cms_WV
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129 rows where "filedate" is on date 2015-01-01
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10563 | 10563 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2009-10-29 | 279 | E | 0 | 1 | 0YSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on medical record review and staff interview, the facility failed to develop care plans to address physician orders [REDACTED].#10, #46, and #65). Facility census: 114. Findings include: a) Resident #10 Review of the resident's medical record found a Physician order [REDACTED]. The form indicated the resident was not to be resuscitated and was to be provided comfort measures. A review of the most recent care plan for the resident found it did not address that comfort measures were to be provided to the resident or what specific activities constituted "comfort measures" for this resident. b) Resident #46 Review of the resident's medical record found a POST form had been signed by the resident's legal health care representative on 09/04/07. The form indicated the resident was not to be resuscitated and was to be provided comfort measures. A review of the most recent care plan for the resident found it did not address that comfort measures were to be provided to the resident or what specific activities constituted "comfort measures" for this resident. c) Resident #65 Review of the resident's medical record found a POST form had been signed by the resident's legal health care representative on 04/30/09. The form indicated the resident was not to be resuscitated and was to be provided comfort measures. A review of the most recent care plan for the resident found it did not address that comfort measures were to be provided to the resident or what specific activities constituted "comfort measures" for this resident. d) Review of the POS [REDACTED]. --- Part II -- Based on observation, staff interview, and record review, the facility failed to include in the care plan the use of physician-ordered Hipsters to address injuries with falls, nor did the care plan address the fact that the resident would frequently remove this safety device. This was evident for one (1) of twenty (20) sampled residents. Resident identifier: #49. Facility ce… | 2015-01-01 |
| 10564 | 10564 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2009-10-29 | 225 | E | 0 | 1 | 0YSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on incident / accident report review and staff interview, the facility failed to immediately report and/or thoroughly investigate four (4) injuries of unknown source affecting two (2) of twenty (20) sampled residents. Resident identifiers: #2 and #15. Facility census: 114. Findings include: a) Resident #2 1. Review of an incident report, dated 06/11/09 at 9:00 a.m., found the resident had a bruise on the left breast measuring 6 cm x 7 cm., a bruise to the left side of the neck measuring 4 inches x 5 inches, and a bruise under the left breast measuring 4 x 11 inches. The description of the incident also included, "... Bruises are consistent with resident taking ASA (aspirin)." There was no documentation discussing how the use of aspirin would result in extensive bruising of the neck and breast, which are not areas of the body generally vulnerable to trauma. 2. Review of an incident report, dated 06/15/09 at 11:00 a.m., found the resident had six (6) new bruises - a bruise on right upper back measuring 4 x 4 (no units of measurement provided), a bruise on the mid back measuring 3 x 7 (no units of measurement provided), a bruise behind the left knee measuring 5 cm x 1 cm, a bruise to coccyx measuring 4 cm x 5 cm. Also recorded was: "Resident takes ASA therapy. Also she ambulates by herself & bumps into objects at times while ambulating." There was no documentation discussing how the use of aspirin and/or bumping into objects while self-ambulating would result in extensive bruising of the back / coccyx and bruising behind the knee, which are not areas of the body generally vulnerable to trauma. 3. During a review of these incident reports with the director of nursing (DON - Employee #121) on the mid-morning of 10/22/09, the DON related she believed the resident bumped herself while ambulating and this was the cause of the bruising noted on the incident reports of 06/11/09 and 06/15/09. She stated that, after the resident was moved to a diff… | 2015-01-01 |
| 10565 | 10565 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2009-10-29 | 329 | D | 0 | 1 | 0YSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure each resident's drug regimen were free of unnecessary drugs for two (2) of twenty (20) sampled residents. Resident #10 was ordered [MEDICATION NAME] 25 mg on 08/21/08 for depression; the drug was not identified for a gradual dose reduction attempt after twelve (12) months, and there were no documented indications for continued use at the present dose. Resident's #65's physician increased the resident's daily dosages of [MEDICATION NAME] and [MEDICATION NAME] with no evidence found in the resident's behavior records or nursing notes to indicate the resident's target behaviors had increased in frequency or duration necessitating an increase in these medications. Facility census: 114. Findings include: a) Resident #10 Record review found an order for [REDACTED]. A review of the pharmacist's monthly drug regimen reviews for the resident also found no recommendation that a gradual dosage reduction should be attempted for the resident after twelve (12) months of use. b) Resident #65 Record review found the attending physician, on 10/19/09, increased the resident's daily dose of [MEDICATION NAME] from 0.25 mg every morning and 0.5 mg at bedtime (with an additional order for [MEDICATION NAME] 0.25 mg twice daily as needed) to [MEDICATION NAME] 0.5 mg twice daily. At the same time, the physician increased the daily dose of [MEDICATION NAME] from 0.5 mg twice daily to 1 mg twice daily. A review of the psychiatrist's progress notes, dated 10/19/09, found the resident "continues to (illegible) agitation, yelling in appropriately. Cannot be directed, too confused. At present on [MEDICATION NAME] .5 mg bid (twice daily) not over sedated. Recommendations: 1. D.C. (discontinue) [MEDICATION NAME] .5 bid. 2. Give [MEDICATION NAME] 1 mg bid. 3. [MEDICATION NAME] 0.5 mg bid." The resident's [MEDICATION NAME] and [MEDICATION NAME] were increased accordingly, per 10/19/09 physician's… | 2015-01-01 |
| 10566 | 10566 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2009-10-29 | 492 | D | 0 | 1 | 0YSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to provide information regarding hospice-palliative care to residents with orders for comfort measures, as required by Chapter 16, Article 5C of the West Virginia State Code. This occurred for three (3) of twenty (20) sampled residents (#10, #46, and #65) Facility census: 114. Findings include: a) Resident #10 Review of the resident's medical record found a Physician order [REDACTED]. The form indicated the resident was not to be resuscitated and was to be provided "comfort measures". There was no evidence the resident's health care surrogate (HCS) had been provided information about hospice-palliative care. b) Resident #46 Review of the resident's medical record found a POST form had been signed by the resident's legal health care representative on 09/04/07. The form indicated the resident was not to be resuscitated and was to be provided "comfort measures". There was no evidence the resident's HCS had been provided information about hospice-palliative care. c) Resident #65 Review of the resident's medical record found a POST form had been signed by the resident's legal health care representative on 04/30/09. The form indicated the resident was not to be resuscitated and was to be provided "comfort measures". There was no evidence the HCS had been provided information about hospice-palliative care. d) West Virginia State Code (16-5C-20) states: "Hospice palliative care required to be offered. "(a) When the health status of a nursing home facility resident declines to the state of terminal illness or when the resident receives a physician's orders [REDACTED]. If a nursing home resident is incapacitated, the facility shall also notify any person who has been given the authority of guardian, a medical power of attorney or health care surrogate over the resident, information stating that the resident has the option of receiving hospice palliative care. "(b) The facility … | 2015-01-01 |
| 10567 | 10567 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2009-10-29 | 428 | D | 0 | 1 | 0YSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure irregularities in each resident's medication regimen were identified and reported to the attending physician and director of nursing for action. Resident #10 was ordered Zoloft 25 mg on 8/21/08 for depression; the drug was not identified for a gradual dose reduction attempt after twelve (12) months of use, and there were no documented indications for continued use at the present dose. This affected one (1) of twenty (20) sampled residents. Facility census: 114. Findings include: a) Resident #10 Record review found an order for [REDACTED]. A review of the pharmacist's monthly drug regimen reviews for the resident also found no recommendation that a gradual dosage reduction should be attempted for the resident after twelve (12) months of use. An interview with the assistant director of nursing, on 10/21/09 at 11:25 a.m., failed to yield any additional evidence that the need for a gradual dosage reduction attempt was identified. . | 2015-01-01 |
| 10568 | 10568 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2009-10-29 | 203 | E | 0 | 1 | 0YSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's uniform notification of discharge / transfer appeal rights form, given to one (1) of twenty (20) sampled residents (#2), the facility failed to correctly communicate to all residents and responsible parties the contact information of the single State agency responsible for reviewing all appeals of the transfer / discharge decision. Instead, the uniform notice gave residents / responsible parties the option to file such an appeal with six (6) different agencies. This error in the notice may led a resident to mistakenly file an appeal request with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. This deficient practice has the potential to affect more than an isolated number of residents. Facility census: 114. Findings include: a) Resident #2 Review of the uniform notification of discharge / transfer appeal rights form, provided by the facility for Resident #2 and dated 07/09/09, revealed the following: "This is to inform you that you have the right to appeal the decision made by this facility to transfer discharge you to..." This was followed by the names and contact information of the Office of Inspector General Board of Review, the State Ombudsman, the local mental health center, Advocates for Developmentally Disabled and Mentally Ill, Legal Aid of West Virginia, and Office of Heath Facility Licensure and Certification. This notification form contained the following errors: 1. The Office of Inspector General is the only agency in WV to which appeals of transfer / discharge decisions may be made. None of the five (5) other agencies identified in the notice is responsible for this activity. This error in the uniform notice may led a resident to mistakenly file an appeal with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. 2. The single agency designated in WV to provide protection and advocacy to in… | 2015-01-01 |
| 10569 | 10569 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2009-10-29 | 154 | D | 0 | 1 | 0YSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to fully inform one (1) of twenty (20) sampled residents, who had been determined by his physician to have the capacity to make his own healthcare decisions, of his rights as a resident, his healthcare status and the treatment interventions planned, and/or his discharge planning arrangements. Resident identifier: #62. Facility census: 114. Findings include: a) Resident #62 A review of the medical record revealed Resident #62 was a [AGE] year old male with [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE]. His attending physician determined he lacked the capacity to make his own informed healthcare decisions on 04/13/09, and assigned his niece as his health care surrogate (HCS). The social services note, written by the social worker (SW - Employee #80) on 09/29/09, recorded the resident's niece came to the facility on this date and stated that, for health reasons, she could no longer serve as the resident's HCS. She was advised the facility would seek a HCS from WV DHHR. There was also evidence that a 30-day notice of discharge had been mailed to the HCS on or about 09/24/09, although she reported to the SW she had not received it. On 10/06/09, the resident's attending physician determined the resident now demonstrated the capacity to make his own informed healthcare decisions. All social services notes, progress notes, and nurses' notes after that date were reviewed, but there was no evidence that the resident had his care plan (especially his discharge plan) or his rights explained to him. During the general tour at 3:30 p.m. on 10/19/09, this resident approached the surveyor and asked if there was any rule about the sharing of the television in his room; he also asked the surveyor to find out why he had not been discharged yet. At 11:20 a.m. on 10/20/09, the resident was interviewed about his healthcare status. He said he was sick a few months… | 2015-01-01 |
| 10570 | 10570 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2009-10-29 | 156 | E | 0 | 1 | 0YSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to fully inform residents both orally and in writing when changes will occur in their bills and/or of their appeal right to request that a bill be submitted to Medicare for three (3) random reviewed residents, and failed to clearly denote in the resident's clinical record the advance directive formulated by the resident for one (1) of twenty-three (23) sampled residents. Resident identifiers: #100, #118, #49, and #116. Facility census: 114. Findings include: a) Residents #100, #118, and #49 A review of the "Skilled Nursing Facility Determination" letters on file at the facility for Residents #100 (two (2) letters on file) and #118 failed to provide evidence that the resident or the resident's legal representative was informed of the discontinuance of a skilled service prior to the service being stopped, as the signatures of the resident and/or the legal representative were not dated, and on the letter dated 08/27/09 for Resident #100, there was no date for the non-coverage of services. None of the letters reviewed show evidence of the resident's or legal representative's decision to request a bill to be submitted to the intermediary for a Medicare decision, as that area of the letter was blank. During an interview with the administrator at 10:20 a.m. on 10/22/09, she acknowledged the letters were not completed per facility policy and the intent of the form. b) Resident #116 Review of the closed record for Resident #116 revealed a Physician order [REDACTED]. In an interview with the social worker (Employee #80) at 4:00 p.m. on 10/21/09, she agreed there was a potential for error made by the inconsistencies. . | 2015-01-01 |
| 10571 | 10571 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2009-10-29 | 371 | E | 0 | 1 | 0YSZ11 | Based on observation and staff interview, the facility failed to ensure food products were properly stored in a sanitary manner in the central kitchen and the nutrition room on south side. In the central kitchen, observation found frozen vegetables stored on the freezer floor and open containers of cookies and beverage which were not properly labeled with the date opened. In the south side nutrition room, observation found open containers of milk products were not labeled with the date opened, other food products that were not labeled or dated, and drinking straws stored under the sink. These practices have the potential to affect all residents who would have access to these food products. Facility census: 114. Findings include: a) On 10/19/09 at 3:45 p.m., a tour of the kitchen was conducted with the cook (Employee #64). A box of frozen peas was observed on the floor of the freezer. The cook acknowledged the peas should not be stored on the freezer floor and removed the box. Further observation of the kitchen found two (2) bags of cookies to be opened. There was no label observed to indicate the date the cookies were initially opened. Employee #64 acknowledged the cookies were not labeled with a date and discarded them into the trash. b) During the general tour at 3:15 p.m. on 10/19/09, an observation of the refrigerator used to store food items for resident use located in the nutrition room on the south side revealed two (2) open containers of milk and two (2) open containers of half-and-half that were not labeled with the date they had been opened. There was also a covered container of what appeared to be vegetable soup with a label reading only "my mom" and no date and a second container of vegetables labeled with a name and room number but no date. Further observation of the nutrition room found open containers of packaged straws stored below a sink. The director of nurses, when informed of these observations, stated she would take care of it immediately. . | 2015-01-01 |
| 10572 | 10572 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2009-10-29 | 441 | E | 0 | 1 | 0YSZ11 | Based on observation and staff interview, the facility failed to ensure equipment intended for common use by residents was stored in a sanitary manner. During the general tour at 3:15 p.m. on 10/19/09, observation of the clean linen room on the south side revealed several fabric items lying on the floor including mechanical lift slings on various colors. This practice has the potential to affect more than an isolated number of residents. Facility census: 114. Findings include: a) During the general tour at 3:15 p.m. on 10/19/09, observation of the clean linen room on the south side revealed several fabric items lying on the floor including mechanical lift slings on various colors. This observation was relayed to the director of nursing at 3:50 p.m. on 10/19/09, who said she would take care of it immediately. A subsequent observation of this clean linen room, on the morning of 10/20/09, revealed the items were no longer on the floor. . | 2015-01-01 |
| 10573 | 10573 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2009-10-29 | 514 | E | 0 | 1 | 0YSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the completeness and/or the accuracy of the medical records within acceptable professional standards for five (5) of twenty-three (23) sampled residents. Resident identifiers: #25, #115, #6, #38, and #9. Facility census: 114. Findings include: a) Resident #25 A review of the physician's orders [REDACTED].) The resident's Medication Administration Record [REDACTED]. This finding was pointed out to the assistant director of nursing at 9:50 a.m. on 10/20/09, who acknowledged the double orders and stated she would clarify the order. b) Resident #115 Resident #115's closed medical record, when reviewed on 10/21/09 at 3:00 p.m., disclosed a [AGE] year old female who was discharged from the facility on 09/24/09. The resident was receiving physical therapy post-operatively after a recent [MEDICAL CONDITION]. The admission physician orders, dated 07/10/09, reported the physician had ordered [MEDICATION NAME] 40 mg via subcutaneous injection every day for twelve (12) weeks. The July 2009 MAR indicated [REDACTED]. There was no evidence in the medical record the physician had discontinued the medication. The director of nurses (DON - Employee #121), when interviewed on 10/22/09 at 1:00 p.m., reported the primary physician gave a verbal order to discontinued the medication twenty-one (21) days post-operation. The DON acknowledged there was no evidence in the medical record to indicate the verbal order was received or signed by the physician. c) Resident #6 Resident #6's medical record, when reviewed on 10/20/09 at 11:30 a.m., revealed the October 2009 treatment sheet was incomplete for nurses' initials indicating treatments were completed as ordered by the physician. The physician orders [REDACTED]. The remedy skin repair cream treatment was not initialed for 10/10/09, 10/11/09, 10/12/09, 10/15/09, and 10/16/09 for 3:00 p.m.-11:00 p.m. shifts. The DON, when interviewed on 10/21/09 a… | 2015-01-01 |
| 10574 | 10574 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2009-10-29 | 367 | D | 0 | 1 | 0YSZ11 | Based on observation, medical record review, resident interview, and staff interview, the facility failed to assure one (1) of twenty (20) sampled residents received a mechanically altered diet as prescribed by the physician. A resident, who was ordered a pureed diet, failed to receive the correct texture as ordered by the physician. Resident identifier: #6. Facility census: 114. Findings include: a) Resident #6 On 10/19/09 at 6:00 p.m., Resident #6 was observed in her room eating dinner. The entree was chili hot dogs. The resident was attempting to eat, yet consumed only a few small bites. The tray ticket read, "Mechanically soft with ground meat." The resident stated, "It's hard to eat this." The medical record, when reviewed on 10/19/09, disclosed the physician ordered a " puree diet with enhanced foods" on 10/07/09. The licensed practical nurse (LPN - Employee #77), when interviewed on 10/19/09 at 6:08 p.m., revealed the resident's current diet order was for "puree consistency" and the LPN stated, "We got her a new tray." The assistant dietary manager (Employee #24), when interviewed on 10/21/09 at 2:30 p.m., acknowledged the resident received the incorrect diet on 10/19/09. The assistant dietary manager revealed, "The computer program froze up, and the dietary aide did not see the memo I put up." . | 2015-01-01 |
