/29/13 at 19:12, the family was notified this resident was ordered [MEDICATION NAME] for a urinary tract infection. During an interview conducted on 07/24/13 at 3:11 p.m., with Employee #137 (family nurse practitioner), she stated she did not order [MEDICATION NAME] for a urinary tract infection. She stated, The [MEDICATION NAME] was ordered for results of a chest-x-ray called to me on 06/29/13, by the facility. Review of the medical record identified a chest x- ray dated 06/29/13, with the following impression: under ventilated lungs, mild cardiomegaly, ill-defined densities left lung base could represent atelectasis or mild consolidation, recommend follow up. Employee #137 stated, I wouldn't have ordered [MEDICATION NAME] for a urinary tract infection. c) Resident #115 Medical records reviewed on 07/23/13 at 8:30 a.m. revealed a Discharge Transition Plan was completed for this resident on 05/29/13. Under the allergies [REDACTED]. Review of the admission assessment and the physician orders [REDACTED].>Interview with Employee #123, the director of nursing (DON) on 07/23/13 at 9:00 a.m., confirmed the Discharge Transition Plan was inaccurate. She further confirmed Resident #115 was allergic to aspirin and sulfa. d) Resident #123 Review of the medical records on 07/24/13 at 2:00 p.m. revealed this resident was originally admitted to the facility on [DATE]. A physician's orders [REDACTED]. No further documentation of the resident's condition at the time of transfer could be located. During an interview on 07/24/13 at 3:00 p.m. with Employee # 123, the director of nursing (DON), she was unable to provide evidence the transfer form was completed by nursing staff and sent to the hospital with the resident. No copy of the transfer form could be located in the resident's medical records. e) Resident #116 Medical record review on 07/23/13 at 11:00 a.m., revealed the resident was originally admitted to the facility on [DATE]. The resident was transferred to an acute care facility on 06/27/13. The resident was re-admitted to the facility on [DATE] and then transferred again on 07/04/13. During an interview on 07/24/13 at 3:00 p.m. with Employee # 123, the director of nursing (DON), she was unable to provide evidence the transfer form was completed by nursing staff and sent to the hospital with the resident. No further documentation could be located in the resident's medical records. f) Resident #44 Medical record review on 07/23/13 at 1:00 p.m., revealed the resident was originally admitted to the facility on [DATE]. The resident was transferred to an acute care facility on 07/18/13. During an interview on 07//24/13 at 3:00 p.m. with Employee # 123, director of nursing (DON), she was unable to provide evidence the transfer form was completed by nursing staff and sent to hospital with the resident. No documentation could be located in the resident's medical records. g) Review of the facility's policy on Discharge and Transfers reads, 5.2. A Patient Transfer Form will be completed and sent to the hospital with the patient. 5.2.1 A copy of the form will be placed in the patient's medical record.",2016-07-01
8231,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2012-05-03,241,D,0,1,9YCU11,"Based on observations and interview, the facility failed to maintain dignity for 2 residents during the service of the morning meal on 05/02/12. This affected 2 of 27 residents eating breakfast in their rooms on Unit 2. (Resident #22 and Resident #51) Findings include: a) Resident #22 During observation on 05/02/12, of the morning meal service on the B hall of Unit 2, trays were observed being passed by staff. At 8:03 a.m., on 05/02/12 Resident #22, was observed to be seated in her wheelchair next to her bed. Resident #99, who resides in the same room, was observed to be seated in a stationary chair next to her bed. Resident #99 was eating from a breakfast tray that had been delivered by Nurse Aide (NA) #120. Resident #22 did not receive her breakfast tray until 8:24 a.m. b) Resident #51 Resident #148 was observed to be seated on the edge of the bed facing Resident #51 in Bed B of the room. Resident #148 stated at the time of the observation that she was finished eating her meal. Resident #51 did not yet have a meal tray. During interview on 05/02/12 at 9:00 a.m., Resident #51 stated she was waiting for her breakfast. At 9:04 a.m., NA #99 had brought Resident #51's breakfast tray into the room and assisted her to eat. c) During interview, on 05/02/12 at 9:25 a.m., with NA #120, it was stated the meal carts are not filled with trays in any particular order and sometimes the residents eating in their rooms do not receive a tray at the same time. On 05/02/12 at 9:30 a.m., the Director of Nursing (DON) stated during interview, Residents #22 and # 51 should not have to wait on their food while their roommates eat their meal. Staff delivering the meal trays should ensure they provide both residents with their food near or at the same time. The DON also verified the trays should be ordered in the meal delivery cart in a manner that would help prevent this undignified situation when possible.",2016-07-01
8232,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2012-05-03,242,D,0,1,9YCU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interview, the facility failed to assess a resident's food preferences. This affected 1 of 2 sampled residents of 14 residents interviewed. (Resident #53) Findings include: a) Resident #53 During an interview with Resident #53, on 04/30/12 at 11:29 a.m., he revealed he does not get to participate in the choice of foods he receives. He stated they just give him whatever they want to bring him. Review of the medical record revealed no evidence of a dietary assessment indicating what foods Resident #53 likes and dislikes. Interview with Resident #53, on 05/01/12 at 1:04 p.m., revealed he has never been asked what kind of foods he likes and does not like. He said they always bring him Rice Crispies in the morning and he has told them he wants Cheerios. He said, how hard can it be for an [AGE] year old man to just get some Cheerios? He says if he complains enough about it, sometimes the staff will go get him Cheerios, but most of the time he just eats what he is delivered. Further interview with Resident #53 was conducted at 9:12 a.m. on 05/02/12. The resident stated he would like to have some involvement in the food he receives at the facility. He stated he is not satisfied with the fact he does not get Cheerios in the morning for breakfast. His breakfast tray was still in front of him and he pointed to his cereal bowl. He said as you can see they gave me Rice Crispies again this morning. He said he ate them only because he loves cereal, but they are not really what he likes. He stated at home he always had a bowl of Cheerios in the morning and he does not understand why he can not have them here. He again said if he keeps asking the staff to get him Cheerios, sometimes they will take the time and go get him some, but this does not happen often. He stated he does not remember any staff ever coming in and asking him about what kind of food he likes and does not like. He said he will usually just eat what he is served, but that does not mean he has to be happy about it. If he does not like what he is served he will just leave it and not eat it. Interview with the dietary manager, on 05/02/12 at 9:55 a.m., revealed they do have Cheerios they can serve Resident #53, but she was not aware he liked them. She stated she does do a likes/dislikes list a few days after a new resident is admitted . The dietary manager further stated they have a form they use to assess the resident's likes and dislikes, but she had not completed one for Resident #53. The surveyor shared Resident #53's diet card with the dietary manager and noted that the only likes and dislikes recorded were the recent addition of super foods. She stated she put this on his diet card to remind the staff he is to receive super foods with each meal due to his weight loss. She showed me a card stating he does not like spicy foods or acidic foods, but this card did not include things he does like to eat. The dietary manager stated she would add Cheerios to his diet card to ensure he receives them in the mornings.",2016-07-01
8233,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2012-05-03,279,E,0,1,9YCU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to develop a comprehensive care plan reflective of the resident's condition for 5 residents reviewed in stage 2. Forty-seven (47) care plans were reviewed for the areas of pressure ulcer prevention, range of motion services, physical restraints and discharge planning. (Residents #2, #58, #29, #32, and #135) Findings include: a) Resident #58 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set, dated dated [DATE], documented the resident was at risk for the development of a pressure ulcer and required the extensive assistance of 2 staff members for bed mobility. This MDS also documented Resident #58 had a deep tissue injury wound and necrotic skin tissue and had pressure reduction to her bed. The care plan for skin, dated 12/13/11, documented impaired skin integrity and impaired mobility. Staff were to do weekly skin assessments, encourage fluids, pressure reducing mattress, assist with repositioning and minimize pressure on bony prominences and use pillows for support. Staff were to observe skin during care and report changes to the nurse. On 01/17/12, the care plan indicated a new entry of a pressure ulcer to the right heel. On 02/03/12, the care plan was updated to reflect a heel riser when in bed, as tolerated. Review of the current physician orders [REDACTED]. The nursing weekly skin assessments, documented on 12/17/11, indicated the resident continued to have a Stage 2 open ulcer to right heel. On 03/10/12, this area was noted to be documented as a dry scabbed area. Observation of Resident #58, on 05/01/12 at 10:05 a.m., revealed she was in bed on her back with her feet elevated off the bed with the heel elevator in place. On this date, at 12:26 p.m., the resident was observed in her wheelchair in the hall with no pressure relieving device noted in her chair. She was noted to have non-skid socks on her feet and her heels were resting on the cement tile floor. There was no observation of any pressure reduction for her heels during this observation. Interview with the treatment nurse at this time revealed she thought the resident should have shoes on, but was not sure. In an interview with the Nursing Assistant (NA) #102, at 12:35 p.m., the NA stated the resident had not worn shoes in a long time. All they put on her feet were non-skid socks when she was up in her wheelchair. On 05/01/12 at 12:57 p.m., Resident #58 was observed in her wheelchair with no pressure relief in the chair, but the staff had placed house slippers on her feet. The current care plan indicated the resident was at high risk for the development of pressure ulcers and staff should minimize pressure to all bony prominences. Observation of the wound, on 05/02/12 at 11:00 a.m., revealed the resident's heels were floated off the bed with a pressure relieving device. Observation of the area on her right outer heel revealed only a small scabbed area with a white flaky surface. The wound nurse stated the area had been healed for a while, but they were just doing a preventive treatment to the area since she was susceptible to skin breakdown in that area again. Surveyor: Massey, Glenna b) Resident # 29 Review of the annual Minimum Data Set (MDS), dated [DATE], revealed Resident # 29 was coded as being severely impaired in her cognitive skills for daily decision making. She was coded as being totally dependent on staff for: bed mobility, transfer, locomotion, dressing, toileting, and personal hygiene. She required extensive assistance with eating. Walking did not occur. She was coded as having impairment on lower extremities, was not coded as using bed rails, nor a trunk restraint. Review of a nursing assessment for side rail use dated 02/17/12 revealed: Not Alert & Oriented, is confused Not awake at night Not able to ambulate Unable to release side rails Able to use call lights Side rail easily available Padded side rails are up at all times due to [MEDICAL CONDITION] activity Side rail use is for resident protection due to [MEDICAL CONDITION] activity Side rails to be raised at all times when in bed Safety concerns Side rails will remain in place for protection d/t [MEDICAL CONDITION] activity Observations: -- Observation of Resident #29, on 04/30/12 at 12:08 p.m., revealed her to be seated in a wheelchair in her room. She had a seat belt on across her lap. Her bed was observed with padded half side rails raised on both sides of the bed and a fall mat was on the floor on the left side of the bed. -- Observation on 05/01/12 at 9:30 a.m. revealed Resident #29 to be in bed sleeping. Her bed was observed with padded half side rails up on both sides. There was also a fall mat on the floor beside the bed. -- Resident # 29 was observed in the dining room at 12:40 p.m. on 05/02/12. She was seated in her wheelchair with a seat belt on. -- Observation on 05/03/12 at 8:45 a.m., revealed Resident #29 in bed sleeping. Her bed was observed with padded side rails up on both sides. There was also a fall mat on the floor beside the bed. Review of a physician order, dated 09/14/09, revealed an order for [REDACTED]. On 05/12/11, a seat belt when in the wheelchair was added to the resident's orders. The device was identified to provide safety and support to the resident. On 09/09/11, another support device was added to the resident's orders, padded double half side rails when in bed to maintain bed boundaries for safety due to due to [MEDICAL CONDITION] and severe MR for thrusting movements of the upper body. Further review of the clinical record did not reveal a care plan addressing the use of the seat belt or the use of the side rails. The Director of Nursing (DON) was asked, on 05/02/12 at 4:00 p.m., if there was a care plan for the resident related to the use of side rails or her seat belt. The DON returned with the printed care plans for Resident #29. Side rails and the seat belt were listed on the care plan as interventions for, potential for trauma-falls injury. However, neither the side rails nor the seat belt were care planned as potential restraints with identified risks for their use and interventions to ensure proper application and use. c) Resident #32 This resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS), dated [DATE], revealed the resident was a [AGE] year- old male. He was coded as a 14 on the BIMS, indicating he was cognitively able to make daily decisions. He was also coded as having unclear speech, but was usually understood. The resident was coded as having difficulty communicating some words or finishing thoughts, but was able if prompted or given time. He was coded as not having any behaviors. His functional status was assessed as requiring extensive assistance with bed mobility, transfer, personal hygiene, and ambulation did not occur. He was coded as being totally dependent on staff for locomotion, dressing, toilet use and bathing. For eating he required limited assistance. He was coded as unsteady for moving on/off toilet and surface to surface transfer: he was only able to stabilize with staff assist. For functional range of motion (ROM), he was coded as having impairment on both sides of upper and lower extremities. He used a wheelchair (w/c) for mobility. During an interview, on 04/30/12, with Nurse #62, she identified Resident #32 as having a contracture of the right hand. While the MDS revealed Resident #32 to have many functional deficits, review of the clinical record, beginning on 04/30/12, revealed there was no care plan related to (r/t) a hand contracture. The Director of Nursing (DON) was asked, on 05/02/12 at 4:00 p.m., if there was a care plan for the resident related to the hand contracture. The DON was asked again, on 05/03/12, about the resident's contracture and she referred the surveyor back to the therapy dept. The physical therapy supervisor was interviewed at 3:25 p.m. on 05/02/12. She stated Resident #32 had been on the occupational therapy (OT) caseload in 2009 for treatment of [REDACTED]. Neither therapies nor nursing could explain why a care plan r/t the resident's hand contracture had not been developed. Surveyor: Reed, Bonnie d) Resident #135 Review of the medical record for Resident #135 revealed an admission date of [DATE]. Pertinent [DIAGNOSES REDACTED]. Review of the most recent MDS, dated [DATE], revealed there was no active discharge planning occurring for the resident to return to the community. A social service progress note, dated 04/05/12 revealed Resident #135 did express a desire to return to the community. Review of the care plans for Resident #135 revealed no care plan related to discharge planning. During an interview with Resident #135, on 05/03/12, he stated he is taking his discharge planning one day at a time and does plan to return to the community. During an interview with the Social Service Director, on 05/03/12 at 1:20 p.m., it was verified there was no care plan in place related to Resident #135's desire to return to the community. e) Resident #2 Review of the medical record for Resident # 2 revealed [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), a comprehensive assessment, dated 04/11/12, revealed Resident #2 had functional limitations in range of motion (ROM) with impairment of the upper and lower extremities of one side of the body. The MDS did not include documentation of the resident receiving restorative range of motion services. Further review of the MDS revealed Resident #2 was dependent on staff for bed mobility, transfer, locomotion on and off the unit, and dressing. The MDS also indicated Resident #2 did not stand or walk. Review of the care plans for Resident #2 revealed no plan had been established related to the resident's limited ROM. Review of a document titled, Rehab Screening, dated 05/02/12, revealed the physical therapist assessed Resident #2 to have a contracture of the right knee at 100 degrees flexion. Resident #2 was observed in bed with both legs bent at the knee on 05/01/12 at 10:09 a.m., 12:42 p.m., 1:54 p.m., and 3:12 p.m. Resident #2 was also observed in bed with both knees bent on 05/02/12 at 7:00 a.m. and 12:40 p.m. During interview with Nurse Aide (NA) #109, on 05/02/12 at 12:40 p.m., she stated she provides ROM daily for Resident #2 with morning care. NA #109 also stated the resident's right leg draws up underneath her and they have to pull it down routinely. During interview with Registered Nurse #47, the unit manager, on 05/02/12 at 2:55 p.m., she stated the facility performs ROM assessments for residents upon admission and quarterly. During interview, on 05/02/12 at 3:13 p.m., with the Director of Nursing (DON), it was stated physical therapy screens the residents in the facility during their assessment period. The DON verified at that time there was no documentation in the resident's electronic record of a ROM plan of care. During interview with the rehabilitation department manager, on 05/02/12 at 3:15 p.m., it was stated she was provided with a calendar from the MDS coordinator to make them aware of the residents scheduled for review. The rehabilitation manager also verified there was no ROM care plan related to Resident #2's contracted knee. During interview with RN #41 on 05/02/12 at 3:30 p.m., it was verified there was no care plan developed related to Resident #2's contracted knee.",2016-07-01
8234,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2012-05-03,280,D,0,1,9YCU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to revise the care plan to reflect the resident's current condition. This affected 2 of 3 residents reviewed out of 8 residents identified for significant weight loss (Residents #53 and #71), and 1 of 10 residents reviewed for unnecessary medications (Resident #53). Findings include: a) Resident #53 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum (MDS) data set [DATE] documented Resident #53 required minimal assistance of one staff for eating. Review of the dietary assessment, dated 02/21/12, documented Resident #53 weighed 156 pounds and was 72 inches tall. This note also documented a weight of 167 on admission and revealed he had experienced a 6.6% weight loss since admission. The resident's current diet order was a low concentrated sweets diet with mechanical ground meat and super foods with all three meals. A dietary note, dated 04/11/12, identified the addition of super foods to Resident #53's diet related to weight loss. The nutritional care plan documented the resident was at nutritional risk due to inadequate food intake, nausea, and presence of a pressure ulcer. Review of the nutritional care plan revealed interventions to maintain weight at 181 pounds, plus or minus 7 pounds, encourage intake, offer fluids at every care encounter, offer substitutes as needed, and encourage frequent intake. The nutrition care plan did not include the intervention of super foods that had been ordered by the physician. According to an interview with the the dietary manager, on 05/02/12 at 1:30 p.m., she verified that she had not updated the nutrition care plan to include the new intervention of super foods. b) Resident #53 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A new order, dated 03/28/12, had been written for [MEDICATION NAME], a benzodiazepine, 0.5 mg 1 by mouth every eight hours, as needed, for anxiety. Review of the Medication Administration Record [REDACTED] 4/2/12 at 1:48 p.m. per resident request 4/3/12 at 9:57 a.m. per resident request / no visible signs of anxiety. 4/4/12 at 8:19 a.m. and 3:24 p.m. per resident request 4/5/12 at 9:35 a.m. and 4:40 p.m. 4/7/12 at 10:44 a.m. per resident request 4/9/12 at 11:54 a.m. per resident request 4/10/12 at 10:26 a.m. per resident request 4/14/12 at 11:38 p.m. given for agitation documentation revealed the resident was upset because his medication was late. 4/16/12 at 9:49 a.m. per resident request 4/17/12 at 9:42 a.m. per resident request 4/18/12 at 9:25 a.m. per resident request 4/19/12 at 10:54 a.m. for anxiety, restless agitation 4/20/12 at 8:37 a.m. given for restlessness. Documentation revealed the nurse attempted other interventions prior to giving the medication 4/23/12 at 11:36 p.m. and 8:24 a.m. given for anxiety / no other interventions attempted prior to giving the medication 4/24/12 at 8:25 a.m. for anxiety other intervention attempted prior to giving the medication 4/25/12 at 9:12 a.m. no other interventions attempted prior to administering this medication 4/28/12 at 8:56 a.m. for anxiety with no other interventions attempted prior to administering this medication 4/30/12 at 12:36 a.m. for anxiety no other interventions attempted prior to administering this medication 5/1/12 at 3:51 a.m. for anxiety and restlessness / no other interventions attempted prior to administering this medication Review of the care plans revealed there had been no revision to the current care plan in to include the use of [MEDICATION NAME] ordered by the physician on 03/28/12 for the treatment of [REDACTED]. Interview with the DON, on 05/02/12 at 2:30 p.m., revealed Resident #53's care plan did not include revisions to address his anxiety and the use of [MEDICATION NAME], or any non-pharmacological approaches to be attempted prior to giving the [MEDICATION NAME]. c) Resident #71 This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review, on 04/30/12, revealed Resident #71 had experienced a 6.94% weight loss from the time of her admission until 04/26/12, when she was weighed a second time. This was a significant loss for the resident. Review of the Admission MDS, of 04/12/12, revealed a BIMS score of 13, indicating she was cognitively able to make daily decisions., She was coded on the MDS to be 61 inches tall and as weighing 173 pounds. The MDS also was coded as the resident not having any weight loss, as receiving a mechanically altered diet, and a therapeutic diet. The assessment also indicated she had loss of solids/fluids from her mouth when eating. Review of the care plans revealed nutrition had been care planned on 04/19/12, however, it did not reflect the resident's current status including her weight loss. The care plan identified: -- resident leaves greater than 25% of her meals uneaten; -- resident should maintain a weight of 174 pounds +/- 8 pounds until the next review; -- resident should eat 50-75% of meals through the next review (7/17/12); -- resident should be weighed as ordered; -- staff should monitor serum protein and medications; -- staff should assure adequate assist at meals and encourage intake; -- staff should set up foods as needed and provide cues and encouragement; -- staff should offer substitutes, as needed; -- staff should offer snacks; -- staff should encourage comments on food, especially favorite foods, report complaints; -- staff should provide the diet as ordered, mechanical soft/ground; -- staff should offer substitutes; -- staff should determine resident food likes and dislikes; Review of the admission nutrition note, dated 04/19/12, revealed: admission weight of 173, reviewed and updated see CP. There was no evidence of nutrition charting after 04/19/12, which would have captured the weight loss had end of month weights been reviewed. The Registered Dietitian (RD) was interviewed at 2:12 p.m. on 05/02/12. She stated they missed the weight on 04/26/12, so they did not identify the significant loss and the care plan had not been updated.",2016-07-01
8235,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2012-05-03,282,D,0,1,9YCU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interview, the facility failed to implement the care plan for 1 of 3 residents reviewed with pressure ulcers; and 1 of 3 residents reviewed, out of 4 residents identified for investigation in the Care Area of Activities of Daily Living, as being inappropriately dressed for the time of day.(Resident #58 and Resident #13) Findings include: a) Resident #58 This resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set, dated dated [DATE], found the resident was at risk for the development of a pressure ulcer and required the extensive assistance of 2 staff members for bed mobility. This MDS also documented Resident #58 had a deep tissue injury wound and necrotic skin tissue and was to have pressure reduction to her bed. The care plan, dated 12/13/11, documented impaired skin integrity and impaired mobility. Staff were to conduct weekly skin assessments, encourage fluids, provide a pressure reducing mattress, assist with repositioning, minimize pressure on bony prominences and use pillows for support. Staff were to observe skin during care and report changes to the nurse. On 01/17/12, the care plan indicated a new entry of a pressure ulcer to the right heel. On 02/03/12, the care plan was updated to reflect heel riser when in bed, as tolerated. Review of the current physician orders [REDACTED]. Review of the nursing weekly skin assessments, on 12/17/11, found the resident continued to have a Stage 2 open ulcer to right heel. On 03/10/12, this area was documented as a dry scabbed area. The skin care plan remained in place indicating the staff should minimize pressure on the resident's bony prominences Observation of Resident #58, on 05/1/12 at 10:05 a.m., revealed she was in bed on her back with her feet elevated off the bed with the heel elevator in place. Also on this date, at 12:26 p.m., the resident was observed in her wheelchair in the hall with no pressure relief device noted in her chair. She was noted to have non-skid socks on her feet and her heels were resting on the cement tile floor. There was no observation of any pressure reduction to relieve pressure on the bony prominence of her heels during this observation. Interview with the treatment nurse at that time revealed she thought the resident should have shoes on, but was not sure. In an interview with the Nurse Assistant #102, at 12:35 p.m., she stated the resident had not worn shoes in a long time and she wears only non-skid socks when she is up in her wheelchair. On 05/01/12 at 12:57 p.m., Resident #58 was observed in her wheelchair with no pressure relief in the chair, but the staff had placed house slippers on her feet. The current skin care plan documented the resident was at high risk for the development of pressure ulcers and staff should minimize pressure to all bony prominences. Observation of the wound, on 05/02/12 at 11:00 a.m., revealed the area on her right outer heel was a dark scabbed area with a white flaky surface. The wound nurse stated the area had been closed for awhile, but they were just doing a preventive treatment to the area since she was susceptible to skin breakdown in that area again. This observation was shared with the DON during an interview interview at 3:20 p.m. on 05/02/12. She indicated the resident's heels should not be resting on the hard surface of the floor. She said she would make a referral to the podiatrist to obtain something to ensure pressure relief to the resident's heels while she was up in her wheelchair. b) Resident #13 Review of the medical record for Resident #13 revealed a most recent admission date of [DATE] and pertinent [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), a comprehensive assessment dated [DATE], revealed Resident #13 had both short and long term memory problems. The MDS also revealed the resident had moderately impaired decision-making skills and required cues and supervision. Resident #13 was also assessed to be dependent on staff for bed mobility, transfers, dressing, eating and personal hygiene. Review of the care plans for Resident #13 revealed a care plan dated 03/14/12 related to the resident's self care deficit due to her chronic illness, [MEDICAL CONDITION], weakness and decreased ability for understanding. The interventions for the care plan included: to provide the resident with a wet wash cloth and give simple instructions and cues to wash her own face and hands, to provide assistance with oral hygiene and grooming daily, to provide extensive to total assistance during shower and daily bathing, and to provide simple choices of clothing daily. The same interventions were noted to be listed on a document titled, CNA Care Card, found in a binder at the nurses' station. Resident #13 was observed in bed wearing a pink night gown on 04/30/12 at 2:40 p.m., on 05/01/12 at 10:02 a.m., 11:11 a.m., 12:45 p.m., 1:59 p.m., and 3:14 p.m. Resident #13 was also observed in bed wearing the same pink night gown on 05/02/12 at 7:06 a.m. and 11:15 a.m. During an interview, on 05/02/12 at 11:15 a.m., with nurse aide (NA) #83, identified as one of the NAs caring for Resident #13, it was stated the resident gets up to the chair once a day around 4:30 in the afternoon, receives a bed bath daily and a shower twice a week in the afternoon around 2:30 p.m. NA #83 stated there is a shower book that tells them when the residents are to receive a shower and another book that tells them what care each resident required. During an interview, on 05/02/12 at 12:34 p.m., with NA #109, identified as the NA caring for Resident #13, it was stated the resident gets a shower every Tuesday and Saturday or whenever she gets time. It was verified during the interview that Resident #13 did not have a shower on 05/01/12, as she should have and NA #109 did not change her night gown because she did not have time to do it. NA #109 verified she was scheduled to work 05/01/12, 05/02/12, and 05/03/12. During an interview with the Director of Nursing on 05/03/12 at 10:27 a.m., it was verified the expectation was Resident #13 would have her clothes changed daily as stated in the Activities of Daily Living care plan. It was also verified the NAs were to provide care as directed by the NA care cards located in binders at the nurses' station.",2016-07-01
8236,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2012-05-03,309,D,0,1,9YCU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interivew, the facility failed to provide care and services to prevent skin tears for 1 of 3 residents reviewed who were identified to have skin conditions other than pressure ulcers. (Resident #57) Findings include: a) Resident #57 This resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The most recent Minimum Data Set, dated dated [DATE], documented Resident #57 had no impairment to her upper extremities and was documented to have skin tears. Review of the skin care plan, dated 02/15/12, revealed the resident was at risk for impaired skin integrity due to impaired circulation, diabetes, and she was prone to skin tears. The physician orders [REDACTED]. The care plan documented staff were to assist her with positioning. The skin care plan did not address how staff should be careful when providing care to the resident due to her high risk for skin tears. Review of the physician orders [REDACTED].#57 had experienced on 04/15/12 to the upper left wrist and 04/19/12 to the left forearm. The nursing notes revealed documentation on 03/28/12 of a skin tear to the resident's right outer forearm and on 04/06/12 these notes revealed nursing documentation stating the resident's skin was fragile and was prone to bruising easily. Resident #57 was observed on 05/01/12 to be in bed with bilateral half bed rails in the raised position on her bed. The resident was observed to have multiple bruises on both arms and hands. She had a dressing on the left wrist and a second dressing observed on her left upper arm. She also had a bruise on her mid chest area. A sign was noted hanging on the inside of her bathroom door directing staff should place long sleeves on the resident. She was observed to be in a sleeveless gown in bed with no covering or blankets to her upper body. Observation, on 05/01/12 at 12:18 p.m., revealed Resident #57 was in the dining room for lunch. She was dressed in a short sleeve shirt with her arms exposed. At 2:00 p.m., the resident was in a geri-chair in the entryway of the facility. She remained in a short sleeved shirt. The left arm of the geri-chair was noted to have torn areas. The resident's left arm was lying against the left armrest of the chair where it was noted to be torn and ragged. On 05/01/12 at 2:20 p.m., the administrator was observed to be standing beside the resident and was running his hand along the torn ragged edges of the geri chair the resident was seated in. Interview with Nurse Assistant #102, on 05/01/12 at 3:00 p.m., revealed the geri-chair the resident was seated in was the chair she normally sat in. Interview with the DON on 05/02/12 at 3:20 p.m. revealed the resident was at high risk for skin tears and had fragile skin. The observation made of the resident seated in the geri-chair with the torn jagged edges was shared with the DON at this time. Further interview with the DON, on 05/03/12 at 1:30 p.m., revealed Resident #57 has been at risk for skin tears for a very long time. She stated the resident will hit her arm on the chair or on the door in her room while up in her wheelchair. The DON verified the resident should have interventions in place and implemented to assist in the preventions of skin tears. The DON shared on 5/3/12 at 10:02 a.m. they had placed protective sleeves on Resident #57 to assist in the prevention of on-going skin tears.",2016-07-01
8237,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2012-05-03,312,D,0,1,9YCU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide the care and services needed for a resident comprehensively assessed as dependent on staff for activities of daily living. This affected 1 of 5 residents reviewed for the care area of Activities of Daily Living. (Resident # 13) Findings include: a) Resident #13 Review of the medical record for Resident #13 revealed a most recent admission date of [DATE]. Pertinent [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) a comprehensive assessment, dated 02/27/12, revealed Resident #13 had both short and long term memory problems. The MDS also revealed the resident had moderately impaired decision-making skills and required cues and supervision. Resident #13 was also assessed to be dependent on staff for bed mobility, transfers, dressing, eating and personal hygiene. Review of the care plans for Resident #13 revealed a care plan dated 03/14/12 related to the resident's self-care deficit due to her chronic illness, [MEDICAL CONDITION], weakness and decreased ability for understanding. The interventions for the care plan included: to provide the resident with a wet wash cloth and give simple instructions and cues to wash her own face and hands, to provide assistance with oral hygiene and grooming daily, to provide extensive to total assistance during shower and daily bathing, and to provide simple choices of clothing daily. The same interventions were noted to be listed on a document titled, CNA Care Card, found in a binder at the nurses station. Resident #13 was observed in bed wearing a pink night gown on 04/30/12 at 2:40 p.m., on 05/01/12 at 10:02 a.m., 11:11 a.m., 12:45 p.m., 1:59 p.m., and 3:14 p.m. Resident #13 was also observed in bed wearing the same pink night gown on 05/02/12 at 7:06 a.m. and 11:15 a.m. On 05/02/12 at 11:15 a.m., Nurse Aide (NA) #83, identified as one of the NAs caring for Resident #13, stated the resident gets up to the chair once a day around 4:30 in the afternoon, receives a bed bath daily and a shower twice a week in the afternoon around 2:30 p.m. NA #83 stated there was a shower book that told them when the residents were to receive a shower and another book that told them what care each resident required. During an interview on 05/02/12 at 12:34 p.m., NA # 109, identified as the NA caring for Resident #13, stated the resident received a shower every Tuesday and Saturday or whenever she had time. It was verified during the interview that Resident #13 did not have a shower on 05/01/12 as she should have and NA #109 did not change her night gown because she did not have time. NA #109 verified she was scheduled to work 05/01/12, 05/02/12, and 05/03/12. During interview with the Director of Nursing, on 05/03/12 at 10:27 a.m., it was verified the expectation was Resident #13 would have her clothes changed daily. It was also verified the NAs were to provide care as directed by the NA care cards located in binders at the nurses' station.",2016-07-01
8238,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2012-05-03,314,D,0,1,9YCU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide care and services to prevent the development of a pressure ulcer for 1 of 3 residents reviewed for the Care Area of Pressure Ulcers. (Resident #58) Findings include: a) Resident #58 This resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set, dated dated [DATE], found the resident was assessed at risk for the development of a pressure ulcer. The resident required the extensive assistance of 2 staff members for bed mobility. This MDS also documented Resident #58 had a deep tissue injury wound and necrotic skin tissue and was to have pressure reduction to her bed. Review of the skin care plan, dated 12/13/11, documented impaired skin integrity and impaired mobility. Staff were to do weekly skin assessments, encourage fluids, provide pressure reducing mattress, assist with repositioning and minimize pressure on bony prominences and use pillows for support. Staff were to observe skin during care and report changes to the nurse. On 01/17/12, the care plan indicated a new entry of a pressure ulcer to the right heel. On 02/3/12, the care plan was updated to reflect heel risers to be used when in bed to reduce the pressure to the resident's heels. Review of the current physician orders [REDACTED]. Review of the nursing weekly skin assessments documented on 12/17/11 indicated the resident continued to have a Stage 2 open ulcer to right heel. On 3/10/12 this area was documented as a dry scabby area. Observation of Resident #58, on 05/01/12 at 10:05 a.m., revealed she was in bed on her back with her feet elevated off the bed with the heel elevator in place. On this, date at 12:26 p.m., the resident was observed in her wheelchair in the hall with no pressure relief device noted in her chair. She was noted to have non-skid socks on her feet and her heels were resting on the cement tile floor. No pressure reduction measures for her heels were in evidence during this observation. Interview with the treatment nurse, on 05/01/12 at 10:05 a.m., revealed she thought the resident should have shoes on, but was not sure. During interview with Nursing Assistant #102, at 12:35 p.m., she stated the resident had not worn shoes in a long time. All they were putting on the resident's feet were non-skid socks when she was up in her wheelchair. On 05/01/12 at 12:57 p.m., Resident #58 was observed in her wheelchair with no pressure relief in the chair, but staff had placed a pair of thin house slippers on her feet. The current care plan related to skin documented the resident was at high risk for the development of pressure ulcers and staff should minimize pressure to all bony prominences. Observation of the wound, on 05/02/12 at 11:00 a.m., revealed the right heel to have a dark colored scabbed area with a white flaky surface. The wound nurse stated the area had been closed for a while, but they were just doing a preventive treatment to the area since she remained susceptible to skin breakdown in that area again. During an interview with the DON, on 05/02/12 at 3:20 p.m., the observation of Resident #58 seated in the wheelchair with her heels resting on the concrete tile floor surface was shared. The DON verified the resident's heels should not be resting on the hard surface of the floor and she would make a referral to the podiatrist to obtain something to ensure pressure relief to the resident's heels while she was up in her wheelchair.",2016-07-01
8239,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2012-05-03,318,D,0,1,9YCU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide treatment and services to maintain and prevent further decrease in range of motion. This affected 2 of 3 residents reviewed for the care area of Range of Motion. (Resident #2 and Resident #32) Findings include: a) Resident #2 Review of the medical record for Resident #2 revealed [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), a comprehensive assessment dated [DATE], revealed Resident #2 has functional limitations in range of motion (ROM) with impairment on both the upper and lower extremities of one side of the body. The MDS did not include documentation of the resident receiving restorative range of motion services. Further review of the MDS revealed Resident #2 is dependent on staff for bed mobility, transfer, locomotion on and off the unit and dressing. The MDS also indicated Resident #2 does not stand or walk. Review of the care plans for Resident #2 revealed no plan of care related to the Resident's limited ROM. Review of a document titled, Rehab Screening, dated 05/02/12 revealed the physical therapist assessed Resident #2 to have a contracture of the right knee at 100 degrees flexion. Resident #2 was observed in bed with both legs bent at the knee on 05/01/12 at 10:09 a.m., 12:42 p.m., 1:54 p.m., and 3:12 p.m. Resident #2 was also observed in bed with both knees bent at 7:00 a.m. and 12:40 p.m. on 05/02/12. During an interview, on 05/02/12 at 12:40 p.m., with nurse aide (NA) #109, she stated that she provides ROM daily for Resident #2 with morning care. NA #109 also stated the resident's right leg draws up underneath her and they have to pull it down routinely. During interview with Registered Nurse #47, the Unit Manager, she stated the facility performs ROM assessments for residents upon admission and quarterly. During interview on 05/02/12 with the Director of Nursing (DON), rehabilitation department manager and RN #42, the MDS coordinator, it was verified that Resident #2 was not receiving ROM services to prevent further decrease in the ROM of her right knee. b) Resident #32 This resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS), dated [DATE], revealed the resident is a [AGE] year old male. He was coded as a 14 on the BIMS, indicating he was independent in his cognitive ability for daily decision making. He was also coded as having unclear speech, however was usually understood. He was coded to have difficulty communicating some words or finishing thoughts but was able if prompted or given time. He was coded as not having any behaviors. His functional status was assessed as requiring extensive assistance with bed mobility, transfer, personal hygiene, and ambulation does not occur. He was coded as being totally dependent on staff for locomotion, dressing, toilet use and bathing. For eating he required limited assistance. He was coded as, unsteady, for moving on/off toilet and surface to surface transfers. He was only able to stabilize with staff assistance. For functional ROM, he was coded as having impairment on both sides of upper and lower extremities. He used a wheel chair (w/c) for mobility. During an interview on 04/30/12 with Nurse #62, she identified Resident #32 as having a contracture of the hand. She stated he was not receiving range of motion (ROM) services nor did he use a splint device. While the MDS identified Resident #32 to have many functional deficits, review of the clinical record, beginning on 04/30/12, revealed there was no care plan related to (r/t) a hand contracture. Further, there was no evidence of a restorative nursing assessment, progress notes, or a care referral for therapies. There was no evidence of recent evaluation from either occupational (OT) or physical (PT) therapies. During an interview with Resident #32, on 04/30/12, his right hand was observed to be pulled inward with fingers also bent inward. The physical therapy supervisor was interviewed at 3:25 p.m. on 05/02/12. She stated, Although we see him every day, we have not had a lot of treatment time with him. A physical therapist (PT) joined the conversation and stated, I'm not sure at all if he has a contracture. He continued that he did an evaluation on 06/02/11 related to the resident's desire to stand during transfer. The PT stated if he had a contracture, he would have addressed it on the June evaluation. The two therapists informed the surveyor that occupational therapy (OT) determined whether a resident had a contracture. The supervisor stated OT had seen Resident #32 in the past. The PT stated, The previous OT would have treated it, if there was a contracture. She was very thorough with her patients - if someone needed services or a splint she ordered it. The therapy supervisor looked up the OT documentation. She stated Resident #32 was on the OT caseload in October of 2009 for treatment of [REDACTED]. The PT was asked whether the OT findings of a contracture would prompt a review by physical therapy. The PT responded, If it is fixed we wouldn't do anything. The PT was asked whether interventions had the potential to prevent further decline. The PT stated, But, if it's a fixed contracture, a device would only cause the resident pain and he wouldn't like that. The PT was asked whether he had evaluated the contracture to make that determination. The PT responded, I'm making an assumption, I don't know that it's fixed. Review of the PT assessment of 06/1/11 revealed the resident's contracture had not been addressed; the only area addressed on the evaluation was the resident's ability to stand. The Director of Nursing (DON) was interviewed on 05/03/12 at 9:15 a.m She was asked how the facility knew residents with contractures were not decreasing in functional abilities. She stated, They should be receiving a therapy screen quarterly. She continued that nursing also makes referrals to therapy for any reported change in condition (COC), they observe in the residents. Further record review did not reveal any evidence that a therapy screen r/t the hand contracture for Resident #32 had been conducted, since the OT screen in 2009. Nor was there evidence that therapies were conducting quarterly screenings. The Nursing Home Administrator (NHA) was interviewed on 05/03/12 at 3:00 p.m He stated they talk about COC in care plan meetings. We have a referral process. Therapists do a room to room visit to ensure that residents don't need services . That was the expectation that was delivered to our therapist at one time. If the resident's quality of life can be improved, therapy should be providing services. The NHA was asked whether that process was ongoing. He responded, Yes, I thought that was happening. There was no documentation in the resident's clinical record or in therapy notes to support either the DON's or the NHA's statements that a system was in place to ensure ROM services were provided for residents with contractures.",2016-07-01