| 10575 | 10575 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2009-10-29 | 328 | D | 0 | 1 | 0YSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure specialized medical equipment was stored in a sanitary location. This was true for one (1) of twenty (20) sampled residents. A resident's nebulizer, nebulizer tubing, and oral suction machine were observed on the floor. Resident identifier: #38. Facility census: 114. Findings include: a) Resident #38 Observation, on 10/20/09 at 8:10 a.m., found Resident #38 in bed receiving oxygen at a rate of 2 liters per minute via nasal cannula. A nebulizer, nebulizer tubing, and oral suction machine were observed on the floor beside the bed. This alert resident, when interviewed, stated she received nebulizer treatments daily. Resident's #38's medical record, when reviewed on 10/19/09 at 4:00 p.m., revealed a [AGE] year old female with [MEDICAL CONDITION]. The resident's physician ordered suctioning as needed and [MEDICATION NAME] 600 mg via nebulizer treatments twice a day. The licensed practical nurse (LPN - Employee #137), when interviewed on 10/20/09 at 8:15 a.m., was shown the suction and nebulizer machines laying directly on the floor; she stated, "They should not be there," and picked up the nebulizer and suction machines from the floor and removed them from the resident's room. . | 2015-01-01 |
| 10576 | 10576 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2009-10-29 | 323 | D | 0 | 1 | 0YSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to provide care and services for one (1) of twenty (20) sampled residents with a history of falls with injuries, to reduce the likelihood of repeat fall-related injuries, by failing to ensure he wore Hipsters at all times when out of bed in accordance with physician orders. Resident identifier: #49. Facility census: 114. Findings include: a) Resident #49 Observation of Resident #49, on 10/20/09 at 4:15 p.m., revealed he was exiting his bathroom and standing at his bathroom door unattended. This surveyor immediately notified the closest nurse, who assisted him to dress and return to bed. There were no alarms sounding. After he was dressed and back in his bed, the nurse (Employee #150) stated, when asked, that he had no Hipsters in his room to put on, nor were there any Hipsters in the bathroom from where he had just been. She said he sometimes takes them off and puts them under the mattress or in the trash can. She said she looked under his mattress and in the bathroom and did not see them and would get a new pair to put on him. When the above findings were reported to the assistant director of nursing (ADON) on 10/20/09 at 4:35 p.m., the ADON stated Resident #49 will take off his TED stockings and Hipsters. Interview, on 10/21/09 at 10:30 a.m., with the DON and Employee #150 revealed they were aware he would take off his Hipsters. Review of the medical record revealed this resident entered the facility within the past year after sustaining a broken hip. Further review revealed the September 2009 monthly recapitulation of physician's orders [REDACTED]. Remove for bathing. Check every shift." Review of nurses' notes, dated 09/15/09 at 2:30 p.m., revealed the nursing assistant reported Resident #49 stated he fell ; the resident was standing by the bed with full range of motion. The note did not state whether or not he was wearing Hipsters at this time. The following da… | 2015-01-01 |
| 10577 | 10577 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2009-10-29 | 314 | D | 0 | 1 | 0YSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, treatment record review, and staff interview, the facility failed to care and services to promote the healing of existing pressure sores as directed by the physician's orders [REDACTED]. Resident identifier: #49. Facility census: 114. Findings include: a) Resident #49 Review of October 2009 monthly recapitulation of physician's orders [REDACTED]. Medical record review revealed Resident #49 was admitted to the facility several months ago following a [MEDICAL CONDITION] repair after a fall at home. Medical record review further revealed that he had healing Stage III pressure ulcers to his heels. Review of Resident #49's care plan revealed an intervention for "Posey gel boots bilaterally as ordered" related to being at risk for alteration in skin integrity due to the presence of pressure areas on admission. On Tuesday, 10/20/09 at 4:30 p.m., the nurse (Employee #150) removed Resident #49's socks to inspect the status of the pressure ulcers on his heels. He was wearing a pair of mid-calf white socks with a pair of blue non-skid socks over them. He was not wearing Posey gel boots. She returned and said he was supposed to wear the Posey gel boots while in bed. These findings were reported to the director of nursing (DON) at 5:00 p.m. on 10/20/09. . | 2015-01-01 |
| 10578 | 10578 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2011-09-20 | 164 | D | 1 | 0 | KU2H11 | . Based on observation and staff interview, the facility did not ensure the confidentiality of medical records when a nurse left a binder of residents' medication administration records (MARs) on unattended and open to view in the hallway during a medication pass. Facility census: 119. Findings include: a) A random observation, on 09/19/11 at 7:30 p.m., found an unattended medication cart on top of which was a binder of MARs open to view. The MAR indicated [REDACTED]. At that time, a visitor was walking in the hallway and would have been able to view the contents of that resident's MAR. Shortly thereafter, the nurse (Employee #136) arrived at the medication cart and closed the binder, after the situation was brought to her attention. In an interview on 09/19/11 at 7:35 p.m., Employee #136 stated she knew the MAR indicated [REDACTED]. . | 2015-01-01 |
| 10579 | 10579 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2011-09-20 | 323 | E | 1 | 0 | KU2H11 | . Based on observation and staff interview, the facility failed to maintain a resident environment as free of accident hazards as possible, by staging unused equipment on both sides of the hallway for two (2) of eight (8) hallways observed. Facility census: 119. Finding include: a) Observation of the facility's hallways, beginning at 7:20 p.m. on 09/19/11, found two (2) of eight (8) hallways (with room numbers from 154 to 163 and room numbers 140 to 149) had unused equipment staged on both sides of the halls. The equipment that was staged / not in use included wheelchairs, portable vital sign equipment, a physical therapy storage unit, linen barrels, a wheeled cane, a linen rack, and a linen cart. In an interview on 09/19/11 at 7:25 p.m., a nurse (Employee #136) reported these hallways did not usually have the equipment stored on both sides of the hallways. She further stated, "I know that the equipment can't block the hallway." An interview with the administrator, on 09/19/11 at 7:45 p.m., revealed staff was aware that only one (1) side of the hallway can be used to store equipment. Staging or storage of equipment on both sides of a hallway results in a narrowed corridor width that can impede evacuation of residents from the rooms on these hallways in the event of an emergency. | 2015-01-01 |
| 10580 | 10580 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 152 | D | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the legal surrogate, of one (1) of thirteen (13) residents reviewed, exercised the resident's rights in accordance with State law. Resident #24 had designated a medical power of attorney representative (MPOA) to make health care decisions for her in the event she should lack the capacity to do so. The MPOA was making health care decisions on the resident's behalf, although there was no determination of incapacity in her record to reflect she was incapable of making these decisions for herself. Resident identifier: #24. Facility census: 60. Findings include: a) Resident #24 The medical record of Resident #24, when reviewed on 07/27/09, disclosed this [AGE] year old female had been admitted to the facility on [DATE], following hospitalization after a fall resulting in a subdural hematoma and cervical fracture. Review of the resident's admission documents, as well as the physician's orders [REDACTED]. The resident's medical record contained no document stating she herself did not have the capacity to make her own health care decisions. The facility's director of nursing (DON), when interviewed related to these findings on 07/29/09, confirmed that, although the resident was indeed unable physically and mentally to make her own decisions, there was no determination of incapacity completed by the attending physician for this resident. . | 2015-01-01 |
| 10581 | 10581 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 279 | D | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to develop care plans, for three (3) of fifteen (15) residents reviewed, to reflect each resident's current needs. Resident #56 had experienced a substantial weight gain above her ideal body weight, and this was not reflected in the care plan. Resident #48 was receiving [MEDICAL CONDITION] treatments at an outside facility five (5) days per week, and the plan of care did not mention this. Resident #15 had developed a Stage II pressure ulcer, and this was not reflected in the plan of care. Facility census: 60. Findings include: a) Resident #56 The medical record for Resident #56, when reviewed on 07/28/09, disclosed the resident had been admitted to this facility from another facility on 01/12/09. At the time of admission, the resident was noted to weigh 102 pounds with a height of 62 inches. The initial note completed by the facility's registered dietitian stated her ideal body weight was 110 pounds. Her most recent minimum data set (MDS) assessment, and abbreviated quarterly assessment with an assessment reference date (ARD) of 07/09/09, revealed her weight during the assessment reference period was 119#. The resident's most recent care plan, revised on 07/09/09, stated the resident was "at nutritional risk related to disease process". The goal stated, "Resident will maintain weight." The interventions determined necessary to address this problem were: "Monitor intake and provide supplement PRN (as needed). Monitor weight, food and fluid intake. Provide food preferences upon request." The care plan had not been changed to reflect the resident's surpassing her ideal body weight. b) Resident #48 The medical record of Resident #48, when reviewed on 07/29/09, disclosed a physician's orders [REDACTED].@ 1300 (1:00 pm) last treatment 07/10/09." The resident's most current care plan, revised on 07/09/09, contained no mention of the resident's [MEDICAL CONDITION]. The faci… | 2015-01-01 |
| 10582 | 10582 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 280 | D | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed, for one (1) of fifteen (15) residents reviewed, to ensure each resident's plan of care was prepared by an interdisciplinary team including all staff involved in the care of the resident and as determined by the needs of the resident. The record record contained two (2) separate care plans, one (1) by facility staff and the other developed by the Hospice Agency contracted to provide care to the residents. Furthermore, the goals of the care plans and interventions to meet those goals were not integrated in a manner to provide the greatest benefit to the resident. Resident identifier: #3. Facility census: 60. Findings include: a) Resident #3 The medical record of Resident #3, when reviewed on 07/29/09 at 3:00 p.m., disclosed this [AGE] year old male had been admitted to the facility on [DATE], and had been admitted to the services of Hospice on 06/11/09 with the terminal [DIAGNOSES REDACTED]. The resident's record contained two (2) separate care plans, one (1) developed by facility staff and another developed by the Hospice agency providing care to the resident. The facility's care plan, dated 07/02/09, recognized problems such as risk of alteration in comfort related to decreased mobility, arthritic joints, compression fracture; risk for impaired communication; risk for impaired skin integrity; etc. The Hospice document entitled "Interdisciplinary Plan of Care" recognized similar problems, but the interventions stated by the facility were not integrated with those of the Hospice. Neither plan of care displayed involvement of the other entity in its development. | 2015-01-01 |
| 10583 | 10583 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 281 | D | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on observation, review of the facility's "Do not crush list", and staff interview, it was determined one (1) of three (3) nurses observed (Employee #11) passing medications during the medication observation task failed to provide care for Resident #55 that met current standards of care, by crushing and administering two (2) medications on the list that were not formulated to be crushed. Resident identifier: #55. Facility census: 60. Findings include: a) Resident #55 During the medication pass observation on 07/27/09 at 3:30 p.m., the nurse (Employee #11) was observed preparing the following medications for Resident #55: [MEDICATION NAME] 400 mg, EC ([MEDICATION NAME] coated) Aspirin 81 mg, Senna tab, [MEDICATION NAME] 100 mg, and Vitamin C 500 mg. During the preparation, the nurse crushed all of these medications except [MEDICATION NAME] 100 mg. When this surveyor questioned the nurse which medications were crushed, the nurse stated, "I crushed everything except the [MEDICATION NAME]." Review of the facility's "Do not Crush list" revealed the [MEDICATION NAME] coated aspirin and [MEDICATION NAME] should not have been crushed. During an interview on 07/29/09 at 10:30 a.m., the director of nursing (DON - Employee #4) confirmed [MEDICATION NAME] coated aspirin and [MEDICATION NAME] should not have been crushed. --- Part II -- Based on record review and staff interview, the facility permitted a nurse to function outside of her scope of practice, by allowing her to order a change in treatment for one (1) of thirteen (13) residents reviewed. Resident identifier: #11. Facility census: 60. Findings include: a) Resident #11 The medical record of Resident #11, when reviewed on 07/28/09, disclosed the resident had been experiencing increased difficulty swallowing, and a swallowing evaluation was completed at 12:35 p.m. on 07/27/09. Following the evaluation, the individual completing the evaluation (unable to read professional title) reco… | 2015-01-01 |
| 10584 | 10584 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 329 | D | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, and review of OBRA's (Omnibus Budget Reconciliation Act of 1987) "Unnecessary Drugs in the Elderly", the facility failed to ensure the drug regimen of three (3) of thirteen (13) sampled residents was free from unnecessary drugs. Residents #12, #20, and #11 were receiving medications given in excessive doses, for excessive duration, and/or without adequate monitoring. Resident #12 was receiving [MEDICATION NAME], a sedating drug, in excessive doses not recommended for use in the elderly. Resident #20 had received [MEDICATION NAME], a sedating drug, for excessive duration. Resident #11 had received [MEDICATION NAME], an antipsychotic drug, in excessive doses not recommended for the elderly. Resident identifiers: #12, #20, and #11. Facility census: 60. Findings include: a) Resident #12 Medical record review, on 07/28/09, discovered this [AGE] year old resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On admission, the physician ordered [MEDICATION NAME] 1 mg po (by mouth) TID (three-times-a-day) for restlessness / anxiety. Review of July 2009 monthly physician orders [REDACTED]. - [MEDICATION NAME] 1 mg po every four (4) hours PRN (as needed) and may repeat in two (2) hours if not effective for anxiety, originally ordered on [DATE]; - [MEDICATION NAME] (an antipsychotic) 1 mg at HS (hour of sleep), originally ordered on [DATE] for agitation / restlessness; and - [MEDICATION NAME] 0.5 mg every morning, originally ordered on for dementia with agitation. Review of the Medication Administration Record [REDACTED]. Additionally, the resident received a total daily dose of 4 mg of [MEDICATION NAME] on 06/05/09, 06/06/09, 06/07/09, 06/08/09, 06/11/09, 06/27/09, and 06/28/09. According to OBRA's "Unnecessary Drugs in the Elderly," 2 mg is the maximum dose of [MEDICATION NAME] recommended for use in the elderly. This resident was receiving 3 mg routinely and with t… | 2015-01-01 |
| 10585 | 10585 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 386 | E | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the attending physician for seven (7) of thirteen (13) sampled residents failed to review the resident's total plan of care with each assessment visit by failing to co-sign visits made by a physician's assistant and other consulting physicians, acknowledging lab values, and acknowledging resident visits to the emergency room . Resident identifiers: #56, #1, #24, #20, #49, #15, and #12. Facility census: 60. Findings include: a) Resident #56 The medical record of Resident #56, when reviewed on 07/28/09, disclosed the resident's attending physician had visited on 07/26/09, which was the first visit in several months. At this time, the physician wrote a progress note but failed to acknowledge by co-signing physician's assistant visit to the resident in February or to acknowledge abnormal lab results that had been obtained since his last visit. There was no evidence the physician was aware of these abnormal lab values other than a statement on each "faxed Dr. (name) NCF I 1/13/09". There was no signature to signify who had faxed them or that the physician had received the fax. b) Resident #1 The medical record of Resident #1, when reviewed on 07/29/09, disclosed the resident's attending physician had visited on 07/10/09, which was the first visit in several months. At this time, the physician wrote a progress note but failed to acknowledge by co-signing two (2) visits made to the resident by a physician's assistant on 02/24/09 and 02/26/09. c) Resident #24 The medical record of Resident #24, when reviewed on 07/28/09, disclosed the resident's attending physician had visited the resident on 07/26/09, which was the first visit in several months. Although the physician wrote a progress note at this time, he failed to acknowledge by signing or co-signing a hospital discharge report from 05/04/09 and abnormal lab values obtained on 05/05/09 which had been reviewed by another physician. These documents… | 2015-01-01 |
| 10586 | 10586 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 387 | E | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the attending physician for seven (7) of thirteen (13) residents reviewed failed to complete a physician's visit at least once every thirty (30) days for the first ninety (90) days after admission and at least once every sixty (60) days thereafter, as required. Resident identifiers: #24, #56, #1, #41, #12, #49, and #15. Facility census: 60. Findings include: a) Resident #24 When reviewed on 07/27/09, the medical record disclosed this resident had been admitted to the facility on [DATE], following hospitalization for fall resulting in vertebral fracture and a subdural hematoma. Further review disclosed no evidence the resident was seen by her attending physician until 07/26/09. When interviewed on 07/27/09, the facility's director of nursing (DON - Employee #4) could provide no further evidence to reflect the physician had seen the resident at an earlier date. b) Resident #56 When reviewed on 07/28/09, the medical record disclosed this resident had been admitted to the facility on [DATE], having transferred from another facility. Further review disclosed the resident's attending physician had seen her and written a progress note on 01/16/09. A physician's assistant (PA) had visited the patient for a "chart review" on 02/26/09. The resident's physician had not made a second visit until 07/26/09. This was confirmed by the DON during an interview at 3:00 p.m. on 07/28/09. c) Resident #1 When reviewed on 07/29/09, the medical record disclosed this resident had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. A progress note, dated 07/10/08, was written by the resident's attending physician. Although the record disclosed numerous physician orders [REDACTED].#1 since that date (07/10/08), until 07/28/09. No evidence to the contrary could be provided by facility staff at the time of exit at 3:00 p.m. on 07/30/09. d) Resident #41 When reviewed on 07/29/09, the medical record disclo… | 2015-01-01 |