8240,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2012-05-03,323,D,0,1,9YCU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure an environment free of accident hazards for 1 of 3 sampled residents reviewed for the care area of accidents related to the use of bed rails. (Resident # 83) Findings include: a) Resident #83 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set, dated dated [DATE], documented the resident required extensive assistance of 2 staff for bed mobility. The resident was identified as cognitively intact on the MDS. Review of the side rail assessment, dated 02/19/12, revealed the resident was not able to ambulate on her own, had no problem with trunk control, needed assistance with bed mobility, and stated the resident wanted the side rails to hold on to when she was being turned and changed. Review of the current physician orders [REDACTED]. Review of the care plan for ADL function revealed that on 04/30/11, the care plan was updated to include the use of half rails on both sides of the bed to assist the resident with bed mobility. This care plan also revealed documentation that the resident had decreased participation in her ADL's. She also has a plan of care for Cognitive loss due to Alzheimer's dementia, decline in memory. Observation of Resident #83, on 04/30/12 at 9:07 a.m., revealed she was in bed with bilateral half rails on her bed in the raised position. The rails were observed to be very loose on the bed. When the rails were touched they moved back and forth easily and were not firmly attached to the bed. This was verified with another surveyor at this time. This was also shared with the DON at the same time and she verified the rails should not be loose and that she would notify maintenance. Interview with the resident at this time revealed that she does use the rails to assist in turning herself. These loose rails could present an accident hazard for the resident if she attempted to turn herself. Also, during the 04/30/12 observation at 9:07 a.m., the resident's call light was observed to be out of her reach. The call light was clipped to the call light cord under the the area where the call light plugs into the wall. If the resident had attempted to reach the call light at this time and pushed on the loose rail there was a potential that the rail would move farther away from the bed causing a potential entrapment danger if the rail became dislodged from the bed. Interview with the DON, on 04/30/12 at 9:15 a.m., verified the rails were very loose on the bed and should be tight against the bed to prevent potential injury to the resident. She reported the loose side rails to the maintenance department at this time. During a follow-up interview with the DON, on 05/02/12, she verified the loose rails on Resident #83's bed posed an accident hazard and entrapment risk for the resident.",2016-07-01
8241,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2012-05-03,325,D,0,1,9YCU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to implement interventions to prevent significant weight loss for 2 of 3 sampled residents of 8 residents identified with weight loss. (Resident # 53 and Resident #71) Findings include: a) Resident #53 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set, dated dated [DATE], documented Resident #53 required minimal assistance of one staff for eating. Review of the physician orders [REDACTED].#53 had a diet order of, Low concentrated sweets/diabetic/no added salt. On 04/11/12, a new order was received for super foods three times a day with meals. Review of the dietary assessment, dated 02/21/12, found Resident #53 weighed 156 pounds and was 72 inches tall. This note stated he weighed 167 pounds on admission and had experienced a 6.6% weight loss since admission. His ideal body weight was 161-195 pounds and the current BMI was 21.5. The dietary assessment documented the resident had good dietary intake and staff were to monitor his daily intake. This dietary assessment noted the resident was at high risk for weight loss. The resident's usual meal intake was 76-100%, and he had a good appetite. Review of a dietary note, dated 03/06/12, documented the resident's weight was now 170 pounds. He was noted to be receiving a supplement, Ensure, three times a day. His meal intake was 50-70%. Dietary recommendations documented that the resident was upset with the need to have further therapy and did not want to discus his dietary concerns. Review of a dietary note, dated 04/02/12, revealed Resident #53's weight had dropped to 166 pounds. The assessment documented staff were to monitor him closely for adequate intake due to his complaints of stomach pain. A dietary note, dated 04/11/12, identified a change in the diet order to also include super foods related to weight loss. He was to receive super foods at all three meals. This was the last dietary note despite the fact the residents weight had dropped eight pounds to 158 on 04/18/12. Review of the weight records revealed the following documented weights: 02/11/12; Weight: 167; BMI: 23 02/18/12; Weight: 156; BMI: 21 03/10/12; Weight: 181; BMI: 25 03/17/12; Weight: 174; BMI: 24 04/07/12; Weight: 156; BMI: 21 04/18/12; Weight: 158; BMI: 21 Fluctuations had occurred; however, the trend was downward, indicating a weight loss had occurred since admission to the facility. The nutritional care plan documented the resident was at nutritional risk due to inadequate food intake, nausea, and presence of a pressure ulcer. Review of the nutritional care plan revealed interventions to maintain weight the resident's weight at 181 pounds, plus or minus 7 pounds. The plan was to encourage the resident's food intake, to offer fluids at every care encounter, to offer substitutes as needed, and to encourage frequent intake. The care plan did not include the 04/11/12 physician ordered super foods. Interview with the the dietary manager, on 05/02/12 at 1:30 p.m., verified she had not updated the nutrition plan of care to include the new intervention of super foods. Observations, on 05/02/12 at 9:35 a.m., revealed Resident #53 still had most of his eggs, bacon, and toast on his breakfast tray. He stated the eggs and toast were cold and the bacon was fried to a crisp. His cereal bowl was empty, but it had remnants of Rice Crispies on the side of the bowl. These were the only food items on his tray. His current diet orders documented he was to receive super foods at all meals. An interview was conducted, on 05/02/12 at 10:20 a.m., with the nurse taking care of Resident #53. She provided documentation in her computer where she had documented that Resident #53 had consumed 100% of his super cereal that morning. She stated that she had observed his tray this morning when she gave him his medications and noted that he had eaten all of his super cereal. Interview with the dietary manager, on 05/02/12 at 10:25 a.m., revealed the resident was to receive super cereal at breakfast and either super pudding or super mashed potatoes at lunch and supper. She stated he received these fortified food items because he had lost so much weight since his admission to the facility. She stated the nurse monitors and documents how much of the super food the resident takes in the Medication Administration Record [REDACTED]. Further interview, on 05/02/12 at 10:25 a.m., with dietary staff who served the food that morning verified she had not remembered to serve Resident #53 his super cereal this morning and she only gave him Rice Crispies. Interview with Resident #53, on 05/02/12 at 10:30 a.m., revealed he very seldom received hot cereal in the morning. He stated his cereal was almost always dry cereal, but he might occasionally receive some hot oatmeal. He stated he does occasionally receive pudding or mashed potatoes at mealtime, but it is not every day that he received these items. Interview with Nursing Assistant #99, on 05/02/12 at 10:50 a.m., revealed Resident #53 always received cold cereal for breakfast. The NA stated that on occasion the resident might get hot oatmeal, but not very often. He verified the resident received pudding and mashed potatoes sometimes, but did not receive these items everyday. The NA said he would know because he is there for all three meals the resident eats. During an interview with the dietitian, on 05/02/12 at 10:40 a.m., she stated the use of super foods is very new to the facility and she was not sure of the procedure they use to ensure residents received the super foods that were ordered. The dietary manager was present during this interview and stated the addition of the super foods had been added to the resident's diet card. She was not sure why the resident had not been served the ordered enhanced cereal for breakfast. She confirmed the importance of the resident receiving the super foods due to his significant weigh loss. b) Resident #71 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review, on 04/30/12, revealed Resident #71 had experienced a 6.94% weight loss from the time of her admission until 04/26/12, when she was weighed a second time. The resident's admission weight was 173 pounds; her weight on 04/26/12, was 161 pounds. This 13 pound loss in one month was a significant loss. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed a BIMS score of 13, indicating she was cognitively able to make daily decisions. She was coded on the MDS to be 61 inches tall and weighed 173 pounds. The MDS also coded no recent weight loss. Additionally, the MDS identified that the resident received a mechanically altered diet and a therapeutic diet. Loss of solids/fluids from mouth when eating was also marked on the MDS. Review of the care plans revealed nutrition had been care planned on 04/19/12, however, it did not reflect the resident's current status including weight loss. The nutrition care plan did identify that the resident frequently leaves more than 25% of her meals uneaten. The care plan goal was for the resident to maintain a weight of 174 pounds, plus or minus 8 pounds until the next review date, 07/17/12. Staff planned to record weights, as ordered by the physician, and to monitor serum protein levels and medications. Staff also planned to ensure adequate assistance at meals, encourage intake, set up foods as needed, provide cues and encouragement, offer substitutions as needed, offer snacks, and encourage comments on food and favorite foods, report complaints. Dietary staff planned to offer the ordered diet, mechanically soft/ground, and to offer substitutes when requested by the resident. Staff also planned to determine the resident's food likes and dislikes. Review of the admission nutrition note, dated 04/19/12, revealed an admission weight of 173 pounds. There had been no subsequent nutrition notes, therefore, the resident's weight loss had not been addressed by facility nutrition staff. The Registered Dietitian (RD) was interviewed at 2:12 p.m. on 05/02/12. She stated the dietary manager (DM) gives her (the RD) a list of new admissions, readmits or concerns from weight review. The RD checked her list, but Resident #71 was not on the list. The RD stated, We review weights and skin every Tuesday. Our last meeting was 04/24/12. We covered all the weights in April at that meeting. We did not review weights on 05/01/12, because we didn't yet have any May weights. She (Resident #71) fell through the cracks. We have to figure out a system to catch everyone. We don't want to miss anyone.",2016-07-01
8242,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2012-05-03,329,D,0,1,9YCU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure each resident's medication regime was free of unnecessary medications. This affected 2 of 10 residents whose medication regimen was reviewed for unnecessary medications and 1 of 3 residents reviewed for the appropriate use of benzodiazepines. (Resident #53 and Resident #71) Findings include: a. Resident #53 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was hospitalized and re-admitted on [DATE]. A new [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED] -- 04/02/12 at 1:48 p.m. per resident request; -- 04/03/12 at 9:57 a.m. per resident request / no visible signs of anxiety; -- 04/04/12 at 8:19 a.m. and 3:24 p.m. per resident request; -- 04/05/12 at 9:35 a.m. and 4:40 p.m. per resident request; -- 04/07/12 at 10:44 a.m. per resident request; -- 04/09/12 at 11:54 a.m. per resident request; -- 04/10/12 at 10:26 a.m. per resident request; -- 04/14/12 at 11:38 p.m. given for agitation documentation revealed the resident was upset because his medication was late; -- 04/16/12 at 9:49 a.m. per resident request; -- 04/17/12 at 9:42 a.m. per resident request; -- 04/18/12 at 9:25 a.m. per resident request; -- 04/19/12 at 10:54 a.m. for anxiety, restless agitation; -- 04/20/12 at 8:37 a.m. given for restlessness. Documentation revealed the nurse attempted other interventions prior to giving the medication; -- 04/23/12 at 11:36 p.m. and 8:24 a.m. given for anxiety no other interventions attempted prior to giving the medication; -- 04/24/12 at 8:25 a.m. for anxiety / other intervention attempted prior to giving the medication; -- 04/25/12 at 9:12 a.m. no other interventions attempted prior to administering this medication; -- 04/28/12 at 8:56 a.m. for anxiety with no other interventions attempted prior to administering this medication; -- 04/30/12 at 12:36 a.m. for anxiety / no other interventions attempted prior to administering this medication; -- 05/01/12 at 3:51 a.m. for anxiety, restlessness. No other interventions attempted prior to administering this medication. Review of the medical record revealed staff were not observing, nor were they monitoring target behaviors or monitoring for the potential reasons for the resident agitation. Review of the care plans revealed no current plan of care to address the use of [MEDICATION NAME]. Interview with the DON, on 05/02/12 at 2:30 p.m., revealed Resident #53 did not have a plan of care to address his anxiety and the use of [MEDICATION NAME], nor were there any documented non-pharmacological approaches to be attempted prior to giving [MEDICATION NAME] to Resident #53. Review of the behavior log revealed a lack of documentation regarding any agitated behaviors exhibited by Resident #53. This was verified with the DON on 05/02/12 at 2:32 p.m. Further interview with the DON, on 05/03/12 at 1:11 p.m. revealed they currently do not have a system in place to ensure the staff attempt non-pharmacological approaches with residents prior to administrating a benzodiazapine medication. This failure created the potential for the resident to receive an unnecessary medication. b) Resident #71 This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review, on 04/30/12, revealed Resident #71 was receiving [MEDICAL CONDITION] meds, including an antipsychotic, an anti-anxiety and a hypnotic medication. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed a BIMS score of 13, indicating she was cognitively able to make daily decisions. She was coded on the MDS as receiving an antipsychotic medication, an anti-anxiety medication and an antidepressant. The facility failed to provide justification for the use of the antipsychotic medication. Record review of the resident's medication regimen revealed Resident #71 was ordered to take the antipsychotic medication, [MEDICATION NAME] 50 mg, 1/2 tab, for a [DIAGNOSES REDACTED]. Further review of the Medication Administration Record [REDACTED]. twice daily for anxiety. According to regulations, residents receiving antipsychotic drugs, unless they have a mental illness diagnosis, should receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Since resident #71 was a new admission, there had not been sufficient time for a GDR nor a pharmacy review. However, due to the resident's newly admitted status in the facility, behavior monitoring during the first month following admission was paramount to initial assessments of the resident and the facility's ability to plan for delivery of ongoing care and services. Guidance for monitoring symptoms include; they are significant enough that the resident is experiencing one or more of the following: inconsolable or persistent distress (e.g., fear, continuously yelling, screaming, or distress associated with end-of-life). The behaviors the facility was monitoring were: excessive use of call light, yelling loudly, and attention seeking. There was no evidence in the clinical record these behaviors were producing inconsolable or persistent distress to the resident, as there were only 3 episodes of behaviors recorded from 04/05/12, the admitted , through the end of the month of April 2012. Review of the behavior tracking revealed 3 notes: 1) The first behavior note, dated 04/06/12, the day of her admission, stated, 2 CNAs turning resident is upset about needing to stay off back r/t sores on buttocks. Resident screaming/disruptive sounds Behavior occurred daily 2) The second note was dated 04/08/12, and stated, Resident putting her call light on every 5 minutes and when you enter the room, she is beating her TV remote against the bed rail and screaming. When she sees whoever enters the room to assist her she is asking for things such as to move blanket off from her that is already folded and at the foot of the bed, or to put a pillow under an arm that is already there. When you try to explain these things to her she becomes agitated and starts screaming again There were additional questions on the 04/08/12 documentation form which queried impact on the resident and impact on others. The additional questions were: Impact on the resident: Behavior put resident at significant risk for physical illness/injury? Yes. Behavior significantly interfered with resident care? Yes. Behavior significantly interfered with resident's participation in activities or social interaction? Yes. Impact on Others: Behavior put others at significant risk for physical illness/injury? Yes. Significantly intrude on the privacy or activity of others? Yes Significantly disrupts care or living environment? Yes. 3) The third note was dated 04/23/12 and stated, Behavior occurred daily very demanding when resident turns call light on within seconds if staff does not answer, resident will begin banging cup on table or start yelling loudly. Nurse was standing outside of doorway when call light came on and nurse immediately told resident that I was coming in as soon as I finished getting meds off the top of my cart. Before I finished my sentence resident was yelling I need someone right now. When nurse went in to assist resident only thing she ask for the table to be pulled closer to her table was within reach of resident and all she would have to do was reach out and pull the table herself. Review of nursing notes for April 2012 revealed only 2 episodes of agitated behaviors. Both behaviors occurred on 4/8/12 and were: 1) agitation and inability to sleep; and, 2) banging television remote control on the bed side rails. The facility failed to offer non-pharmacologic interventions before administering an anti-anxiety medication. Also, the facility failed to monitor behaviors justifying use of the medication: Guidance for use of non-pharmacological interventions (such as behavioral interventions), are that they should be considered and used when indicated, instead of, or in addition to, medication administration. Behavioral interventions are individualized non-pharmacological approaches (including direct care and activities) that are provided as part of a supportive physical and psychosocial environment and are directed toward preventing, relieving, and/or accommodating a resident's distressed behavior. Distressed Behavior As with all symptoms, it is important to seek the underlying cause of the distressed behavior, either before or while treating the symptom. Examples of potential causes include psychological stressors (e.g., disruption of the resident's customary daily routine, grief over nursing home admission or health status). Since Resident #71 was a new admission to the facility, non-pharmacologic interventions potentially might have comforted Resident #71 and helped her cope and adjust to her new environment and the people around her, more than receiving an antipsychotic and an anti-anxiety medication. Record review revealed there was no evidence in the clinical record that non-pharmacologic interventions had been attempted before administering the medications. OBSERVATIONS: -- Multiple observations of resident #71 throughout the survey revealed her to be pleasant and cooperative. -- Observation on 04/30/12 at 3:10 p.m. revealed she was sitting in her room. She was pleasant and answered questions politely. -- Observation again, on 05/01/12 at 8:30 a.m., revealed her to be sitting up in bed eating her breakfast. -- Later in the day on 05/01/12 at noon, Resident #71 was observed in the dining room eating lunch. She stated the food was good. -- Observation on 05/02/12 at noon revealed her eating lunch, again stating the food was good. -- On 05/02/12, an observation at 3:00 p.m. revealed her sitting at an activity table watching another resident get a manicure. She talked about her nails and how nice they looked. INTERVIEWS: -- Social Services (SS) was interviewed on 05/02/12 at 10:22 a.m. She was asked about the depression [DIAGNOSES REDACTED]. She stated Resident #71 was on the list to see the psychiatrist related to the use of [MEDICAL CONDITION] medications. She stated the [DIAGNOSES REDACTED]. SS stated the psychiatrist had not determined the date of his visit. SS acknowledged depression was not justification for the use of an antipsychotic medication. -- The Assistant Director of Nursing (ADON) joined the conversation on 05/22/12 at 10:30 a.m She stated, When they come in on a medication, we have to monitor the resident. She stated the [DIAGNOSES REDACTED]. We can't just get rid of it. (Resident #71) is scheduled to see the psychiatrist. The Director of Nursing (DON) was interviewed on 05/03/12 at 9:15 a.m She stated she was aware the [DIAGNOSES REDACTED]. That is a hospital diagnosis. She continued that they could not change the diagnosis, they have referred her to the psychiatrist and until he can see her, the facility will monitor her behaviors. If she does not have any behaviors, they will attempt a gradual dose reduction (GDR). She stated the attending or primary physicians are reluctant to address [DIAGNOSES REDACTED]. The Assistant Director of Nursing (ADON) was asked about behavior tracking on 05/22/12 at 10:30 a.m She stated the nurses documented target behaviors at the end of each shift on the Medication Administration Record [REDACTED]. The ADON continued that the facility had recently addressed [MEDICAL CONDITION] medications in their Quality Assurance (QA) process. She stated they would be forming a formal committee to review the [MEDICAL CONDITION] medications for the residents quarterly or as needed. She acknowledged that currently there was not a formal review process by the interdisciplinary team (IDT) to review psych meds and behaviors.",2016-07-01
8243,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2012-05-03,364,F,0,1,9YCU11,"Based on observation and interview, the facility failed to serve food to residents that was palatable and served at the proper temperatures. This had the potential to affect 105 of 107 residents residing in the facility. Findings include: a) During observation in the main dining room, on 04/29/12 at 12:20 p.m., both Resident #113 and Resident #117 stated the meat was too tough to eat. Several residents in the main dining room at this time were observed attempting to cut their meat and were unable to cut it. These residents were observed to pick up the piece of meat and bite it to tear it apart. The meat was observed to be a very thinly cut piece of beef and very dry around the edges. b) Observation of lunch being served on C Wing, on 04/29/12 at 12:30 p.m., revealed there was one staff on the unit serving trays. Continued observations at 1:05 p.m. revealed there were still 6 trays on the meal cart left to be served to the residents. At 1:25 p.m., another nurse aide came to the unit to assist with passing trays. She passed one of the 6 remaining trays to a resident; the food on the tray was observed to be pureed. Nurse aide #106 sat down to feed the residents. She was asked if it normally took over an hour to pass the meal trays on this hall. She stated yes it takes 1-1.5 hours to pass trays and feed the residents on the C Wing. When asked if she ever re-heated the food after it had sat in the non-heated cart for an hour, she said if it was not still hot she would, but she felt the pureed food she was feeding the resident was still hot and continued to feed the resident. This food had been on the cart for 55 minutes before it was served to the resident. The resident was not able to be interviewed. c) A second dining observation was conducted on the C wing on 05/02/12 for concerns regarding food temperature and palatability. The main dining room was served at 7:05 a.m. There were 8 residents observed in the dining room. The residents were served bacon and eggs. They ordered their egg the way they wanted it cooked and it was served to them directly from the kitchen. The rest of their food items came out on their tray. The staff stated only a few residents eat in the dining room for breakfast. She said most residents eat their breakfast meal in their room. On 05/02/12 at 7:37 a.m., one cart of trays was delivered to the C Wing. There was no nursing staff available at that time to begin delivering the trays to the residents. At 7:41 a.m., a staff member arrived to begin distributing the trays from this cart. There were approximately 30 trays to be distributed to residents on this Wing. At 7:44 a.m., a second cart of trays was delivered to the C Wing. There was still only one staff member observed to be passing the trays to the residents on this wing. There was another staff member observed on the hall, but she was obtaining resident vital signs. There were approximately 30 residents on the C Wing with trays to be served to them and at 8:03 a.m., there was still only one nursing assistant (NA), #109, passing the trays to the residents on this hall. An interview was conducted with NA #109 on C Wing at 8:07 a.m. on 05/02/2012. She stated she was the only staff passing trays to all the residents on C Wing. At 8:09 a.m. another NA arrived on the unit to assist serving the breakfast trays to the residents. At 8:33 a.m., there were still 5 trays left to be served to residents on C Wing. NA #109, who was passing the food trays, had to cease serving the residents their trays to assist a resident to the bathroom. At 8:39 a.m., Staff #93 served the resident in room 140 bed A a pureed diet tray. This resident required staff assistance to eat so Staff #93 sat to feed her. This tray of pureed food had been on the cart since 7:37 a.m. and she did not reheat the food before feeding it to the resident. d) The last tray was served to a resident at 8:40 a.m. The temperatures of the food items were taken on this tray by dietary staff (#18) at that time and the following temperatures were obtained: Milk was 52 degrees Fahrenheit (F); Juice was 56 degrees F and tasted lukewarm; Cream of wheat was 100 degree F Pureed eggs were 98 degrees F The eggs had no taste and all the food items tasted were only warm, not hot. Interview with NA #109, on 05/02/2012 at 8:55 a.m., revealed she does not find it necessary to re-heat the residents food after it had been on the cart for over an hour. She felt it would still be warm enough to feed to the resident. Interview with alert Resident #53 and alert Resident #24, on 05/02/12 at 9:22 a.m., revealed complaints about their cold breakfast. Resident #53 stated his eggs and toast were cold and his bacon was burnt. He said his breakfast was never hot so he just eats his cold cereal and leaves the rest. Resident #24 stated her breakfast was almost always cold and she thinks the staff are just too busy to bother them with trying to get them to re-heat it. The above observations were shared with the dietitian at 2:02 p.m. on 05/02/12. She stated the residents have complained in the past about the meat being tough during the resident council meeting. She said they speak of food in every resident council meeting and they try to address the concerns. Review of the Resident Council minutes for February, March, and April 2012 revealed resident complaints of cold food. In February 2012 residents had also complained of tough meat. There was no evidence of any follow up to these concerns that had been voiced by the residents. This information was shared with the DON at 2:35 p.m. on 05/02/12. She verified it was difficult to get the trays out timely because they have so many residents that require assistance to be fed. e) During a dining observation, on 05/02/12, the A hall of Unit 1 was observed for the morning meal service. The meal carts arrived to hall A at 7:13 a.m. At 7:23 a.m., the carts remained untouched. As the food carts were on the hall, Nurse Aide (NA) #99 was observed obtaining blood pressure and temperature readings of some residents, NA #120 was observed answering call lights, and Licensed Practical Nurse (LPN) #59 was observed counting narcotics with the nurse going off duty and then passing medications. At 7:34 a.m., NA #120 was observed taking the first 2 trays from the food service cart. At 8:19 a.m., NA #99 was observed to assist with the meal service on the A hall. At 8:48 a.m., there were still trays observed on the food service cart. At 9:15 a.m., the last tray was observed being delivered to a resident. During an interview with Resident #24 at 8:24 a.m., she stated her eggs and bacon were cold. When asked if she had ever asked anyone to warm it up for her she stated she did not want to bother anyone because they have so much to do. During an interview with Resident #46, she stated her eggs were cold and she did not say anything to the staff about it. During an interview with Resident # 51, she stated she does not eat her eggs and they were probably cold anyway. During an interview on 05/02/12 at 9:26 a.m., with NA #120, it was verified it was normal for breakfast to take as long as it had that day. NA #120 also stated they have a lot of residents to feed on the A hall. NA #120 also stated during the interview there were 2 residents on the A hall who always get their trays first because they always complain about cold food. During an interview with the Director of Nursing (DON) on 05/02/12, she verified the meal service on the A hall should not have taken as long as it did.",2016-07-01
8244,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2012-05-03,371,F,0,1,9YCU11,"Based on observation and interview, the facility failed to maintain and distribute food under sanitary conditions. This had the potential to affect 105 of 107 residents residing in the facility. Findings include: a) Observation of the food being plated in the kitchen was conducted at 12:15 p.m. on 04/30/12. Dietary staff #17 was observed to pick up plates and bowls with gloved hands and touch the portion of the plate on which the food was placed. She was then observed to touch her hair, glasses, and clothing, and continue with the same practice of touching the portion of the plates she would be placing the food items on. She was observed serving roast beef with a spatula and it was difficult for her to pick up the pieces of meat with this utensil. Wearing the same gloves, she was observed to place the meat on the plate and then used the potentially contaminated gloved hands to hold onto the meat while she cut the meat into pieces. There were times she had difficulty picking the pieces of meat up out of the serving container so she was observed to use the potentially contaminated gloved hands to pick the meat up by sticking her fingers into the container to pick up the meat. At times she was unable to cut the meat with the knife and stated, it is so hard to cut this stuff, so then she would just pull the meat apart with her fingers. This surveyor shared with the dietary staff during this observation the need to change gloves before serving any additional food items due to the potential for cross-contamination. An interview was conducted with the dietary manager and the dietitian at 10:15 a.m. on 05/02/2012. The observations of staff #17 serving food in an unsanitary manner during the first day of the survey were shared at this time. The dietary manager stated this staff member should know better. The dietitian stated it seems once the staff put on gloves they think they can touch anything and then come back to serving food and touching items with the same gloved hands. This allowed for a potential of food borne illness related to the cross-contamination practices observed. Both the dietitian and the dietary manager stated that in-service and education of their staff would be necessary to prevent this from happening again.",2016-07-01
8245,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2013-07-30,166,D,1,0,YIJO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and grievance record review, the facility failed to resolve a grievance for one (1) of twelve (12) sampled residents in a timely manner. A resident who allegedly lost her glasses in early March, had no grievance report made until nearly four (4) months later. There was no resolution of the grievance prior to her discharge from the facility. Resident identifier: #122. Facility census: 119. Findings include: a) Resident #122 Review of the medical record, on 07/29/13 at 2:00 p.m., revealed Resident #122 was a [AGE] year old resident with dementia. She was admitted to the facility on [DATE] for rehabilitation following a [MEDICAL CONDITION]. Review of the inventory list, dated 03/05/13, found she had one (1) pair of glasses at the time of admission to the facility. An interview was conducted with the Licensed Social Worker (LSW), Employee #20, on 07/29/13 at 4:00 p.m. She said the Medical Power of Attorney (MPOA) called after the resident's discharge to home on 06/12/13, and asked about the resident's missing glasses. The LSW said an eye exam was done on this resident on 04/03/13 at the facility, and on 05/15/13 she was again seen by the eye doctor at the facility. The LSW said the thought there was some kind of issue at the doctor's office, and a delay with the laboratory (lab) that makes the glasses. She gave this as the reasons the resident did not receive the glasses before going home. Review of the medical record, on 07/29/13 at 4:30 p.m., confirmed a visual analysis was completed by an eye doctor on 05/15/13. The written treatment plan indicated a new prescription was medically necessary to improve distance and near vision in both eyes. On 07/30/13 at 9:00 a.m., review of the grievance reports revealed a grievance dated 06/27/13. The heading was Customer First Concern/Grievance Report. Attached to the grievance was a typed letter from the MPOA of Resident #122, dated 06/24/13, with an allegation that stated, Her glasses were lost the first week she was there and she never received a new pair although I was told that they would be sent to her. Medical record review revealed the resident was discharged from the facility on 06/12/13. On 07/30/13 at 9:15 a.m., an interview was completed with LSW, Employee #72. She said the resident's family told her, possibly in April, that the resident's glasses were missing. The resident was seen in May by the eye doctor. The resident was discharged to home in June, but did not receive her glasses prior to the discharge. The LSW said she assumed this was due to billing issues. She said there was no grievance report completed initially for the glasses when the loss was first discovered. The LSW said she did not know why a grievance report was not done at that time. An interview was conducted with the administrator on 07/30/13 at 9:20 a.m. She said she would have expected a grievance report to have been made initially when there was a complaint about missing glasses. She said the facility was not obligated to purchase new glasses for this resident since she was a short stay customer, but did so as a courtesy. The administrator said there was a delay in payment because the corporate office was not considered a critical vendor, and this negatively affected payment. She produced a copy of the bill for the lenses and frame for $171.00, dated 05/15/13, with a handwritten notation that the bill was paid on 07/01/13. The administrator said after payment of the bill, she thought there was some problem with the lab that makes the glasses. She acknowledged that as of this date, the resident had still not received the new pair of glasses.",2016-07-01
8246,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2013-07-30,225,E,1,0,YIJO11,"Based on resident interviews, staff interviews, review of grievance reports and reportable allegations, and policy reviews, the facility failed ensure misappropriation of property was thoroughly investigated and/or reported to the appropriate State agencies. Three (3) of twelve (12) residents reviewed for personal property issues had a total of five (5) instances of missing money which were not reported and/or investigated. Resident identifiers: #46, #27, and #81. Facility census: 119 Findings include: a) Resident #46 On 07/24/13 at 2:30 p.m., grievance and concern forms were reviewed for the months of May, June, and July 2013. It was noted Resident #46 had filed a concern/grievance report on two (2) different occasions regarding money taken from his room. A concern form dated 05/19/13, indicated the resident placed $20.00 in his Bible, and placed the Bible under the sheets. When he returned from bingo, his Bible had been moved and the money was gone. No evidence was present to indicate the incident was investigated. Another grievance form, dated 07/16/13, indicated the resident had hidden $5.00 in quarters in his Santa Claus, and it was missing. Review of reportable allegations for May, June, and July 2013 provided no evidence the incidents were reported to the State agencies. An interview with Resident #46, on 07/25/13 at 8:30 a.m., revealed the resident was alert, coherent, and oriented. He confirmed money was taken from his room on two (2) different occasions. He said on the first occasion, money was taken from a Bible, which was hidden beneath his sheets. On the most recent occasion, quarters were taken from his Santa Claus. He indicated the money had been stolen. He said he did not misplace it. During an interview with Employee #7, a licensed practical nurse (LPN), on 07/30/13 at 11:30 a.m., the LPN said Resident #46 had complained someone had gone through his belongings. b) Resident #27 During a review of the grievance/concern forms, on 07/24/13 at 2:30 p.m., it was noted Resident #27 reported $22.00 was missing from her lock box on 05/28/13. She said she must have left her key lying out. The investigation consisted of only one (1) witness statement. On another occasion, dated 07/16/13, the resident said $21.00 was missing from her room. No evidence was available to indicate an investigation was completed for this allegation. An interview with Employee #7 (LPN), on 07/30/13 at 11:30 a.m., revealed Resident #27 had complained about people going in her room. c) Resident #81 Review of grievance/concern forms for May, June, and July 2013, on 07/24/13 at 2:30 p.m., revealed Resident #81 expressed a concern that $3.00 was missing from an envelope in her bedside table. Reportable allegations were also reviewed. No evidence was present to indicate the incident was investigated. An interview was conducted with Employee #20 (social worker), on 07/25/13 at 8:15 a.m. She said she did not know if the money was reported to the State agencies. She said she utilized the Table 1 - Abuse/Neglect reporting requirements for WV Nursing Homes and Nursing Facilities protocol (revised October 2011) to determine what needed reported. The social worker said it should have been reported to State agencies. During another interview with Employee #20, on 07/30/13 at 8:45 a.m., she said money was reported to State authorities only if it was deemed to have been stolen. The social worker said if it was only considered missing, it would not be reported. When asked how she would differentiate between stolen and missing money, she said she was not sure. d) During an interview with Employee #72 (director of social work), on 07/30/13 at 9:00 a.m., she said the money was not reported to State authorities unless the resident specifically stated the money was stolen. Employee #72 said if the resident reported money was missing it was not reported to State authorities. Employee #72 confirmed the missing monies for Resident #46 on 05/19/13 and 07/16/13; Resident #27 on 07/16/13 and 05/28/13; and Resident #81 on 05/28/13 were not reported. During another interview at 5:00 p.m., the social worker confirmed the money was not reported to the proper State authorities. The administrator (Employee #111) was interviewed on 07/30/13 at 2:34 p.m. She confirmed the missing money had not been reported to the proper State agencies.",2016-07-01
8247,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2013-07-30,309,D,1,0,YIJO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, medical record review, policy review, and incident/accident review, the facility failed to ensure one (1) of ten (10) residents maintained his highest level of well-being. The facility did not accurately and timely assess and monitor an abrasion. Resident identifier: #46. Facility census: 119. Findings include: a) Resident #46 Review of an incident report, dated 07/07/13, indicated Resident #46 received an injury while two (2) nursing assistants were assisting him onto the toilet with a lift on 07/05/13. The report indicated he had an open wound, identified as an abrasion, that was bleeding onto the floor. During an interview with Resident #46, at 8:30 a.m. on 07/25/13, he confirmed the incident and injury. The medical record, reviewed on 07/25/13 at 8:45 a.m., revealed no evidence the wound was treated, or evaluated prior to 07/08/13. An order was entered on 07/08/13, to apply [MEDICATION NAME] to abraded scar tissue. The care plan, dated 07/07/13, indicated the wound was to be assessed frequently to ensure healing. Further review of the medical record revealed no ongoing assessment or monitoring of the wound. The nurses' notes and the treatment administration record were reviewed with the wound/treatment nurse, (Employee #58), a registered nurse. She confirmed a wound evaluation form had not been completed as of 07/25/13, nor was the any evidence of ongoing wound assessments. An interview with Employee #122, a registered nurse (RN), on 07/25/13 at 3:30 p.m., revealed he became aware of the incident on 07/07/13. The nurse said he did not evaluate the wound because he was not caring for the resident. The RN said he initiated an investigation, but was unaware of anything else related to the incident. Review of the facility's 1.40 First Aid Policy, on 07/29/13 at 10:00 a.m., revealed all injured persons were to receive immediate interventions and measures to prevent further injury. Emergency treatment included cleansing the affected area and covering the wound with a [MEDICATION NAME] pad or other dressing. The incident was to be documented in the chart and/or report with the date and time of incident, what happened, assessment of the situation and person, all interventions implemented, and notification of the family and attending physician. Completed reports were to be submitted to the nursing supervisor. The 1.1 Accidents, Incidents, and Adverse Events Policy was reviewed on 07/29/13 at 10:00 a.m. It noted the nurse was to examine the resident, provide first aid, notify the physician, and obtain orders if indicated. The incident report was to be submitted to the administrator, director of nursing, or designee within 24 hours of the occurrence. Employee #7, a licensed practical nurse (LPN) was interviewed on 07/30/13 at 10:20 a.m. The LPN said he received information regarding the incident on 07/07/13, during morning report from Employee #108 (RN). Employee #7 said he later spoke with Resident #46, and asked him how he had acquired his wound. The LPN said the resident told him he had been dropped while two (2) nursing assistants were transferring him to the toilet on the night of 07/05/13. When questioned about the facility's protocol related to incident/accidents, the LPN said the incident should have been reported the date it occurred, an investigation completed, and charting should have been completed every shift for at least three (3) days. The nurse further stated charting should have included the appearance of the wound, drainage, inflammation, odor, or anything like that. He also said a weekly measurement should have been completed. Employee #7 said the wound nurse (Employee #58), usually completed the measurements, but if not on duty, the unit charge nurse was to initiate the form. During an interview with the administrator and director of nursing, on 07/30/13 at 5:00 p.m., they acknowledged no evidence was present to indicate the abrasion had been monitored and accurately assessed since the occurrence.",2016-07-01
8248,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2013-07-30,425,D,1,0,YIJO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, review of incident reports, and medical record review, the facility failed to provide pharmaceutical services for one (1) of ten (10) sample residents. A Duragesic patch (pain medication) was not available in the facility when it was due for administration. The patch was not received from the pharmacy until the following day, and was not applied until twenty-six (26) hours after it was originally due. Resident identifier: #121. Facility Census: 119. Findings include: a) Resident #121 A 07/24/13 review of an incident report, created on 06/30/13, described a situation in which Resident #121 was due a Duragesic patch on 06/29/13. The patch was not available from the pharmacy because a new prescription (Rx) was required from the physician for this medication. The report described repeated conversations by the nurse, Employee #89, and the Administrator, Employee #111, with the pharmacy and physician in attempts to get the Rx faxed to the pharmacy. An interview was conducted with Employee #89, Licensed Practical Nurse (LPN), on 07/29/13 at 3:30 p.m. The interview with the LPN was consistent with the medical record. Both the nursing notes and the Medication Administration Record [REDACTED]. A physician's orders [REDACTED]. The medication was signed into the narcotic drawer as received from the pharmacy on 06/30/13, on the Master controlled medication log for medication cart for RRS Front. It was not until 06/30/13 that both the nurse's note and the MAR indicated [REDACTED]. It was signed off as given at 11:00 a.m. (twenty-six (26) hours after it was originally due) on 06/30/13 by Employee #89, LPN. She verified this in her interview on 07/29/13 at 3:30 p.m. This matter was discussed with the Administrator on 07/29/13 at 3:30 p.m. She agreed the medication was not available. No additional information was provided by the end of the survey.",2016-07-01
8249,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2013-07-30,514,D,1,0,YIJO11,"Based on medical record review and staff interview, the facility failed to ensure the medical record for (1) of three (3) residents reviewed for blood sugar monitoring, contained an accurate representation of the resident's medical status. This resident's blood sugar monitoring documentation contained an entry which was illegible. Resident identifier: #98. Facility census: 119. Findings include: a) Resident #98 On 07/30/13 at 4:30 p.m., Resident #98's medical record was reviewed for blood sugar monitoring. Review of the Medication Administration Record [REDACTED]. A nurses' note, dated 07/05/13, indicated the physician was notified the blood sugar was completed late, but did not require coverage. During an interview with Employee #35 (director of nursing) and Employee #111 (administrator), on 07/30/13 at 5:00 p.m., they acknowledged the entry was illegible. They confirmed the results of the blood sugar could not be determined from the documentation on the MAR.",2016-07-01
8250,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2012-06-08,166,D,0,1,26RQ11,"Based on interview and record review, the facility failed to develop an effective grievance program that included follow-up visits to ensure residents' grievances had been resolved to their satisfaction for three (3) residents reviewed. Resident identifiers: #84, #18, and #74. Findings include: 1. Review of the documentation provided by the Social Services Assistant (SSA) on 6/6/12 revealed the following information: a) Resident #84 The SSA was advised on 01/26/12 that R84 had voiced a complaint about noise on his hallway. The SSA visited R84 on 01/27/12 at 11:56am and he stated that he was disturbed in the middle of the night when the residents on either side of him were yelling and screaming. The SSA documented that there was little the facility could do to prevent the residents in question from yelling at night. She informed R84 that the facility had ear plugs which might help him sleep. The SSA reported R84 ' s concern to the nurse on his unit and the nurse stated that she would make an effort to keep the other residents as quiet as possible at night. As of 06/08/12 at 12:00 noon, there was no subsequent documentation relative to R84 ' s grievance. The facility failed to follow up with R84 to ensure that his grievance had been resolved to his satisfaction. There was no documentation relative to the potential intervention (ear plugs), or if the resident continued to be disturbed in the middle of the night by the loud residents on his hallway. An interview with the SSA on 06/06/12 at 4:00pm confirmed that she had failed to follow up with R84 to ensure that he was able to sleep throughout the night without being disturbed. b) Resident #18 The SSD visited R18 on 02/06/12 at 2:54 pm and again on 4:15pm because she was upset over her roommate (R60) and she was expressing fear of her. The SSD spoke with R18 ' s family and they stated that they did not want R18 to change rooms but they wanted the facility to relocate her roommate, R60 instead. They stated that R18 was in the room first, and felt that she had the right to remain there. Per the documentation, the facility decided to relocate R60 to another room. There was no further documentation. Interview with the SSA on 06/06/12 at 4:00pm confirmed she had not scheduled a follow up visit with R18 and did not know if her grievance had been resolved. c) Resident #74 The SSA visited R74 on 05/07/12 at 12:33pm because she was unhappy with the temperature in her room. R74 stated that she was sensitive to the cold but she did not want to offend her roommate, R73 who was sensitive to the heat. The SSA emphasized to R74 that when two residents share a room, they must compromise in order to make sure both are comfortable. There was no further documentation. Interview with the SSA on 06/06/12 at 4:00 pm confirmed that she had not followed-up with R74 and her roommate.",2016-07-01