| 10587 | 10587 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 514 | D | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, facility staff failed to maintain medical records, for three (3) of fifteen (15) fifteen residents reviewed, in a well organized, accurate, and complete manner. Medical documents and resident information related to services contracted through a hospice provider were not available on the resident's medical record for two (2) residents, and a document completed on an occupational therapy form incorrectly stated several resident diagnoses. Resident identifiers: #11, #3, and #56. Facility census: 60. Findings include: a) Resident #11 The medical record of Resident #11, when reviewed on 07/27/09 at 3:00 p.m., disclosed this [AGE] year old male had been admitted to the facility on [DATE] and admitted to the services of Hospice on 06/11/09 with the terminal [DIAGNOSES REDACTED]. The resident's medical record contained no information related to Hospice. A Hospice nurse (Employee #84) at the facility at that time explained that each Hospice patient had a separate chart for this information. The Hospice record was reviewed. A document titled "Interdisciplinary Group Meeting" (with no date) stated the Hospice chaplain visit frequency was "1 X month (once a month)". Further review disclosed no evidence the Hospice Chaplain had visited the resident. The Hospice nurse was again questioned and stated this documentation would be on his record at the Hospice office. The Hospice nurse agreed the information should be on the record at the nursing facility, and she called the Hospice office to have the documents faxed to the facility. b) Resident #3 The medical record of Resident #3, when reviewed on 07/29/09 at 3:00 p.m., disclosed this [AGE] year old male had been admitted to the facility on [DATE] and admitted to the services of Hospice on 06/11/09 with the terminal [DIAGNOSES REDACTED]. The Hospice record was reviewed. A document titled "Interdisciplinary Group Meeting" (with no date) stated the Hospice cha… | 2015-01-01 |
| 10588 | 10588 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 332 | D | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater. One (1) of three (3) nurses (Employee #11) observed administering medications, with forty (40) opportunities for error, incorrectly crushed two (2) medications for Resident #55 that were not formulated to be crushed. Resident identifier: #55. Facility census: 60. Findings include: a) Resident #55 During the medication pass observation on 07/27/09 at 3:30 p.m., the nurse (Employee #11) was observed preparing the following medications for Resident #55: [MEDICATION NAME] 400 mg, EC ([MEDICATION NAME] coated) Aspirin 81 mg, Senna tab, [MEDICATION NAME] 100 mg, and Vitamin C 500 mg. During the preparation, the nurse crushed all of these medications except [MEDICATION NAME] 100 mg. When this surveyor questioned the nurse which medications were crushed, the nurse stated, "I crushed everything except the [MEDICATION NAME]." Review of the facility's "Do not Crush list" revealed the [MEDICATION NAME] coated aspirin and [MEDICATION NAME] should not have been crushed. During an interview on 07/29/09 at 10:30 a.m., the director of nursing (DON - Employee #4) confirmed [MEDICATION NAME] coated aspirin and [MEDICATION NAME] should not have been crushed. . | 2015-01-01 |
| 10589 | 10589 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 371 | F | 0 | 1 | OPXH11 | Based on observation and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 60. Findings include: a) During the initial tour of the kitchen, on 07/27/09 at 1:15 p.m., observation found coffee cups stacked on top of each other on trays. The cups had been stacked prior to complete air drying and had trapped moisture, creating a medium for bacteria growth. b) During the initial tour of the kitchen on 07/27/09 at 1:15 p.m., and during further kitchen observations on 07/29/09 at 11:00 a.m., flies were observed in the food preparation and serving areas. This practice had the potential to result in food contamination and compromised food safety. c) During an interview on 07/27/09 at 1:30 p.m., the assistant dietary manager (Employee #82) confirmed there was trapped moisture in the coffee cups and flies were a problem in the kitchen due to use of the back door located in the kitchen area. . | 2015-01-01 |
| 10590 | 10590 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 469 | E | 0 | 1 | OPXH11 | Based on observation, resident interview, and staff interview, the facility failed to maintain an effective pest control program so the facility was free of flies in the kitchen and resident living areas. During the course of the survey, flies were observed in the facility kitchen and in resident care areas of the facility on the hospital side. A confidential resident interview revealed flies were a problem in resident rooms and in the facility dining areas. This had the potential to affect all residents who reside in the facility. Facility census: 60. Findings include: a) During the initial tour of the kitchen on 07/27/09 at 1:30 p.m., and during additional kitchen observations on 07/29/09 at 11:00 a.m., flies were noted in the food preparation and serving areas of the kitchen. In an interview on 07/27/09 at 1:30 p.m., the assistant dietary manager confirmed flies were a problem in the kitchen due to a back door used in the kitchen area. b) During the medication pass observation task on 07/27/09 at 3:30 p.m., a fly was observed around the medication cart in the hallway in the hospital side of the facility. c) During a confidential resident interview on 07/28/09 at 4:00 p.m., the resident complained that flies were occasionally a problem in both resident rooms and in the resident dining areas. d) During an interview on 07/30/09 at 2:15 p.m., the administrator was informed of the observation and complaint about flies in the facility. . | 2015-01-01 |
| 10591 | 10591 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 315 | D | 0 | 1 | OPXH11 | Based on record review and staff interview, the facility failed to ensure planned interventions for improving a resident's urinary continence status were implemented for one (1) of thirteen (13) residents reviewed. Resident identifier: #56. Facility census: 60. Findings include: a) Resident #56 A comparison of Resident #56's two (2) most recent minimum data set (MDS) assessments disclosed a decline in the resident's urinary continence status. On the MDS with an assessment reference date (ARD) of 04/19/09, the assessor entered a code of "1", indicating she was "occasionally incontinent". On the MDS with an ARD of 07/09/09, the assessor entered a code of "2", indicating she was now "frequently incontinent". Review of the resident's most current care plan, revised on 07/09/09, found the following problem statement: "Risk for alteration in patterns of Urinary Elimination RT (related to) disordered thought processes and infrequent urinary incontinence." The goal related to this problem stated: "Resident will not experience further loss of urinary function by review date." Interventions to achieve this goal included: "Implement bladder re-training program with all personnel, resident and family if indicated. Observe voiding pattern determine what stimuli precipitate voiding. Comprehensive evaluation of incontinence pattern to determine potential for management program." A nurse responsible for this resident on 07/29/09 at 3:00 p.m. (Employee #29), when questioned as to what steps were being taken with this resident related to her urinary incontinence, stated the nursing assistants documented each time the resident voids. When further questioned, this nurse stated the resident was not now and, as to her knowledge, never was on a bowel and bladder retraining program. . | 2015-01-01 |
| 10592 | 10592 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-09-13 | 157 | D | 1 | 0 | XZJR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, and staff interview, the facility did not notify both interested family members when one (1) of five (5) sampled residents had a change in medication, in accordance with the resident's wishes. Resident #66 had informed the facility that two (2) family members were to be notified with any change in condition or treatment. The resident's physician discontinued a pain medication and prescribed another medication. The two (2) family members were not notified of these changes in medication regimen. Facility census: 73. Findings include: a) Resident #66 Record review revealed this [AGE] year old female was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician determined this resident possessed the capacity to understand and make her own informed health care decisions. According to documentation on the resident's admission form, her two (2) sisters were to be notified whenever changes occur in her condition and/or treatment. Further record review revealed the resident was receiving [MEDICATION NAME] 7.5-500 mg once daily for pain beginning on 03/25/11. The order was changed to three (3) times daily with an as needed dose. According to pain assessments, the resident was continuing to have pain, and the physician ordered [MEDICATION NAME] 60 mg daily for the increased pain. The [MEDICATION NAME] was discontinued. The resident started the [MEDICATION NAME] 60 mg daily on 04/09/11. There was no evidence in the resident's chart to reflect the two (2) family members listed on the admission form were notified of changes in the resident's medication regimen. The resident was sent to the hospital on [DATE]. A hospital report dated 04/17/11 revealed: "Hospital Course - This lady is admitted to the hospital with [REDACTED]. She was treated with intravenous [MEDICATION NAME] and [MEDICATION NAME]. She received nebulizer. She has some upper airway sounds, but her lungs themselves are clear. I bel… | 2015-01-01 |
| 10593 | 10593 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 225 | E | 0 | 1 | 5BYT11 | Based on a review of personnel files and staff interview, the facility failed to adequately screen employees to ensure they were free from personal histories of criminal conviction which would indicate unfitness for service in a nursing facility. The facility did not complete statewide criminal background checks for four (4) of five (5) sampled employees who lived in Ohio. Employees: #1, #2, #3, and #4. Facility census: 95. Findings include: a) Employees #1, #2, #3, and #4 Review of sampled personnel files revealed four (4) of five (5) new employees lived in another State (Ohio). Further review failed to find evidence of statewide criminal background checks completed for this individuals in that State. Interview with human resources personnel, on the late morning of 05/22/09, verified the above findings. . | 2015-01-01 |
| 10594 | 10594 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 253 | E | 0 | 1 | 5BYT11 | Based on observation and staff interview, the facility failed to assure the doors to resident rooms, bathrooms, and closets were in good repair. Ten (10) doors observed on the 200 Hall were in need of repair, with deep scratches and holes in the doors making these surfaces difficult to clean thoroughly. This was true for one (1) of four (4) hallways observed. Facility census: 95. Findings include: a) 200 Hall During a tour of the facility on 05/19/09 at 9:30 a.m., observation found doors to resident rooms, bathrooms, and closets on the 200 Hall were in poor condition, with deep scratches and holes in need of repair. The doors were for the following rooms: 201, 202, 204,205, 206, 207, 209 210, 211, and 212. During a tour with the maintenance personnel, staff confirmed these doors were scratched and/or had holes in them. . | 2015-01-01 |
| 10595 | 10595 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 272 | D | 0 | 1 | 5BYT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure one (1) of thirty-two (32) residents reviewed during Stage II of the survey was assessed for fluid needs. Resident #106, admitted about one (1) week ago, was receiving [MEDICAL TREATMENT] three (3) times a week, and her record contained no evidence of any assessment with respect to daily fluid needs. After surveyor intervention, the [MEDICAL TREATMENT] center's physician ordered a fluid restriction of 1500 cc daily. Facility census: 95. Findings include: a) Resident #106 Resident #106 was a fairly new admission of one (1) week's duration whose interim care plan did not address her daily fluid needs. Interview with Resident #106, on 05/21/09 at 11:30 a.m., revealed she was unaware of any type of fluid restriction. She also seemed somewhat confused at this time. Medical record review, on 05/21/09 at 2:35 p.m., revealed no physician orders dictating the amount of daily fluids allowed for this resident who received [MEDICAL TREATMENT] treatments three (3) times weekly. On 05/21/09 at 2:35 p.m., a staff nurse (Employee #25), when interviewed regarding fluid needs for this resident, reviewed the medical record and plan of care and agreed there was no order regarding daily fluid intake. She stated she thought there was no fluid restriction for this resident or, perhaps, the order got lost between the physicians. She immediately called the [MEDICAL TREATMENT] center, received an order for [REDACTED]. . | 2015-01-01 |
| 10596 | 10596 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 279 | D | 0 | 1 | 5BYT11 | **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 for two (2) of thirty-two (32) residents in Stage II. The antipsychotic medication of Resident #53, with a history prior to admission of exhibiting violent behavior, was discontinued, and the care plan did not direct staff to monitor the resident for a resurgence of violent behavior following discontinuation of the drug, did not identify non-pharmacologic approaches to use when the behavior occurred, and did not specify the therapeutic goal(s) of the other psychoactive medications the resident was still receiving. Resident #219 was admitted for falls and decreased mobility, and care plans for not developed to address either of these concerns. Facility census: 95. Findings include: a) Resident #53 Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 04/02/09 hospital discharge summary revealed the resident had been admitted from another hospital on [DATE], due to violent behavior and increased confusion. "According to the facility administrator, the patient the day prior to admission (on 03/26/09) became very violent and punched 2 female staff members and attempting to twist the wrist of another one, and as a result, was sent to the Emergency Department at __________(on 03/27/09)." Record review resident's admission orders [REDACTED]"agitation", and [MEDICATION NAME] 0.5 mg every six (6) hours PRN for "anxiety." A hospital history and physical examination [REDACTED]." A review of the nursing notes found an entry, dated 04/04/09 at 2300, recording, "Wakeful - numerous attempts to get OOB (out of bed) unassisted. Alert - confused x 3." On 04/05/09 the 10:00 a.m., a nurse wrote, "In bed with legs hanging out over the edge - When this nurse attempted to put legs back in bed Resident attempted kick and then striked (sic) at this nurse." A 04/12/09 nursing note recorded the physician's discontinuation of [MEDICA… | 2015-01-01 |
| 10597 | 10597 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 280 | D | 0 | 1 | 5BYT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to review and revise a resident's care plan when the reason for use of an indwelling Foley urinary catheter changed. This was true for one (1) of thirty-two (32) residents in the Stage II sample. Resident identifier: #78. Facility census: 95. Findings include: a) Resident #78 Medical record review revealed a care plan, written on 02/05/09, addressing the presence of an indwelling Foley urinary catheter. According to this care plan, the problem stated: "Risk for infection indwelling catheter d/t (due to) pressure area (hx of UTI'S) (history of urinary tract infections). The three (3) goals associated with this problem were: 1) "Resident will be free of complications of indwelling catheter daily", 2) "Will remain free from s/s (signs and symptoms) of UTI by next review date, and 3) "Foley will be d/c (discontinued) as condition and mobility improve prior to d/c (discharge) home." There was no evidence found in the medical record to show that, on 02/05/09, Resident #78 had pressure ulcers necessitating the use of an indwelling urinary catheter as stated in the plan of care. A quarterly care conference was held on 04/29/09, but the use of this catheter was not reviewed. There was no evidence, as of 05/20/09, to reflect this care plan had been reviewed or revised. Further review of the medical record revealed this catheter had been discontinued and was subsequently reinserted due to the resident's [MEDICAL CONDITION]. During an interview on 05/22/09 at 10:30 a.m., the care plan nurse confirmed this care plan should have been reviewed and revised during the 04/29/09 care plan meeting. After surveyor intervention, a new physician's orders [REDACTED]. . | 2015-01-01 |
| 10598 | 10598 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 309 | D | 0 | 1 | 5BYT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, family interview, resident interview, and policy review, the facility failed to establish parameters for the administration of pain medication when multiple pains medications were ordered; failed to document the effectiveness of PRN pain medication after it was given; and failed to report to the physician when "as needed" (PRN) medications were used frequently, so the physician would order around-the-clock pain medication for increased pain management. This was evident for three (3) of thirty-two (32) Stage II residents reviewed for pain management. Resident identifiers: #135, #9, and #137. Facility census: 95. Findings include: a) Resident #135 During an interview on the afternoon of 05/19/09, Resident #135 expressed pain in his stomach. Interview with the resident's nursing assistant (Employee #83), at 9:10 a.m. on 05/21/09, revealed Resident #135 did reported stomach pain and received medication for this symptom. Interview with the licensed practical nurse (LPN - Employee #16), at 10:45 a.m. on 05/21/09, revealed the resident expressed stomach discomfort, and this had also been reported by the resident's wife. The wife confirmed this at lunch time when interviewed on 05/21/09. She reported he had an ongoing problem with stomach pain for which they had not been able to determine the cause. He received [MEDICATION NAME], and this brought relief. A review of his medical record revealed Resident #135 had orders for Tylenol 325 mg two (2) tablets by mouth every four (4) hours PRN for pain and [MEDICATION NAME] with [MEDICATION NAME] 10-500 mg tablet by mouth every six (6) hours PRN for pain with a pain assessment to be completed every morning. The pain assessment was to include asking the resident what level the pain he was experiencing prior to medication administration on a scale from "0" to "10", with "10" being the worst. Review of the May 2009 Medication Administration Record [REDACTED]. On the reve… | 2015-01-01 |
| 10599 | 10599 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 323 | D | 0 | 1 | 5BYT11 | Based on observation, review of manufacturer's instructions for the application of a wrist restraint, and staff interview, the facility failed to apply a physical restraint, to one (1) of thirty-two (32) residents in the Stage II sample, in accordance with the manufacturer's instructions. Resident #137 was observed with the wrist restraint secured to the side rail, rather than the bed frame per the manufacturer's instructions. This practice placed the resident at risk for an accident. Facility census: 95. Findings include: a) Resident #137 On 05/21/09 at 11:00 a.m., observation by two (2) surveyors found the resident with a wrist restraint tied to the side rail. The side rail was a one-quarter length rail raised to an approximate forty five degree position, and the wrist restraint was tied to the bottom part of the rail. The resident was then observed with the director of nursing (DON) immediately after the first observation. Per the DON, the wrist restraint was applied to prevent the resident from pulling out a tracheostomy and a feeding tube. The DON indicated, during the observation, that the wrist restraint should not have been tied to the side rail, but should have been tied to the bed frame. According to the product's instructions, the device should have been secured to the movable part of the bed frame. . | 2015-01-01 |