8251,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2012-06-08,241,D,0,1,26RQ11,"Based on observation, interview, and clinical record review the facility required three (3) cognitively impaired residents wear helmets that a reasonable person would not if given the choice. Resident identifiers: #34, #57, and #78. Findings include: a) Resident #78 Observation on 06/06/12 at 3:30 pm, revealed R 78 lying in bed asleep with a beige helmet on his head. The helmet had a hard outer shell and foam inside. Several holes placed about the helmet presumably for ventilation. The helmet was square in shape at the top front and had large loops hanging down from the ears. The helmet was secured with a strap under the chin. R 78 ' s helmet was pushed forward and sideways on his head causing his brow to be wrinkled and covering his right eye. Observation on 06/06/12 at 4:00 pm, revealed R 34 was ambulating in the hallway near the nurse ' s station. Each time she turned her head the helmet obstructed her vision. Each time she would remove the helmet, staff would replace it. When the helmet was off, the resident ' s hair was matted and wet. Review of R 78 ' s clinical record revealed that before his current illness he had been a professional person held in high esteem by his peers and having distinguished himself in his field. b) Resident #57 Observation of R57 on 06/05/12 at 1:30 pm revealed that she was seated in an arm chair across from the 1st floor nursing station. She was wearing eye glasses and a soft helmet that was secured under her chin. She was talking out loud to herself and asking questions. Her questions were not directed at anyone. She appeared cognitively impaired. On 06/05/12 at 1:45pm, R57 began to pull at her helmet. As she twisted the helmet to the left side of her head, her glasses fell off and landed on the floor. She removed her helmet and placed it on the chair beside her. She continued to talk to herself. R57 did not want the helmet on her head. On 06/05/12 at 1:55pm, a staff member who had passed by saw R57 without her helmet and glasses. Staff picked R57 ' s glasses up off the floor and took the helmet off the chair, and told R57 that she needed these items. She proceeded to place the items back on R57 ' s face and head and then she walked away. She did not ask the resident if she wanted these items, she just put them back in place. Interview with the Director of Nursing (DON) at the exit conference on 06/08/12 at 12:00 noon, confirmed that the residents who wore helmets in this facility were residents who had fallen often and were at risk of injury. She stated that they needed to wear the helmets to ensure that they would not sustain a head injury if they were to fall. The DON stated that many of their residents fell in the facility but only 4 had to wear helmets. When interviewed about why the other residents who had fallen in the facility were not required to wear helmets, the DON stated the other residents don ' t want to wear the helmets . Only the residents, who were cognitively impaired and unable to make day to day decisions, were required to wear helmets.",2016-07-01
8252,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2012-06-08,279,D,0,1,26RQ11,"Based on observation, interview and record review, the facility failed to develop an individualized dental care plan that included specific requirements for one of 19 sampled residents, R34. Findings include: Observation of R34 during the initial tour on 6/5/12 at 9:30am revealed that she was in bed and her dentures were in her mouth. Upon closer inspection of R34 ' s dentures at that time, revealed that they were visibly soiled. During an interview with R34 ' s family member on 6/7/12 at 10:15am via telephone revealed that they were unhappy because they believed that the facility had not been taking R34 ' s dentures out at night before she went to bed. Observation of R34 on 6/7/12 at 10am revealed that she was in bed, fully dressed, and sleeping. Her dentures were in her mouth and her denture cup was empty. Interview with the Certified Nursing Assistant (CNA #19) who was assigned to R34 on 6/7/12 at 10:25am confirmed that it was the facility ' s policy to take the residents ' dentures out after breakfast and after dinner. She stated that staff was supposed to take R34 ' s dentures out after breakfast, brush them and put them in a denture cup to soak. After dinner, staff was supposed to do the same thing. This practice was to happen every day. She stated that on at least 3 occasions, when she went into R34 ' s room to get her up for the day, her dentures were still in her mouth. She stated that the evening staff had failed to take R34 ' s dentures out before she went to bed. The CNA #19 stated that she had reported this deficient practice to the charge nurse. Interview with the Charge Nurse, LPN #55 on 6/7/12 at 10:40am confirmed that CNA #19 had reported the night shift staff for not removing R34 ' s dentures before putting her to bed. She stated that she had spoken to the night shift staff about this concern, but she did not document that meeting. Review of the facility provided documentation, the ADL Observations which had been completed by the CNAs on a daily occasion, revealed that R34 required assistance with her personal hygiene needs. However, there was no documentation that reflected that staff taken R34 ' s dentures out at night before she went to bed. Review of the Activities of Daily Living (ADL) care plan dated 03/07/12, revealed that staff were to assist with oral care daily . It was not individualized or specific as to when staff were to place R34 ' s dentures into her mouth, when to take them out, or how her dentures should be brushed and soaked in the evening before assisting her to bed.",2016-07-01
8253,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2012-06-08,280,E,0,1,26RQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family/staff interviews and clinical record review, the facility failed to ensure that the comprehensive care plans were revised as needed for 4 of 19 sampled residents (R9, R10, R14, and R34). Findings include: 1. Observation of R34 during the initial tour on 06/05/12 at 9:30am revealed that she was in bed and her dentures were in her mouth. Closer inspection of R34 ' s dentures at that time revealed they were visibly soiled. An interview with R34 ' s family member on 06/07/12 at 10:15am via telephone revealed they were unhappy because they believed the facility had not been taking R34 ' s dentures out at night before she went to bed. Observation of R34 on 06/07/12 at 10:00am revealed that she was in bed, fully dressed, and sleeping. Her dentures were in her mouth and her denture cup was empty. Interview with Certified Nursing Assistant (CNA) #19, who was assigned to R34, on 06/07/12 at 10:25am, confirmed that it was the facility ' s policy to take the residents ' dentures out after breakfast and after dinner. She stated that staff was supposed to take R34 ' s dentures out after breakfast, brush them and put them in a denture cup to soak. After dinner, staff was supposed to do the same thing. This practice was to happen every day. She stated that on at least 3 occasions, when she went into R34 ' s room to get her up for the day, her dentures were still in her mouth. She stated that the evening staff had failed to take R34 ' s dentures out before she went to bed. CNA19 stated that she had reported this to the charge nurse. Interview with the Charge Nurse, Licensed Practical Nurse (LPN) #55 on 06/07/12 at 10:40am confirmed that CNA19 had reported the night shift staff for not removing R34 ' s dentures before putting her to bed. She stated that she had spoken to the night shift staff about this concern, but she did not document that meeting. Review of the facility provided documentation, the ADL Observations which had been completed by the CNAs on a daily occasion, revealed that R34 required assistance with her personal hygiene needs. However, there was no documentation that reflected staff had taken R34 ' s dentures out at night before she went to bed. Review of the Activities of Daily Living (ADL) care plan, dated 03/07/12, revealed staff were to assist with oral care daily. Although nursing staff had been made aware of problems regarding dental care, R34 ' s care plan was not revised to include individualized, specific information as to when staff were to place R34 ' s dentures into her mouth, when they were to take them out, or how her dentures should be brushed and soaked in the evening before assisting her to bed. 2. R9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R9 sustained falls on 02/24/12, 04/15/12, 04/20/12, 05/03/12, 05/09/12, 05/11/12 (twice), and 05/18/12. Review of R9 ' s care plan (dated 12/19/06) indicated: Interventions: 02/27/12 - Continue current interventions; 04/16/12 - Continue current interventions. 04/23/12 - Restraint assessment completed. PT (Physical Therapy) notified of falls and need for screen. Continue current interventions. 05/03/12 - Continue current interventions. When the fall interventions were unsuccessful and R9 continued to fall, the facility failed to review and revise the care plan as necessary. (Refer to F323.) 3. R10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R10 sustained falls on 04/15/12, 04/17/12, 05/16/12, and 05/18/12. Review of R10 ' s care plan (dated 04/06/12) indicated: Interventions: 04/16/12 - Isolated incident. Continue current interventions. 04/17/12 - Restraint assessment done. Not a candidate for restraints at this time. When the fall interventions were unsuccessful and R10 continued to fall, the facility failed to review and revise the care plan. (Refer to F323.) 4. R14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R14 sustained a fall on 04/30/12 which resulted in a [MEDICAL CONDITION] tibia. Review of R14 ' s care plan (dated 04/27/06) indicated: Interventions: 04/30/12 - Isolated incident. No new interventions warranted at this time. May be weight bearing. Physician order [REDACTED]. However, these interventions were not added to the care plan. 5. R34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Fall care plan, dated 03/07/12, revealed that R34 was at risk for falls due to her [MEDICAL CONDITION] disorder, dementia and [MEDICAL CONDITION] medications. She was to have a sensor cushion placed in her bed and one placed in her wheelchair. If the resident attempted to get out of bed or rise from her wheelchair, the sensor cushion would sound which alerted staff that the resident had moved and may be at risk for falls. Review of the Risk Management Accident/Incident (A/I) Report dated 03/10/12 revealed that R34 fell on [DATE] at 2:45pm. Per the documentation, R34 was ambulating from the dining room and was waiting for the elevator doors to open. After she entered the elevator she lost her balance and fell . Per the fall care plan, R34 had a bed and chair alarm, but because she was ambulating and not in bed or in her wheelchair at the time of the fall, staff were not alerted to the oncoming fall. Review of the fall care plan revealed that after R34 fell in the elevator on 03/10/12, the facility failed to revise the care plan to include interventions such as necessary additional precautions, or the potential for assistance when she ambulated. The care plan read, RM (Risk Management) - Continue current interventions. Review of the A/I report dated 03/19/12 revealed that R34 fell and sustained a large hematoma to the left side of her forehead. After R34 fell on [DATE] and sustained injury to her forehead, the facility revised the care plan to state, RM Hip pads. Continue current interventions. Review of the A/I report dated 03/21/12 revealed that R34 had tried to ambulate and fell . She hit the right side of her head on the floor. The fall care plan that was revised on 03/22/12 read RM Soft helmet prn (as needed). Continue current interventions Review of the A/I reports for the month of April 2012 revealed that R34 fell 3 more times. On 04/07/12, R34 fell when she attempted to get out of her wheelchair. She was sitting close to the nurse ' s station and per the documentation, R34 tried 4 separate times to get out of her chair. Nursing documented that she redirected R34 each time with success. However, when nursing turned around to walk toward the desk, R34 got out of her wheelchair and fell backwards. She sustained a skin tear to her right elbow. Nursing documented that she educated the resident and reminded her that she could not walk without assistance. However, the fall care plan revised on 04/09/12 after R34 ' s fall on 04/07/12 failed to include that information. It read, the RM -Continue current interventions. On 04/23/12, R34 ambulated to a room across the hall from hers and she fell between the two beds. She fell face first per the A/I report. She sustained a hematoma to the right side of her forehead and a skin tear to her left elbow. The fall care plan that was revised on 04/24/12 after the fall stated, RM - Continue current interventions On 04/28/12, R34 was found, per the A/I report, on the floor, on her back, and her head was in the closet. Her soft helmet was found on the floor. Per the documentation, the bed sensor alarm was in place, however, neither the nurse nor the CNA heard it alarm when the resident got out of her bed. Nursing documented on the A/I report that at night, R34 was at a greater risk for falls because she would not remain in bed if staff put her to bed too early. On 04/30/12, the care plan again was documented, RM - continue current interventions Although staff had identified a possible factor related to R34 ' s falls, review of the fall care plan revealed it was not revised to include this information. R34 experienced another fall on 05/30/12. The fall care plan dated 05/31/12 read, RM- continue current interventions. Although R34 continued to fall and sustain injuries, the facility failed to review and revise the care plan as necessary. (Refer to F323.) During an interview conducted with the Director of Nursing (DON) on 06/07/12 at 3:00pm, the DON acknowledged that care plans had not been revised with new solutions/ interventions, even when previous approaches were not successful in preventing multiple falls.",2016-07-01
8254,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2012-06-08,309,G,0,1,26RQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review the facility failed to ensure that timely care and services were provided for two (R10 and R14) of a total of nineteen residents. R14 did not receive timely treatment for [REDACTED]. Findings include: a) Resident #14 R14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility assessed R14 as being interviewable. A review of the Nurse ' s Notes indicated the following: 04/30/12 at 5:00am: Resident lost balance when CNA (Certified Nursing Assistant) transferring from BSC (bedside commode) to W/C (wheelchair). CNA lowered (resident) to floor. 04/30/12 at 10:30am: Resident insisting on taking her shoes off to use the restroom this am. Tried to explain to resident that her socks alone were too slippery. She took her shoe off herself. As she was transferring herself she tried to sit herself on the floor. 04/30/12 at 3:00pm: Has large swollen area in outer left ankle. She said she bumped it on chair during transfer. Dr. (doctor) ordered x-ray. 04/30/12 at 5:00pm: X-ray at bedside to do x-ray. 04/30/12 (no time documented): X-ray results of left ankle. There is no evidence for fracture; mild lateral soft tissue swelling is identified. 05/01/12 at 3:00am: Swelling noted to left ankle. Resident refused to stand to transfer to BSC and refuses to use bed pan. Several incontinence episodes this shift. 05/01/12 at 12:00pm: Bruising to left foot. Will monitor. 05/02/12 at 2:00am: Mild swelling in left ankle. 05/02/12 at 3:00am: Resident continues to refuse to stand up and refuses to use bed pan. Several incontinence episodes and refuses to be changed. 05/02/12 at 9:00pm: Resident alert with pleasant confusion at times - attention seeking most of shift. Bruising and small amount of swelling to left ankle. Resident c/o (complains of) pain in left ankle upon weight bearing/ambulation. 05/03/12 at 3:00am: Follow-up to fall with injury to left ankle. Area swollen with bruising present. Resident continues to c/o pain in left lower extremity upon ambulation/weight bearing activity. 05/03/12 3:00-11:00pm shift: Resident confused at times and physically abusive to staff. Resident hit staff several times while staff attempted to get resident up for dinner. 05/08/12 at 2:30pm: Mobile Imaging called. Resident has questionable fx (fracture) to left foot. MD called, order obtained to send to ER. A review of the Physician order [REDACTED]. 04/30/12: Left outer ankle x-ray order for large raised area. 05/01/12: May be WB (weight bearing) 05/03/12: Repeat left ankle x-ray on 05/08/12. Ice ankle 20 minutes three times a day. A review of x-ray reports indicated the following: 04/30/12: History: Bumped outer ankle/swollen, painful to touch. Bony structures left ankle are intact. There is no evidence for fracture. Mild lateral soft tissue swelling is identified. 05/08/12: History: Pain, swelling, S/P (status [REDACTED]. Indication: Pain and swelling after trauma. Comparison is made to study of 04/30/12. A non-displaced fracture is possible with this appearance. This was present on prior study of 04/30/12, but is better seen on today ' s study due to technique. A review of the Incident Report-Investigation of Unit form indicated the following: 04/30/12 at 5:00am: I (CNA) was assisting resident from BSC to W/C and her left leg gave our and I assisted her to the floor and she was saying her ankle was hurting, but then after she got it straightened out she said it felt better. R14 was interviewed on 06/06/12 at 7:40am. R14 stated Yes, I had a fall, my foot got twisted and I ended up under the bed. During an interview conducted with the Director of Nursing (DON) on 06/07/12 at 11:00am, the DON could not explain why further investigation was not conducted on the statement made by the CNA who witnessed the fall on 04/30/12. The DON could not explain what the CNA meant by straightened out . The DON acknowledged that the physician was not notified that R14 was refusing to stand, was having an increase in incontinence episodes or displaying behaviors when staff attempted to ambulate the resident. The DON could not explain why R14 ' s statement and the investigation about this statement were not documented on the Risk Management Accident/Incident (A/I) Report. b) Resident #10 R10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Physician order [REDACTED]. On 05/17/12, an order was written to: Apply gauze padding to right great toe . During an observation of a dressing change to R10 ' s right heel wound the following was observed on 06/07/12 at 10:30 am: Licensed Practical Nurse (LPN) 64 applied normal saline to the wound and patted it dry. Silver alginate was applied to the wound then covered with gauze and Kling. During an interview with the Wound Nurse (LPN54) on 06/07/12 at 12:00pm, she stated The order reads to clean the wound with soap and water; I don ' t know why the nurse used normal saline.",2016-07-01
8255,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2012-06-08,323,E,0,1,26RQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and clinical record reviews, review of policies and procedures, and review of accident and incident reports, the facility failed to provide an environment free of hazards The facility failed to ensure adequate supervision and assistive devices needed to prevent accidents for six (6) of nineteen (19) sampled residents. The facility failed to determine possible root causes for multiple falls, and/or provide assistive devices/supervision needed to prevent further accidents. Resident identifiers: #9, #10, #33, #34, #78 and #85. Findings include: a) Resident #9 R9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R9 sustained falls on 02/24/12, 04/15/12, 04/20/12, 05/03/12, 05/09/12, 05/11/12 (twice), and 05/18/12. A review of the Risk Management Accident/Incident (A/I) Report for each of these falls indicated that an investigation form was completed. However, review of the reports revealed that the data gathered during the investigation was not assessed by the Interdisciplinary team (IDT) to determine possible root causes for each fall. There was no evidence the IDT evaluated why identified interventions had not been successful in preventing the multiple accidents, and R9 ' s care plan was not revised with new approaches as needed. (Refer to F280.) b) Resident #10 R10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R10 sustained falls on 04/15/12, 04/17/12, 05/16/12, and 05/18/12. A review of the Risk Management Accident/Incident (A/I) Report for each of these falls indicated that an investigation form was completed. However, review of the reports revealed that the data gathered during the investigation was not assessed by the Interdisciplinary team (IDT) to determine possible root causes for each fall. There was no evidence the IDT evaluated why identified interventions had not been successful in preventing the multiple accidents, and R10 ' s care plan was not revised with new approaches as needed. (Refer to F280.) c) Resident #33 R33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R33 sustained a fall on 04/10/12 which resulted in a fracture of the right femur. A review of the Risk Management Accident/Incident (A/I) Report for this fall indicated that an investigation form was completed; however, the IDT did not determine a possible root cause for the fall. d) Resident #34 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Fall care plan dated 03/07/12 revealed that R34 was at risk for falls due to her seizure disorder, dementia and psychotropic medications. She was to have a sensor cushion placed in her bed and one placed in her wheelchair. If the resident attempted to get out of bed or rise from her wheelchair, the sensor cushion would sound which alerted staff that the resident had moved and may be at risk for falls. Review of the Risk Management Accident/Incident (A/I) Report dated 03/10/12 revealed that R34 fell on [DATE] at 2:45pm. Per the documentation, R34 was ambulating from the dining room and was waiting for the elevator doors to open. After she entered the elevator, she lost her balance and fell . The resident had a bed and chair alarm, but because she was ambulating and not in bed or in her wheelchair prior to the fall, staff were not alerted to the potential for an accident. Review of the fall care plan revealed that after R34 fell in the elevator on 03/10/12, the facility failed to revise the care plan to include interventions such as necessary additional precautions, or the potential for assistance when she ambulated. The facility failed to complete a thorough investigation and identify a possible root cause of the fall. Review of an A/I report dated 03/19/12 revealed that R34 fell and sustained a large hematoma to the left side of her forehead. Nursing documented that R34 would be evaluated by the physician. Review of an A/I report dated 03/21/12 revealed that R34 tried to ambulate and fell . She hit the right side of her head on the floor. Per the documentation, the facility decided to place a soft helmet on R34. The helmet was placed on R34 on a trial basis. R34 experienced three falls in March 2012. The first fall occurred on 3/10/12, the second one on 3/19/12, and the third one on 03/21/12. Review of the clinical record revealed a Physical Therapy (PT) note dated 03/23/12 that stated, Falls on 3/10/12, 3/19/12, 3/21/12, resident on hospice with confusion. Unable to comprehend safety awareness . Will monitor. PT not helpful at this time. The Occupational Therapist was not consulted. There was no evidence of an assessment to get to the root cause of the falls, or recommendations for any necessary safety interventions or precautions. During an interview with the PT Assistant, Employee #104 on 06/8/12 at 9:35pm confirmed that the PT did not complete any further assessments of R34 relative to her three falls in March 2012. Review of the A/I reports for the month of April 2012 revealed that R34 fell 3 more times. On 04/07/12, R34 fell when she attempted to get out of her wheelchair. She was sitting close to the nurse ' s station and, per documentation, R34 tried 4 separate times to get out of her chair. Nursing documented that she redirected R34 each time with success. However, when nursing turned around to walk toward the desk, R34 got out of her wheelchair and fell backwards, sustaining a skin tear to her right elbow. The facility failed to assess possible root causes of the accident, such as why R34 wanted to get out of her wheelchair on 5 separate occasions. On 04/23/12, R34 ambulated to a room across the hall from hers and she fell between the two beds. She fell face first per the A/I report, sustaining a hematoma to the right side of her forehead and a skin tear to her left elbow. On 4/28/12, per the A/I report, R34 was found on the floor in her room, on her back, and her head was in the closet. Her soft helmet was found on the floor. Per the documentation, the bed sensor alarm was in place; however, neither the nurse nor the CNA heard it alarm when the resident got out of her bed. R34 experienced another fall on 05/30/12. The facility failed to evaluate why R34 continued to fall, implement any additional potential interventions, or follow the incident and accident policy and procedure. e) Resident #78 Observation of R78 on 06/06/12 at 3:30pm, revealed the resident was lying in bed with one leg hanging off the side of bed and bed alarm in place The resident ' s room was located at the far end of the hallway and no staff was noted in the area. During observation on 06/07/12 at 9:10am, R78 was noted to be in a Geri chair located near the nursing station. Two other residents were sitting nearby and observation revealed no staff was available. Review of R78 ' s quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was cognitively impaired and required the assistance of 2 people for transfers, mobility, and all Activities of Daily Living (ADL ' s.) Review of Accident/Incident reports revealed that from 11/10/11 to 5/16/12, R78 fell 12 times. Review of the A/I reports revealed they did not indicate what the possible root cause of the falls might have been. No new interventions to prevent falls were implemented. Review of the facility ' s Policy and Procedure, Accident and Incident Evaluation & Investigation, Tracking and Monitoring, dated 02/09/10, revealed that the Risk Management (RM) team would analyze for the root cause after any of their residents experienced a fall. Per the policy, if the RM team determined that the current interventions were not working, they would have further discussions of other potential solutions/interventions. In addition, the policy stated that any resident who had experienced two or more falls within one month would be screened by the Physical Therapist (PT) and the Occupational Therapist (OT). The facility failed to follow the Incident and Accident policy and procedure after each fall for these residents. Although the forms included data regarding the accidents, the facility did not analyze the data to determine a possible root cause of each fall. During an interview conducted with the Director of Nursing (DON) on 06/07/12 at 3:00pm, the DON acknowledged that although the Risk Management Accident/Incident report form had been filled out, root causes of the multiple accidents had not always been identified. The DON also acknowledged that new solutions/ interventions were not consistently attempted, even when previous interventions were not successful. f) Resident #85 On 05/10/12 at 3:09pm the Registered Nurse Assessment Coordinator (E111) documented that she had spoken with R85 ' s family member about her seating arrangement. The family felt that R85 was now able to sit safely in a wheelchair rather than in a Geri chair and they requested a trial period to assess the seating situation. The Hospice nurse stated that R85 was sitting in the wheelchair with her upper body draped over the arm rests which placed her at risk for falls. However, a trail period was ordered and staff was to monitor R85 ' s positioning while she was seated in her wheelchair. E111 did not follow-up or document until 11 days later on 05/21/12 at 7:55am. At that time, E111 documented that R85 liked the wheelchair but she did not like the way her left foot fit in the leg rest. The leg rest was adjusted at that time. As of 06/08/12 at 12:00 noon, the facility had not assessed or documented whether or not the resident continued to be at risk for falls.",2016-07-01
8256,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2012-06-08,364,F,0,1,26RQ11,"Based on observation and staff interview, the facility failed to prepare and serve palliative foods for all of the residents who had a physician ordered pureed diet. This deficient practice affected three (3) of nineteen (19) sample residents as well as the other sixteen (16) residents who were ordered pureed diets. Residents #R62, R77, R79, R5, R7, R19, R21, R22, R35, R94, R93, R92, R91, R90, R83, and R80. Findings include: 1. Observation of the dinner meal that was served in the dining rooms on 06/05/12 at 5:30pm revealed that all of the residents who were ordered a pureed diet received a cold plate that consisted of; lumpy pureed turkey salad, pureed macaroni salad, lumpy pureed tomatoes and a slice of white bread. All of the pureed foods were placed on the same dinner plate and all were floating in cold white milk. The slice of bread was saturated with milk and it was losing its shape on the plate. Observation of the residents who had been served that puree meal in the dining rooms revealed that they were eating less than 25% of their meal on average. 2. Review of the Spring/Summer, Week Three preplanned menu revealed that the residents who were ordered a pureed diet and those residents who were ordered a regular diet were to have the same food except the food would be pureed for those residents who required it. The following foods were prepared for dinner on Tuesday 06/05/12: a. Cold Turkey salad b. Crescent rolls c. Macaroni Salad d. Lettuce and Tomato slices. 3. During an interview with R33, on 06/05/12 at 5:45pm in the 2nd floor dining room, the fine dining room revealed that she was unhappy with the appearance of her puree food and she had refused to eat it. She stated, I don ' t want that stuff. An interview with a Certified Nursing Assistant (CNA) #38 on 05/06/12 at 5:45pm, in the dining room on the 1st floor, confirmed that the residents did not like lumpy, cold puree foods. She stated, the residents don ' t really like cold plates for dinner and the plates don ' t look very appetizing. When interviewed about why the residents who were on a puree diet received their food floating in milk, the Assistant Dietary Manager (ADM) stated on 06/05/12 at 5:50pm the facility soaked bread in cold milk rather than preparing pureed bread and that was the reason for the floating milk throughout the plate. Per the Academy of Nutrition and Dietetics Association, a pureed diet consists of pureed, homogenous, and cohesive foods. Food should be pudding-like. The puree foods that were served on 06/05/12 to the residents was not aesthetically pleasing, the food was not holding its shape, and the puree foods were running together, which created an unpalatable meal.",2016-07-01
8257,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2012-06-08,365,F,0,1,26RQ11,"Based on observation, staff interview and record review, the facility failed to prepare and serve food in a form that met the individualized needs of those residents who had physician ordered puree diets. The facility did not serve puree foods that were smooth in texture and holding their shape. This deficient practice affected three (3) of nineteen (19) sample residents as well as the other sixteen (16) residents who were ordered pureed diets. Residents #R62, R77, R79, R5, R7, R19, R21, R22, R35, R94, R93, R92, R91, R90, R83, and R80. Findings include: 1. Observation of the kitchen and the steam table on 06/05/12 at 5:00 pm revealed that the dinner meal was prepared and ready for service. Observation of the ready to eat foods revealed that there were chunks of green particles throughout the puree turkey salad. Upon closer inspection, at that time, revealed that the green chunks were pieces of pickles. The turkey salad was not smooth in texture. Observation of the dinner meal that was served in the dining rooms on 06/05/12 at 5:30pm revealed that all of the residents who were ordered a pureed diet ((R58, R33, R89, R62, R77, R79, R5, R7, R19, R21, R22, R35, R94, R93, R92, R91, R90, R83, R80) received a cold plate that consisted of; lumpy pureed turkey salad, pureed macaroni salad, lumpy pureed tomatoes and a slice of white bread. All of the pureed foods were placed on the same dinner plate and all were floating in cold white milk. The slice of bread was saturated with milk and it was losing its shape on the plate. When the puree food came in contact with the milk on the plate the consistency was changed. It was runny and not holding its shape. When interviewed about why the residents who were on a puree diet received their food floating in milk, the Assistant Dietary Manager (ADM) stated on 06/05/12 at 5:50pm that the facility soaked bread in cold milk rather than preparing pureed bread and that was the reason for the floating milk throughout the plate. Per the Academy of Nutrition and Dietetics Association, a pureed diet consists of pureed, homogenous, and cohesive foods. Food should be pudding-like. Review of the standardized recipes which were located in a notebook in the kitchen, revealed that the facility did not have recipes for puree foods. An interview with the Certified Dietary Manager (CDM) on 6/6/12 at 10:45am confirmed that the facility did not utilize standardized recipes and they did not have recipes for puree foods.",2016-07-01
8258,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2012-06-08,371,F,0,1,26RQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to utilize sanitary techniques in the food service department when they; did not sanitize the thermometer probe before use, did not clean and sanitize the Robot Coupe (blender) after use, when they did not operate the dish machine in a safe and sanitary fashion, and when they created a potential for cross contamination when taking food temperatures and serving cold foods. This deficient practice had the ability to affect all the residents who received meals from the kitchen. Findings include: 1. Observation of the kitchen and the steam table on 06/06/12 at 7:00am revealed that the breakfast food had been prepared and it was ready for service. At that time, the morning cook (E77) had begun to take the temperatures of the ready to eat foods. She removed the thermometer probe from the protective sleeve and then she laid the probe on an un-sanitized wood counter. Before she sanitized the probe, she inserted it into the center of the ready to eat pancakes which created the potential for cross contamination. During an interview with E77, at that time, she confirmed that she had made a mistake when she placed the contaminated probe into the center of the pancakes before she sanitized it. During observation of the steam table and E77, on 06/06/12 at 7:00am, revealed she had created a potential for cross contamination when she laid the thermometer ' s protective sleeve across the ready to eat pureed sausage patties. Interview with E77, at that time, confirmed that she had not sanitized the protective sleeve and she should not have laid it across the ready to eat pureed sausage. Observation of the Robot Coupe (blender) on 06/06/12 at 7:30am revealed that the inside of the blender contained sitting water and food debris on the blade, the sides of the blender, and under the blender lid. Interview with E77 on 06/06/12 at 7:35am confirmed that she had used the blender to grind sausage patties for breakfast and she had placed the blender back on the base before it was cleaned and sanitized effectively. This practice created the potential for cross contamination. Observation of the kitchen on 06/06/12 at 7:00am revealed that there were 24 plastic bowls filled with cold cereal and they were stacked on top of each other. The bowls did not have lids. Consequently, the bottom of the cereal bowl came in contact with the ready to eat cereal. This practice created a potential for cross contamination. 2. Observation of the kitchen and the dish room on 06/05/12 at 9:30am revealed that the dish machine was in operation and not sanitizing the dishes effectively. Observation of three separate trials, at that time, confirmed that the water temperature in the final rinse cycle, the sanitizing cycle, had reached an unsafe temperature of 195 and 196 degrees Fahrenheit (F). Review of the Temperatures for Food Safety by Gordon Food Service (the facility ' s food distributor) revealed that the required temperature of the water during the sanitation cycle was a minimum of 180 degrees F and a maximum of 194 degrees F to inhibit bacterial growth and ensure food safety. Review of the 2009 Food Code in Section 4-501.112 revealed that the Temperature of the hot water used for sanitation should not exceed 194 degrees F. Review of the Hazard Analysis Critical Control Point (HACCP) Sanitation Manual Fifth Edition page 63 revealed that The final rinse temperature should be less than 194 degrees F. If the final (sanitizing cycle) rinse temperature is too high, the water is atomized and thus is inadequate for sanitizing . Interview with the Certified Dietary Manager (CDM) and the Assistant Dietary Manager (ADM) on 06/05/12 at 10:00am revealed that they were unaware that the water temperature in the final rinse cycle had a maximum safe temperature of 194 degrees F to ensure food safety. Many food products have the ability to leave pathogenic (production of disease) microorganisms on dinner plates, utensils, and cookware if they are not cleaned and sanitized effectively. These microorganisms can lead to food borne illness. Review of the preplanned menu the Spring/Summer Week 3 , the week of survey, revealed that the facility prepared a wide variety of entrees including pork, chicken, fish, ground beef, turkey, tuna, swiss steak and roast beef. These food products had the ability to leave pathogenic microorganisms on un-sanitized dishes such as; Salmonella, Campylobacter, ,[MEDICAL CONDITION]. perfringens and E. coli. All of which could cause food borne illness. Observation of the walk - in refrigerator located in the kitchen on 06/05/16 at 9:30am, revealed the facility had approximately 75 unpasteurized raw eggs. Interview with the Administrator, at that time revealed that the eggs were used for frying and for preparing egg recipes for the residents. Unpasteurized raw eggs also had the potential to leave pathogenic microorganisms on un-sanitized dinner wear which can lead to food borne illness. Review of the posted Dish Machine Temperature Log dated 06/2012 revealed that the rinse temperature exceeded a safe temperature of 194 degrees F on 06/02/12 at breakfast and on 06/03/12 at lunch. Review of the temperature log for 05/2012 revealed that the rinse cycle had reached an unsafe temperature on the following days: 05/01/12, 05/06/12, 05/07/12, 05/10/12, 05/13/12, 05/18/12, 05/19/12, 05/20/12, 05/21/12, 05/23/12, 05/26/12, 05/27/12, 05/28/12 and on 05/29/12. In addition, the facility had failed to record the water temperatures on 21 days of the month either after the breakfast, lunch, or dinner meals. Consequently, they were unable to determine if the dishes had been washed or sanitized effectively. Review of the temperature log for 04/2012 revealed that the temperature in the rinse cycle had reached an unsafe temperature of above 194 degrees F on 17 days either after the breakfast, lunch or dinner meal. The facility failed to demonstrate that they had prepared, served, and cleaned equipment in a safe and sanitary fashion.",2016-07-01
8259,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2012-06-08,441,E,0,1,26RQ11,"Based on observations, staff interviews, and Policy and Procedure review, the facility failed to implement their infection control policy for one of nineteen sampled resident (R88) and one un-sampled resident (R15.) Eye drops were administered with contaminated gloves. Staff was observed tasting medication with a bare finger. Residents ' foods were handled with unwashed or bare hands. Findings include: 1. During medication pass conducted on 06/05/12 at 4:00pm, Licensed Practical Nurse (LPN) #66 donned gloves, poured R15 ' s medications, locked the medication cart, knocked on the door, entered the room, gave R15 her medications, and touched R15 ' s glass. LPN66 then administered eye drops to both of R15 ' s eyes without changing her gloves. 2. Observation on 06/05/12 at 4:10pm revealed LPN68 pouring Prosource (liquid protein supplement) 30ml (milliliters). After pouring the medication, LPN68 stated I wonder how this tastes and proceeded to stick his bare finger into the medicine cup and tasted the medication from his finger. Review of the facility policy titled ' Standard Precautions revealed, Hands are to be washed before and after each resident contact and after removing gloves. During an interview with the Director of Nursing (DON) on 06/06/12 at 3:00pm, the DON acknowledged that LPN66 should have changed her gloves before administering the eye drops to R15 and the DON indicated the observation of LPN68 tasting medication was unacceptable. 3. During observation on 06/06/12 at 7:45am, Certified Nursing Assistant (CNA) #12 placed R88 ' s breakfast tray on the nurses ' desk, removed the cover, picked up a piece of toast with her bare hand and applied jelly. When finished with the first piece of toast, she picked up the second and did the same. She then recovered the plate and took the tray into the resident ' s room. Interview on 06/06/12 at 7:45am, with CNA12 revealed that, when asked if she washed her hands before picking up the resident ' s toast barehanded, she stated, No. 4. Observation of the dining room on 06/06/12 at 7:10am revealed that Activity Assistant (AA) #11 was assisting the residents with their breakfast trays. The residents were served boiled eggs which were placed on their trays with the shell still on. AA11 was observed cracking the hard egg shell with his bare hands, peeling it, and then placing the ready to eat hard-boiled egg back onto the residents ' plates. Interview with AA11 on 6/6/12 at 7:10am confirmed that, on a daily occasion, he assisted residents with their meals. He stated that he had been instructed on how to safely assist the residents with their meals, but was unaware that he should not handle ready to eat foods with his bare hands. Review of the facility policy titled Dietary Services revealed, Fingers are to be kept out of food.",2016-07-01
8260,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2012-06-08,456,E,0,1,26RQ11,"Based on observation and interview, the facility failed to maintain their essential kitchen equipment, the Robot Coupe (blender) blades, in safe operational condition. This deficient practice had the ability to affect five (R58, R33, R34, R85 and R89) residents in a sample of 19 and 29 (R62, R77, R79, R5, R7, R19, R21, R22, R35, R94, R93, R92, R91, R90, R83, R80, R57,R63, R71, R12, R13, R21, R23,R30, R32, R38, R36, R86, and R82) un-sampled residents all of whom require a mechanically altered diet. Findings include: Observation of the kitchen during the initial tour on 06/05/12 at 9:30am revealed that the metal blades inside the Robot Coupe (blender) were chipped and missing small pieces of metal. Interview with the Assistant Dietary Manager (ADM) on 06/05/12 at 9:35am confirmed that the facility used the Robot Coupe to grind and puree foods for those residents who required a mechanically altered diet. She confirmed that the blades were chipped and missing metal pieces and that the facility had not maintained the blades in a safe operating fashion. When the solid food came into contact with the chipped metal blades, it created the potential for small slivers of metal to dislodge from the blade and enter into the residents mechanically altered foods. If consumed, the small slivers of metal had the potential to contaminate the food and cause internal injury for those residents.",2016-07-01
8261,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2012-06-08,497,F,0,1,26RQ11,"Based on interview and personnel training record review for five Certified Nursing Assistants ( ' s) (12,15, 17, 19, and 21) , the facility failed to ensure CNAs received at least twelve hours of in-service education. The facility also failed to develop a program of in-service education based on areas of weakness identified through annual performance reviews. Findings include: Review of personnel records for CNAs employed for more than one year revealed no documentation for total hours of in-service education received during the year of 2011. During an interview on 06/08/12 at 10:20am, the Assistant Director of Nursing (ADON) confirmed she could not verify if each CNA was provided at least twelve hours of continuing education for 2011. She indicated that all employees were to attend a series of mandatory trainings, as well as education in other areas as needed. Further interview with the ADON confirmed there was no system to track the actual number of hours/minutes each staff attended to assure they received a minimum of 12 hours per 12 months.",2016-07-01
8262,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2012-05-03,247,D,0,1,POUN11,"Based on resident interview, policy and procedure review, and staff interview, the facility failed to notify a resident he would be receiving a new roommate. This was found for one (1) of 36 Stage II sample residents. Resident identifier: #73. Facility census: 64. Findings include: a) Resident #73 On 04/30/12 at 2:24 p.m., Resident #73 answered No when asked if he was given notice before a roommate change. This resident stated, The new roommate was just brought in and no one told me. A review of the facility policy and procedure titled 1.81 Room Changes, on 05/03/12 at 9:00 a.m., revealed, under Process, the following: 6. For a patient who is receiving a new roommate: 6.1 Give the patient as much notice as possible. 6.2 Provide information about the new roommate while maintaining confidentiality regarding medical information. On 05/03/12 at 10:00 a.m., the admission coordinator (Employee #46) and the director of nursing (Employee #76), both agreed Resident #73 had not been informed about a new roommate. They could provide no evidence the notification had been made.",2016-07-01
8263,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2012-05-03,272,D,0,1,POUN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, incident and accident report review, and staff interview, it was determined the facility had not completed a comprehensive assessment for the need for side rails and/or for the use of alternative or less restrictive devices for two (2) of 36 stage II sample residents who were observed with four (4) quarter (1/4th) side rails attached to their beds. Resident identifiers: #60 and #83. Facility census: 64. Findings include: a) Resident #60 Review of accident and incident reports revealed this resident was found lying on her back on the floor on 04/25/12. The resident stated she had no pain any where and she was just trying to get out of bed. No injuries were noted at the time of the fall. The resident was assisted to a geri-chair with the use of a total lift and assistance of three (3) staff members. The quarterly Minimum Data Set (MDS) assessment, dated 03/06/12, noted the resident had no falls prior to admission. The current care plan indicated the resident was at risk for falls. According to the care plan, bilateral upper and lower rails were in use due to the request of the resident's medical power of attorney (MPOA). There was no evidence of an assessment for the need for side rails, and or the least restrictive type of device to prevent falls. This resident was observed on 05/02/12, at approximately 4:10 p.m., with four (4) quarter (1/4th) side rails attached to the bed. Medical record review revealed a physician's orders [REDACTED]. The use of the upper side rails for turning and positioning was understandable; however, the use of the lower side rails for turning and positioning did not seem plausible. Discussion with the director of nursing, Employee #75, and the administrator, Employee #71, immediately following the observation of the resident, verified the facility had not assessed the resident for the use of side rails. This discussion revealed the lower side rails were for safety, not positioning. At that time, it was confirmed there had been no assessments for the use of safer alternatives, other than side-rails, to prevent falls. The side rails were used at the request of the MPOA. There was discussion of soft bolster cushions, which would be less of an accident hazard for the resident. b) Resident #83 Review of a restraint evaluation form, dated 05/01/12, completed by a licensed nurse (Employee #14), revealed a decision for bilateral upper and lower bed rails fro Resident #83's bed. Alternatives that had been tried included low bed/soft mat, verbal/visual reminders, and increased monitoring. The result was the this resident continued to slide off the mattress onto the floor. Assessment information included the resident had impaired cognition, a decline in self-performance, and a decline in body control. Review of a post fall evaluation document revealed the resident fell from her bed to the floor on 05/01/12. The resident's explanation of how the fall occurred was, I needed to get up. At the time of the fall, she had only bilateral upper 1/4-size rails raised on her bed. Review of physician's orders [REDACTED]. These rails were also noted as used due to requirements in the use of a M2500 [MEDICATION NAME] air mattress and the manufacturer's recommendations regarding the use of the mattress. Observation on 05/02/12, at approximately 10:00 a.m., found Resident #83 lying in bed with both upper and lower 1/4 size rails raised on each end of the bed, leaving a large open area between the two (2) rails on each side. A telephone call to the [MEDICATION NAME] air mattress technical service department, on 05/02/12, at approximately 3:30 p.m., found it was incorrect that bilateral upper and lower rails were required with the use of this mattress. According to the technical service department, only the upper side rails must be used with the [MEDICATION NAME] mattress to prevent falls. Any decision to use bilateral lower rails, in additional to the upper rails was entirely up the user. Review of the [MEDICATION NAME] operator's manual for the M2500 series mattress, found no mention of the necessity to have bilateral rails in place to prevent falls when this mattress was in use. During an interview with the administrator, on 05/02/12, at approximately 4:00 p.m., he said the facility should have tried a less restrictive measure, such as a bed bolster, rather than applying bottom rails to the bed on 05/02/12. Subsequently, the facility removed the bottom bed rails and replaced them with a bed bolster on 05/02/12. During an interview with Employee #14 on 5/3/12 at 9:49 am., she said she completed the initial assessment for bottom rails on 05/01/12 due to the resident sliding out of bed onto the floor. She stated she did not know for certain if the resident slid out of the bed from the slippery material of the [MEDICATION NAME] mattress, or if she was trying to get out of bed intentionally. Employee #14 stated they were currently on day one (1) of a three (3) day restraint release/reduction program.",2016-07-01