| 10600 | 10600 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 329 | D | 0 | 1 | 5BYT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (1) of thirty-two (32) residents in the Stage II sample. Resident #53 was admitted to the facility on [DATE] with physician's orders [REDACTED].", and [MEDICATION NAME] 0.5 mg every six (6) hours PRN for "anxiety." These medications were used in an excessive dose (duplicate therapy), without adequate monitoring for the resurgence of behaviors after the Zyprex was discontinued, and without monitoring to evaluate the efficacy of the medications and for possible adverse side effects. Facility census: 95. Findings include: a) Resident #53 Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 04/02/09 hospital discharge summary revealed the resident had been admitted from another hospital on [DATE], due to violent behavior and increased confusion. "According to the facility administrator, the patient the day prior to admission (on 03/26/09) became very violent and punched 2 female staff members and attempting to twist the wrist of another one, and as a result, was sent to the Emergency Department at __________(on 03/27/09)." Record review resident's admission orders [REDACTED]"agitation", and [MEDICATION NAME] 0.5 mg every six (6) hours PRN for "anxiety." A hospital history and physical examination [REDACTED]." A review of the nursing notes found an entry, dated 04/04/09 at 2300, recording, "Wakeful - numerous attempts to get OOB (out of bed) unassisted. Alert - confused x 3." On 04/05/09 the 10:00 a.m., a nurse wrote, "In bed with legs hanging out over the edge - When this nurse attempted to put legs back in bed Resident attempted kick and then striked (sic) at this nurse." A 04/12/09 nursing note recorded the physician's discontinuation of [MEDICATION NAME]. On 05/14/09 the 9:00 a.m., a nurse wrote, "Rsdt (resident) down in bed Nursing Assistants at bedside providing … | 2015-01-01 |
| 10601 | 10601 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 463 | E | 0 | 1 | 5BYT11 | Based on observation and staff interview, the facility's call alarm system was altered and not functioning as intended for the 100 Hall. The ceiling-mounted speaker used for the nurse call system's auditory alarm was covered with tape to make the volume too low to be heard by staff on the unit; the auditory alarm could only be heard at the nurses' station. Additionally, the length of the pull cord for call light in the bathroom of Room #113 was too short to be reached from the toilet if the resident needed to summon staff assistance. This deficient practice had the potential to affect all twenty-five (25) residents residing on 100 Hall. Facility census: 95. Findings include: a) Nurse call system on 100 Hall When verifying the functionality of the nurse call system on the 100 Hall on 05/21/09 at 11:00 a.m., observation revealed the visual alarm activated in the corridors above each resident doorway, and an auditory alarm sounded at the nurses' station. However, an auditory alarm could not be heard sounding on the hall itself. The environmental supervisor (Employee #103) went to the speaker where the sound should have been coming out and found the speaker was covered with surgical tape, which muted the auditory alarm. When the tape was removed, the alarm was audible from the speaker. The environmental supervisor verified the tape should not have been on the speaker. b) Call light for Room 113's bathroom Observation of the nurse call system serving the bathroom in Room 113 revealed the pull was only approximately 2 inches in length. A resident using the toilet, or a resident having fallen to the floor, would not have been able to reach the pull cord to summon assistance. The environmental supervisor was made aware of light, and a new pull cord was installed. . Resident 1: call alarms were covered with tape and inaudible | 2015-01-01 |
| 10602 | 10602 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 514 | B | 0 | 1 | 5BYT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 1: oxygen tubing treatment sheets not complete Based on observation, medical record review, and staff interview, the facility failed to each resident's clinical record was accurate and complete. Staff failed to document weekly oxygen tubing changes ordered by the physician. Resident identifiers: #2188 and #3439 on the 400 Hall, and Residents #3163 and #1889 on the 100 Hall. Facility census : 95. Findings include: a) Residents #2188, #3439, #3163, and #1889 During random observations during tour on 05/19/09 and during resident interviews on the day of entry, four (4) residents were observed to have no dates on their oxygen tubings to indicate when they had most recently been changed. Also, there was no documentation on the residents' treatment records to reflect the tubing had been changed weekly as the physician had ordered. 1. Residents #2188 and #3439 On the 400 Hall on 05/19/09 at 9:30 a.m., Residents #2188 and #3439 were noted to have oxygen concentrators in use with no dates to show when the tubing had been changed. The filters on both concentrators were dirty. On 05/20/09 at 9:55 a.m., interview with the charge nurse (Employee #26) revealed the facility did not have a separate respiratory therapy department. Rather, a nurse came to the facility twice weekly, and she changed all the oxygen tubing in the facility on Fridays. Employee #26 also reported they had aides change the tubing if the nurse is not there. The charge nurse and surveyor checked the residents' treatment records and found Resident #2188's tubing change was not recorded for 05/08/09, and Resident #3439's tubing change was not recorded for 05/08/09 or 05/15/09. Both residents had orders for oxygen tubing to be changed weekly. The director of nursing (DON), who was present at this time, stated oxygen tubing was changed weekly in the facility and, when told of the above findings, said they would take care of it right away. 2. Residents #3163 and #1889 On the 100 Hal… | 2015-01-01 |
| 10603 | 10603 | SALEM CENTER | 515071 | 146 WATER STREET | SALEM | WV | 26426 | 2011-09-08 | 425 | D | 1 | 0 | 9J3I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of eight (8) residents reviewed, to provide medications as ordered by the physician in a timely manner. The resident was ordered an antibiotic that was available in the facility's emergency drug kit, but staff did not administer the first dose of this antibiotic until over twenty-four (24) hours after it was ordered. Resident identifier: #91. Facility census: 99. Findings include: a) Resident #91 When reviewed on 09/08/11, the medical record of Resident #91 revealed a physician's orders [REDACTED]. (There was no time of day associated with this order.) According to the resident's Medication Administration Record [REDACTED]. The unit manager for Hilltop Unit (Employee #104), when questioned related to this delay in administering the medication, confirmed that Cipro was kept in the emergency medication box and should be available at all times. She further stated she did not know why the medication was not started on 08/09/11 (when ordered). The unit manager reviewed the record and found the order was entered into the computer at 5:45 p.m. on 08/09/11 by the nurse who received the order. The first dose of Cipro was not administered until 8:00 p.m. on 08/10/11, even though the medication was in the facility at the time it was ordered. The unit manager agreed this was not acceptable and that the medication should have been started when it was ordered. . | 2015-01-01 |
| 10604 | 10604 | SALEM CENTER | 515071 | 146 WATER STREET | SALEM | WV | 26426 | 2011-09-08 | 431 | D | 1 | 0 | 9J3I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed, for one (1) of eight (8) residents reviewed, to assure the accurate labeling of medications. an order for [REDACTED].#91. Facility census: 99. Findings include: a) Resident #91 When reviewed on 09/08/11, the medical record for Resident #91 revealed the resident's anti-seizure medication had undergone numerous dosage changes in recent weeks. The resident's available medications were reviewed in the medication cart. The medication Dilantin was available in two (2) boxes. - The label on one (1) box read: "Dilantin Infatabs Chew 50 mg give 1 tab by mouth twice daily. Take with 200 mg = 250 mg." - The label other the box read: "Phenytoin Sodium ER 100 mg capsule Generic for Dilantin, give 3 caps Q (every) morning and 1 cap by mouth every evening." The most recent medication change had occurred on 08/29/11 and was for the resident to receive 250 mg twice daily. The resident's Medication Administration Record [REDACTED] When interviewed on 09/08/11, a licensed practical nurse (LPN - Employee #50) was asked how the medication labels were updated when the ordered dosage is changed. This employee stated the pharmacy was notified, and when a new order was received, the label would be correct (after the current meds had been administered). The facility's Pharmacy Policy Manual was requested and received. The policy titled "4.4 Reordering, changing, and discontinuing orders" stated, on Page 2 "3.5. If the Pharmacy receives a new order that changes the strength or dose of a medication previously ordered, and there is adequate supply on hand:" "... 3.5.3. Facility should notify the Pharmacy not to send the medication. The facility should attach a 'change in directions' sticker to the existing quantity of medications until the pharmacy permanently affixes the label to the medication package or container." These medication boxes contained no such "change in direction" stickers, a… | 2015-01-01 |
| 10605 | 10605 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 152 | E | 1 | 0 | 0VZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and review of State law, the facility failed to determine a resident's capacity according to State law (WVC 16-30 - West Virginia Health Care Decisions Act) for six (6) of eight (8) sampled residents. Resident identifiers: #38, #40, #17, #35, #9, and #5. Facility census: 38. Findings include: a) Residents #38, #40, #17, and #35 1. Resident #38 A review of Resident #38's medical record revealed the resident was determined to be incapacitated due to bilateral hearing impairment and dementia. - 2. Resident #40 A review of Resident #40's medical record revealed the resident was determined to be incapacitated due to dementia. - 3. Resident #17 A review of Resident #17's medical record revealed the resident was determined to be incapacitated due to dementia. The form was not dated as to when the determination of capacity had been made. - 4. Resident #35 A review of Resident #35's medical record revealed the resident was determined to be incapacitated due to dementia. - 5. According to WVC 16-30-7. "Determination of incapacity. "(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. "(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ..." - 6. On 09/28/11 at 12:12 p.m., an interview with the director of nursing (DON - Employee #169) and the … | 2015-01-01 |
| 10606 | 10606 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 309 | D | 1 | 0 | 0VZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide services and care for two (2) of eight (8) sampled residents. Resident #35 was in the facility for seven (7) days with no bowel movement before interventions were implemented for constipation. Resident #39 was noted by a nurse to have experienced a possible "change in condition", for which there was no description, no assessment, and no evidence of follow-up. Resident identifiers: #35 and #39. Facility census: 38. Findings include: a) Resident #35 Record review revealed Resident #35 was admitted on [DATE]. The bowel elimination record revealed no recorded bowel movements until 06/14/11. A small hard bowel movement was recorded on this date. Bowel movements were recorded daily through 06/20/11. From 06/21/11 through 06/24/11, the resident did not have a bowel movement. An order was obtained on 06/25/11 for milk of magnesia (MOM) 30 cc every three (3) days as needed (PRN) for constipation. On 06/25/11 and 06/26/11, there were eight (8) extra, extra large bowel movements recorded. There were no recorded bowel movements from 06/27/11 through 07/03/11, when the record revealed the resident had a large bowel movement. The Medication Administration Record [REDACTED]. On 09/29/11 at 2:32 p.m., an interview with the director of nursing (DON - Employee #169) and the vice president of patient care (Employee #134) revealed there was no formal protocol for staff to follow regarding constipation. Employee #134 stated, "It was understood, an order would be obtained for the resident to receive milk of magnesia every three days, if they had not had a bowel movement." This employee further agreed there was "a lack of consistency" in doing this. -- b) Resident #39 Closed record review, on 09/29/11, revealed a nurse's note, dated 06/10/11 at 02:21, indicating this resident had a possible "COC" (change of condition). The note indicated the resident "seemed dazy". The situation was seriou… | 2015-01-01 |
| 10607 | 10607 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 329 | D | 1 | 0 | 0VZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and observation, the facility failed to assure the medication regimens of three (3) of eight (8) sampled residents were free from unnecessary medications. These residents were given medications without evidence of need, without attempts at non-pharmacological interventions, without adequate assessment of possible causes for changes in behavior, and/or without adequate monitoring. Resident identifiers: #9, #5, and #35. Facility census: 38. Findings include: a) Resident #5 Medical record review, on 09/28/11, revealed this resident was admitted to the facility on [DATE]. She had been receiving [MEDICATION NAME] 100 mg at hs (bedtime) since 06/23/11. On 07/04/11, the dosage of [MEDICATION NAME] was doubled to 100 mg twice a day. Review of the resident's nursing notes, dated 07/01/11, revealed the resident was more agitated and was going to the bathroom more frequently. A urine culture and sensitivity was ordered on that date. On 07/02/11, the resident was ordered Bactrim DS twice daily for three (3) days, then Bactrim 80/400 mg daily "ongoing". (Bactrim is an antibiotic medication used frequently for a urinary tract infections [MEDICAL CONDITION].) On 07/04/11, nursing notes described the resident was "Very mobile while up in w/c (wheelchair). Goes from one door to another door setting off alarm. In constant motion & movement. Wanderguard system functioning well. Still on po (by mouth) antibiotic therapy ..." There was no evidence of attempts at redirection or other non-pharmacological interventions. Additionally, there was no evidence that possible causal factors for the behaviors had been assessed. On 07/04/11 at 20:00 (8:00 p.m.), a verbal order was received to increase the [MEDICATION NAME] from 100 mg daily to 200 mg daily. Interview with the acting director of nursing (DON - Employee #171), at 10:30 a.m. on 09/29/11, confirmed there was no evidence of need for this increased dosage of [MEDICATION N… | 2015-01-01 |
| 10608 | 10608 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 151 | D | 1 | 0 | 0VZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to allow one (1) of eight (8) sampled residents the right to exercise her rights as a resident of the facility. This resident was not permitted to choose how she wished to live her everyday life and receive care. The facility cleaned the resident's room without permission and did not allow the resident to refuse a medication when she clearly stated she did not want the medication. Resident identifier: #41. Facility census: 38. Findings include: a) Resident #41 Closed medical record review, on 09/28/11, revealed this resident was admitted to the facility on [DATE]. The resident was determined to possess the capacity to understand and make informed health care decisions in May 2011. According to the medical record, the resident was very upset on 06/06/11, because a nurse cleaned her dresser drawers, threw away some newspapers, and sent some soiled clothing to the laundry. There was no evidence that staff had obtained her permission to go through the resident's personal belongings when cleaning her room. Instead, all evidence suggested the resident was told, after the fact, why it was done. This was an infringement on the resident's rights which led to the following infringement on the resident's rights: - On 06/07/11, nurse's notes described the resident continued to be upset about her room being cleaned and her possessions being thrown away. Additionally, nurse's notes indicated the resident continued to be angry and agitated up to and including 06/10/11. - On 06/10/11, nurse's notes described the resident was agitated about the change in her medications and refused to take them. At 20:00 (8:00 p.m.), a telephone order was obtained for "[MEDICATION NAME] 1 mg IM now". At 20:10 (8:10 p.m.), when staff attempted to give the injection to this resident, the resident screamed, "You're not giving me no shot." The resident was walked to her room, all the while screaming "No, no… | 2015-01-01 |
| 10609 | 10609 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 222 | D | 1 | 0 | 0VZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure one (1) of eight (8) sampled residents had the right to be free from chemical restraints. This resident was given a medication to control behaviors for staff convenience and not to treat identified medical symptoms. The medication was used without assessing possible causes for the resident's behavior and/or without first attempting non-pharmacological interventions. The medication was used as a means of managing the resident's behaviors with a lesser amount of effort by facility staff, and not because the medication was in the resident's best interest. Resident identifier: #41. Facility census: 38. Findings include: a) Resident #41 Closed medical record review, on 09/28/11, revealed this resident was admitted to the facility on [DATE]. The resident was determined to possess the capacity to understand and make informed health care decisions in May 2011. According to the medical record, the resident was very upset on 06/06/11, because a nurse cleaned her dresser drawers, threw away some newspapers, and sent some soiled clothing to the laundry. There was no evidence that staff had obtained her permission to go through the resident's personal belongings when cleaning her room. Instead, all evidence suggested the resident was told, after the fact, why it was done. On 06/07/11, nurse's notes described the resident continued to be upset about her room being cleaned and her possessions being thrown away. Additionally, nurse's notes indicated the resident continued to be angry and agitated up to and including 06/10/11. On 06/10/11, nurse's notes described the resident was agitated about the change in her medications and refused to take them. At 20:00 (8:00 p.m.), a telephone order was obtained for "[MEDICATION NAME] 1 mg IM now". At 20:10 (8:10 p.m.), when staff attempted to give the injection to this resident, the resident screamed, "You're not giving me no shot." The… | 2015-01-01 |
| 10610 | 10610 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 250 | D | 1 | 0 | 0VZD11 | . Based on medical record review and staff interview, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-bring for two (2) of eight (8) sampled residents. The facility failed to assure staff was knowledgeable regarding the provision of alternatives to drug therapy and/or chemical restraints. Additionally, there was no evidence staff understood why residents act as they do, what residents are attempting to communicate by their actions, and what individual needs the staff must meet for each resident. Resident identifiers: #41 and #5. Facility census: 38. Findings include: a) Resident #41 This resident was given a medication to control behaviors for staff convenience and not to treat identified medical symptoms. The medication was used without assessing possible causes for the resident's behavior and/or without first attempting non-pharmacological interventions. The medication was used as a means of managing the resident's behaviors with a lesser amount of effort by facility staff, and not because the medication was in the resident's best interest. There was no evidence staff were assisted in understanding this resident had a right to autonomy and self determination, so taking away these rights resulted in unacceptable behaviors, resulting in a chemical restraint. According to the medical record, the resident was very upset on 06/06/11, because a nurse cleaned her dresser drawers, threw away some newspapers, and sent some soiled clothing to the laundry. There was no evidence that staff had obtained her permission to go through the resident's personal belongings when cleaning her room. Instead, all evidence suggested the resident was told, after the fact, why it was done. On 06/07/11, nurse's notes described the resident continued to be upset about her room being cleaned and her possessions being thrown away. Additionally, nurse's notes indicated the resident continued to be angry and agitated up to and including 06/10/… | 2015-01-01 |
| 10611 | 10611 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 514 | D | 1 | 0 | 0VZD11 | . Based on medical record review and staff interview, the facility failed to assure the clinical record for one (1) of eight (8) sampled residents was complete. This resident was noted to have a change in condition. The documentation regarding this change in condition did not contain enough information to indicate staff knew the status of the resident. This documentation was needed to assure necessary care and services were provided the resident. Resident identifier: #39. Facility census: 38. Findings include: a) Resident #39 Closed record review, on 09/29/11, revealed a nurse's note, dated 06/10/11 at 02:21, indicating this resident had a possible "COC" (change of condition). The note indicated the resident "seemed dazy". The situation was serious enough the nurse documented she believed the resident should be sent to the emergency room (ER). Vital signs were documented on the note dated 06/10/11 at 02:21 (2:21 a.m.). The note contained no documentation which described the COC. There were no further nursing notes until 06/13/11 at 04:49 (4:49 a.m.). The contents of this note were not related to the COC. Interview with the acting director of nursing (DON - Employee #171), at 10:15 a.m. on 09/30/11, confirmed COC meant "change of condition". Employee #171 also confirmed there was no description of the COC, which was necessary to assure the optimum provision of care and services for this resident. | 2015-01-01 |