8264,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2012-05-03,279,E,0,1,POUN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility's interdisciplinary team failed to develop comprehensive care plans to assist the resident in reaching his or her highest practicable level of well-being. The care plans were not complete, or did not provide instructions to provide care, in the areas of: depression for two (2) residents; the use of side rails; and prevention of falls. This was true for four (4) of thirty-six (36) residents. Resident identifiers: #125, #3, #60, and #48. Facility census: 64. Findings include: a) Resident #125 Medical record review found the resident was admitted to the facility on [DATE]. Hospital discharge records, accompanying the resident upon admission found, . She has tried to hurt herself in the past by taking pills which she was hospitalized for [REDACTED]. Further review of the pre-admission screening (PAS) found a Level II evaluation was completed on 03/20/12. Although the PAS reviewer found the resident did not need specialized services at that time, the following was documented, .She has displayed thoughts of hopelessness, worthlessness, and thoughts that life is not worth living during her stay. .In the event that (name of resident) physical conditions improves in the nursing facility and the thoughts of self-harm continue, a psychiatric consultation may be warranted at this time. Particularly if she voices a specific plan of how she would harm herself and this plan would be feasible for her to complete. Review of the interim care plan, on 05/03/12, found the facility had not addressed the residents [DIAGNOSES REDACTED]. Review of the facility policy entitled: 4.0 Care Plan: Patient, found, An initial care plan is developed within 24 hours of admission. Employee #61, the care plan coordinator, was interviewed on 05/04/12 at 9:00 a.m. She was unable to provide information to demonstrate the facility had addressed the resident's depression in the care plan. b) Resident #3 Review of the physician's orders found the resident was prescribed [MEDICATION NAME] 10 milligrams at bedtime on 03/08/12 for treatment of [REDACTED]. An interview with Employee #61, the care plan coordinator, at 11:20 a.m. on 5/3/12, found the facility failed to develop a care plan addressing the resident's depression and the need for [MEDICATION NAME]. c) Resident #60 The current care plan had interventions listed as: bilateral upper and lower rails per MPOA (Medical Power of Attorney) request, bed to be in lowest position, dycem in seat of geri chair. Nursing staff had not developed a plan to indicate less restrictive types of devices had been attempted to ensure the resident had proper devices in place that would assist with positioning and prevent possible falls. The staff was using the MPOA request to determine what device to have in place. The resident was observed on 05/02/12 at approximately 4:10 p.m. to have four (4) 1/4 th size side rails attached to the bed. There were current physician orders for these rails. The order stated bilateral 1/4 upper and lower rails due to an enabler for turning and positioning. Discussion with the director of nursing, Employee #75, and the administrator, Employee #71, revealed they had not attempted the use of less restrictive alternatives such as soft bolster cushions. They confirmed other measures should have been attempted and assessed. This discussion was immediately after the above observation. d) Resident #48 Review of the medical record revealed Resident #48 was admitted on [DATE]. Medical [DIAGNOSES REDACTED]. A review of incident reports, on 05/02/12 at 1:00 p.m., revealed Resident #48 experienced falls on 02/12/12 and 04/09/12. On 05/02/12 at 1:15 p.m., the care plan for Resident #48 was reviewed. The care plan, which was initiated 04/28/10, assessed the resident as being at risk for additional falls related to [MEDICAL CONDITION], impaired mobility, cognitive loss, lack of safety awareness, use of [MEDICAL CONDITION] meds, attempts to place self out of bed, refuses to wear glasses at times, history of falls. An intervention, initiated on 07/29/10, stated, Provide frequent rounds to assess for and anticipate needs such as offering fluids/snacks, positioning for comfort and ensuring resident is warm and dry, Resident is unable to use call light effectively due to cognitive impairment. This intervention was revised on 06/14/11. An additional intervention, initiated on 01/19/12, stated, Make frequent rounds to assist resident with any need she may have, offer foods of choice, beverages of choice and offer to get resident from her bed to recliner and let her sit with nursing staff at nurses station. On 05/02/12 at 2:10 p.m., an interview was conducted with the minimum data set coordinator (MDSC), Employee #61. When asked the meaning of frequent rounds, this employee stated normal rounds are every two (2) hours. Frequent rounds would probably be at least every hour. If we need to be more specific let us know. The Kardex review revealed the following: Provide frequent rounds to assess for and anticipate needs such as offering fluids/snacks, positioning for comfort and ensuring resident is warm and dry. Resident is unable to use call light effectively due to cognitive impairment, An interview was conducted, on 05/02/12 at 3:30 p.m., with two (2) nursing assistants (NA). These were Employees #44 and #19. When asked what would be considered frequent rounds for Resident #48, Employee #44 stated every time I pass by the room, which is pretty frequent, I look in to see if the resident needs anything. Employee #19 made no comment. The care plan did not have a measurable time as to the frequency of rounds in order to potentially prevent a fall from the bed for Resident #48.",2016-07-01
8265,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2012-05-03,280,D,0,1,POUN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise a care plan for a resident who had experienced actual falls in the facility after admission. This resident's current care plan did not include any new interventions related to falls beyond those listed on the initial care plan dated 04/16/12. This was evident for one (1) of thirty-six (36) sampled residents. Resident identifier: #83. Facility census: 64. Findings include: a) Resident #83 Care plan review found Resident #83 was at risk for falls related to impaired mobility, cognitive loss, and lack of safety awareness, and the overall goal was for her to have no falls with injury in the next 90 (ninety) days, beginning 04/16/12. Interventions included a low bed, a total lift with a sling, and quarter rails for turning and repositioning. Review of an incident report, dated 04/20/12, found this resident sustained [REDACTED]. The post-fall evaluation contained new interventions and preventive measures of bilateral mats to the floor. However, review of the care plan found no revision for bilateral mats to the floor by the bed. Review of an incident report, dated 05/01/12, found this resident sustained [REDACTED]. She was again found sitting on the floor by her bed. The post-fall evaluation contained new interventions and preventive measures of bilateral upper and lower rails to the bed. However, review of the care plan found no revision for lower rails to the bed. During an interview with the Director of Nursing, on 05/02/12 at 9:28 a.m., she agreed there were no written revisions on the care plan related to the two (2) falls since admission on 04/03/12, or of new interventions to try to prevent falls beyond those listed on the care plan on 04/16/12.",2016-07-01
8266,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2012-05-03,425,D,0,1,POUN11,"Based on observation and staff interview, the facility failed to ensure the correct dosage of an antidepressant medication was supplied when the dosage was decreased, or the label on the medication was changed to reflect only half of the provided dosage should be administered. This had the potential for a medication error if any nurse failed to realize the dose that was written on the Medication Administration Record [REDACTED]. Resident identifier: #66. Facility census: 64. Findings include: a) Resident #66 During medication pass observation on 05/02/12 at 8:36 a.m., a licensed nurse, Employee #88, removed a 40 milligram (mg.) tablet of Celexa from Resident #66's medication box, and broke the tablet in half with her bare hands. She then discarded half the tablet, and gave the other half to Resident #66. Observation of the Medication Administration Record [REDACTED]. daily, until the dose was decreased to 20 (twenty) mg. daily on 04/25/12. Observation of the box of Celexa in the medication cart for Resident #66 found only Celexa 40 (forty) mg. tablets for dispensing, and the box contained no directives to administer only one-half tablet to achieve the correct dose. During interview with Employee #88 at this time, she said pharmacy will need to be called to obtain the correct dosage of Celexa. During an interview with the Director of Nursing, on 05/02/12, at approximately 10:00 a.m., she said she was made aware of this issue today by the nurse, and the pharmacy would take care of the problem.",2016-07-01
8267,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2012-05-03,431,E,0,1,POUN11,"I. Based on observation and staff interviews, the facility failed to ensure all opened vials of Purified Protein Derivative (PPD), used for tuberculin skin testing, and all opened vials of insulin, were discarded timely after opening. This was evident for one (1) partially used vial of PPD stored in the medication room refrigerator that had no date of opening, and for one (1) partially used vial of regular insulin on the B Hall medication cart that contained no date as to when it had first been opened. This had the potential to affect more than a limited number of residents. Facility census: 64. Findings include: a) Medication storage room Observation of the medication storage room, on 04/30/12 at 12:47 p.m., found there was one (1) partially used vial of Purified Protein Derivative (PPD), that had no date of opening. During an interview with a licensed nurse, Employee #87, at that time, she stated that once opened, the vial of PPD should have been discarded after 30 (thirty) days. She acknowledged there was no date of opening, and it could not be verified how long it had been since the vial had been opened. b) B Hall medication cart Observation of the B Hall medication cart, on 04/30/12, at approximately 1:00 p.m., found one (1) partially used vial of Humulin R insulin with no date of opening. Licensed nurse, Employee #87, said that most insulins are discarded after having been opened for 28 days. She agreed this vial had no date of opening, and it could not be verified how long it had been opened, or which resident it belonged to. During an interview with the Director of Nursing, on 05/03/12 at approximately 10:00 a.m., she said they discard opened vials of injectable medications at 30 (thirty) days after opening, although certain insulins may be stored a short while longer. She further stated that all vials of insulin, and other injectables, were to be dated when opened. II. Based on observation and staff interview, the facility failed to ensure the provision of a medication cart with a functional locking mechanism. This was evident for one (1) of two (2) medication carts that had a drawer filled with resident's medications that could be pulled open when the cart was locked. This had the potential to affect more than a limited number of residents. Findings include: a) B Hall medication cart Observation of the B Hall medication cart on 05/02/12 at 8:02 a.m. found that the second drawer of the medication cart did not shut properly when the nurse closed and locked the cart. When licensed nurse Employee #88 left the cart and entered a room to administer the medication, the second drawer in the cart remained partially opened. During interview with the Director of Nursing (DON) at this time, she acknowledged that the drawer was open while the cart was locked, and summoned a maintenance employee to check the cart. The maintenance employee was able to open the same drawer while the cart was locked, by just wiggling the drawer slightly and gently pulling on it. The DON instructed the medication nurse to park the medication cart in the DON's office when not in use until the pharmacy technician could fix the problem.",2016-07-01
8268,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2013-08-15,157,G,1,0,RDF011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of hospital records, and policy review, the facility failed to ensure the physician was notified as directed by facility policy when a resident's blood sugars were over 400. The resident's condition declined, she was sent to the hospital, and subsequently expired. One (1) of five (5) sampled residents was affected. Resident identifier: #63. Facility census: 62. Findings include: a) Resident #63 Medical record review on [DATE], noted the resident had a medical history of [REDACTED]. When she was transferred to the long term care facility on [DATE], she was placed on finger sticks twice a day at 7:00 a.m. and 9:00 p.m. upon admission for two (2) weeks and the nurses were instructed to draw a HgbA1c with the next lab draw on [DATE]. According to the Medication Administration Record [REDACTED]. Although the finger stick blood sugar results were elevated, the medical record contained no evidence of notification of the physician. On [DATE] at 9:00 p.m., the resident's blood sugar result was 416. On [DATE] at 9:13 p.m., the resident's blood sugar was 475. On [DATE] at 7:00 a.m., the resident's blood sugar was 408. On [DATE] at 12:30 p.m., (more than five (5) hours after the results of the finger stick was recorded), Employee #32, a registered nurse (RN), notified the physician of the elevated finger stick blood sugars and received an order for [REDACTED].>At 4:05 p.m. (16:05) on [DATE], an order was obtained to send the resident to the emergency room . At 8:26 p.m. (20:26) the resident expired at the acute care facility emergency room . This matter was discussed with the DON at 2:30 p.m. on [DATE]. She said a blood sugar value that was over 400 was considered an urgent value for a finger stick that required immediate notification of the physician. She provided the facility's policy on finger sticks. The Policy Diabetic Care Protocol 15.14, effective [DATE] revised [DATE], in Section 9.1.1 included If parameters are not ordered, report following to physician URGENT: Notify immediately if blood glucose is greater than 400 or less than 70 .",2016-07-01
8269,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2013-08-15,309,G,1,0,RDF011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of hospital records, and policy review, the facility failed to provide timely care and services for a resident with a [DIAGNOSES REDACTED]. The resident was on scheduled and sliding scale insulin coverage. The physician was not notified, as directed by facility policy, when the resident's blood sugars were over 400 at varying times on three (3) consecutive days. The resident's condition declined, she was sent to the hospital, and subsequently expired. One (1) of five (5) sampled residents was affected. Resident identifier: #63. Facility census: 62. Findings include: a) Resident #63 Medical record review on [DATE], noted the resident had a medical history of [REDACTED]. When she was transferred to the long term care facility on [DATE], she was placed on finger sticks twice a day at 7:00 a.m. and 9:00 p.m. upon admission for two (2) weeks. The the nurses were instructed to draw a HgbA1c with the next lab draw on [DATE]. According to the Medication Administration Record [REDACTED]. Although the finger stick blood sugar results were elevated, the medical record contained no evidence of intervention by nursing, or notification of the physician. On [DATE] at 9:00 p.m., the resident's blood sugar result was 416. On [DATE] at 9:13 p.m., the resident's blood sugar was 475. On [DATE] at 7:00 a.m., the resident's blood sugar was 408. On [DATE] at 12:30 p.m., (more than five (5) hours after the results of the finger stick was recorded), Employee #32, a registered nurse (RN), notified the physician of the elevated finger stick blood sugars and received an order for [REDACTED]. Employee #32, an RN, was interviewed on [DATE] at 3:30 p.m. She said she could not remember the situation, but it was likely the time from the receipt of the order until administration (12:30 p.m. to 3:30 p.m.) of the insulin was how long it took to obtain the medication from the pharmacy, as it was a new order. At 4:05 p.m. (16:05) on [DATE], an order was obtained to send the resident to the emergency room . At 8:26 p.m. (20:26) the resident expired at the acute care facility emergency room . This matter was discussed with the director of nursing (DON) at 2:30 p.m. on [DATE]. She said a blood sugar value that was over 400 was considered an urgent value for a finger stick that required immediate notification of the physician. She provided the facility's policy on finger sticks. The Policy Diabetic Care Protocol 15.14, effective [DATE] revised [DATE], in Section 9.1.1 included, If parameters are not ordered, report following to physician URGENT: Notify immediately if blood glucose is greater than 400 or less than 70.",2016-07-01
8270,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2013-08-15,514,D,1,0,RDF011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of acute care hospital records, the ambulance transfer report, and the death certificate, the facility failed to provide a clinical record that accurately depicted a resident's transfer from the facility. A nurse repeatedly documented the wrong acute care facility in the medical record when a resident was transferred. This practice affected one (1) five (5) sample residents. Resident identifier #63. Facility census: 62. Findings include: a.) Resident #63 Review of the resident's medical record on [DATE] noted the resident experienced a change in condition on [DATE] at 4:00 p.m. according to the Nursing Progress Notes signed by Employee #32, a registered nurse (RN). There was a physician's orders [REDACTED]. There was a nursing note, dated at 4:15 p.m. (16:15), which stated the resident was transferred to Acute Care Hospital A. An ambulance transfer form provided by the director of nursing (DON) identified the resident was transferred to Acute Care Hospital A. An interview was held with Employee #32, an RN. She she said resident was sent to Acute Care Hospital A specifically at the family's request. A progress note from Acute Care Hospital A stated the resident expired in the emergency room (ER) of Acute Care Hospital A. The resident's death certificate was reviewed. It noted the place of death was in Acute Care Hospital A. A licensed practical nurse (LPN), Employee #46, wrote a nursing note, at 8:00 p.m. (20:00) on [DATE], stating she called Acute Care Hospital B and Nurse states res is being admitted to ICU. This same employee then wrote a physician's orders [REDACTED]. At 8:20 p.m. (20:20) on [DATE], a nursing note was composed by Employee #46, LPN stating Acute Care Hospital B called facility .and stated that res had passed away. The DON was interviewed at 2:30 p.m. on [DATE] regarding this matter. She provided documentation regarding the ambulance transfer which did not support Employee #46's documentation. She was unable to provide further information. Employee #46 was not on the schedule during the remainder of the survey for interview.",2016-07-01
8271,UNITED TRANSITIONAL CARE CENTER,515107,327 MEDICAL PARK DRIVE,BRIDGEPORT,WV,26330,2013-01-23,167,D,0,1,C0FX11,"Based on observation and staff interview, the facility failed to ensure it had posted a sign informing residents of where the state and federal survey results were located. This practice had the potential to affect more than an isolated number of the facility's residents. Facility census: 26. Findings include: a) On 01/22/13 at 1:00 p.m., an observation revealed the facility had a folder inside a plastic box mounted on the wall across from the nursing station. Further observation revealed the folder contained the survey results. Without inspecting the folder one would not have known it contained the results of the facility's last inspection. On 01/22/13 at 1:10 p.m., the director of nursing (Employee #10) agreed to put a sign on the plastic box notifying residents the survey results were inside the box.",2016-07-01
8272,UNITED TRANSITIONAL CARE CENTER,515107,327 MEDICAL PARK DRIVE,BRIDGEPORT,WV,26330,2013-01-23,225,D,0,1,C0FX11,"Based on a review of the facility's abuse/neglect policy, reportable allegations of abuse and neglect, and staff interview, the facility failed to ensure implementation of their policy on reporting allegations of abuse, neglect, and misappropriation of resident property. The facility had failed to report one (1) of three (3) reviewed allegations to the appropriate outside agencies required by State law as well as their own policy. Facility census: 26. Findings include: a) On 01/16/13 at 2:10 p.m., a review of the facility's reportable allegations of abuse, neglect, and misappropriation of resident property revealed the facility had failed to report one (1) allegation of misappropriation of property to an outside agency as required by State law. The allegation, which took place in January 2012, involved missing money. A resident had reported that a nurse aide had taken five (5) dollars from her. The investigation revealed the facility did not report this to their local law enforcement agency. The abuse reporting requirements for West Virginia nursing homes, revised in October 2011 requires nursing homes to report any suspicion of a crime against a resident to their local law enforcement. A review of the facility's policy and procedure on abuse and neglect (revision 09/21/11) revealed the following excerpt In instances of visitor to resident abuse, mistreatment or misappropriation of property, the appropriate law enforcement agency will be notified to conduct an investigation as they deem necessary. On 01/16/13 at 5:00 p.m., the administrator (Employee #3) confirmed she did not report this allegation to local law enforcement.",2016-07-01
8273,UNITED TRANSITIONAL CARE CENTER,515107,327 MEDICAL PARK DRIVE,BRIDGEPORT,WV,26330,2013-01-23,226,D,0,1,C0FX11,"Based on a review of the facility's abuse/neglect policy, reportable allegations of abuse and neglect review, and staff interview, the facility failed to ensure they implemented their policy on reporting allegations of abuse, neglect, and misappropriation of resident property. The facility had failed to report one (1) of three (3) reviewed allegations to the appropriate outside agencies required by their policy and state law. Facility census: 26. Findings include: a) On 01/16/13 at 2:10 p.m., a review of the facility's reportable allegations of abuse, neglect, and misappropriation of reside property revealed the facility had failed to report one allegation of misappropriation of property to an outside agency as required by West Virginia state law and their policy on reporting. The allegation, which took place in January 2012, involved missing money. A resident had reported a nurse aide had taken five (5) dollars from her. The investigation revealed the facility did not report this to their local law enforcement agency. The abuse reporting requirements for West Virginia nursing homes, revised in October 2011 requires nursing homes report any suspicion of a crime against a resident to their local law enforcement. A review of the facility's policy and procedure on abuse and neglect (revised 09/21/11) revealed the following excerpt In instances of visitor to resident abuse, mistreatment or misappropriation of property, the appropriate law enforcement agency will be notified to conduct an investigation as they deem necessary. On 01/16/13 at 5:00 p.m., the administrator (Employee #3) confirmed she did not report this allegation to local law enforcement.",2016-07-01
8274,UNITED TRANSITIONAL CARE CENTER,515107,327 MEDICAL PARK DRIVE,BRIDGEPORT,WV,26330,2013-01-23,241,D,0,1,C0FX11,". Based on observation and staff interview, the facility failed to provide care for residents in a manner and environment that maintained or enhanced each resident's dignity by leaving urinary catheter bags uncovered and visible from the hallway. This was found for two (2) of sixteen (16) Stage II sample residents. Resident identifiers: #102 and #223. Facility census: 26. Findings include: a) Resident #102 The resident's Foley catheter bag was observed to be uncovered, hanging on the right side of the resident's bed and visible from the hall way on 01/15/13 at 2:33 p.m. A follow up observation of Resident #102, on 01/17/13 at 9:23 a.m., again found the Foley catheter bag to be uncovered and visible from the hall way. An interview with a nursing assistant, Employee #36, on 01/17/13 at 10:20 a.m., confirmed the catheter bag was not covered, because the facility no longer stocked the covers. On 01/17/13 at 2:25 p.m., the Director of Nursing (DON), Employee #10, reported the resident's catheter bag was now covered. The DON confirmed the catheter bag needed to be covered to maintain the dignity of the resident. b) Resident #223 During an observation of Resident #223, on 01/14/13 at 3:30 p.m., he was lying in bed, with a Foley catheter bag uncovered at his bedside. The catheter bag, which contained urine, could be seen from the hallway. During another observation, on 01/15/13 at 9:07 a.m., the Foley catheter bag was again observed uncovered. Employee #10, the director of nurses, observed the uncovered Foley catheter bag on 01/15/13 at 9:30 a.m. She confirmed the Foley catheter should have been covered to promote the dignity of the resident. She said she would have staff put a cover on the catheter bag.",2016-07-01
8275,UNITED TRANSITIONAL CARE CENTER,515107,327 MEDICAL PARK DRIVE,BRIDGEPORT,WV,26330,2013-01-23,242,D,0,1,C0FX11,"Based on resident interview, resident observation, record review, and staff interview, the facility failed to ensure (3) three of (6) six stage II residents exercised her right to make choices with bathing and diet preferences. Resident identifier: #220, #225, #223. Facility census: 26. Findings include: a) Resident #220 During a stage I interview, on 01/15/13 at 2:17 p.m., Resident #220 said she was not given a choice of bathing options. She said, You can't get a tub bath, they don't have one. Review of the interim care plan on 01/17/13 at 5:00 p.m. revealed no bathing preference was identified. Employee #4, registered nurse, stated the comprehensive care plan would not be completed until 01/28/13. The director of nurses (DNS), Employee #10 , was interviewed on 01/17/13 at 5:33 p.m. She stated she was employed as DNS in April 2012. She verified a bathtub was available for residents use. She said, No one has used it since I've been here; there is a shower in each room. The nursing assessment was reviewed with the DNS. She stated, There is nothing to ask about bathing preference on nursing assessment. She also stated occupational therapy may make recommendations regarding bathing. In addition, the nursing assistant may ask the resident his/her bathing preference. Employee #36, a nursing assistant, was interviewed on 01/22/13 at 8:25 a.m. She stated she was unsure how to determine a residents preference for taking a tub bath, shower, or bed bath. Additionally, during an interview with Resident #220, on 01/15/13 at 2:27 p.m., she stated she was not pleased with the meals because they serve the same thing over and over. She further added, You don't get what you ask for. b) Resident #225 During an observation at on 01/14/12 at 6:03 p.m., Resident #225, complained they did not send her tomato and lettuce. In addition, she received carrot cake, rather than the angel food cake she had ordered. She added, They never give me what I ask for. Employee #10, director of nursing (DON), spoke with the patient, reviewed the tray ticket, and verified the resident did not receive what she had requested for dinner. The DON stated, I don't know why they didn't send it. She further added, The angel food cake would have been better for her than the carrot cake . because of her diabetes. The patient's tray ticket indicated she was to receive lettuce, tomato, and angel food cake. c) Resident #223 During a Stage I interview, on 01/15/13 at 9:07 a.m., Resident #223 stated, What gets me, is they come in here and ask you, then they do the opposite. They brought me spaghetti for dinner. I don't like the sauce. I didn't eat it and my blood sugar was 55 this morning. I felt really terrible. I asked for sprite zero on my trays. They didn't bring it this morning. I told them I don't like coffee, and they brought it anyway. A coffee cup was observed on his tray. Also, during a conversation with a family member, on 01/16/13 at 2:36 p.m., she stated, I asked them for cottage cheese. She said she would send it tomorrow. An interview with Employee #75, registered dietitian/licensed dietitian (RDLD), on 01/17/13 at 9:00 a.m., revealed the galley tech visited the residents each day and obtained meal requests from the menu provided by the dietary department. She stated while most are entered electronically, some are handwritten. She also said, Some patients or families prefer to write down their preferences, and those are not entered into the computer. Employee #75 related staff uses the exact form completed by the patient, on tray line. She said if a resident has a special request for a food item, the computer will automatically generate this information. She said she, did not know why the items were not sent as requested.",2016-07-01
8276,UNITED TRANSITIONAL CARE CENTER,515107,327 MEDICAL PARK DRIVE,BRIDGEPORT,WV,26330,2013-01-23,248,D,0,1,C0FX11,"Based on staff interview, record review, family interview, and observation, the facility failed to provide activities of interest, or encourage a resident to attend activities, for (1) one of (3) three Stage II sampled residents. Resident identifier: #102. Facility Census: 26 Findings include: a) Resident #102 During a family interview, on 01/15/13 at 11:39 a.m., Resident #102's daughter stated she had never seen him participate in any activities and did not know of anyone offering him activities. The medical record was reviewed on 01/17/13 at 8:50 a.m. The minimum data set with an assessment reference date of 12/19/12 under section F labeled Interview for Activity Preferences identified the following activities: books, newspapers and magazines; keeping up with the news; doing things with groups of people; and going outside for fresh air in good weather, as being coded as a 2 indicating these activities are somewhat important. Random observations on 01/14/13, 01/15/13, 01/16/13 and 01/21/13 found the resident alone in his room with the television on. No newspapers, books, or magazines were present. No staff interactions were observed except during morning care or meal deliveries. An interview, on 11/17/23 at 4:00 p.m., with the activities director, Employee #2, verified she had completed the resident's activity assessment on 12/18/12, and commented he liked fishing. She said she used to stop in and visit him everyday, but he was usually sleeping, so she had not been visiting. She presented the resident's daily activity record and acknowledged it was blank from 12/20/12 through 01/12/13 because she had not been visiting him.",2016-07-01
8277,UNITED TRANSITIONAL CARE CENTER,515107,327 MEDICAL PARK DRIVE,BRIDGEPORT,WV,26330,2013-01-23,272,D,0,1,C0FX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of the minimum data set (MDS) definitions of pressure ulcers at each stage, and staff interview, the facility failed to ensure pressure ulcers were accurately assessed for two (2) Stage II sample residents. Staff assessed a red blanchable area as a Stage I pressure ulcer for one resident and another resident was noted to have an abrasion which was a Stage II pressure ulcer. Resident identifiers: Resident identifiers: #68 and #217. Facility census: 26 Findings include: a) Resident #68 On 01/21/13 at 1:30 p.m., a review of Resident #68's closed medical record, revealed the resident had Stage I pressure ulcers on the [MEDICATION NAME] spine, elbows, heels, and coccyx. Each of the Stage I pressure ulcers was described as area red blanchable. The facility's Weekly Pressure Ulcer Progress Report defined a Stage I as A persistent area of skin redness (without a break in the skin) that does not disappear when pressure is relieved. The MDS, under Section M Skin Conditions, defines a Stage I pressure ulcer as Intact skin with non-blanchable redness of a localized area usually over a bony prominence. In an interview with the director of nursing (DON), on 01/21/13 at 2:00 p.m., she stated the staff did not appropriately assess this resident (Resident #68), as a redness that is blanchable is not a stage I pressure ulcer. She further agreed the nursing staff needed to be educated on the staging of pressure ulcers. b) Resident #217 01/17/13 at 10:30 a.m., a review Resident #127's medical record revealed the resident was admitted from an acute care unit on 12/31/12 with a Stage II pressure ulcer on the right buttock. The Weekly Skin Condition Report included Wound Type: Abrasion. Measurements of 2.0 cm (centimeter) x (by) 2.0 cm x 0 cm with granulation tissue were noted on admission. On 01/06/13 measurements of 2.0 cm x 2.0 cm x 0.1 cm were noted. On 01/09/13. the weekly skin condition report noted area healed cont. (continue) [MEDICATION NAME] and stop [MEDICATION NAME]. After the area healed notation, on 01/12/13, measurements of 2.0 cm x 2.0 cm x 0.1 cm, were noted. During this medical record review, the minimum data set (MDS) with an assessment reference date (ARD) of 01/07/13, revealed the area on the right buttock was a stage II pressure ulcer. In an interview with the director of nursing (DON), on 01/17/13 at 11:22 a.m., after being shown the measurements and notations, she agreed Resident #217's pressure ulcer had not healed. On 01/17/13 at 12:20 p.m., the DON produced a picture of the pressure ulcer and stated she could not determine from the picture if it was a pressure ulcer or a skin tear/abrasion from shearing. On 01/17/13 at 2:00 p.m., with Resident #217's permission, an observation of the wound with the DON and a staff nurse, Employee #58, revealed a healed pressure ulcer on the coccyx. The DON agreed the area was a healed pressure ulcer and not an abrasion from shearing.",2016-07-01
8278,UNITED TRANSITIONAL CARE CENTER,515107,327 MEDICAL PARK DRIVE,BRIDGEPORT,WV,26330,2013-01-23,279,D,0,1,C0FX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, family interview, care plan review, medical record review, and staff interview, the facility failed to ensure care plans were developed to meet the immediate needs for eight (8) of twenty- one (21) residents reviewed in Stage II. Residents had no care plan or care plans did not include measurable goals and interventions to meet those goals for areas such as activities, dental, activities of daily living, pain management and pressure ulcers. Resident identifiers: #207, #102, #224, #123, #226, #223, #220, and #217. Facility census: 26. Findings include: a) Resident #226 On 01/15/13 at 12:05 p.m., an observation of Resident #226 revealed she had a red area on her left arm covered with a clear dressing. The resident stated she had fallen and scratched her arm while at the facility. On 01/21/13 at 12:20 p.m., a review of the incident/accident reports revealed the resident had stood up from her chair and fallen, hitting her arm on the chair. She sustained a skin tear/abrasion to the left forearm and left flank. Further medical record review revealed no evidence of the facility having developed a care plan for this resident who was admitted to the facility on [DATE], over 30 days ago. On 01/21/13 at 12:30 p.m., the director of nursing (Employee #10) confirmed the facility had not developed a care plan. The director of nursing said the admission nurse should have started the development of the resident's interim care plan. However, this did not occur. b) Resident #102 During a family interview on 01/15/13 at 11:26 a.m., the daughter of Resident #102 reported that her father's fingernails needed trimmed. On 01/17/12, review of the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/19/12, verified the resident required extensive assistance with personal hygiene. The care area assessment summary identified the activities of daily living as a triggered care area with the decision to develop a care plan. The current care plan, dated 12/26/12, lacked measurable goals and interventions to address the care and treatment related to the resident's activities of daily living. During an interview with the director of nursing, Employee #10, on 01/17/13 at 4:02 p.m., she stated the expectation was for the initial care plan to address all of the resident's problems. The resident's needs associated with activities of daily living were not addressed. There are no expectations for the care plans to be updated because we are a short stay facility. c) Resident #223 The medical record was reviewed on 01/17/13 at 8:50 a.m. The admitting MDS, with an ARD of 12/26/12, and a completion date of 01/08/13 verified the resident was admitted with one 1 unstageable pressure ulcer with suspected deep tissue injury. The care area assessment summary, completed on 12/26/12, identified the area of pressure ulcers was to be addressed in the care plan. The care plan dated 12/26/12 lacked measurable goals and interventions to address the care and treatment related to the resident's pressure ulcer on his right heel. In an interview, on 01/17/13 at 11:00 a.m., Employee #4, a registered nurse, stated the current care plan did not address care of the pressure ulcer on the resident's heel because it was created following the initial MDS which was coded as a deep tissue injury not a pressure ulcer. During a staff interview with the director of nursing, Employee #10, on 01/17/13 at 4:02 p.m., she agreed the unstageable pressure ulcer with suspected deep tissue injury on the initial assessment was a pressure ulcer and the care plan should address the issue. d) Resident #123 On 01/22/13 at 1:00 p.m., a review of the interim care plan, dated 08/16/12, revealed Resident #123 was at high risk for skin breakdown and noted a wound with no specific information as to the type of wound, size or location. A review of the care plan, dated 08/28/12 revealed a problem statement Stage II ulcer to right and left buttock related to immobility. The goal stated Pressure ulcer will show signs of healing and remain free from infection through next review. The care plan did not include interventions to meet the goal of healing and/or preventing infection of the wound. In an interview with the director of nursing (DON), on 01/22/13 at 1:00 p.m., she agreed the interim care plan did not include measurements of the admission pressure ulcers and/or specific treatments/interventions to care for the wound. She further stated the interim care plan was based on the admission assessment of the admitting nurse and a final care plan was not completed until twenty-one (21) days after admission. The resident did not remain at the facility 21 days. The interim care plan, however, did not provide needed information to meet the resident's immediate needs related to pressure ulcers. e) Resident #217 On 01/17/13 at 10:30 a.m., a review of the medical record revealed Resident #217 was admitted on [DATE] from acute care with a Stage II pressure ulcer on right buttock. The Weekly Skin Condition Report had under the section Wound Type: Abrasion. Measurements of 2.0 cm (centimeter) x (by) 2.0 cm x 0 cm with granulation tissue were noted on admission. On 01/06/13 measurements of 2.0 cm x 2.0 cm x 0.1 cm were noted. On 01/09/13 the weekly skin condition report noted area healed cont. (continue) [MEDICATION NAME] and stop [MEDICATION NAME]. On 01/12/13 measurements of 2.0 cm x 2.0 cm x 0.1 cm were noted. The minimum data set (MDS), with an assessment reference date (ARD) of 01/07/13, revealed under Section M - Skin Conditions, item M0150 Does the resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? was coded 1. Yes. Item M0300 B. 1. was coded as 1 for the number of Stage 2 pressure ulcers. M0300 B. 2. Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry was coded as 1. The interim care plan, dated 12/31/13 at 16:07 (4:07 p.m.), made no mention of the pressure ulcer. f) Resident #207 During an interview with Resident #207, on 01/14/13 at 10:54 a.m., she related she had difficulty chewing due to loose dentures. She stated, The lower ones don't fit that good, they want to float around in my mouth. She further added, I told the nurse. During another interview, on 01/23/13 at 8:15 a.m., the resident again stated her teeth did not fit properly. She stated it interfered a little bit with chewing things like salad. Employee #9 (registered nurse) was interviewed at 8:35 a.m. He stated he was aware the resident's teeth did not fit properly. He added, You can hear them clanking. Employee #9 stated he had requested the daughter bring Fixadent. No follow up had been completed. In a discussion with Employee #4 (charge nurse), on 01/16/13, she related she had completed the minimum data set for the long term care unit. She further added, the comprehensive care plan would not be completed until 01/28/13. Review of the medical record, on 01/22/13 at 3:30 p.m., revealed no evidence the interim care plan had addressed the resident's immediate dental needs. g) Resident #220 Resident #220's medical record was reviewed on 01/23/13 at 3:30 p.m. The resident's [DIAGNOSES REDACTED]. Review of the interim care plan related to pain revealed the goal was to experience An interview with Employee #4 (registered nurse), on 01/16/13, revealed the resident's comprehensive care plan would not be completed until 01/28/13. h) Resident #223 Review of the resident's medical record on 01/17/13 at 7:30 p.m., with Employee #10, director of nursing services (DNS), revealed no evidence a care plan had been initiated for Resident #223. She was unable to provide evidence an interim care plan had been established related to the immediate care of pressure ulcers and a urinary catheter. An interview with Employee #4, on 01/16/13, revealed the comprehensive care plan would not be completed until 01/29/13. However, care of the resident's pressure ulcers and urinary catheters would be considered immediate care needs and should be addressed in an interim care plan.",2016-07-01
8279,UNITED TRANSITIONAL CARE CENTER,515107,327 MEDICAL PARK DRIVE,BRIDGEPORT,WV,26330,2013-01-23,280,D,0,1,C0FX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure resident care plans were revised to meet the resident's current needs and to reflect their current status. Two (2) of twenty-one (21) residents whose care plans were reviewed in Stage II of the survey had identified problematic issues related to nutrition, or pressure ulcers. The facility had not updated the care plans to reflect the current care needs of these residents. Resident identifiers: #205 and #68. Facility census: 26. Findings include: a) Resident #205 A review of the care plan for Resident #205, on 01/16/13 at 11:00 a.m., revealed the facility had developed a care plan for with the problem of weight gain. The care plan stated the resident had gained 40 pounds in four (4) days. On 01/16/13 at 1:00 p.m., Employee #73 (registered dietitian) reviewed the resident's care plan. She stated she had assessed the resident upon admission and explained his normal weight was 190 pounds. She said the resident weighed 190 pounds on 12/18/12, 229.5 pounds on 12/22/12, and 191 pounds on 12/29/12. According to the dietitian, the 229.5 pound weight was inaccurate. She agreed the care plan was not updated to accurately reflect the resident's needs, the resident had not experienced a 40-pound weight gain in four (4) days. b) Resident #68 Resident #68 was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS) assessments, with assessment reference dates (ARD) of 11/21/12 and 11/27/12, under item M0210, indicated this resident did not have one or more unhealed pressure ulcer(s) at Stage I or higher. On the MDS with an ARD of 12/08/12, item M0100 indicated the resident having a Stage I or greater pressure ulcer. Item M300 indicated the resident had a stage II pressure ulcer and M0900 was marked as No indicating there were pressure ulcers present on the prior assessment. The facility Weekly Skin Condition Report, dated 11/15/12, revealed the resident had a Stage I pressure ulcer on the [MEDICATION NAME] spine. The anatomical diagram was noted as an area which was red blanchable. The treatment included turn q (every) 2 hrs. (hours). Use [MEDICATION NAME]. A review of the facility pressure ulcer report form revealed on 12/2/12 a Stage II pressure ulcer on the [MEDICATION NAME] area measuring 1.0 cm (centimeter) x (by) 1.0 cm x 0.1 cm. with serosanginous drainage. Interventions for the pressure ulcer included [MEDICATION NAME] foam, turn q 2 hrs. and a waffle cushion to chair. An additional assessment, dated 12/08/12, revealed a Stage II pressure ulcer on the [MEDICATION NAME] area measuring 1.0 cm x 1.0 cm x 0.1 cm, no drainage, no odor, dry yellow center surrounded by redness. Specialty bed. A review of the care plan, dated 11/27/12, revealed a problem statement of potential for skin breakdown or pressure ulcers related to decreased mobility. The goal statement revealed will maintain intact skin, free of redness, blisters or discoloration through review date. The resident's care plan had not been revised from the potential to develop skin breakdown to address the actual skin breakdown that had occurred. During an interview with the director of nursing (DON), on 01/17/13 at 3:00 p.m., the DON agreed the care plan was not revised when Resident #68 developed a Stage II pressure ulcer.",2016-07-01
8280,UNITED TRANSITIONAL CARE CENTER,515107,327 MEDICAL PARK DRIVE,BRIDGEPORT,WV,26330,2013-01-23,312,D,0,1,C0FX11,"Based on observation, resident interview, family interview, staff interview, and record review, the facility failed to provide three (3) of twenty-six (26) Stage I dependent residents the necessary services to maintain good grooming and personal hygiene. There was a failure to trim and clean fingernails for three (3) residents and failure to groom facial hair for one (1) of the those (3) residents. Resident identifiers: #102, #208, and #224. Facility census: 26. Findings include: a) Resident #102 During a family interview, on 01/15/13 at 11:26 a.m., the daughter of Resident #102 reported her father's fingernails needed trimmed. An observation, on 01/15/13 at 2:33 p.m., found Resident #102 to have dirty untrimmed fingernails with jagged edges. On 01/17/12, review of the Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/19/12, verified the resident required extensive assistance with personal hygiene. An interview with a registered nurse, Employee #9, on 01/17/13, confirmed Resident #102 needed his fingernails cleaned and trimmed. A follow up observation, on 01/21/13 at 11:30 a.m., again found the resident's nails to be dirty and untrimmed with jagged edges. b) Resident #208 On 01/15/13 at 3:14 p.m., during a family interview, the son of Resident #208 indicated he often had to groom the facial hair off his mother's chin. On 01/21/13 at 12:55 p.m., an observation of Resident #208, revealed she had long chin hair. On 01/21/13 at 1:01 p.m. Employee #1 (nurse aide) said the resident could wash her own face, but would not be able to remove the chin hair on her own. She said she had not trimmed the resident's chin hair. On 01/21/13 at 1:28 p.m., the interim care plan for Resident #208 was reviewed and revealed she needed ongoing assistance with maintaining hygiene. c) Resident #224 On 01/21/13 at 4:45 p.m., observation of the hands of Resident #224 revealed dark brown debris beneath her fingernails and her nails were chipped. Her daughter was at the bedside and said the resident's nails were dirty and needed cleaned. Employee #43 (nursing assistant) was interviewed at 5:02 p.m. on 01/21/13. She stated an audit is to be done weekly, on the weekend, which included fingernail care. During an interview with Employee #56 (registered nurse), on 01/21/13 at 5:00 p.m., she agreed the resident's fingernails needed cleaned. She stated she would put that on the report to be done. During an interview with Employee #36 on 01/22/13 at 8:27 a.m., she indicated the resident's nails are cleaned during activities of daily living care, as needed. On 01/22/12 at 6:30 p.m., an observation of Resident #224's fingernails revealed they had been cleaned. Debris was not present.",2016-07-01