| 10612 | 10612 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2011-09-21 | 225 | D | 1 | 0 | CW0X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the facility's resident concern forms, staff interview, and review of policies and procedures, the facility failed to assure allegations of mistreatment, abuse, neglect, and/or misappropriation of resident property (made by a resident or any person acting on behalf of a resident) were reported to State officials as required by law. Review of the facility's concern forms found allegations of abuse / neglect that were not immediately reported to State officials as required by law. This deficient practice was true for three (3) of thirty-five (35) grievance / concern forms reviewed, involving two (2) residents. Resident identifiers: #132 and #157. Facility census: 153. Findings include: a) Resident #132 1. Review of the facility's resident concern forms found a record of a complaint voiced by Resident #132 dated 08/03/11, stating: "1. Resident complaining that her buttocks has been hurting and staff haven't been putting the cream on which is provided by the facility. 2. Ears packed and needs cleaned out. 3. Teeth aren't being cleaned regularly. 4. Flies in the room. 5. Roommates BSC (bedside commode) didn't have a lid on it and when asked to fix this the nurse just pulled the curtain. 6. Resident was cold and asked for the air conditioner to be turned down and the family heard per telephone a staff member turning it up. 7. When the current roommate was admitted she yelled for several nights and kept the pt. (patient) awake. When family complained (name of nurse) explained that the issue would be resolved in six hours. They took (name of this resident) to the dining room during this time and the issue was resolved. There are no current issues between pt. (patient) and the roommate. The family doesn't understand why pt. (patient) had to remain in the dining room. 9. Sunday 07/31 (name of resident) and (name of another resident) were left in the dining room from breakfast time until after lunch. They were yelling for help and n… | 2015-01-01 |
| 10613 | 10613 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-09-16 | 226 | E | 1 | 0 | W01Y11 | . Based on family interview, review of the facility's abuse policies and procedures, review of in-service records, and staff interview, the facility failed to operationalize their policies and procedures regarding training of staff on the facility's process on how and to whom concerns were to be reported. This was one of the aspects of the facility's training regarding actions to prevent abuse, neglect, involuntary seclusion, and misappropriation of property. This practice had the potential to affect more than an isolated number of residents. Facility census: 66. Findings include: a) On the morning of 09/13/11, a family member (who requested anonymity) mentioned she was not certain her concerns were recorded and addressed by the facility. - Review of the facility's policy entitled "Abuse Prohibition" revealed process #4, "Actions to prevent abuse, neglect, involuntary seclusion, and misappropriation of property will include:" "4.1 providing customers, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution, and provide feedback regarding the concerns that have been expressed." - Interview with the social worker (Employee #47), at 11:00 a.m. on 09/14/11, revealed the facility had recently held in-services for staff on the use of the grievance / complaint forms. Employee #47 stated all employees were required to attend. - Review of attendance records revealed no evidence thirty-seven (37) of seventy-eight (78) facility employees attended this required in-service. - The facility had not operationalized its policy to assure training for all employees in the process to assure all grievances and concerns were were documented, provided to appropriate personnel, and addressed by the facility. . | 2015-01-01 |
| 10614 | 10614 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-09-16 | 243 | E | 1 | 0 | W01Y11 | . Based on review of the facility's resident council meeting minutes and staff interview, the facility failed to assure the written concerns expressed by residents at their resident council meetings were acted upon. Residents expressed the same concern regarding soiled linens left on the floor during the past four (4) resident council meetings. This practice had the potential to affect more than an isolated number of residents. Facility census: 66. Findings include: a) Review of the facility's resident council meeting minutes for 09/02/11, 08/05/11,07/08/11, and 06/02/11 revealed the residents expressed the same concern regarding soiled linens each month. Each month, the residents stated soiled linens were being left in the floor of resident rooms and bathrooms. Review of the minutes revealed no written response to this concern. Based upon the continued complaints by the residents, the situation had not been acted upon by the facility. Interview with the activity director (Employee #8), at 2:00 p.m. on 09/15/11, confirmed there was no evidence this concern had been addressed. . | 2015-01-01 |
| 10615 | 10615 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-09-16 | 309 | D | 1 | 0 | W01Y11 | . Based on medical record review, review of incident reports, policy review, and staff interview, the facility failed to assure one (1) of twelve (12) sampled residents was provided the necessary care and services to attain or maintain his highest practicable physical well-being. This resident had four (4) unwitnessed falls and one (1) additional fall, during which he struck his head, for which neurological assessments were not performed according to nursing standards of practice and as required by facility policy. Resident identifier: #67. Facility census: 66. Findings include: a) Resident #67 Medical record review and review of incident reports, on 09/15/11, revealed this resident had unwitnessed falls on 06/04/11, 06/08/11, 06/09/11 and 07/26/11. Additionally he had a fall on 08/13/11, at which time he hit his head. The facility's Falls Management policy, revised 02/28/11, directed nursing personnel to: "Perform neurological assessment (neuro-check) for all unwitnessed falls and witnessed falls with head injury." There was no evidence in the medical record or the incident reports that neurological evaluations were done for any of these falls. Interview with the facility's director of nursing (DON - Employee #93), at 2:00 p.m. on 09/15/11, confirmed there should have been neuro-checks initiated and continued for each of these five (5) falls. The DON reviewed available facility records and reported, at 3:00 p.m. on 09/15/11, the neuro-checks had not been completed after any of this resident's falls. . | 2015-01-01 |
| 10616 | 10616 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-09-16 | 312 | D | 1 | 0 | W01Y11 | . Based on observation, medical record review, and staff interview, the facility failed to assure two (2) of eight (8) sampled residents, who were dependent on staff for assistance with eating, were provided services to maintain good nutrition. These residents were unable to independently feed themselves, yet were not provided assistance from nursing staff to assure adequate intake. Resident identifiers: #17 and #55. Facility census: 66. Findings include: a) Resident #17 This resident was observed at breakfast, beginning at 7:45 a.m. on 09/14/11. She was sitting up in bed with her opened, uneaten meal in front of her. At 8:00 a.m., the resident was asleep. She was observed to be asleep at 8:15 a.m. and at 8:30 a.m. A licensed practical nurse (LPN) entered the room at 8:30 a.m. to assist her roommate. The LPN did not awaken Resident #17 and/or attempt to assist her with her meal. The hallway outside Resident #17's room was observed continuously from 7:45 a.m. to 8:35 a.m., and staff was not observed making any attempt to assist this resident or awaken this resident between 7:45 a.m. and 8:35 a.m. At 8:35 a.m., the resident had not touched her meal. No one checked on the resident during the entire meal time to determine if she needed assistance, and she was not provided assistance in eating her meal. This resident's care plan, when reviewed, disclosed the following problem: "Resident is a nutritional risk due to resident with slow wt (weight) loss trend." There was a goal for the resident to consume 75% of her meals. One (1) of the interventions for this goal was: "Monitor for changes in nutritional status (changes in intake, ability to feed self..." This care plan was not implemented at breakfast on 09/14/11. -- b) Resident #55 This resident was observed at breakfast, beginning at 7:45 a.m. on 09/14/11. She was sitting up in bed with her opened, uneaten meal in front of her. At 8:00 a.m., the resident was asleep. She was observed to be asleep at 8:15 a.m. and at 8:30 a.m. The hallway outside of her room was observ… | 2015-01-01 |
| 10617 | 10617 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-09-16 | 368 | F | 1 | 0 | W01Y11 | . Based on review of the facility's planned meal times and staff interview, the facility failed to assure there were no more than fourteen (14) hours between a substantial evening meal and breakfast the following day. This was not a plan agreed to by the resident council when a nourishing snack was provided at bedtime. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 66. Findings include: a) Review of the facility's planned meal times revealed there were fourteen and one-half (14-1/2) hours between a substantial evening meal and breakfast the following day. When this was brought to the attention of the administrator (Employee #1) at 10:00 a.m. on 09/14/11, Employee #1 reviewed the times and confirmed there was one-half (1/2) hour more time between these meals than allowed by this regulation. . | 2015-01-01 |
| 10618 | 10618 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-09-16 | 241 | E | 1 | 0 | W01Y11 | . Based on observation and staff interview, the facility failed to promote dignity for four (4) of eight (8) sampled residents during mealtime. Residents were placed outside the 100 hallway dining area for up to an hour waiting for their breakfast. These four (4) residents were able to view other residents being fed while they waited for their meal. Additionally, after being taken into the dining area, two (2) of these four (4) residents were not served at the same time as other residents in the room. This resulted in them watching other residents being fed while still not receiving their meal. Resident identifiers: #1, #3, #12, and #66. Facility census: 66. Findings include: a) Residents #1 and #3 At 7:15 a.m. on 09/14/11, Residents #1 and #3 were observed outside the 100 hallway dining area. At this time, the residents were watching other residents being served breakfast and they had not been served their breakfast. An hour passed before these residents were taken into the dining area at 8:15 a.m. After the residents were taken into the dining room, they sat for an additional ten (10) minutes before being served their breakfast at 8:25 a.m. These residents sat for a total of one (1) hour and ten (10) minutes watching other residents eating breakfast before being provided their meals. -- b) Resident #12 On 09/14/11 at 7:15 a.m., Resident #12 was observed outside the 100 Hall dining area. At this time, the resident was watching other residents being served breakfast and she had not yet been served her breakfast. The resident was not taken into the dining room until 8:00 a.m. This resident sat for forty-five (45) minutes watching other residents eating before she was served her breakfast. -- c) Resident #66 On 09/14/11 at 7:15 a.m., Resident #66 was observed sitting outside the 100 Hall dining area. At this time, the resident was watching other residents being served breakfast and she had not yet been served her breakfast. The resident was not taken into the dining room until 7:40 a.m. For twenty-five (25) minutes… | 2015-01-01 |
| 10619 | 10619 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-09-16 | 353 | F | 1 | 0 | W01Y11 | . Based on observation, staff interview, confidential family interview, and review of resident council meeting minutes, the facility failed to deploy and supervise staff in a manner which assured the provision of assistance residents required for six (6) of twelve (12) sample residents and one (1) resident randomly identified during the survey. Residents were not provided assistance with meals in a timely manner, were not assisted in getting dressed in time to go to the dining room, and meals were not offered in the dining room due to staffing. Additionally, the resident council minutes revealed the lack of availability of staff had an impact on their lives in the facility. This practice affected seven (7) residents during the survey, but it had the potential to affect all facility residents. Resident identifiers: #1, #3, #12, #21, #66, #55, and #17. Facility census: 66. Findings include: a) Residents #1 and #3 At 7:15 a.m. on 09/14/11, Residents #1 and #3 were observed outside the 100 hallway dining area. At this time, the residents were watching other residents being served breakfast and they had not been served their breakfast. An hour passed before these residents were taken into the dining area at 8:15 a.m. After the residents were taken into the dining room, they sat for an additional ten (10) minutes before being served their breakfast at 8:25 a.m. These residents sat for a total of one (1) hour and ten (10) minutes watching other residents eating breakfast before being provided their meals. -- b) Resident #12 On 09/14/11 at 7:15 a.m., Resident #12 was observed outside the 100 Hall dining area. At this time, the resident was watching other residents being served breakfast and she had not yet been served her breakfast. The resident was not taken into the dining room until 8:00 a.m. This resident sat for forty-five (45) minutes watching other residents eating before she was served her breakfast. -- c) Resident #66 On 09/14/11 at 7:15 a.m., Resident #66 was observed sitting outside the 100 Hall dining area. A… | 2015-01-01 |
| 10620 | 10620 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-09-16 | 225 | D | 1 | 0 | W01Y11 | . Based on review of the facility's incident reports and staff interview, the facility failed to investigate and report an unwitnessed and unexplained bruise for one (1) of twelve (12) sample residents. Resident #12 had a bruise on her right breast with no indication the facility had reported this injury of unknown origin or conducted an investigation to rule out potential abuse and/or neglect. Resident identifier: #12. Facility census: 66. Findings include: a) Resident #12 On 09/14/11, the facility's incident reports from March through September 2011 were reviewed for reports of injuries of unknown origin. This review revealed a bruise was identified on the right breast of Resident #12 at 5:30 p.m. on 07/17/11. The bruising was described as purple, green, and yellow in color by a registered professional nurse (RN - Employee #73). Upon inquiry by staff at that time, the resident stated she did not know how this bruise happened. On 09/15/11 at approximately 10:00 a.m., the director of nursing (DON - Employee #93) was asked to provide evidence to reflect this injury of unknown origin had been immediately reported (to State agencies as required by law) and thoroughly investigated. At 4:15 p.m. on 09/15/11, the DON reported there was no evidence the facility had reported or investigated the bruising found on this resident. She stated, "I don't know why it wasn't reported." . | 2015-01-01 |
| 10621 | 10621 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 156 | D | 0 | 1 | GCMN11 | . Based on record review and staff interview, the facility failed, for one (1) of two (2) applicable residents / responsible parties, to provide notice of the right to request a demand bill when the resident's Medicare-covered services were discontinued by the facility. Resident identifier: #3. Facility census: 83. Findings include: a) Resident #3 During the morning of 12/08/10, records were reviewed for three (3) residents whose Medicare-covered services had been discontinued by the facility. At the same time, interviews were conducted with facility corporate office personnel who were assisting with bookkeeping responsibilities in the absence of the facility's bookkeeper. Record review revealed Resident #3's Medicare-covered services were discontinued on 09/16/10, because he had reached his maximum potential in occupational therapy services. The corporate persons were unable to locate evidence Resident #3 received a notice his Medicare services were discontinued, and no evidence the resident / responsibility party had been given the opportunity to request a demand bill. On 12/09/10, the facility's bookkeeper (Employee #18) searched her records for evidence that the appropriate notices had been given to Resident #3. During the morning of 12/09/10, Employee #18 reported the "cut letter" and opportunity to request a demand had not been provided this resident / responsible party. . | 2015-01-01 |
| 10622 | 10622 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 159 | B | 0 | 1 | GCMN11 | . Based on resident and staff interview, the facility failed to assure residents had access to their funds on weekends and/or at other times the business office was closed. This practice had the potential to affect all residents for whom the facility managed funds. At the time of the survey, the facility maintained a trust fund for sixty-nine (69) residents. Facility census: 83. Findings include: a) During Stage I confidential resident interviews on 11/29/10 and 11/30/10, four (4) residents described that their personal funds were not available on weekends and/or at other times the business office was not open. On 12/08/10 at 2:00 p.m., an interview was conducted with the business office staff member who assists in resident funds. At that time, this staff member described that, prior to 11/30/10, residents had not been able to get funds except during business office hours. This person stated that, on that date, resident funds became available to residents at times the business office was closed, by means of a small amount of money provided to nursing personnel for this purpose. . | 2015-01-01 |
| 10623 | 10623 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 167 | C | 0 | 1 | GCMN11 | . Based on observation and staff interview, the facility failed to assure the facility's survey results were posted in an area that was accessible to all residents. The results that were in the posting did not include the deficiencies cited during complaint investigations that were conducted since the facility's last standard annual survey. This practice had the potential to affect all residents who desire to review the facilities survey results. Facility census: 83. Findings include: a) Observation of the facility's publicly posted information, on the morning of 12/01/10, found the facility's survey results were posted between the two (2) front double doors in an area where most of the residents were not permitted. Review of the survey results that were posted found they did not contain the results of complaint investigations that had been conducted since the facility's last standard annual survey, during which the facility was cited deficiencies. The administrator was notified of this finding at 12:45 p.m. on 12/08/10. She verified the survey results that were posted were not complete and were not posted in an area that was accessible to all residents. . | 2015-01-01 |
| 10624 | 10624 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 241 | D | 0 | 1 | GCMN11 | . Based on observation, the facility failed to ensure one (1) of eighteen (18) residents seated in the dining room for the evening meal on 11/29/10 was treated in a dignified or respectful manner as he waited for his meal. The resident was ignored by staff when he asked for assistance with drinking the orange beverage which had been placed in front of him. Resident identifier: #10. Facility census: 83. Findings include: a) Resident #10 On 11/29/10 at 5:05 p.m., this resident was seated in the dining room when a refreshment cart was brought to the room by staff members. An orange beverage was placed in front of the resident. The resident was unable to grasp or drink the beverage without assistance, and he requested assistance with drinking from staff. Four (4) different staff members passed by the resident and failed to acknowledge the resident or his request. The fifth time the resident asked for a drink, a nurse stopped and told the resident he could not have his beverage until his special cup came out on his tray. On the resident's sixth request to get a drink, another staff member stopped what she was doing, acknowledged the resident's request, and assisted him in drinking the beverage. It should be noted that the resident's tray, with the special cup, was not served the resident until after 5:30 p.m. . | 2015-01-01 |
| 10625 | 10625 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 242 | D | 0 | 1 | GCMN11 | . Based on resident interview, medical record review, and staff interview, the facility failed to assure one (1) of thirty-two (32) Stage II sample residents was provided showers as she desired, on her scheduled shower days. Resident identifier: #32. Facility census: 83. Findings include: a) Resident #32 During Stage I resident interviews on 11/30/10 at 3:29 p.m., this resident described she was not receiving her showers as scheduled. The resident stated she was scheduled for showers on Mondays and Thursdays, but these showers were not always provided by staff. Further interview revealed the showers were not provided on other days, if they happened to be missed on Mondays and Thursdays. The resident's choice was for her showers to be provided twice weekly and on Mondays and Thursdays as scheduled. On 12/06/10 at 4:45 p.m., this resident's nursing assistant flow sheets were reviewed. As stated by the resident, she was scheduled for showers on Mondays and Thursdays on the 3-11 shift. Review of the October, November, and December 2010 records revealed the resident was not provided showers on the following Mondays: 10/04/10, 11/08/10, and 11/25/10. Additionally, she was not provided showers on the following Thursdays: 11/11/10, 11/25/10, and 12/02/10. (There was one (1) refusal on a scheduled shower day in October, and this day was not counted in the assessment of showers provided.) This information was brought to the attention of the director of nursing (DON). During the morning of 12/09/10, the DON reported she was unable to locate any information which disputed the showers had not been given as scheduled. . | 2015-01-01 |
| 10626 | 10626 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 244 | E | 0 | 1 | GCMN11 | . Based on a review of the resident council meeting minutes and staff interview, the facility failed to assure requests made by residents during the monthly resident council meeting were acted upon. During the October 2010 resident council meeting, the residents asked to have copies of the meal menus posted in their rooms. No action was taken to comply with this request as of 12/09/10. This practice has the potential to affect more than an isolated number of residents. Facility census: 83. Findings include: a) According to the October 2010 resident council meeting minutes, the residents in attendance verbalized that they would like to have menus of the meals posted in their rooms. The response from the facility's dietary department was that they would post them as soon as the menus changed. As of the 12/09/10, the menus were still not posted in the residents' rooms, and there was no further response to the council members' request. . | 2015-01-01 |
| 10627 | 10627 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 253 | D | 0 | 1 | GCMN11 | . Based on observation and staff interview, the facility failed to provide maintenance services to maintain a comfortable interior for the residents. Observation found the corridors to rooms #153 and #101 were not properly functioning and would not remain open, and the corridor door to room #158 had scratched / splintered pealing wood on the door. This practice affected three (3) of thirty-two (32) doors to residents' rooms. Facility census: #83. Findings include: a) Room #153 Observation found the corridor door to this room was closed on multiple occasions throughout the first week of the survey. When observed at 10:00 a.m. on 12/08/10, the door was propped open with a trash can. When the trash can was moved, the door automatically went shut on its own and would not remain open. b) Room #101 Observation found the corridor door to this room was propped open with a trash can on 12/08/10. When the trash can was moved by this surveyor, the door would not remain open but, instead, closed on its own. c) Room #158 Observation found the corridor door to this room had peeling wood that was splintered on the edges of the door. d) Employee #22 (the maintenance supervisor) was made aware of the issues with these three (3) doors at 1:00 p.m. on 12/09/10. He verified the doors were in need of repair at that time and stated he would address them. . | 2015-01-01 |
| 10628 | 10628 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 272 | D | 0 | 1 | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, and staff interview, the facility failed to assess one (1) of thirty-two (32) Stage II sample residents for his continued need for thickened liquids. Resident identifier: #10. Facility census: 83. Findings include: a) Resident #10 During the evening meal observation on 11/29/10, this resident was provided an orange beverage which was of regular consistency. Observation revealed no coughing, choking, or strangling as the resident drank the beverage. At that time, it was not known that the resident had a physician's orders [REDACTED]. On 12/07/10, review of the resident's medical record found a physician's orders [REDACTED]. There was a speech therapy assessment, dated 11/11/09, which indicated a need for honey thick liquids. There was no evidence of a more current speech therapy assessment. Additionally, on 03/18/10, the facility had a "hold harmless" form completed by the appropriate representative, so the resident could drink regular "Coca Cola". On 12/08/10 at 1:30 p.m., an interview regarding this resident was conducted with the director of nursing (DON). After hearing the resident drank thin liquids without evidence of a problem on 11/29/10, the DON confirmed a new speech therapy evaluation was indicated. . | 2015-01-01 |
| 10629 | 10629 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 280 | D | 0 | 1 | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to review and revise Resident #115's plan of care to reflect the diet that was being provided by the facility. The resident had dietary restrictions ordered by her physician and included in her care plan that restricted the use of added salt. Observation found she received a package of salt on her meal tray, and staff added the salt to her food. The facility did not assure the resident's care plan was revised to include the resident's wishes and refusal to eat meals without salt. This was observed for one (1) of thirty-two (32) Stage II sample residents. Resident identifier: #115. Facility census: 83. Findings include: a) Resident #115 Review of Resident #115's medical record found, on the monthly recapitulation of physician orders [REDACTED]. Observations were made of this resident eating lunch at 12:15 p.m. on 12/02/2010. She had a package of salt on her tray. The restorative nursing assistant (Employee #94) opened the salt packet and sprinkled it on the resident's food. Resident #115 ate some of her lunch in the restorative dining program, then she was fed by the staff. Employee #94, when interviewed regarding the salt, she said this resident will not eat food without adding salt. "If you do not salt it, she will send you after the salt before she will eat the food." She stated they started just sending it on her tray, because staff would have to go get it anyway. The medical record was reviewed again, and there was no evidence that the resident's non-compliance with her no added salt diet had been recorded and addressed with the physician. The director of nursing (DON), when interviewed on the afternoon of 12/02/10 regarding this resident's diet, verified that, according to the physician's orders [REDACTED]. She agreed the care plan should have been revised to address the resident's non-compliance with her diet instead of just going ahead and sending her salt.… | 2015-01-01 |
| 10630 | 10630 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 282 | D | 0 | 1 | GCMN11 | . Based on observation, medical record review, and staff interview, the facility failed to implement the current care plan for one (1) of thirty-two (32) Stage II sample residents. The facility did not implement the resident's care plan for thickened liquids. Resident identifier: #10. Facility census: 83. Findings include: a) Resident #10 During observation of a pre-meal activity prior to the evening meal on 11/29/10, this resident was provided an orange beverage which was of regular consistency. Observation revealed a nursing staff member assisted the resident in drinking this beverage. On 12/07/10, the resident's medical record was reviewed. The resident had current care plan approaches to "Provide honey thickened liquids" and "Encourage resident to drink thickened liquids only." The resident was provided the thin liquids at his table on 11/29/10. When assisting the resident to drink the beverage, nursing staff did not mention to the resident that the beverage was not thickened and/or provide the resident with a beverage of the proper consistency. On 12/08/10 at 1:30 p.m., an interview regarding this resident was conducted with the director of nursing (DON). At that time, the DON confirmed the care plan should have been followed and the resident should have had thickened liquids at the pre-meal activity. . | 2015-01-01 |
| 10631 | 10631 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 309 | D | 0 | 1 | GCMN11 | . Based on medical record review, review of the facility's bowel protocol, and staff interview, the facility failed to implement its bowel protocol for one (1) of thirty-two (32) Stage II sample residents. Additionally, the facility failed to assure this resident, who had serious problems with constipation, had an individually written bowel protocol. The facility's protocol called for interventions beginning when a resident did not have a bowel movement (BM) in three (3) days. This resident was not provided interventions until nine (9) days when indicated on one (1) occasion and six (6) days when indicated on another occasion. Resident identifier: #5. Facility census: 83. Findings include: a) Resident #5 Medical record review, on 12/07/10, revealed a nursing note dated 10/06/10 at 7:10 a.m., which stated, "Resident given enema d/t (due to) (symbol for 'no') BM's (bowel movements) charted for 9 days." Continued review of the record, including the medication administration records (MARs) and BM records revealed no interventions prior to the enema, which was given after nine (9) consecutive days with no BM. Another nursing note, on 11/10/10 at 10:00 p.m., stated, "Resident on day 6 of BM (without a bowel movement for 6 days). MOM (milk of magnesia) given..." Continued review of the record, including the MARs and BM records, revealed no interventions prior to the MOM which was given after six (6) consecutive days with no BM. The facility had standing orders, which were called "Routine Protocol" with a revision date of November 2006. A copy of this protocol was in the resident's medical record. This routine protocol contained a protocol for constipation, which stated: "The BM record should be checked daily on 3-11 shifts. If a resident has not had a BM in 3 days, give MOM 30 cc PO (by mouth) at H.S. (bedtime). On the third day force fluids unless contraindicated, at least 2000 cc/24 hours. If no results from MOM administration, then the next morning of the fourth day 7-3 shift the resident needs to be checked for pres… | 2015-01-01 |
| 10632 | 10632 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 312 | D | 0 | 1 | GCMN11 | . Based on family interview, resident interview, staff interview, and observation, the facility failed to assure one (1) of thirty-two (32) Stage II sample residents received necessary services to maintain good personal hygiene. This resident, who was unable to perform her own activities of daily living, had dry, flaky feet and long, jagged, dirty fingernails. Resident identifier: #5. Facility census: 83. Findings include: a) Resident #5 On 12/06/10, a family interview was conducted with this resident's sister. During this interview, the sister expressed concern that the resident's feet were not routinely cleaned by facility staff. She stated the resident's feet were often dry and flaky, and that she (the sister) often soaked and cleaned them herself. Interview with the resident, at 1:00 p.m. on 12/07/10, revealed her feet were always cold, so she wore socks all the time. Further interview revealed the resident was rarely showered due to her severe pain, and she preferred bed baths. Upon inquiry, the resident stated she did not feel her feet received the care they required, and that her sister often had to soak them and clean them. She stated staff did not perform this care routinely. Review of the resident's care plan, on 12/07/10, revealed no specific care plan regarding the resident's foot care. On 12/08/10 at 9:00 a.m., this resident's feet were observed with a registered nurse (Employee #20). The resident's feet were dry and flaky. According to Employee #20, the resident needed foot care. Employee #20 stated she would assure the resident received this care. During this observation, the resident's fingernails were noted to be long, jagged, and dirty. The resident's care plan indicated the resident liked long fingernails. Upon inquiry, the resident confirmed she liked long fingernails, but she looked at her nails and stated, "Not this long. They need trimmed." . | 2015-01-01 |
| 10633 | 10633 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 323 | E | 0 | 1 | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and record review, the facility failed to maintain an environment free of accident hazards for two (2) of thirty-two (32) Stage sample residents. Resident #90 was observed on several occasions wearing socks without non-skid soles, when he was care planned to wear non-skid sole shoes. Resident #10 was observed drinking thinned liquids, when he was ordered thickened liquids. Also, on the East Wing in the shower room, a shower chair was found sitting in the corner with rusted wheels that were in poor condition. This shower chair, which was available for use, presented an accident hazard to more than an isolated number of residents. Resident identifiers: #90 and #10. Facility census: 83. Findings include: a) Resident #90 On 11/29/10 at 3:50 p.m., the resident was observed in the activities room, propelling himself in wheelchair and wearing white socks without non-skid soles. The resident was again observed propelling himself in wheelchair on 11/30/10 at 2:00 p.m., wearing white socks without non-skid soles. On 12/01/10, 12/02/10, 12/06/10, 12/07/10, and 12/08/10, the resident was observed propelling himself in wheelchair wearing white socks with non-skid soles. Review of the resident's care plan revealed he was to wear non-skid sole shoes due to risk of falls. An interview with a licensed practical nurse (LPN - Employee #5) revealed the resident was capable of transferring himself without assistance from the bed to the wheelchair, and he also ambulated to the restroom occasionally without assistance. On 12/08/10 at 1:30 p.m., an interview with registered nurse (RN - Employee #70) revealed she was unaware if the resident had a pair of non-skid sole shoes, but she would put some non-skid socks on the resident. An observation, on 12/08/10 at 4:00 p.m., found the resident was wearing non-skid socks while propelling himself down the hallway. b) Resident #10 During observation of a pre-meal activity prior to the… | 2015-01-01 |
| 10634 | 10634 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 325 | D | 0 | 1 | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to assure feeding recommendations made by the speech-language pathologist (SLP) for Resident #115 were implemented as written. The facility also failed to assure the diet ordered by the physician was followed and that the physician was notified when the resident was non-compliant with the diet, to see if the diet order could be changed. This resident had a history of [REDACTED]. This practice affected one (1) of thirty-two (32) Stage II sample residents. Resident identifier: #115. Facility census: 83. Findings include: a) Resident #115 Review of Resident #115's medical record found, on the monthly recapitulation of physician orders [REDACTED]. Further review of the record found a speech therapy evaluation and recommendations made by the SLP on 11/12/10. The SLP stated the goal for this resident was "to decrease risk of aspiration and increase PO (by mouth) intake". The recommendations included: placement of the resident in the restorative feeding program; she was not to have straws in her drinks, she was to be provided verbal cueing to swallow with her meals due to her issue of pocketing food in her mouth; and she was to have two (2) to three (3) bites of food alternated with one (1) drink. Further review of the medical record revealed that, when the resident was admitted to the facility on [DATE], her weight was 103#. Her weight on 09/01/10 was 116#. The resident's weight on 10/01/10 was 113#. The resident's weight on 11/15/10 was 107#. This represented a weight loss of 9# in two (2) months and 6# in one (1) month. Observations were made of this resident eating lunch at 12:15 p.m. on 12/02/2010. She had a package of salt on her tray. The restorative nursing assistant (Employee #94) opened the salt packet and sprinkled it on the resident's food. Resident #115 ate some of her lunch in the restorative dining program, then she was fed by the staff. She had a straw in… | 2015-01-01 |
| 10635 | 10635 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 332 | D | 0 | 1 | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, review of the facility's drug handbook, and staff interview, the facility failed to ensure that it was free of medication error rates of five percent (5%) or greater. Out of fifty-one (51) medication opportunities, there were three (3) errors observed. This resulted in an error rate of five and eighty-eight-one hundredths percent (5.88%). This practice effected three (3) of ten (10) residents. Resident identifiers: #50, #43, and #42. Facility census: 83. Findings include: a) Resident #50 During medication pass on 12/06/10 at 1:50 p.m., a registered nurse (RN - Employee #75) was observed to administer eye drops to Resident #50. The physician's orders [REDACTED]. Employee #75 was observed to administer one (1) gtt (drop) to both eyes. When questioned about the eye drops and why they were administered to both eyes, Employee #75 stated this was how the resident wanted it. She agreed the physician needed to be contacted to have the order changed. -- b) Resident #43 During medication pass on 12/07/10 at 9:20 a.m., an RN (Employee #77) administered an inhaler "[MEDICATION NAME] Diskus 1 (one) puff" to Resident #43 and then told the resident to get herself a drink. Employee #77 was questioned about the use of the inhaler and asked if she instructed residents to rinse and spit after this inhaler was administered. The RN stated she had never been told that they had to spit; she just had them to get a drink to rinse out their mouth. She was asked, at that time, to refer to the manufacturer's instructions in the package insert accompanying the box containing the [MEDICATION NAME] Diskus. It was noted that the [MEDICATION NAME] was in a plastic bag with a label for the use on the bag, but there was no box or manufacturer's instructions included. The nurse was asked for the facility's drug reference book used by the nurses to research the medications that are administered. There were no instructions in the drug book f… | 2015-01-01 |
| 10636 | 10636 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 353 | F | 0 | 1 | GCMN11 | . Based on review of the facility's nursing schedules and staff interview, the facility failed to designate a licensed nurse to serve as a charge nurse on each shift. According to facility staff, nursing employees "know" who the charge nurse is, but this person is not designated as required by this regulation. This practice has the potential to affect all facility residents. Facility census: 83. Findings include: a) Review of the facility's nursing schedules revealed a licensed nurse was not designated to serve as the charge nurse on each shift. The staff development coordinator (Employee #109) stated, at 9:30 a.m. on 12/07/10, the facility has "never designated a person in charge, they just know." . | 2015-01-01 |
| 10637 | 10637 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 356 | C | 0 | 1 | GCMN11 | . Based on observation and staff interview, the facility failed to assure the required information regarding nursing staffing was posted at the beginning of each shift. The census and/or the hours actually worked were not posted in a clear and readable format. Seventeen (17) days was reviewed, and there were twenty (20) shifts for which no information was available on these postings. This information is provided so residents and the public can review the facility's staffing patterns at any given time. The practice of not posting complete and accurate information has the potential to affect all residents and visitors who would like to review the staffing. Facility census: 83. Findings include: a) Observation of the facility's posting of nurse staffing data, on 12/08/10 at 10:30 a.m., found it did not contain the hours actually being worked at that time. The posting is required to be updated at the beginning of each shift; therefore, this posting should have been completed at 7:00 a.m. Further review of the facility's nurse staffing data sheets found there were twenty (20) shifts in the last seventeen (17) days that had not been posted. The staffing sheets did not record the census at the beginning of each shift and the actual hours worked by the nursing staff responsible for care per shift. The registered nurse supervisor (Employee #20) was made aware that the posting was not being completed as required. . | 2015-01-01 |
| 10638 | 10638 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 371 | F | 0 | 1 | GCMN12 | . Based on observations and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices had the potential to affect all facility residents who received nourishment from the dietary department. Facility census: 84. Findings include: a) During observation of the dietary department with the dietary manager (DM - Employee #63) on 02/22/11 at 3:15 p.m., the following sanitation infractions were identified: 1. The drain of the handwashing sink was too slow to drain quickly enough to prevent hands from coming in contact with the water as hands were being washed. 2. There was no waste receptacle, which was touch free, at the handwashing sink to dispose of paper towels after washing hands. 3. The large blue soup / cereal bowls contained debris which could be scraped off with a fingernail. When observed, the DM took a bowl into the dish room and used a non-scratch abrasive sponge on a bowl. The debris was removed by this method. 4. Clear beverage containers were not air dried prior to lids being placed on them and lids for the pellet system were stacked with moisture between them. The trapped moisture in these items created a potential for bacterial growth. 5. Clean plates were placed in the plate warmer prior to cleaning crumbs and debris from the warmer. 6. The underneath of the clean silverware rack contained a greasy / dusty debris which was able to be removed upon touch. The facility's food handler gloves were stored under this silverware rack. -- b) On 02/24/11 at 1:00 p.m., a dietary employee (#92) was observed serving a meal. He touched his face around his nose and mouth with his gloved hand, then immediately resumed serving food without changing his gloves and washing his hands. -- c) On 03/02/11 at 12:55 p.m., a meal tray, which was tested for temperatures in the presence of the DM, revealed the colesl… | 2015-01-01 |
| 10639 | 10639 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 425 | D | 0 | 1 | GCMN11 | . Based on observation, review of the facility's drug reference handbook, and staff interview, the facility failed to assure the pharmaceutical services provided to residents included assuring that staff had the proper instructions available for administering medications ordered by the physician. There were no instructions available in the facility to instruct the nurse of the proper administration of Advair Diskus. The medication did not come from the pharmacy in its original container, and there were no manufacturer's instructions available and no instructions in the facility's drug reference handbook. The nurse instructed the resident to take a drink instead of instructing the resident to rinse her mouth following the administration of the Advair Diskus inhaler. This affected one (1) of one (1) resident observed to receive this type of inhaler. Resident identifier: #43. Facility census: 83. Findings include: a) Resident #43 During medication pass on 12/07/10 at 9:20 a.m., an RN (Employee #77) administered an inhaler "Advair Diskus 1 (one) puff" to Resident #43 and then told the resident to get herself a drink. Employee #77 was questioned about the use of the inhaler and asked if she instructed residents to rinse and spit after this inhaler was administered. The RN stated she had never been told that they had to spit; she just had them to get a drink to rinse out their mouth. She was asked, at that time, to refer to the manufacturer's instructions in the package insert accompanying the box containing the Advair Diskus. It was noted that the Advair was in a plastic bag with a label for the use on the bag, but there was no box or manufacturer's instructions included. The nurse was asked for the facility's drug reference book used by the nurses to research the medications that are administered. There were no instructions in the drug book for the proper use of the Advair Discus. During an interview with the facility's consultant pharmacist on the afternoon of 12/07/10, she was asked about the correct way to adminis… | 2015-01-01 |
| 10640 | 10640 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 431 | E | 0 | 1 | GCMN11 | . Based on observation and staff interview, the facility failed date open medications in accordance with current standards of practice. This deficient practiced has the potential to affect more than an isolated number. Facility census: 83. Findings include: a) On 11/29/10 at 2:30 p.m., an observation was made in the East Wing medication storage room, in the company of a licensed practical nurse (LPN - Employee #5) revealed a vial of influenza vaccine with no date was found open in the medication storage refrigerator. With a date to reflect when this vial was opened, it was not possible to determine when the contents of the vial were no longer safe for use. . . | 2015-01-01 |
| 10641 | 10641 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 441 | E | 0 | 1 | GCMN12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, staff interview, and policy review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help help prevent the transmission of disease and infection, by failing to immediately implement transmission-based precautions when Resident #38 returned from a hospital stay with a [DIAGNOSES REDACTED]. These practices had the potential to affect all residents in the facility. Facility census: 84. Findings include: a) Review of Resident #38's medical record revealed a discharge summary from a local hospital, dated 02/17/11, with a discharge [DIAGNOSES REDACTED]. Review of Resident #38's facility admission orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. A nurse's note, dated 02/18/11 at 3:00 a.m., revealed the resident remained on antibiotic therapy due to a positive Clostridium difficile culture. A nurse's note, dated 02/18/11 at 12:00 p.m., revealed the resident changed rooms due to positive Clostridium difficile with five (5) days of antibiotic therapy remaining. An interview with Employee #64, on 03/01/11, revealed Resident #38 was placed in isolation "a little before 12:00 p.m. on 02/18/11." Employee #64 also stated the resident returned to the facility on [DATE] with a discharge [DIAGNOSES REDACTED]. Review of the facility policy regarding "Isolation - Categories of Transmission - Based Precautions" revealed contact precautions should be implemented "for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. ... Place the individual in a private room if it is not feasible to contain drainage, excretions, blood or body fluids (e.g. the individual is incontinent on the floor, or wanders and touches others)." Re… | 2015-01-01 |
| 10642 | 10642 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 463 | D | 0 | 1 | GCMN11 | . Based on observation, resident interview, and staff interview, the facility failed to assure residents' rooms were equipped with functioning nurse call systems. Room #123 had a private bathroom that had no string on the call bell system to ring if the occupant of the room fell . This resident took her self to the bathroom and stated she had to reach up and push the button, because there was no string on her call light. This practice was found to be true for one (1) of forty (40) call lights observed. Facility census: 83. Findings include: a) During a tour of the environment on 12/10/10, observation of Room #123 found the private bathroom did not have a string on the call light. Without the string, if the resident were to fall in the bathroom, she would not be able to call for assistance. During an interview with the resident on the morning of 12/10/10, she stated she uses that call bell, but she has to reach up and push the button because there is no string. A registered nurse (RN - Employee #20) was made aware that this call light did not have a string to pull in case of an emergency at 11:30 a.m. 12/10/10. . | 2015-01-01 |
| 10643 | 10643 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 318 | D | 0 | 1 | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident observation, and staff interview, the facility failed ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM, as evidenced by the facility's failure to ensure a resident wore a splint ordered by a physician. One (1) of forty (40) residents on the Stage I sample was affected. Resident identifier: #85. Facility census: 83. Findings include: a) Resident #85 During the Stage I information gathering phase of the survey, staff reported this resident was supposed to wear a splint to her left hand. An observation, during Stage I on 11/30/10 at 3:24 p.m., revealed the resident did not have a splint in place. On 12/18/10 at 4:15 p.m., review of the resident's December 2010 physician's orders [REDACTED]." This order originated on 05/27/10. At 10:40 a.m. on 12/09/10, an observation revealed the resident, again, did not have a splint in place. On 12/09/10 at 10:45 a.m., an interview with a registered nurse (RN - Employee #70) revealed the resident had not worn the splint for approximately one (1) week. Employee #70 stated that staff oftentimes forgot to put the splint on the resident, but if they did, the resident often took it off. Review of the resident's nursing notes revealed no entries stating that staff had attempted to place the splint on the resident's left hand. Further review of the nursing note revealed no entries stating that the resident refused to wear the splint. . | 2015-01-01 |
| 10644 | 10644 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 492 | C | 0 | 1 | GCMN11 | . Based on staff interview and review of individual food service workers' permits, the facility was not in full compliance with local laws regarding food handler's cards. One (1) of ten (10) dietary employees, who was currently working, had an expired food handler's card. This is a local requirement for the county in which the facility is located. This practice had the potential to affect all facility residents who received nourishment from the dietary department. Facility census: 83. Findings include: a) During the survey, each dietary employee's food handler's card was reviewed. No card was available for Employee #111. The dietary manager (Employee #68) was asked to determine if Employee #111 had a current food handler's card. Employee #68 reported that Employee #111's food handler's card was expired and that she was now scheduled to renew the card. . | 2015-01-01 |
| 10645 | 10645 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2011-03-02 | 469 | F | 0 | 1 | GCMN12 | . Based on observation and staff interview, the facility failed to provide an effective pest control program which assured the facility was free of insects. Small black flying insects were observed in hallways and resident rooms. This practice affected two (2) of nineteen (19) sample residents and one (1) resident identified during a random opportunity for observation. The insects were also noted in the hallway of the West Hall. This situation had the potential to affect all facility residents. Resident identifiers: #16, #18, and #3. Facility census: 84. Findings include: a) Resident #3 During a random opportunity for observation, small flying black insects were observed in this resident's room at 9:30 a.m. on 02/23/11. -- b) Resident #16 During a discussion with this resident on 02/23/11 at 10:00 a.m., small flying black insects were observed in this resident's room and around her head. During the conversation, the resident was observed swatting at one (1) of the insects as it continually landed on her face. -- c) Resident #18 During an interview with this resident at 2:30 p.m. on 02/28/11, small flying black insects were observed flying around this resident's room and around her head. The resident swatted at the insects several times during the interview. -- d) At 10:00 a.m. on 03/01/11, small black flying insects were observed on the West hallway. -- e) Just prior to noon on 03/01/11, a discussion was held with the administrator (NHA - Employee #117) regarding the small flying black insects which had been observed during the survey. The NHA confirmed the existence of the insects and referred to them as "gnats". He stated he was aware of the problem and that the exterminator had been there "last Friday". At that time, it was confirmed that the problem was not resolved, as the insects remained in the facility. . | 2015-01-01 |
| 10646 | 10646 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2011-03-02 | 520 | F | 0 | 1 | GCMN12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, resident interview, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to identify quality deficiencies of which it should have been aware, reflective of system failures in the areas of implementation of each resident's written plan of care, accident hazards, food preparation and appearance, dietary sanitation, infection control, and accurate and complete clinical records; and failed to develop and implement appropriate plans of action to correct these quality deficiencies. Each of these deficiencies was a repeat deficiency from previous surveys. This failure has the potential to affect more than an isolated number of residents. Facility census: 84. Findings include: a) Failure to implement each resident's written plan of care: 1. During the initial tour at 3:15 p.m. on 02/22/11, Resident #41 was observed with a very red face and was coughing. Two (2) staff members (Employees #30 and #7) were in the room but did not appear to notice anything happening with the resident. Another resident's family member had to summon the employees to help the resident. The resident had choked on the cheese puffs he was eating. Review of the resident's medical record, on 02/23/11, revealed he was assessed with [REDACTED]. The resident's care plan, dated 02/14/11, contained the following goal: "Resident will have no unidentified s/s (signs and symptoms) of aspiration through the next review 05/14/11." One (1) of the interventions for this goal was: "Monitor for increased incidence of choking, coughing during meals or PO (by mouth) intake, red face, watery eyes, difficulty breathing and notify MD (physician)." On 02/22/11 at 3:15 p.m., this resident was not being monitored while eating, as directed by the care plan. - 2. Review of accident and incident reports, on 02/23/11, revealed Resident #16 spilled coffee on herself on 12/05/10. She was not burned. The incident report also indica… | 2015-01-01 |
| 10647 | 10647 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2009-08-27 | 226 | E | 0 | 1 | W65Z11 | Based on a review of the facility's abuse policy, personnel files, and staff interview, the facility failed to assure their written policies and procedures were designed to prohibit mistreatment abuse, neglect, of residents and misappropriation of resident property. The policies were not clear and did not contain adequate information in the areas of pre-employment screening, training, prevention and identification. It was not clear when this policy was developed or last reviewed. By not developing specific policies to resident prevent abuse / neglect, and misappropriation of property, there was no evidence to reflect the facility was doing everything within their control to prevent such occurrences. This practice has the potential to affect more than an isolated number of residents. Facility census: 59. Findings include: a) Abuse Policy and Procedures Review of the facility's "Abuse Policy and Procedure", on 08/25/09, found this policy to be very brief in length. Further review revealed this policy did not cover in detail, as required, the areas of pre-employment screening, training, prevention and identification, to assure the facility was detecting and preventing resident abuse, neglect, and misappropriation of property occurrences to the extent possible. 1. Pre-employment screening In the area of "screening", the facility's policy did not include how they would screen backgrounds for those who indicated that they had worked, lived, or attended school in another state. It was unclear how the facility would assure these staff members did not have criminal backgrounds in the states of prior employment / residence, etc. that would make them unfit to work in a nursing facility. The area of screening did not specify what thresholds would have to be exceeded (e.g., barrier crimes) that would result in not hiring an applicant to work in the nursing facility . Review of the sampled employees' personnel files, on 08/27/09, revealed the facility had identified two (2) individuals (Employees #22 and #69) who had previous … | 2015-01-01 |
| 10648 | 10648 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2009-08-27 | 221 | D | 0 | 1 | W65Z11 | Based on observation, record review and staff interview, the facility failed to assure side rails were used on residents only after being properly assessed for the necessity of these devices. A staff member was observed putting up full length side rails when Resident #4 was sleeping. It was indicated in the medical record that this resident did not require the use of bed rails on her bed. Applying these devices for a resident when there is no indication for their use was observed for one (1) of fifteen (15) sampled residents. Resident identifier: #4. Facility census: 59. Finding include: a) Resident #4 During an observation of Resident #4 on 08/26/09 at 4:00 p.m., Employee #34 put up bilateral full length side rails on the bed of this resident. Review of the medical record revealed a physician's order for a lateral support when the resident was up in the chair because she had a tendency to lean to the side. However, there was no physician's order to utilize side rails for this resident. Further review of the medical record found a bed safety assessment completed on 12/14/08. This assessment indicated no rails were present on this bed and there was no indication for side rail use for this resident. The director of nursing (DON), when questioned about the use of side rails for this resident on 08/26/09 at 5:00 p.m., confirmed there was no indication for this resident to utilize side rails. . | 2015-01-01 |
| 10649 | 10649 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2009-08-27 | 225 | E | 0 | 1 | W65Z11 | Based on a review of sampled employees' personnel records, policy review, and staff interview, the facility failed to conduct thorough background checks on applicants who had identified previous residences, work histories, and/or educational experiences in other States, in order to uncover information about any past criminal convictions that would indicate unfitness for employment in a nursing facility. This was true for two (2) of five (5) sampled employees, and this practice has the potential to affect more than an isolated number of residents. Employee identifiers: #22 and #69. Facility census: 59. Findings include: a) Employees #22 and #69 On 08/27/09, a review of sampled employees' personnel files found two (2) individuals who had identified on their employment applications having had residences, work experiences, and/or educational experiences in other states. Employee #22 listed on her application for employment having worked in Jackson, Wyoming and Knoxville, Tennessee. There was no evidence the facility checked for criminal backgrounds in these states. Employee #69 was a nursing assistant who was hired on 06/01/09. He indicated on his application for employment having worked in South Boston, Virginia and Washington, DC within the past two (2) years. There was no evidence the facility attempted to check this employee's background for past criminal convictions that would make him unfit to work in the nursing home in states of his prior employment. After an incident involving another employee and Employee #69, on 08/20/09, this employee was suspended. A national background check was then conducted on 08/25/09, and the facility did uncover a criminal background in a state where he was previously employed. This employee was then terminated from this facility. The facility currently conducts fingerprinting of all employees. The fingerprints are sent to the West Virginia State Police for investigation of crimes committed in the State of West Virginia. Review of the facility's policy titled "Abuse Policy and Pro… | 2015-01-01 |
| 10650 | 10650 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2009-08-27 | 248 | E | 0 | 1 | W65Z11 | Based on group interview, family interview, activity calendar, activity staff schedule, and staff interview, the facility failed to provide an activity program designed to meet the assessed needs of the residents. It was identified that this facility had a large number of residents who wandered, with eleven (11) of fifty-nine (59) residents who wandered and would benefit from activity programming late in the evening. There were no planned activities scheduled to decrease this behavior for these residents, which affected the other residents in the facility. Resident identifiers: #10, #14, #18, #25, #28, #29, #31, #33, #40, #57, and #58. This practice has the potential to affect more than an isolated number of residents. Facility census: 59. Findings include: a) Activity Program A review of the monthly activity calendars for August and September 2009 revealed, in each of these months, there were only five (5) evening activities (after dinner) scheduled for the entire month. Each of those five (5) activities that was scheduled in the evening was a church service. There were no other evening activities scheduled. During a confidential interview on 08/26/09, a family member related having frequently observed, when visiting this facility in the evening, a lot of residents who wandered into other residents' rooms and bothered things. The facility had no structured activities going on for these cognitively impaired residents who were active in the evening, and the staff trying to provide care to the other residents often had to interrupt resident care to try to deal with the behaviors of these wandering residents. During a confidential resident group interview held on 08/26/09 at 10:00 a.m., six (6) of six (6) alert and oriented residents interviewed agreed the behaviors of that wandering residents were a problem. They related the facility had been made aware of this and had tried using stop signs on the doors, but this did not work. The group agreed this occurred mostly in the evening and late at night. They all agreed … | 2015-01-01 |
| 10651 | 10651 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2009-08-27 | 356 | C | 0 | 1 | W65Z11 | Based on observation and staff interview, the facility failed to assure the nursing staffing data were current and posted on a daily basis at the beginning of each shift. The posting was not complete for the evening shift at 5:30 p.m. on 08/24/09. This posting was to allow the public visitors to know how many staff members are caring for the residents at any given time. Not posting this information has the potential to affect anyone who would like to review the facility's current staffing. Facility census: 60. Findings include: a) Review of the required posting for the number of caregivers in the facility and the hours worked, at 5:30 p.m. on 08/24/09, revealed the evening shift (3:00 p.m. to 11:00 p.m.) nursing staffing data had not been posted. The nurse (Employee #10) was made aware this posting was blank for the evening shift, and she confirmed it should have been completed at the beginning of the shift. She completed the information at 5:32 p.m. . | 2015-01-01 |
| 10652 | 10652 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2009-08-27 | 428 | D | 0 | 1 | W65Z11 | Based on record review and staff interview, the facility failed to assure a physician reviewed and acted upon the consultant pharmacist's recommendations. The pharmacist identified a resident was receiving two (2) antidepressants and recommended the physician consider discontinuing one (1) of them. There was no evidence to reflect this recommendation was acted upon. This was true for one (1) of fifteen (15) sampled residents. Resident identifier: #5. Facility census: 59. Findings include: a) Resident #5 Medical record review, on 08/25/09 at 3:00 p.m., revealed a consultant pharmacist's report dated 06/13/09, which identified Resident #5 was on two (2) antidepressants. The pharmacist recommended the physician consider the discontinuation of one (1) of these antidepressants. The physician responded to this recommendation with the following, "Antidepressants managed by her longtime psychiatrist." Review of the medical record found no evidence to reflect the psychiatrist was asked to review the pharmacist's recommendation. A request was made, on 08/25/09, for any outstanding psychiatric consults that may not yet have been filed on Resident #5's active record. On 08/25/09 at 2:31 p.m., the psych consult reports, which had been were faxed that day to the facility, were reviewed. The most recent psych consult for this resident occurred on 05/29/09, prior to receipt of the pharmacist's recommendation. On 08/25/09, the director of nursing (DON - Employee #69) was informed of this situation and had no additional information to provide. The facility failed to act on a pharmacy recommendation. . | 2015-01-01 |
| 10653 | 10653 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2009-08-27 | 315 | E | 0 | 1 | W65Z12 | **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 treatment and services to restore as much normal bladder function as possible for two (2) of nine (9) sampled residents. Each of these residents had a decline in bladder continence but were not assessed for the causal factors for the incontinence. In addition, no interventions were established to help restore or maintain bladder function for these individuals. Resident identifiers: #2 and #38. Facility census: 59. Findings include: a) Resident #2 This resident was admitted to the facility on [DATE]. Her initial minimum data set (MDS), with an assessment reference date (ARD) of 04/14/09, indicated the resident was coded "2" - occasionally incontinent of urine. Review of the resident's quarterly MDS, with an ARD of 07/17/09, revealed the resident was coded "4" - incontinent of bladder. The next quarterly MDS also noted the resident was "4" - incontinent. The facility had not assessed the change in the resident's continence, had not evaluated the resident for causal factors, and had not implemented any interventions in effort to restore normal bladder functioning. On 12/03/09, this resident's medical record was reviewed. This review revealed that, on 10/07/09, the facility implemented a three (3) day continence diary, which was completed on 10/09/09. There was no evidence that anything else was done regarding the resident's incontinence. There was no evidence the facility had evaluated the results of the voiding diary, evaluated the resident for causal factors, or implemented any interventions in effort to restore normal bladder functioning. On 12/03/09 at 3:50 p.m., the assistant director of nursing (ADON) stated the resident could usually tell staff when she needed to void. At 4:30 p.m., the ADON confirmed the facility had not completed a thorough evaluation of the resident's incontinence and had not implemented any interventions in effort to res… | 2015-01-01 |
| 10654 | 10654 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2009-08-27 | 492 | D | 0 | 1 | W65Z12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide information regarding hospice to one (1) resident, of nine (9) sampled residents, who had a physician's orders [REDACTED]. This is required by West Virginia Code 16-5C-20. Resident identifier: #17. Facility census: 59. Findings include: a) Resident #17 Medical record review, on 12/03/09, revealed this resident had a physician's orders [REDACTED]. Further review revealed no evidence the resident and family had been provided information regarding hospice. Interview with the social worker, on 12/03/09 at 1:15 p.m., revealed this information had not been provided. | 2015-01-01 |
| 10655 | 10655 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2009-08-27 | 364 | F | 0 | 1 | W65Z11 | Based on observation and resident interview, the facility failed to assure foods were attractive and appetizing as served. This practice has the potential to affect all residents who receive nourishment from the dietary department. Facility census: 59. Findings include: a) During the confidential group interview with the residents at 10:15 a.m. on 08/26/09, the residents in attendance reported the meals were not attractive. One (1) resident even stated, "It almost turns your stomach when you take the lid off." b) Observation of the noon meal, on 08/26/09, revealed a lack of variety in color. The menu was pork chops, potatoes, squash, roll, Snickerdoodles, and milk. All these items were observed to be white to pale yellow. Additionally, there were no garnishes or other means to improve the appearance of the meal. At 1:00 p.m. on 08/26/09, this was discussed with the dietary manager, who confirmed that menu changes and garnishes would enhance the appearance of the meals. c) During observation of the noon meal on 08/27/09, pureed meat and carrots were thin, ran into each other, and spread over the plates, resulting in an unattractive, unappetizing meal for residents who required pureed diets. . | 2015-01-01 |
| 10656 | 10656 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2009-08-27 | 371 | F | 0 | 1 | W65Z11 | Based on observation, food temperature measurement, and staff interview, the facility failed to assure that foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 59. Findings include: a) On 08/27/09 at 11:15 a.m., a dietary employee was observed without a beard protector. Effective hair and beard coverings are required to protect food and food service surfaces from the potential contamination by hairs falling into foods and onto food surfaces. b) At 11:15 a.m. on 08/27/09, bowls, cups, and plate covers were observed to be stacked inside of each other or inverted on trays prior to air drying. These items were observed with trapped moisture, creating a medium for bacterial growth. c) During observations in the kitchen, at noon on 08/27/09, various dietary personnel were observed washing hands, then re-contaminating them by lifting a barrel lid, turning off faucets with bare hands, and/or turning off faucets with towels, then drying hands again with the soiled towels. d) During the initial tour, on 08/24/09, Gatorade was observed in the refrigerator. It was dated 08/06/09. Undated tomato juice was also observed. e) On 08/24/09, a portion of ham was being held for one (1) resident for the evening meal. It was not being held in any type of food temperature holding device. When measured, the ham was 122 degrees Fahrenheit. f) These sanitation infractions were discussed and confirmed with the dietary manager at 1:00 p.m. on 08/26/09 and at 11:15 a.m. on 08/27/09. . | 2015-01-01 |
| 10657 | 10657 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2009-08-27 | 363 | E | 0 | 1 | W65Z11 | Based on review of menus, medical record review, observation, and staff interview, the facility failed to assure that menus were prepared in advance and/or that menus were followed for ten (10) of fourteen (14) residents reviewed. Resident Identifiers: #1, #5, #8, #18, #21, #22, #47, #48, #51, and #59. Facility census: 59 Findings include: a) Resident #1 Medical record review, on 08/26/09, revealed this resident was ordered a 1200 calorie diet. According to the menu, at noon on 08/27/09 this resident was to be provided 1/3 cup (c) of low fat parslied rice and 1/2 c low fat carrot coins. Observation of the noon meal, on 08/27/09, revealed the resident was provided 1/2 c regular parslied rice and 1/2 c regular carrots instead. No low fat products were available to serve at that meal. b) Resident #5 Medical record review, on 08/26/09, revealed this resident was ordered a 4 gram sodium low cholesterol / low fat diet. According to the menu, at noon on 08/27/09 this resident was to be provided 3 oz low sodium pepper steak/gravy, 1/2 c low fat parslied rice and 1/2 c low fat carrot coins. Observation of the noon meal, on 08/27/09, revealed the resident was provided 3 oz regular pepper steak / gravy, 1/2 c regular parslied rice and 1/2 c regular carrots instead. No low fat products were available to serve at that meal. c) Resident #8 Medical record review, on 08/26/09, revealed this resident was ordered a low cholesterol / low fat diet. According to the menu, at noon on 08/27/09 this resident was to be provided 1/2 c low fat parslied rice and 1/2 c low fat carrot coins. Observation of the noon meal, on 08/27/09, revealed the resident was provided 1/2 c regular parslied rice and 1/2 c regular carrots instead. No low fat products were available to serve at that meal. d) Residents #21, #51, and #59 Medical record review, on 08/26/09, revealed each of these resident was ordered a "diabetic" diet. Review of the menu and tray cards revealed there was no plan for this diet. e) Residents #18 and #29 Medical record review, on 08/… | 2015-01-01 |
| 10658 | 10658 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2009-08-27 | 367 | E | 0 | 1 | W65Z11 | Based on medical record review, observation, and staff interview, the facility failed to assure that each resident received foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician. This practice affected seven (7) of fourteen (14) residents reviewed. Resident identifiers: #12, #21, #30, #35, #47, #51, and #59. Facility census: 59. Findings include: a) Resident #12 Medical record review, on 08/26/09, revealed this resident was ordered a low cholesterol / no added salt diet. Review of the tray card revealed only a "ground" diet. b) Residents #21, #51, and #59 Medical record review, on 08/26/09, revealed each of these residents was ordered a "diabetic" diet. Review of the menu and tray card revealed there was no plan for this diet. c) Resident #30 Medical record review, on 08/26/09, revealed this resident was ordered an 1800 ADA/cardiac diet. Review of the tray card revealed an 1800 ADA NAS diet. Additionally, the menu contained no plan for a "cardiac" diet. d) Resident #35 Medical record review, on 08/26/09, revealed this resident was ordered a low cholesterol / low fat diet. Review of the tray card revealed a NAS regular diet. e) Resident # 47 Medical record review, on 08/26/09, revealed this resident was ordered a vegetarian low fat / low cholesterol NCS diet. Review of the menu and resident's tray card revealed no plan for this diet. . | 2015-01-01 |
| 10659 | 10659 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2009-08-27 | 325 | D | 0 | 1 | W65Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of menus, observation of tray cards, and staff interview, the facility failed to recognize, evaluate, and address the nutritional needs of one (1) of fifteen (15) sampled residents. In addition, the facility failed to provide a therapeutic diet that takes into account the resident's clinical condition and preferences. This resident was ordered a vegetarian diet, for which there was no assessment (including nutritionally significant laboratory values) or plan to assure the provision of adequate protein and nutrients for this resident. Resident identifier: #47. Facility census: 59. Findings include: a) Resident #47 Medical record review, on 08/26/09, revealed this resident had a physician's orders [REDACTED]. Review of the menu and the resident's tray card revealed no plan to provide a vegetarian diet which suppled adequate protein and other nutrients. Observation of the noon meal, on 08/27/09, revealed the resident was provided rice, potatoes, green beans, tomato juice, and no milk. Inquiry of dietary staff revealed they provided the resident what was on the menu, excluding meat, plus another vegetable. Medical record review revealed there was no evaluation of the resident's protein and nutrient needs and no plan to assure adequate protein and nutrient intake. For example, there were no laboratory values for [MEDICATION NAME] or pre-[MEDICATION NAME] to help identify impaired nutrition. . | 2015-01-01 |
| 10660 | 10660 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2009-08-27 | 318 | D | 0 | 1 | W65Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to assure Resident #4, who had severe contractures to both of her hands, received care and services to prevent further contractures. The facility also failed to implement a physician's orders [REDACTED]. This practice was observed for one (1) of fifteen (15) residents. Resident identifier: #4. Facility census: 59. Findings include: a) Resident #4 Observation, on initial tour on 08/24/09 at 5:00 p.m., found this resident sitting in the hallway in a geri-chair with lateral supports on her chair for positioning. She had severe contractures to both hands and did not have any type of devices in her hands for the contractures. This was observed again in the mornings and afternoons of 08/25/09 and 08/26/09. Review of the medical record for Resident #4 revealed occupational therapy had treated this resident in March 2009 for splinting / palm protectors of her hands. It was then recorded that education was given to the nursing assistants, and the resident was discharged to the services of a restorative nursing program (RNP) for splinting on 03/04/09. Review of the resident's care plan found an intervention related to the hand contractures had been discontinued on 06/17/09; this discontinued intervention stated, "RNP to wash hands / place cones per order to avoid pressure." After this RNP intervention was discontinued, there was no further evidence this resident's severe contractures were addressed on the comprehensive care plan. This resident was observed multiple times throughout the survey, at various times of the day, with no cones, palm protectors, braces, or any other type of interventions for her hand contractures. She was observed each day from 08/24/09 to 08/26/09, throughout the day and on both day and evening shifts. There was nothing observed in her hands for treating the contractures. It could not be verified through reviewing the medical record or the nursing as… | 2015-01-01 |
| 10661 | 10661 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2011-09-09 | 246 | D | 1 | 0 | 6V5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, medical record review, and staff interview, the facility failed to evaluate and individualize the call bell for one (1) of eight (8) sampled residents. The resident, whose only movement was in the left hand and fingers, could not reach for or operate the push button style call bell. Resident identifier: #48. Facility census: 77. Findings include: a) Resident #48 On 09/08/11 at 12:55 p.m., this resident was observed lying in bed with the push style call bell clipped to the sheet below the resident's left side. When asked if the resident could use the call bell, the resident responded, "Yes." When asked to demonstrate the use of the call bell, the resident moved the contracted fingers and thumb of his left hand as if to press the call bell, but the call bell was not in his hand. He did not recognize the call bell was not in his hand. When it was explained that the call bell was not in his hand, the resident stated he once had a call bell that he could use by moving his head, but he did not know what happened to it. When asked what he did if he needed help, he stated, "I yell." A review of the medical record revealed this [AGE] year old male had [DIAGNOSES REDACTED]. The director of nursing (DON - Employee #38) and the assistant directors of nursing (ADONs - Employees #40 and #41) were informed of Resident #48's inability to use his call bell at 2:15 p.m. on 09/08/11. Employee #41 stated she was not aware the resident could not use the call bell and that he yelled if he needed help. At 2:30 p.m. on 09/08/11, observations were made in the resident's room with Employees #40 and #41. Employee #41 placed the call bell in the resident's hand and asked the resident to activate the call bell. The resident was not able to independently hold and activate the call bell after numerous attempts. At that time, the resident was asked what he did to get help and stated, "I yell." Employees #40 and #41 discussed the p… | 2015-01-01 |
| 10662 | 10662 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2011-09-09 | 279 | D | 1 | 0 | 6V5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, resident interview, and staff interview, the facility failed to develop and/or revise the comprehensive care plans for two (2) of eight (8) sampled residents. Resident #28 had a specific indicator regarding when she needed assistance in toileting, which was not incorporated into her care plan. Resident #48 was unable to activate the type of call light he was provided. Additionally, this resident required specific placement of a call light to afford the resident the ability to activate the device. Neither of these specific needs were a part of this resident's care plan. Resident identifiers: #28 and #48. Facility census: 77. Findings include: a) Resident #28 Review of this resident's medical record, on 09/08/11, revealed this confused resident was usually continent of urine. According to her care plan dated 08/04/11, the resident was "...occasionally incontinent of urine r/t (related to) dementia, impaired mobility, and impaired cognition." An interview was conducted with one (1) of the facility's assistant directors of nursing (ADONs - Employee #40) at 1:00 p.m. on 09/08/11. In discussing this resident's incontinence, Employee #40 revealed the resident "gets fidgety when she has to go to the bathroom." Further review of the resident's care plan noted the goal for the resident's incontinence was: "Resident will demonstrate improved urinary elimination control as evidenced by experiencing less than daily episodes of urinary incontinence." This goal was initiated on 08/04/11. The interventions for the goal were: "Complete a voiding diary and evaluate for patterns of incontinence at appropriate intervals. Encourage resident to consume fluids during meals. Complete an incontinence assessment at intervals according to policy and procedure. Observe for signs and symptoms of infection and report to physician if noted. Observe skin daily with ADL (activities of daily living) care and notify nurse of abnor… | 2015-01-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );