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106 rows where "filedate" is on date 2015-07-01
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9993 | 9993 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2012-03-23 | 441 | E | 1 | 0 | 6VB911 | . Based on observation, staff interview, and policy review, the facility failed to dispense ice water to residents in a sanitary manner and according to facility policy. This had the potential to spread infectious microorganisms to any resident who received ice water in the manner it was observed being dispensed. Facility census: 98. Findings include: a) Observation of the ice water pass for the 200 Hall and 100 Hall, on 03/22/12, between 3:30 p.m. to 3:50 p.m., found Employee #66 entered resident rooms and brought out a dozen residents' water pitchers and placed them on a wheeled cart. Observation revealed that Employee #66 did not wash or sanitize her hands before entering any of the rooms to pick up the used pitchers. Further observation revealed that Employee #66 wheeled the cart with the used water pitchers to the kitchenette directly behind the nurses' station. She opened and removed the lids two (2) at a time prior to emptying the contents of each pitcher down the drain. She then placed the lids on top of the pitchers, but did not close them. Next, she wheeled the cart to the ice machine, removed lids two (2) at a time and laid those lids upside down on the cart. She then filled the pitchers two (2) at a time with fresh ice and water. Many of the lids had white plastic straws attached, and when turned upside down on the cart, the straws came in direct contact with the top of the cart. The lids, and lids with straws, were reapplied to the pitchers after two (2) pitchers at a time were filled. Observation revealed that Employee #66 did not wash or sanitize her hands at any time during this procedure. She then returned the pitchers to the residents, again with no handwashing or sanitizing. When the lids with straws were inverted and laid on the cart, the straws came in contact with the area where the bottoms of the pitchers had been and other straws had lain. This created a potential to contaminate the straws with organisms from other residents in addition to organisms from the bottoms of the pitchers. During… | 2015-07-01 |
| 9994 | 9994 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2012-03-16 | 279 | D | 1 | 0 | NOP711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, and review of facility documents, the facility failed to develop a comprehensive care plan for monitoring, assessment, and treatment of [REDACTED].#50. One (1) of five (5) sampled residents was affected. Resident identifier: #50. Facility census: 89. Findings include: a) Resident #50 During random observations of the resident environment, on 03/14/12 at 1:05 p.m., Resident #50 was observed while seated in a wheelchair outside her room. It was noted she had a wound covered by a thick scab on her lower right extremity. Review of facility documents found the resident sustained [REDACTED]. She caught her right leg on her wheelchair causing the skin tear. Medical record review found no orders for treatment of [REDACTED]. A nursing note, written by a registered nurse, Employee #56, on 02/06/12, stated. "...will continue to monitor." Review of the medical record revealed no evidence nursing staff monitored or assessed the skin tear. A nursing entry, dated 02/10/12 at 8:22 p.m., noted the physician had visited the resident and ordered Keflex 500 mg three (3) times a day for ten (10) days for a [DIAGNOSES REDACTED]. Although the wound was sustained more than a month prior to the observation on 03/14/12, the resident's current care plan contained no information about the skin tear or [MEDICAL CONDITION]. There were no goals or interventions for monitoring, assessment, or treatments to promote wound healing for this resident. . | 2015-07-01 |
| 9995 | 9995 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2012-03-16 | 309 | D | 1 | 0 | NOP711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, review of facility documents, and staff interview, the facility failed to ensure one (1) of five (5) sampled residents received care and services to attain the highest practicable physical well-being. The resident sustained [REDACTED]. Nursing staff initially placed steri strips on the wound; however, there was no evidence the skin tear was assessed or monitored by nursing at that time or later. Additionally, there was no evidence treatment was provided to promote healing, as the treatment nurse was not made aware of the skin tear until 03/14/12. Resident identifier: #50. Facility census: 89. Findings include: a) Resident #50 During random observations, on 03/14/12 at 1:05 p.m., Resident #50 was observed while seated in a wheelchair outside her room. It was noted she had a wound covered by a thick scab on her lower right extremity. Review of the medical record found no orders for treatment of [REDACTED]. According to documentation, the resident sustained [REDACTED]. She caught her right leg on her wheelchair causing the skin tear. Further review found a registered nurse, Employee #56, documented applying steri strips to the wound. Under "Recommendations and interventions Post Fall," Employee #56 documented, "Area cleansed and dressed and treatment orders written." The document contained no description or measurements of the skin tear. Review of the medical record, on 03/14/12, found no treatment orders for the resident's skin tear. A nursing note, written by Employee #56 on 02/06/12, stated the responsible party was notified of new orders "...will continue to monitor." Review of the medical record revealed no evidence nursing staff monitored or assessed the skin tear. A nursing entry, dated 02/10/12 at 8:22 p.m., noted the physician had visited the resident. The note described the skin tear on the right lower extremity as "red and warm to touch." The physician ordered Keflex 500 mg three (3) time… | 2015-07-01 |
| 9996 | 9996 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2012-03-16 | 323 | E | 1 | 0 | NOP711 | . Based on observation, staff interview, and review of crash cart contents, the facility failed to ensure the resident environment remained as free of accident hazards as was possible. A nursing staff member left a stocked medication cart unlocked and unsupervised in the resident hallway. Additionally, staff failed to ensure emergency oxygen was maintained on the crash cart utilized in medical emergencies. These practices had the potential to affect more than an isolated number of residents currently residing in the facility. Facility census: 89. Findings include: a) During the initial tour of the facility, on 03/14/12 at 10:30 a.m., with the assistant director of nursing (ADON), Employee #61, a medication cart was noted in the resident hallway. Further observation noted the medication cart was not locked. The stocked medication drawers on the cart opened freely. There were no nursing staff members observed in the hallway. Observation revealed a registered nurse (RN), Employee #38, approached the cart carrying a small carton of ice cream. She relayed she was the nurse responsible for the cart. Employee #38 stated she went to the nutrition pantry to get ice cream for a resident and forgot to lock her cart. Employee #61 agreed the medication cart was not within sight of Employee #38 while she was in the nutrition pantry. b) An inventory of the contents of the crash cart was conducted at 3:30 p.m. on 03/14/12. The ADON, Employee #61 assisted in the inventory. The crash cart did not contain a bottle of emergency oxygen, a regulator, or a key with which to turn on the oxygen. Employee #61 stated the emergency oxygen was utilized from the cart during a medical emergency involving Resident #3 at approximately 8:30 a.m. that morning. She stated the oxygen had not been replaced. It was determined staff would have to exit the building, cross the parking lot, work a combination lock to a storage building, retrieve a bottle of oxygen, relock the door and reenter the building to obtain oxygen during a medical emergency should… | 2015-07-01 |
| 9997 | 9997 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2012-03-16 | 441 | E | 1 | 0 | NOP711 | . Based on review of infection control records and observations, the facility failed to maintain an infection control program designed to provide a safe, sanitary environment to help prevent the development and transmission of disease and infection. The facility failed to maintain the facility crash cart in a sanitary manner; failed to administer eye drops utilizing aseptic technique for one (1) of seven (7) sampled residents; and failed to ensure ice was passed to residents in a manner which prevented cross contamination. These practices had the potential to affect more than an isolated number of residents in the facility. Resident identifier: #19. Facility census: 89. Findings include: a) On 03/14/12, a review of infection control records found the facility was under quarantine due to an outbreak of diarrhea in the resident population. Communal dining, activities, and therapy were suspended to help curtail the spread of the disease. Random observations, conducted with the assistant director of nursing (ADON), Employee #61, noted nursing assistants (NAs) passing ice to residents at 11:15 a.m. on 03/14/12. The NAs entered each resident's room, removed the water pitcher, carried it to the ice chest in the hallway, held the pitcher above the ice, and scooped ice into the pitcher. This practice allowed any contaminates present on the outside of the pitcher to fall into the ice chest and potentially spread the disease for which the facility was under quarantine. b) Resident #19 During random observations of the resident environment, on 03/14/12 at 11:15 a.m., with the ADON, Employee #61, in attendance, Employee #36 (a nurse), removed a box of eye drops from her medication cart for administration to Resident #19. Employee #36 entered the resident's room and put on gloves without first washing or sanitizing her hands. With gloved hands, she touched the outside box of the eye drops and touched the tissue box on the resident's nightstand. She then touched the resident's upper and lower eyelids with her contaminated glove… | 2015-07-01 |
| 9998 | 9998 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2012-03-16 | 514 | D | 1 | 0 | NOP711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, the facility failed to ensure the medical record for one (1) of five (5) sampled residents was accurately documented. Nursing personnel documented the resident received antibiotic treatment on three (3) days after the course of the antibiotic was completed. Resident identifier: #50. Facility census: 89. Findings include: a) Resident #50 Review of physician orders [REDACTED]. The Medication Administration Record [REDACTED]. Further review of the medical record found nursing personnel continued to document the resident received Keflex 500 mg after its completion on 02/20/12. Documentation on 02/21/12, 02/24/12, and 02/27/12 noted the resident continued on antibiotic treatment for [REDACTED]. . | 2015-07-01 |
| 9999 | 9999 | WORTHINGTON NURSING AND REHABILITATION CENTER, LLC | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2010-03-11 | 315 | E | 0 | 1 | XVZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility failed to ensure precautionary measures were taken and causative factors were investigated when four (4) of eighteen (18) sampled residents with urinary tract infections (UTIs) cultured positive for Escherichia coli (E. coli), a bacterium associated with fecal contamination due to poor incontinence care and aseptic practices by staff. Resident #78 was incontinent of bowel and bladder and required extensive physical assistance with transfer, toilet use, and personal hygiene. This resident had a UTI on 02/27/10, and a laboratory report showed the infectious organism to be E. coli. This resident required treatment with [MEDICATION NAME] IM (intramuscular injection) every day for three (3) days. Resident #55 was incontinent of bowel and bladder and required extensive physical assistance with transfer, toilet use, and personal hygiene. This resident had a UTI on 01/04/10, and a laboratory report showed the infectious organism to be E. coli. Residents #70 and #81, who were also incontinent of bowel and bladder and required staff assistance with toileting, developed UTIs with E. coli cultured. Residents #70 and #81 also required antibiotic therapy. Residents #78, #55, #70, and #81. Facility census: 101. Findings include: a) Resident #78 Record review revealed this [AGE] year old female had [DIAGNOSES REDACTED]. Medical record review, on 03/10/10, revealed a physician's orders [REDACTED]. Review of lab reports revealed the antibiotic therapy was to treat a UTI, and the infectious organism was E. coli, a bacterium associated with fecal contamination due to poor incontinence care and aseptic practices by staff. Interview with the director of nursing (DON - Employee #42), on 03/10/10 at 11:30 a.m., confirmed the resident had a UTI with E. coli for which she received [MEDICATION NAME] injections. b) Resident #55 Record review revealed this [AGE] year old female, with [DIAGNO… | 2015-07-01 |
| 10000 | 10000 | WORTHINGTON NURSING AND REHABILITATION CENTER, LLC | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2010-03-11 | 371 | F | 0 | 1 | XVZI11 | . Based on observation and staff interview, the facility failed to ensure store, prepare, distribute, and/or serve food under sanitary conditions. Open containers of milk in the kitchen and in one(1) of the nutrition pantries on the nursing unit were not labeled with dates when opened, and a skillet ready for use to prepare food was not easily cleanable. These issues have the potential to affect all residents who consume foods by oral means, as all food is distributed from this central location. Facility census: 101. Findings include: a) During the initial tour of the dietary department on 03/08/10 at 1:45 p.m., observation found: 1. A large skillet was available for use by the dietary staff which contained a large amount of black build-up on the pan. This did not make the skillet easily cleanable and, therefore, it was not sanitary to use when cooking. 2. A container of white milk was found in the reach-in refrigerator without a date to indicate when it had been opened. Items are to be marked when opened, so the staff can monitor how long the item has been opened and if it is still safe for consumption. 3. The dietary manager was present for these two (2) observations, and they were brought to her attention at the time. b) During a tour of the nutrition pantries on the nursing units on 03/11/10 at 9:03 a.m., observation found a container of chocolate milk in the refrigerator on the West wing without the date to indicate when it was opened. This was brought to the attention of the assistant director of nursing at the time. . | 2015-07-01 |
| 10001 | 10001 | WORTHINGTON NURSING AND REHABILITATION CENTER, LLC | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2010-03-11 | 253 | E | 0 | 1 | XVZI11 | . Based on observation and staff interview, facility staff did not maintain sanitary conditions in the East wing central shower room and in an individual resident toilet area. This was evident for one (1) of two (2) shower areas and for one (1) of fourteen (14) toilet areas serving sampled resident rooms. Facility census: 101 Findings include: a) Observations of the resident environment, on the morning of 03/11/10, discovered a shower chair in the East wing central shower room that was visibly soiled with feces. This was discussed with the director of nursing (DON) shortly after the observation. b) During the same observation period, individual resident rooms were inspected at which time a soiled riser seat was noted in the rest room of Room #25 located on the East wing. This was brought to the DON's attention shortly after oon on 03/11/10. . | 2015-07-01 |
| 10002 | 10002 | WORTHINGTON NURSING AND REHABILITATION CENTER, LLC | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2010-03-11 | 441 | D | 0 | 1 | XVZI11 | . Based on observation, staff interview, and policy review, the facility failed to ensure a sanitary environment during a dressing change to help prevent the development and transmission of disease and infection. This was evident for one (1) of one (1) dressing change observations. Resident identifier: #77. Facility census: 101. Findings include: a) Resident #77 Observation of a dressing change for Resident #77, on 03/09/10 at 11:50 a.m., revealed the treatment nurse (Employee #112), when dropping the sterile 4 x 4 sponges onto a clean surface, inadvertently touched the corner edge of one (1) sponge against the plastic bin which held supplies. Although this sponge was used as a covering and not as packing and did not directly touch the wound, a clean surface should be provided for all dressing materials while preparing to perform a dressing change. Observation during the same dressing change revealed the nurse aide (Employee #6) used a gloved hand, on two (2) occasions, to wipe body fluids from the resident, then proceeded to use the same gloved hand to open the resident's bedside stand and obtain supplies (wipes). A finger of the same gloved hand was also noted to close a box of wipes before opening the stand to return it. These findings were reported to the treatment nurse, who said she was unaware the corner of a sponge had touched anything but her prepared surface. She said she would speak to Employee #6 about touching clean surfaces with unclean gloves. Interview with the infection control nurse and director of nursing revealed evidence of inservicing on proper handwashing and changing of gloves in the fall of 2009 during an annual inservice on those topics, but they would follow-up on this with spot checks and individual inservice as needed. | 2015-07-01 |
| 10003 | 10003 | WORTHINGTON NURSING AND REHABILITATION CENTER, LLC | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2010-03-11 | 279 | E | 0 | 1 | XVZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the facility's incident/accident reports, and staff interview, the facility failed to develop a comprehensive care plan that described the services to be furnished to four (4) of eighteen (18) sampled residents, to prevent elopement from the facility, address incontinence, and prevent urinary tract infections (UTIs). Resident #98 eloped from the facility on 12/27/09, at 9:10 a.m., while nursing staff was busy rendering morning care in resident rooms; staff did not hear the Wanderguard alarm. Review of the resident's comprehensive care plan (dated 02/15/10) found the problem of elopement was not adequately addressed to include specific interventions to be furnished during periods in the mornings and evening when nursing staff would be busy in resident rooms and unable to hear the Wanderguard alarms. Residents #55, #70, and #81 were incontinent of bowel and bladder and required staff assistance for transfers, toilet use, and personal hygiene. These residents developed UTIs, and the infectious organism cultured for each was Escherichia coli (E. coli), a bacterium associated with fecal contamination due to poor incontinence care and aseptic practices by staff. The residents' comprehensive care plans failed to describe the care and services to be provided for the prevention of recurrent UTIs. Facility census: 101. Findings include: a) Resident #98 Observation, during the initial tour of the facility on 03/08/10 at 1:55 p.m., found this resident, who was in a wheelchair with a lap tray, had traveled to the back door of the West wing (which opened to the parking lot), opened the door, and was attempting to get out. The Wanderguard alarm was ringing, and staff ran to assist the resident back in the door. Further observations of this resident, on 03/08/10, found the resident engaging in exit-seeking behavior which required frequent redirection by staff. Review of facility's incident / accident reports, on 03… | 2015-07-01 |
| 10004 | 10004 | WORTHINGTON NURSING AND REHABILITATION CENTER, LLC | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2010-03-11 | 329 | D | 0 | 1 | XVZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the drug regimen for one (1) of eighteen (18) sampled residents was free of unnecessary drugs. Resident #78 was receiving [MEDICATION NAME] for an excessive duration, in the presence of adverse consequences, and without adequate monitoring. Medical record review revealed a gradual dose reduction (GDR), as required for drugs in this category, had not been attempted at least twice within one (1) year, in an effort to discontinue its use. Additionally, there was no evidence of monitoring and/or documentation to support the benefits of the medication outweigh the risks associated with its use either by the attending physician or the psychiatric consult. Facility census: 101. Findings include: a) Resident #78 Medical record review, on 03/10/10, disclosed this [AGE] year old female resident had medical [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. According to OBRA's "Unnecessary Drugs in the Elderly", [MEDICATION NAME] is a sedative drug with strong [MEDICATION NAME] properties with side effects of dehydration, causing dry mouth, confusion, decreased urine output, dry skin, poor skin turgor and constipation, all of which this resident already has and is being monitored for, in addition to problems of impaired nutrition, weight loss, and dehydration. Review of the resident's current comprehensive care plan found the [MEDICATION NAME] was given for behaviors of yelling, screaming, crying, tearfulness, increased anxiety, refusal of necessary hygiene, and refusal to take medications at times. Review of physician's progress notes and a review of the progress note from the psychiatric consult, dated 01/06/10, found no documentation to support the benefits of the medication outweigh the risks associated with its use either by the attending physician or the psychiatric Review of the pharmacist's recommendations to the physician revealed the pharmacist had … | 2015-07-01 |
| 10005 | 10005 | WORTHINGTON NURSING AND REHABILITATION CENTER, LLC | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2010-03-11 | 328 | D | 0 | 1 | XVZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and record review, the facility failed to assure all residents received respiratory treatment and care as ordered by the physician. This was evident for three (3) residents in the dining room who were observed using portable oxygen while eating their meals, each of whom was wearing a nasal cannula connected to an empty oxygen tank. This had the potential to negatively affect the health and well-being of one (10 of eighteen (18) sampled residents and two (2) of six (6) randomly observed residents in the dining room. Resident identifiers: #51, #75, and #27. Facility census: 101. Findings include: a) Resident #51 Observation of Resident #51, on 03/09/10 at 12:30 p.m., found her sitting in the dining room eating lunch while wearing a nasal cannula connected to a portable oxygen tank. Observation of the oxygen tank revealed the needle was pointing all the way on the left in the red portion denoting an empty tank. This finding was reported to the administrator moments later (as she was helping to pass trays) and then relayed to a nurse (Employee #109) who said she would take care of it right away, which she did. Record review revealed physician's orders [REDACTED]. Documentation on the vital sign flow sheet indicated the most recent oxygen saturation level (O2 sat) was at 98% (with oxygen applied) on 03/08/10, but there were blank spaces where O2 sats should have been recorded (but were not) on 03/09/10 and 03/10/10. Review of the nursing notes, from 03/07/10 through 03/11/10, document the resident having used oxygen each day. During an interview with Resident #51 on 03/10/10 at 3:15 p.m., she stated she wears oxygen continuously around the clock each day, removing it only for showers; at bed-time, she wears a Bi-PAP. b) Resident #75 Observation of Resident #75, on 03/09/10 at 12:30 p.m., found her sitting in the dining room eating lunch while wearing a nasal cannula connected to a portable oxygen tank. Obse… | 2015-07-01 |
| 10006 | 10006 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | PO BOX 410 | BLUEFIELD | WV | 24701 | 2010-03-04 | 241 | D | 0 | 1 | 6XNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to ensure the dignity of two (2) residents were preserved and honored, by staff mocking the behavior of Resident #20, and staff labeling a [MEDICATION NAME] medication patch with the date after affixing it to the body of Resident #15. Resident identifiers: #20 and #15. Facility census: 53. Findings include: a) Resident #20 On 03/03/10 at approximately 2:00 p.m., while waiting for the resident group meeting to commence in the dining room on the facility second floor, observation found Employee #6 (a nurse aide) going down the hallway mocking Resident #20's verbal behaviors. Resident #20 had called out "help me, help me, somebody help me" over and over again for a period of time. This behavior occurred frequently with Resident #20. On 03/03/10 at approximately 4:00 p.m., the administrator became aware of the above incident. She reported she would talk to the employee about his behavior. On 03/04/10 at approximately 8:00 a.m., the administrator related she had spoken with the employee regarding his inappropriate actions. The employee told the administrator he experienced a rough day on 03/03/10 and the comments he made were regarding his own frustrations. The administrator agreed the employee needed to refrain from expressing vocal frustrations where other residents or family members can overhear them. b) Resident #15 Review of the medical record found Resident #15 received a [MEDICATION NAME] 0.4 mg each morning. During observations of the medication pass on 03/03/10 at 9:45 a.m., the nurse (Employee #18) applied the [MEDICATION NAME] on the resident's left upper chest. She then removed a marker from her uniform pocket and wrote on the patch while it was affixed to the resident. . | 2015-07-01 |
| 10007 | 10007 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | PO BOX 410 | BLUEFIELD | WV | 24701 | 2010-03-04 | 250 | D | 0 | 1 | 6XNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to ensure one (1) of eleven (11) residents received medically-related social services to assist with acquiring clothing suitable for daily wear. Resident identifier: #21. Facility census: 53. Findings include: a) Resident #21 On 03/01/10 and on 03/02/10, observations of Resident #21 found him wearing hospital gowns and bottoms. The resident was so dressed as he wheeled around the hallways in his wheelchair and attended therapy services. The medical record revealed the resident came to the facility on [DATE]. Employee #36 (a licensed practical nurse) said she did not think the resident had any clothes and that, due to his height, the facility probably did not have any clothes to fit him. Upon interview, the social worker indicated the resident was placed with the facility as part of an adult protective service (APS) intervention, and an APS worker had came to the facility to complete admission process. She said the APS worker acknowledged the resident needed clothing but, thus far, she had not brought any clothes for Resident #21. Upon medical record review, the social work notes did not contain any documentation of communication with the APS worker regarding the resident's clothing situation. On 03/02/10 at approximately 10:00 a.m., during an interview with the social worker, she agreed she had not attempted to locate any clothing for the resident and also confirmed the APS worker had not brought any clothing to the facility. At this time, she placed a call to the APS worker and left a message regarding Resident #21's need for clothing. Subsequent record review revealed a note, entered by the social worker on 03/02/10, stating, "SW (social worker) left message for DHHR (department of health and human resources) worker regarding need for clothes. RN (registered nurse) (name) called and made contact with her. (APS worker's name) states she would go to Salvation Army to get clothes.… | 2015-07-01 |
| 10008 | 10008 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | PO BOX 410 | BLUEFIELD | WV | 24701 | 2010-03-04 | 322 | D | 0 | 1 | 6XNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, and facility policy review, the facility failed to assure licensed nurses administered medications via gastrostomy tube in a manner to avoid potential complications for one (1) of seven (7) residents identified as having a gastrostomy tube ([DEVICE]). Resident identifier: #15. Facility census: 53. Findings include: a) Resident #15 Observation found a licensed nurse (Employee #18) administering medications to Resident #15 via [DEVICE]) at 9:45 a.m. on 03/03/10. She attempted to flush the resident's [DEVICE] utilizing a 60 cc syringe filled with approximately 30 cc of water. When the water did not drain into the tube, the nurse placed the plunger into the 60 cc syringe and exerted pressure to force the water through the tube. The nurse then administered each medication separately with flushes of water between administrations. The resident received a total of eleven (11) medications - [MEDICATION NAME] 5 mg, [MEDICATION NAME] 150 mg, Aspirin 325 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 0.25 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 60 cc, Folic Acid 1 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 75 mg, and Vitamin B6 100 mg. Employee #18 allowed the [DEVICE] to empty between each administration of medications, flushes, and fluids. This procedure allowed air to enter the resident's stomach each time the nurse allowed the tube to drain. Resident #15 belched / hiccupped during the administration of medications via his [DEVICE]. When asked if he noticed any problems when he got his medications, the resident stated, "It always makes me gassy, and I get hiccups when I get my medicine." Employee #95 provided the facility's policy related to [DEVICE] medication administration at 10:45 a.m. on 03/03/10. Review of the policy entitled "Administering Medications through (sic) a Gastrostomy Tube" (revised September 2003) revealed, in the section entitled "Steps in the Procedure", the following: "21. … | 2015-07-01 |
| 10009 | 10009 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | PO BOX 410 | BLUEFIELD | WV | 24701 | 2010-03-04 | 371 | F | 0 | 1 | 6XNG11 | . Based on observation and staff interview, the facility failed to prepare, distribute, and serve food under sanitary conditions. This deficient practice had the potential to affect all residents receiving an oral diet. Facility census: 53. Findings include: a) Observations of the noon meal service in the dietary department, on 02/02/10 at approximately 12:15 p.m., found a dietary staff member's hair was not secured in a manner to prevent unintentional contact with the food while serving from the steam table (Employee #22). The staff member's hair was not secured in the back where tendrils and curls were noted to be loose upon her neck. b) Random observation of the ice machine adjacent to the dietary department, on 03/04/10 at 10:40 a.m., found a large plastic ice scoop lying on top of the ice with the handle in direct contact with the ice. . | 2015-07-01 |
| 10010 | 10010 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | PO BOX 410 | BLUEFIELD | WV | 24701 | 2010-03-04 | 425 | D | 0 | 1 | 6XNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide pharmaceutical services to assure one (1) of eleven (11) residents received ordered medications in a timely manner. Resident identifier: #40. Facility census: 53. Findings include: a) Resident #40 Review of Resident #40's medical record found a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Documentation on the MAR indicated [REDACTED]. An interview with the director of nursing (DON - Employee #96), on 03/03/10 at 12:00 p.m., revealed the facility's back-up pharmacy closes at 5:00 p.m., and orders placed after 3:00 p.m. to their contracted pharmacy are not delivered until approximately 3:00 a.m. She also reported Doxycycline was not among the drugs kept in the emergency drug box. . | 2015-07-01 |
| 10011 | 10011 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | PO BOX 410 | BLUEFIELD | WV | 24701 | 2010-03-04 | 502 | D | 0 | 1 | 6XNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide or obtain laboratory services to meet the needs of one (1) of eleven (11) sampled residents. Resident identifier: #40. Facility census: 53. Findings include: a) Resident #40 Review of Resident #40's medical record found a physician's orders [REDACTED]. Further review found no evidence the resident had been provided with this laboratory service. A review of the resident's bowel history found staff had an opportunity to provide the serial test for blood in the resident's bowel movements on 02/01/10 during the 7:00 a.m. to 3:00 p.m. shift, on 02/02/10 on the 7:00 a.m. to 3:00 p.m. shift, and on the night and morning shifts on 02/04/10. An interview with the director of nursing (DON - Employee #96) confirmed the facility did not provide or obtain this ordered laboratory test. . | 2015-07-01 |
| 10012 | 10012 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | PO BOX 410 | BLUEFIELD | WV | 24701 | 2010-03-04 | 312 | E | 0 | 1 | 6XNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on confidential resident group interview, observation, review of resident bathing information, and staff interview, the facility failed to assure twelve (12) of fifty-three (53) facility residents, with physician's orders [REDACTED]. Resident identifiers: #37, #14, #15, #9, #18, #20, #23, #27, #38, #44, #47, and #50. Facility census: 53. Findings include: a) Confidential Resident Group Meeting (resident identifiers withheld to maintain resident privacy) During the confidential resident group meeting held on the afternoon of 03/03/10, residents stated they wanted to take showers. When asked why they couldn't take showers, they stated the shower bed they had to use for taking showers was broken. b) Resident #37 Following the complaints concerning the lack of showering equipment, Resident #37 was observed in his wheelchair in the resident hallway. Observation found the resident had white scaly patches crusted in and around his ears and hairline. Flakes of skin were noted to be hanging from his eyebrows and the tufts of hair growing from his ears. Review of the medical record found the resident was ordered specialized shampoo and lotions to be applied on shower days. Staff members present in the hallway noted the surveyor looking at the resident. An observation the following morning, at 7:30 a.m., noted the resident's dried, crusty, scaly patches were no longer in evidence. c) The unit charge nurse (Employee #65), was interviewed at 4:45 p.m. on 03/03/10. When asked why the residents did not have a shower bed, she stated it needed a new part. When asked which residents this would affect, she stated all residents who used a mechanical lift for transfers would also need to use the shower bed for showers. On 03/04/10 at 8:00 a.m., nursing assistant Employee #62 was interviewed. She stated that staff had been unable to shower residents who use a mechanical lift for about ten (10) days. d) The director of nursing (DON - Employee #96) was asked… | 2015-07-01 |
| 10013 | 10013 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | PO BOX 410 | BLUEFIELD | WV | 24701 | 2010-03-04 | 309 | D | 0 | 1 | 6XNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation of the medication administration pass, medical record review, facility policy review, and staff interview, the facility failed to assure licensed nurses administered medication in an accurate dose and within acceptable time parameters for two (2) of five (5) residents observed during this medication pass. Resident identifiers: #22 and #15. Facility census: 53. Findings include: a) Resident #22 During observation of the medication administration pass on 03/02/10 at 7:45 a.m., the nurse (Employee #36) prepared the resident's ordered medications for administration. Employee #36 removed a packet of medication from the top of the medication cart. The medication was identified as [MEDICATION NAME] 20 mg. Employee #36 removed one (1) tablet of [MEDICATION NAME] 20 mg from the packet and placed it into a medication cup. After also placing [MEDICATION NAME] 5 mg, Calcium with Vitamin D 600 mg, [MEDICATION NAME] 150 mg, a Multivitamin with minerals, and KDur 20 meq into the cup, Employee #36 locked her medication cart, picked up the cup containing medications, and prepared to leave the cart. Employee #36 was asked if those were the medications she was going to administer to Resident #22. Employee #36 responded in the affirmative. She was asked to reference the Medication Administration Record [REDACTED]. She agreed the resident should receive two (2) [MEDICATION NAME] 20 mg tablets. Review of the medical record found a current physician's orders [REDACTED]. b) Resident #15 An observation of the medication administration pass, on 03/03/10 at 9:45 a.m., found the nurse (Employee #18) administered [MEDICATION NAME] 5 mg via the resident's gastrostomy tube. Review of the MAR found the [MEDICATION NAME] was ordered to be administered at 7:00 a.m. Review of the facility's policy entitled, "ADMINISTERING MEDICATIONS THROUGH A GASTROSTOMY TUBE" (revised September 2003), under the section entitled "General Guidelines", found the following… | 2015-07-01 |
| 10014 | 10014 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2012-03-22 | 274 | D | 1 | 0 | FHEW11 | . Based on observation, record review, and staff interview, the facility failed to conduct a comprehensive assessment of a resident within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's condition. The resident was assessed as having experienced significant declines in most activities of daily living items on her minimum data set (MDS) assessment, in addition to significant declines in bowel and bladder continence, and a significant weight loss. This was found for one (1) of ten (10) residents reviewed. Resident identifier: #19 Facility census: 93. Findings include: a) Resident #19 The comprehensive MDS assessment, completed for Resident #19 on 04/11/11, when compared to the MDS completed on 07/11/11, demonstrated a pattern of significant decline in several areas, including: -- Ability to transfer was coded as requiring extensive assist of one (1) staff on 04/11/11; as requiring extensive assist of two (2) or more staff on 07/11/11. -- Walking in room and in corridors was coded as requiring supervision with setup help only on 04/11/11; as activity did not occur on 07/11/11. -- Locomotion on and off unit was coded as requiring supervision with setup help only on 04/11/11; as requiring extensive assistance of two (2) or more staff on 07/11/11. -- Dressing was coded as requiring extensive assistance of one (1) staff on 04/11/11; as total dependence on two (2) or more staff on 07/11/11. -- Eating was coded as requiring only supervision with setup help only on 04/11/11; as extensive assistance of one (1) staff on 07/11/11. -- Toilet use was coded as requiring extensive assistance of one staff on 04/11/11; as total dependence on two (2) or more staff on 07/11/11. -- Personal hygiene was coded as requiring extensive assistance of one (1) staff on 04/11/11; as total dependence on two (2) or more staff on 07/11/11. -- Bathing was coded as requiring physical help with part of bathing activity by one (1) staff on 04/11/11; as total dependence of two (2)… | 2015-07-01 |
| 10015 | 10015 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2012-03-22 | 279 | D | 1 | 0 | FHEW11 | . Based on review of medical records and staff interview, the facility failed to develop a care plan to address a resident's assessed risk for falls. One (1) of ten (10) residents on the sample was affected. Resident identifier: #6. Facility census: 93. Findings include: a) Resident #6 This resident was assessed as being at risk for falls on a nursing assessment completed 03/12/12. The current care plan addressed a number of issues for the resident, but there was no care plan related to the assessed risk for falls. During an interview, on 03/21/12 at 10:00 a.m., the director of nursing (DON), Employee #68, confirmed there was no care plan in place, developed by the interdisciplinary team, to provide guidance to staff in an effort to prevent or minimize the risk for falls. . | 2015-07-01 |
| 10016 | 10016 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2012-03-22 | 280 | D | 1 | 0 | FHEW11 | . Based on record review and staff interview, the facility failed to review and revise care plans as residents' conditions changed. Residents' care plans were not revised when there was a decline in one or more areas of a resident's functional abilities. One resident's care plan was not revised to correctly identify her ability to communicate. A resident's care plan addressed her status while on a secured unit, but was not revised when she was moved to a unit that was not secured. This was found for two (2) of ten (10) residents reviewed. Resident identifiers: #19 and #60. Facility census: 93. Findings include: a) Resident #19 This resident was assessed as being at risk for falls on a nursing assessment completed on 01/10/12. She had experienced a significant decline in her ability to perform activities of daily living (ADL) which included her ability to walk, her continence status, and her nutritional status between 04/11/11 and 07/11/11, according to her minimum data set (MDS) assessments. Her current care plan addressed a behavior problem of risk for elopement, with the goal that she would not depart unauthorized from the secured unit. She was discharged from the secure unit on 06/02/11. There were ten (10) interventions in place with most based on wandering, exit seeking, elopement alarms, and keeping her within sight. The resident was no longer ambulatory according to the MDS assessment of 07/11/11, and all subsequent MDS assessments. The current Kardex, which included specific instructions for providing individualized care to residents based on the care plan, informed the caregiver that Resident #19 was independent for bed mobility, independent for transfers, and was able to walk in her room with setup help only. There was also a check mark in the box labeled "walking" that stated "to and from meals without assistive device as desired." The resident was assessed as no longer being able to do these tasks independently. During an interview, on 03/21/12 at 10:00 a.m., the director of nursing (DON), Employee #6… | 2015-07-01 |
| 10017 | 10017 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2012-03-22 | 323 | D | 1 | 0 | FHEW11 | . Based on observation, record review, and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision to prevent accidents by storing a reclining chair in an unsafe position creating an accident hazard. This was found for one (1) of ten (10) residents reviewed. Resident identifier: #60. Facility census: 93. Findings include: a) Resident #60 This resident was assessed as being at risk for falls on nursing assessments completed on 11/01/11 and 03/13/12. She had experienced a fall on 01/02/12, in which she suffered a skin tear to her right forearm. She had two (2) separate falls on 01/13/12, one at 10:45 a.m., in which she suffered a laceration to her forehead, and one at 6:25 p.m. with no apparent injury. She fell again on 03/05/12 and 03/12/12. She sustained a laceration to her forehead that required transport to the emergency room for treatment. Three (3) of the five (5) falls were the result of the resident rolling out of her bed. On 03/20/12 at 1:20 p.m., Resident #60 was observed in a reclining chair in the hallway next to her room. She was placing her legs over the sides and moving about constantly. At 2:10 p.m., she was in bed. The bed was in a low position. There were fall mats on both sides of the bed. On the side of the bed that was toward the middle of the room, the reclining chair had been placed on top of the fall mat, parallel to the bed, and was up against the side of the bed. A registered nurse (RN), Employee #83 was called to the room and asked about the placement of the recliner. She stated it was not supposed to be there, and that its placement was unsafe, as the resident was at risk for rolling out of her bed. The nurse immediately moved the recliner to another area of the room. Staff were observed going into the room to put Resident #60's roommate to bed at 2:40 p.m. on 03/20/12. At 3:05 p.m., the reclining chair had been placed on top of the fall mat, parallel to Resident #60's bed, a… | 2015-07-01 |
| 10018 | 10018 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2009-10-15 | 323 | E | 0 | 1 | 5DR211 | Based on medical record review, staff interview, and facility policy review, the facility failed, for fifteen (15) of eighty-three (83) incident / accident reports, to ensure all incidents were thoroughly investigated to determine possible causes in order to develop interventions to prevent recurrences. This practice affected twelve (12) residents. Resident identifiers: #7, #11, #12, #15, #17, #30, #54, #66, #88, #96, #97, and #98. Facility census: 92. Findings include: a) Residents #7, #11, #12, #15, #17, #30, #54, #66, #88, #96, #97, and #98 Review of the facility's incident / accident reports, conducted on the afternoon of 10/14/09, revealed the reports failed to contain any information concerning factors contributing to each event, possible causes, preventive measures already in place, and/or immediate actions taken to prevent further occurrences. In an interview on the afternoon of 10/14/09, the facility's administrator (Employee #54) related an additional form on which staff records an investigation into the event and interventions implemented to prevent further occurrences. Upon request by the survey team, the administrator produced these completed forms. Review of these forms revealed that only the incidents involving resident falls were investigated. A total of eighty-three (83) incident / accident reports was completed between 07/07/09 and 09/30/09. Of these, fifteen (15) did not involve resident falls. These fifteen (15) events were not investigated, and there was no record of interventions implemented to prevent recurrences. On the afternoon of 10/15/09, a follow-up interview with the administrator revealed the facility did have a policy and form which they had not been using, although they were starting some staff education of them. Review of the policy titled "1.1 Accidents / Incidents" (effective 03/01/02) identified the following on page 2 under "Documentation and Investigative Action": "4.1 The staff member must document the incident on the Investigation of Incident form and conduct an immediate … | 2015-07-01 |
| 10019 | 10019 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2009-10-15 | 520 | E | 0 | 1 | 5DR211 | Based upon record review, staff interview, and policy review, the facility's quality assessment and assurance (QAA) process failed to recognize that resident incidents / accidents were not being properly investigated to assure appropriate follow-up, in accordance with facility policy. This was determined for seventeen (17) of eighty-three (83) incident / accident reports reviewed. Resident identifiers: #7, #11, #12, #15, #17, #30 (two (2) occurrences), #54 (two (2) occurrences), #66 (two (2) occurrences), #78, #82, #88, #96, #97, and #98. Facility census: 92. Findings include: a) A review of the facility "Resident / Patient Incident Report" forms, on 10/15/09 at 11:00 a.m., revealed the reports for Residents #7, #11, #12, #15, #17, #30 (two (2) occurrences), #54 (two (2) occurrences), #66 (two (2) occurrences), #78, #82, #88, #96, #97, and #98 did not have "Incident / Accident Investigation" forms completed as instructed on that form, which stated: "Complete this form in conjunction with the 'Resident / Patient Incident Report' for injuries of known or unknown origin, allegations of abuse or neglect, resident-to-resident incidents, elopements, or any other incident determined to need investigation." Further instruction was found within the facility policy "1.1 Accidents / Incidents" under Section 4, "Documentation and Investigative Action: 4.1 The staff member must document the incident on the Investigation of Incident form and conduct an immediate investigation of the accident or incident." All of these incident reports were signed by the facility's director of nursing and the administrator, indicating their review of the incidents. b) During an interview on 10/15/09 at 11:30 a.m., the administrator (Employee #54), who was a member of the facility's QAA committee, indicated that all incident reports were discussed routinely at every monthly quality assurance meeting as part of "Core Data" that was always on the agenda. The purpose of this quality assurance review was to assure appropriate follow-up, to identify … | 2015-07-01 |
| 10020 | 10020 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-03-08 | 323 | E | 1 | 0 | SB5211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of material safety data sheets (MSDS), and staff interview, the facility failed to ensure confused residents did not have access to medications that could be harmful to them. The medication administration cart was observed sitting on the North hallway. It was unlocked and unsupervised with no staff members within site of the cart. There were also medicated creams observed on a bedside table within the reach of a resident with the [DIAGNOSES REDACTED]. The practices of not keeping medications secured and/or on over-bed tables had the potential to affect Resident #12 and any residents who wandered on the North unit from rooms twenty (20) - thirty-two (32). Resident identifier: #12. Facility Census: 112. Findings include: a) North Unit medication cart During an observation, on 03/08/12 at 8:10 a.m., the medication cart on the North Unit short hall was sitting in the hall unlocked. There were no staff members observed in sight of the medication cart at that time. The medication nurse (Employee #103) was observed coming down the hall at 8:13 a.m. This surveyor was standing beside her medication cart. Employee #103 was questioned about her cart being unlocked. She confirmed she had left it unlocked, and she knew it should have been locked. . . b) Resident #12 Observation of Resident #12's room on North Hall found two (2) 30 cc medicine cups located on an over-bed table at approximately 2:30 p.m. on 03/07/12. The resident was in bed and the over-bed table was across the resident's bed. One (1) cup contained a pink cream and the other cup contained a white cream, both within reach of the resident. At approximately 11:00 a.m., on 03/08/12, Employee #79 (a registered nurse on North Hall) was interviewed. She stated the pink cream could have been Calazime paste and the white cream was most likely Nutrishield. The MSDS book, located on the wall behind the North Hall nurses' station, was reviewed with Employee #79. She was u… | 2015-07-01 |
| 10021 | 10021 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2010-02-11 | 225 | D | 0 | 1 | 4T1611 | . Based on a review of personnel files and staff interview, the facility failed to thoroughly screen one (1) of ten (10) sampled employees for findings of abuse or neglect, by failing to make an inquiry to the WV Nurse Aide Registry as required before the new employee was permitted to begin work at the facility. Employee identifier: #75. Facility census: 50. Findings include: a) Employee #75 A review of the personnel file for Employee #75, on the morning of 02/09/10, revealed that she was hired as a nursing assistant on 10/05/09. However, there was no evidence to reflect this individual was screened through the WV Nurse Aide Registry for findings of resident abuse / neglect. When interviewed on 02/09/10 at 3:00 p.m., the director of nursing (Employee #7) confirmed there was no evidence the required registry check was made prior to the employment of Employee #75. . | 2015-07-01 |
| 10022 | 10022 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2010-02-11 | 496 | D | 0 | 1 | 4T1611 | . Based on review of sampled personnel records and staff interview, the facility failed to receive registry verification that individuals met competency evaluation requirements before allowing them to serve as nurse aides. This was found for one (1) of ten (10) records reviewed. Employee identifier: #75. Facility census: 50. Findings include: a) Employee #75 Review of the personnel records of Employee #75 (a nursing assistant), on the morning of 02/09/10, revealed she started working on 10/05/09. The facility had no evidence this nursing assistant was registered with the WV Nurse Aide Registry as having completed the State-required minimum training and competency evaluation. During an interview on 02/09/10 at 3:00 p.m., the director of nursing (DON - Employee #7) confirmed that Employee #75 had been performing direct patient care while the facility had no verification she had successfully completed the training and competency evaluation as required by the State. . | 2015-07-01 |
| 10023 | 10023 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2010-02-11 | 152 | D | 0 | 1 | 4T1611 | . Based on medical record review and staff interview, the facility failed to ensure the rights of one (1) of twelve (12) sampled residents, who had been determined to lack capacity to make informed health care decisions, were exercised by an individual appointed in accordance with State law. The physician appointed two (2) individuals to serve jointly as Resident #49's health care surrogate (HCS); however, WV State Code 16-30-8 allows a physician to appoint only one (1) HCS. Additionally, the facility allowed a family member who had not been appointed to the role of HCS to make health care decisions on Resident #49's behalf. Facility census: 50. Findings include: a) Resident #49 Medical record review revealed the physician appointed two (2) persons to serve jointly as Resident #49's HCS, to make health care decisions for this resident. In addition, record review also revealed health care decisions were being made by the resident's mother, who was had not been appointed to serve as HCS. In an interview with the administrator and the person in charge of resident funds (Employee #5) at 2:15 p.m. on 02/10/10, they acknowledged understanding the State law only allows for the appointment of one (1) person to serve as HCS for an incapacitated individual, and they acknowledged the resident's mother was not the resident's legal representative. They state they would see that all staff was made aware of this. According to WV Code 16-30-8. Selection of a surrogate.: "(a) If no representative or court-appointed guardian is authorized or capable and willing to serve, the attending physician or advanced nurse practitioner is authorized to select a health care surrogate." "(b)(1) Where there are multiple possible surrogate decisionmakers at the same priority level, the attending physician or the advanced nurse practitioner shall, after reasonable inquiry, select as the surrogate the person who reasonably appears to be best qualified." This State law does not allow for the simultaneous appointment of more than one (1) person to s… | 2015-07-01 |
| 10024 | 10024 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2010-02-11 | 156 | D | 0 | 1 | 4T1611 | . Based on record review and staff interview, the facility failed to provide to written notification to one (1) of five (5) randomly reviewed residents, who had been discharged from Medicare-covered skilled services, when the skilled services were discontinued and the resident's payer status changed. Resident identifier: #7. Facility census: 50. Findings include: a) Resident #7 A review of facility records reveals Resident #7 was discharged from Medicare-covered skilled services on 10/11/09, but there was no evidence she received a liability notice to inform her of the reason for the discontinuation of skilled services. This was verified by the nurse case manager (Employee #9) at 3:10 p.m. on 02/09/10, who stated that, because the resident had exhausted her one hundred (100) skilled days, she did not receive an notice. A request was made to the nurse to supply evidence the resident or her responsible party had been notified of this change in payer status. During an interview with the director of nurses, Employee #9, and the administrator at 11:10 a.m. on 02/11/10, Employee #9 acknowledged, after reviewing the record, that she could not state the responsible party had been clearly notified of the change in Resident #9's payer status. . | 2015-07-01 |
| 10025 | 10025 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2010-02-11 | 159 | D | 0 | 1 | 4T1611 | . Based on record review and staff interview, the facility failed to obtain valid written authorizations prior to handling the personal funds of two (2) of twelve (12) sampled residents, and failed to provide quarterly statements of account activity to one (1) of these residents, who was alert and oriented. Resident identifiers: #49 and #44. Facility census: 50. Findings include: a) Resident #49 A review of the financial records revealed the written authorization on file allowing the facility to manage the personal funds of this resident, who has been determined to lack the capacity to make health care decisions, was signed by her mother, who was the resident's health care surrogate (HCS) on admission to the facility. The WV Health Care Decisions Act does not convey to a HCS the authority to make decisions on behalf of an incapacitated individual other than those related to health care (e.g., financial decisions). b) Resident #44 A review of the clinical records for Resident #44 revealed she was alert and oriented to person, place, and time and had been determined by the physician to have the capacity to make her own healthcare decisions. Review of the resident's financial records found the resident's daughter signed the authorization for the facility to manage the resident's personal funds. Upon questioning at 11:30 a.m. on 02/09/10, the office manager (Employee #5) also stated the quarterly statements of account activity were mailed to the daughter. She verified she does not supply a statement to the resident, although she agreed the resident would understand the statement. During an interview with the administrator and the office manager at 2:15 p.m. on 02/10/10, they acknowledged the resident should have been informed of her financial status and given the option to make her own decisions about her personal funds. They related that this matter would be referred to the social worker next week, upon her return from vacation. Employee #5 also stated she would ensure the resident started receiving quarterly statem… | 2015-07-01 |
| 10026 | 10026 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2010-02-11 | 371 | F | 0 | 1 | 4T1611 | . Based on observation and staff interview, the facility failed to ensure the proper sanitation of the kitchen area to prevent potential contamination of food products by inadequate cleaning of the equipment. This had the potential to affect all residents. Facility census: 50. Findings include: a) During the general tour of the kitchen and dry storage room at 12:50 p.m. on 02/08/10, observation found the inner aspect of the steam table to be dirty, with dried food debris and stains visible. The backsplash of the stove was also covered with baked and dried food stains. During service of the noon meal at 11:15 a.m. on 02/09/10, observation found the steam table to be cleaner, but the stove was still very stained. The dietary manager was present during both observations and stated there was a schedule for cleaning the steam table, but it had been overlooked. She agreed the backsplash needed to be cleaned. . | 2015-07-01 |
| 10027 | 10027 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2010-02-11 | 387 | D | 0 | 1 | 4T1611 | . Based on record review and staff interview, the facility failed to assure one (1) of twelve (12) sampled residents was seen by a physician at least once in every sixty (60) days. Resident identifier: #1. Facility census: 50. Findings include: a) Resident #1 A review of the clinical record, completed on 02/09/10, revealed the last entry by a physician was dated 10/02/09. A review of the nurses' notes failed to reveal any other visits. During an interview with the director of nurses (DON) and the administrator at 11:10 a.m. on 02/11/10, the DON stated she had reviewed the record and questioned the nurses, but she could not show evidence to reflect the physician had seen the resident since 10/02/09. The administrator stated he would notify the physician and the quality assurance committee of this problem. . | 2015-07-01 |
| 10028 | 10028 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2010-02-11 | 278 | D | 0 | 1 | 4T1611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure the accuracy of the minimum data set (MDS) assessments by failing to accurately encode the resident's skin condition and/or [MEDICAL TREATMENT] treatments on two (2) different assessments for one (1) of twelve (12) sampled residents. Resident identifier: #13. Facility census: 50. Findings include: a) Resident #13 1. A review of the clinical record revealed, in Section M4 of the 08/14/09 admission MDS, no entry for "Surgical wounds", although the admission nursing assessment dated [DATE] stated the resident was admitted with [DIAGNOSES REDACTED]. 2. A review of the clinical record also revealed, in Item P1b of the 11/13/09 quarterly MDS, no entry to indicate the resident received [MEDICAL TREATMENT], although the resident had orders for and received [MEDICAL TREATMENT] three (3) times weekly on a continuing basis. 3. In an interview with the director of nurses at 1:20 p.m. on 02/10/10, she reviewed the assessments and stated these were oversights and they would be corrected. . | 2015-07-01 |
| 10029 | 10029 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-03-21 | 225 | E | 1 | 0 | YLY611 | . Based on record review, review of concern forms, and staff interview, the facility failed to ensure all allegations involving mistreatment, neglect, abuse, and misappropriation of resident property, were reported immediately to officials in accordance with State law through established procedures. Allegations found in four (4) concern forms, from residents and/or families, included failure to provide mouth care and wound care, verbal abuse, stolen personal property, and failure to provide care for dentures. These allegations were not reported as required. Resident identifiers: #37, #70, #53, and #54. Facility census: 52. Findings include: a) Resident #37 Review of concern forms revealed the family of Resident #37 reported a concern on 10/12/11. The family expressed Resident #37's tooth brushing and oral care were not adequate. The family member alleged while brushing the resident's teeth, just prior to the evening meal, the resident had some type of green material still in her mouth. The family member also reported the previous weekend, when Resident #37 was at the emergency room , emergency room staff had to suction food out of the resident's mouth. This allegation of neglect was not reported to state agencies. On 03/21/11, at approximately 3:00 p.m., the social worker (SW), confirmed this allegation of neglect should have been reported. b) Resident #70 1) Review of concern forms revealed Resident #70 complained to staff, on 12/28/11, that her daily dressing change to a wound was omitted on 12/23/11. The report noted she "...had to 'fuss' at staff on 12/24/11 to get it changed because it leaked all over her slacks." This allegation of neglect was not reported to state agencies. On 03/21/11, at approximately 3:00 p.m., the SW confirmed this allegation of neglect should have been reported. 2) According to concern forms, Resident #70 complained to staff, on 12/28/11, that former nursing assistant, Employee #68, was rude to her when she was asked to change the resident. This allegation of verbal abuse was not repo… | 2015-07-01 |
| 10030 | 10030 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-03-21 | 226 | D | 1 | 0 | YLY611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure their policies and procedures for identification and reporting of abuse were implemented. The facility required immediate reporting of abuse to the supervisor. A nursing assistant (NA) failed to immediately report two (2) witnessed incidents of abuse to the supervisor for more than two (2) months after witnessing the incidents. The alleged abuse was committed by the same NA, involving two (2) different residents. Resident identifiers: #24 and #36. Facility census: 52. Findings include: a) Resident #24 Record review revealed nursing assistant, Employee #27, reported to facility staff, on 02/24/12, during an investigation, she had witnessed a former nursing assistant, Employee #69, slap a resident. Employee #27 stated Employee #69 walked up behind Resident #24, who was being changed from soiled clothing, and "opened handedly slapped the resident on her bare behind." In response, the resident at first screamed aloud, then cursed at Employee #69. Employee #27 then allegedly verbally rebuked Employee #69. Record review revealed this incident allegedly occurred sometime between 11/30/11 and 02/10/12, but the allegation was not reported to facility staff until 02/24/11. Interviews with the social worker and the administrator, on 03/21/12, revealed the facility's expectation was for any allegation of abuse witnessed by staff be immediately reported to the supervisor. b) Resident #36 Record review revealed nursing assistant, Employee #27, reported on 02/24/12 during an investigation, she had witnessed former nursing assistant, Employee #69, [MEDICATION NAME] "in a sexual nature at a resident (Resident #36) embarrassing her," while personal hygiene care was being given by Employee #27. Employee #27 reported she told Employee #69 "to leave the room and stated to him that his actions was both inappropriate and unacceptable." Record review revealed this incident allegedly occurred… | 2015-07-01 |
| 10031 | 10031 | HEARTLAND OF RAINELLE | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2012-03-02 | 362 | F | 1 | 0 | 1KS111 | . Based on observations, review of resident council meeting minutes, and staff interview, it was determined the facility did not have sufficient support staff to carry out the functions of the dietary department in a timely manner. Food products had been delivered and sat for seven (7) hours before being put away. Some of these items required refrigeration, resulting in disposal of the items. Evening meals were not always served on time, and this was confirmed by dietary staff. Additionally, residents had discussed this at resident council meetings. This had the potential to affect all residents who received foods from the facility's dietary department. Census: 54. Findings include: a) The dietary department was entered shortly after 5:00 p.m. on 03/01/12. An initial tour of the dietary area was conducted. Several stacks of food supplies/stock were observed sitting directly on the floor. Some boxes contained scrambled egg product, whipped spread, potato salad, and salad dressings that stated on the boxes the items were to be kept refrigerated. When questioned about what time the supplies had arrived, the dietary aide, Employee #60, replied they had come in about 11:15 a.m. There were only two (2) dietary staff members on duty at the time. They indicated the usual staffing pattern was for two (2) employees on day shift and two (2) on evening shift. According to these employees, another person worked 4:00 p.m. until 8:00 p.m. a few days a week. The staffing information was confirmed with the dietary manager, Employee #20, the morning of 03/02/12. b) Review of resident council meeting minutes for December 2011 and January 2012 revealed residents had expressed a concern with meals being served or delivered late. This was confirmed with Employee #20, at noon on 03/02/12. She commented the evening meal had not been served until 6:00 p.m. sometimes, when the usual time was about 5:15 p.m. . | 2015-07-01 |
| 10032 | 10032 | HEARTLAND OF RAINELLE | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2012-03-02 | 368 | E | 1 | 0 | 1KS111 | . Based on observations and staff interviews, it was found all residents were not offered snacks at bedtime daily as required. Residents on specific types of diets and/or those who dietary staff knew wanted a certain type of snack, were provided with snacks. Other residents were not offered a snack. Staff stated the residents who did not receive snacks routinely could ask for items. This had the potential to affect more than a limited number of residents. Census: 54. Findings include: a) Observations of snack distribution on the evening of 03/01/12 revealed a cart, with a tray of snacks, arrived to the floor at approximately 7:38 p.m.. The tray of snacks contained individual snacks labeled for specific residents. These were for those who had special dietary needs or for residents whom staff knew wanted a particular item for an evening snack. There were no additional items provided to offer to other residents. Employee #49 and Employee #10, nursing assistants (NAs) stopped at rooms with residents who had a snack that was labeled and delivered those. They were not observed to stop at each room and offer snacks to residents who were still awake. The NAs indicated if the other residents wanted something they could ask, and items were kept at the nursing station for them to get. Interview with the dietary manager, Employee #20, on 03/02/12 at 10:00 a.m., revealed she was not aware each resident was to be offered a snack at bedtime. She confirmed items were kept at the nursing station for those who might ask for something after dinner or through the night, but these were not offered to residents routinely. . | 2015-07-01 |
| 10033 | 10033 | HEARTLAND OF RAINELLE | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2012-03-02 | 371 | F | 1 | 0 | 1KS111 | . Based on staff interview and observations, it was determined dietary staff did not store and distribute foods under sanitary conditions. Food items that required refrigeration were delivered mid morning, and had not been refrigerated at 5:00 p.m. Supplies were stored on the floor. Debris was found on the floor of the dry food storage room. The step-on trash can at the handwashing area was not accessible. A refrigerator did not contain a thermometer. There was no detergent in the dishwasher capsule, and none was available in the facility. This had the potential to affect all residents who received foods from this central location. Censes: 54. Findings include: a) On the initial tour, on 03/01/12 after 5:00 p.m., containers of bleach and other items were observed on the floor of the cleaning supply closet. Boxes were observed sitting on top of the step-on trash can, which made it difficult for staff to open the lid and properly dispose of paper towels after washing their hands. Four (4) plastic spoons and 1 (1) plastic fork were on the floor of the dry food storage room, two (2) plastic spoons were on floor of the kitchen area, and there was no thermometer in the reach-in refrigerator. b) During this observation, food items, which had been delivered that day, were observed sitting on the floor of the kitchen near the food preparation area. This included boxes of scrambled egg product, whipped spread, potato salad, and dressings. These items had labels indicating they were to be kept refrigerated. A dietary aide, Employee #60, was asked when the supplies had been delivered. Employee #60 stated the supplies had come in about 11:15 a.m. that morning. These food items remained unrefrigerated after 5:00 p.m. At 6:40 p.m., Employee #20 was observed taking these items to the dumpster area to dispose of them since they had been unrefrigerated for so long. c) At 6:45 p.m., prior to the dietary staff beginning cleanup after dinner, the capsule of the dish machine was checked. The capsule, which should contain dish detergen… | 2015-07-01 |
| 10034 | 10034 | PENDLETON MANOR INC | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2009-11-04 | 278 | D | 0 | 1 | FWJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, facility staff failed to ensure a resident received an accurate assessment concerning behaviors. This was found for one (1) of fourteen (14) residents. Resident identifier: #83. Facility census: 84. Findings include: a) Resident #83 When reviewed on 11/04/09 at 8:00 a.m., the minimum data set assessment ((MDS) dated [DATE] revealed Resident #83 had been identified as having exhibited with a deterioration in behavioral symptoms in Section E5 of the MDS. (The alleged presence of behavioral symptoms was a factor in the selection of residents for the survey sample.) Further review of the MDS revealed that, although Resident #83 was assessed to have had a deterioration in behavioral symptoms, she was coded as not having exhibited any behavioral symptoms in Section E4 of the same assessment of 08/27/09. When interviewed on 11/04/09 at 9:40 a.m., the facility's social worker (Employee #117) confirmed the coding on the MDS indicating Resident #83 had experienced a deterioration in behavioral symptoms was an error. . | 2015-07-01 |
| 10035 | 10035 | PENDLETON MANOR INC | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2009-11-04 | 274 | D | 0 | 1 | FWJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to recognize a significant change in status of one (1) of fourteen (14) sampled residents. Resident #58 exhibited an increase in indicators of depression, anxiety, and/or moods, a decline in bowel continence, an increase in the frequency of her pain, and she developed two (2) Stage II pressure ulcers. As a result, a comprehensive assessment was not completed, applicable resident assessment protocols (RAPs) were not triggered for further review, and the care plan was not revised accordingly. Resident identifier: #58. Facility census: 84. Findings include: a) Resident #58 A review of Resident #58's clinical record revealed an abbreviated quarterly minimum data set (MDS), dated [DATE]. When compared to her previous MDS (a comprehensive annual assessment dated [DATE]), the resident demonstrated a decline in mood, as evidenced by being newly coded as a "1" in seven (7) areas, including sadness and crying, a "2" in four (4) new areas, and a decline from "1" to "2" in one (1) area. Also noted on her abbreviated 08/12/09 MDS, she developed two (2) Stage II pressure ulcers, declined in bowel continence, and increased the frequency of her pain. During an interview with the MDS nurse (Employee #56) at 11:15 a.m. on 11/04/09, she acknowledged these changes should have triggered a comprehensive assessment (for a significant change in status) and the resulting RAPs, and she stated she would complete one (1) as soon as possible. . | 2015-07-01 |
| 10036 | 10036 | PENDLETON MANOR INC | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2009-11-04 | 280 | D | 0 | 1 | FWJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on record review and staff interview, the facility failed to evaluate and revise the care plan when the resident's mood and/or behavior status changed after a change in medication for Resident #70. The facility also failed to ensure that swallowing strategy techniques - as identified by the speech language pathologist - were incorporated into the comprehensive care plan for all staff to follow for Resident #62. This practice affected two (2) of fourteen (14) sampled residents. Facility census: 84. Findings include: a) Resident #70 A review of Resident #70's clinical record revealed an [AGE] year old male admitted on [DATE], with [DIAGNOSES REDACTED]. Since his admission, the resident had been determined to lack the capacity to form health care decisions, but he was alert and oriented and able to take part in his day-to-day care and move about the facility in a wheelchair. He had been receiving [MEDICATION NAME] ([MEDICATION NAME]) to treat depression for a long period of time and, on 09/22/09, his attending physician increased the dosage to 100 mg bid (twice daily) after the resident told him he was "often anxious" and after being told by the nursing staff (i.e., nurses' notes dated 09/22/09) that "resident was upset by his roommate's yelling - yelled at him to 'shut-up'." A review of the physician's progress notes, dated 09/29/09, revealed that, because the resident's daughter had stated concern about the resident having "night-sweats", he conferred with the pharmacist and ordered a tapered reduction of the [MEDICATION NAME] and the introduction of [MEDICATION NAME] over the next few weeks. On 10/05/09, the resident became very anxious and tearful while speaking to his visiting chaplain and told him that he just wanted to die and didn't know why the Lord hadn't taken him when he took his wife. The chaplain repeated this information to the nurse (Employee #95), who recorded in her notes (on 10/05/09) that she informed the unit… | 2015-07-01 |
| 10037 | 10037 | PENDLETON MANOR INC | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2009-11-04 | 329 | D | 0 | 1 | FWJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed, for one (1) of fourteen (14) sampled residents, to ensure [MEDICATION NAME] was given with adequate indications for use and in absence of adverse reactions. Resident identifier: #48. Facility census: 86. Findings include: a) Resident #48 Medical record review, on the morning of 11/04/09, revealed Resident #48 was ordered, on 09/21/09, [MEDICATION NAME] 25 mg one (1) caplet every eight (8) hours as needed for anxiety attacks. According to the facility's medication handbook titled "Nursing 2010 Drug Handbook", on pages 827 and 828, there was no evidence to reflect [MEDICATION NAME] was approved for use in treating anxiety. Additionally, the handbook noted [MEDICATION NAME]'s adverse side effects include dry mouth, nausea, epigastric distress, vomiting, diarrhea, and constipation. Review of the Medication Administration Record [REDACTED]. On 10/13/09, nursing progress notes indicated [MEDICATION NAME] given for complaints of feeling nauseated. On 10/13/09, milk of magnesia was given for constipation. On 10/27/09, [MEDICATION NAME] was ordered for complaints of constipation. On 10/31/09, [MEDICATION NAME] was given for nausea, and around 11:00 a.m., she was noted to be vomiting. At 12:30 p.m., [MEDICATION NAME] was again given for vomiting. On 11/01/09, she complained of nausea and was given [MEDICATION NAME]; she was also found to have a large amount of hard stool in the colon, for which milk of magnesia was given. Later on that morning at 8:30 a.m., she complained her stomach hurt and she was nauseated; bowel sounds were noted to be very sluggish in her lower quadrants. At 9:10 a.m., the physician was notified of her complaints of nausea and constipation and ordered the Senakot be changed to Senakot S and to give a [MEDICATION NAME] rectal suppository if there was no result from the milk of magnesia to be given at 2:00 p.m. Following administration of the [MEDICATION NAME]… | 2015-07-01 |
| 10038 | 10038 | PENDLETON MANOR INC | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2009-11-04 | 309 | G | 0 | 1 | FWJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, staff interview, and facility policy review, the facility failed, for one (1) of seventeen (17) sampled residents, to thoroughly assess a resident who experienced an acute change in condition (increased confusion and yelling out, in addition to elevated temperature), to rule out underlying medical causes and to ensure prompt treatment. Resident #87 exhibited acute behavioral changes on [DATE]. There was no evidence of a thorough nursing assessment of the resident until 5:00 p.m. on [DATE], after he experienced several episodes of foul-smelling diarrhea; at that time, he was treated for [REDACTED]. Resident #87 was transported to the hospital on the evening of [DATE], and expired on the morning of [DATE]; the cause of death was noted to be [MEDICAL CONDITION] secondary to urosepsis. Facility census: 86. Findings include: a) Resident #87 Closed record review, on [DATE], revealed Resident #87 had a history of [REDACTED]. According to the comprehensive admission assessment completed on [DATE], he was able to make himself understood and usually understands others. He required two-person physical assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was frequently incontinent of urine, and he left twenty-five percent (25%) or more of his food on the tray at meals. On [DATE], a nurse recorded that his lungs were clear per auscultation, he was receiving oxygen at a rate of 2 liters per minute, his mucous membranes were moist, and his mood was pleasant. On [DATE], a nurse noted he was exhibiting behavioral changes, becoming really confused and yelling at staff to get out of his room. There was no evidence of a thorough nursing assessment of the resident's overall status (e.g., neurological, respiratory, cardiac, urinary output, etc.) after these behavioral changes were exhibited. On [DATE] at 5:00 p.m., a nurse recorded he had foul-smelling diarrhea times three (3) in two (2) hours, his … | 2015-07-01 |
| 10039 | 10039 | PENDLETON MANOR INC | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2009-11-04 | 371 | F | 0 | 1 | FWJG11 | Based on observation and staff interview, the facility failed to ensure the high temperature dishwasher was functioning properly to effectively sanitized the dishes between uses. Facility census: 86 Findings include: a) Observations of the dietary department, with the dietary manager (Employee #69) on 11/03/09, including observations of the dishwasher. Employee #69 and this surveyor observed the water temperature of the rinse cycle only reached 180 degrees Fahrenheit (F) for approximately four (4) seconds and then the red light would turn off. The dishwasher was sent through ten (10) cycles, and each time, rinse water did not reach the proper temperature and the red light would turn off prematurely during the rinse cycle. Employee #69 acknowledged the rinse cycle temperature should be higher and she would need to make a service call; until then, the facility would complete a bleach dip in the 3-compartment sink in order to ensure the dishes were effectively sanitized between uses. On the afternoon of 11/01/09, Employee #69 reported that the service technician had come to the facility and determined there was a problem with the water pressure to the dishwasher, and he was not able to get the temperature of the rinse water to achieve and maintain 180 degrees F for length of time needed to effectively sanitize. He installed a chemical sanitization unit on the dishwasher and lowered the water temperature to correct the problem. . | 2015-07-01 |
| 10040 | 10040 | PENDLETON MANOR INC | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2009-11-04 | 428 | D | 0 | 1 | FWJG11 | Based on medical record review and staff interview, the facility failed, for two (2) of fourteen (14) sampled residents, to ensure the pharmacist's recommendations were acted upon by the attending physician. Resident identifiers: #29 and #44. Facility census: 86. Findings include: a) Resident #29 Medical record review, completed on 11/02/09 at 3:20 p.m., revealed a consultant pharmacy recommendation dated 06/08/09. Further review found no evidence to reflect the physician had seen or acted upon the recommendation. On the afternoon of 11/03/09, the director of nursing (DON - Employee #132), when interviewed, related she was not sure why the recommendation was placed back on the chart without any doctor notification. She further stated the physician was in the building, and she would ensure that the physician saw the recommendation. b) Resident #44 Medical record review, completed on 11/03/09 at 10:00 a.m., revealed a consultant pharmacy recommendation dated 08/13/09. Further review found no evidence to reflect the physician had seen or acted upon the recommendation. On the afternoon of 11/03/09, the DON, when interviewed, related she was not sure why the recommendation was placed back on the chart without any doctor notification. She further stated the physician was in the building, and she would ensure that the physician saw the recommendation. . | 2015-07-01 |
| 10041 | 10041 | PENDLETON MANOR INC | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2009-11-04 | 441 | E | 0 | 1 | FWJG11 | Based on medical record review and staff interview, the facility failed, for fourteen (14) residents, to obtain informed consent in a timely manner to ensure that residents who wanted the influenza vaccine received it prior to an outbreak of flu-like symptoms in the facility. Resident identifiers: #3, #4, #12, #32, #37, #43, #46, #51, #59, #60, # 65, #77, #84, and #85. Facility census: 86. Findings include: a) Residents #3, #4, #12, #32, #37, #43, #46, #51, #59, #60, # 65, #77, #84, and #85 Review of the facility's influenza vaccination records, completed on 11/03/09, revealed several residents did not receive the influenza vaccine. On 11/04/09 at 1:00 p.m., Employee #88 (the infection control nurse), when interviewed, identified fourteen (14) residents (#3, #4, #12, #32, #37, #43, #46, #51, #59, #60, # 65, #77, #84, and #85) who had not yet received the influenza vaccine, as the facility had not yet obtained consent forms from their legal representatives. She also identified that she did have enough vaccines on hand to administer to all fourteen (14) residents. During this conversation, she related she only worked eight (8) hours per week and did not have enough time each week to obtain consents, give the vaccination, and complete the associated paperwork. Employee #88 identified they have had employees and residents who had exhibited flu-like symptoms. . | 2015-07-01 |
| 10042 | 10042 | PENDLETON MANOR INC | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2009-11-04 | 225 | D | 0 | 1 | FWJG11 | Based upon review of personnel records and staff interview, the facility failed to implement procedures to screen employees for prevention of abuse and neglect, by failing to check appropriate licensing boards and/or registries. This was found for two (2) of ten (10) sampled employees, who were hire within the past twelve (12) months. Employee identifiers: #132 and #19. Facility census: 84. Findings include: a) Employee #132 Review of the personnel record of Employee #132 (the facility's director of nursing), on the afternoon of 11/02/09, revealed she began working at the facility on 12/08/08. There was no evidence that either the West Virginia Board of Examiners for Registered Professional Nurses or the West Virginia Nurse Aide Registry had been checked for findings of resident abuse or neglect that would indicate the employee was unfit for service in a nursing facility. b) Employee #19 Review of the personnel record of Employee #19 (a nursing assistant), on the afternoon of 11/03/09, revealed she had started working on 09/08/09. There was no evidence that the West Virginia Nurse Aide Registry had been checked for findings of abuse or neglect prior to 09/23/09. c) During an interview with the Person in Charge (Employee #107) on 11/04/09 at 11:35 a.m., she confirmed that there was no available verification to reflect these individuals had been properly screened prior to working with facility residents. . | 2015-07-01 |
| 10043 | 10043 | PENDLETON MANOR INC | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2010-01-20 | 514 | D | 0 | 1 | FWJG12 | Based on medical record review and staff interview, the facility failed to ensure the medical record of one (1) of twenty-one (21) sampled residents was accurate and complete. Resident identifier: #46. Facility census: 90. Findings include: a) Resident #46 Medical record review, on 01/20/10 at 11:10 a.m., disclosed the resident's December 2009 Medication Administration Record [REDACTED]. On 01/20/10 at 4:00 p.m., the facility's director of nursing (Employee #132), nurse manager (Employee #55), and administrator (Employee #141) were informed of this, and no additional information was provided these findings prior to the surveyor exiting the building. | 2015-07-01 |
| 10044 | 10044 | PENDLETON MANOR INC | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2010-01-20 | 318 | D | 0 | 1 | FWJG12 | Based on medical record review and staff interview, the facility failed to ensure one (1) of twenty-one (21) sampled residents received services to maintain or prevent the decline in range of motion, in accordance with physician orders, for the months of November and December 2009. Resident identifier: #46. Facility census: 90. Findings include: a) Resident #46 Medical record review, on 01/20/10 at 11:10 a.m., disclosed the physical therapist observed Resident #46 on 11/01/09, at which time the physical therapist identified three (3) problems: decreased right ankle range of motion; decreased right ankle strength; and decreased ambulation distance. The physical therapy department established the following three (3) goals for the resident: increase right ankle range of motion; increase right ankle strength to allow for more normal gait; and increase ambulation distance with normal heel to toe gait pattern. To attain these goals, the following exercises were to be provided: right ankle dorsiflexion stretch three (3) times, thirty (30) seconds each, five (5) times a week; BAPS board dorsiflexion / plantar flexion and circles two (2) sets of ten (10) repetitions, five (5) time a week; and slant board stretch, standing three (3) times, thirty (30) seconds each, five (5) times a week. Review of the resident's rehabilitation / restorative care plan / approach for the month of November 2009 found these exercises were completed only two (2) times during the entire month, on 11/05/09 and 11/20/09. No documentation was found in the medical record concerning why these services were not provided as ordered. Review of the rehabilitation / restorative care plan / approach for the month of December 2009 found these services were provided only four (4) times during the entire month, on 12/03/09, 12/08/09, 12/18/09, and 12/27/09. It was noted the resident refused services only on two (2) occasions, 12/01/09 and 12/10/09. On 01/20/09 at 4:00 p.m., the nurse manager (Employee #55) and the director of nursing (Employee #132), when int… | 2015-07-01 |
| 10045 | 10045 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2012-03-13 | 225 | E | 1 | 0 | 0FUR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, review of facility policy, and staff interview, the facility failed to ensure all allegations of abuse and neglect were immediately reported and thoroughly investigated in accordance with State law and facility policy. The facility failed to immediately report, thoroughly investigate, and provide protection to facility residents related to allegations of abuse/neglect involving three (3) of seven (7) sampled residents. Resident identifiers: #56, #31 and #21. Facility census: 55. Findings include: a) Resident #56 Review of facility documents found this former resident complained to the social worker, on 01/30/12, of staff members being too rough when removing her clothing. The documents indicated the resident had a history of [REDACTED]. Further review of documents found no evidence this allegation had been immediately reported to the state survey and certification agency and other officials in accordance with state law. Additionally, the documents contained no evidence the facility had conducted any investigation or obtained statements from staff members or the resident involved. Review of the facility's policy prohibiting abuse and neglect, amended 09/23/92, section entitled "Reporting," found the following language, "...7. The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law." Further review of policy, section entitled "Investigations," found the following language, "1. The facility will thoroughly investigate all allegations and take appropriate actions. 2. Investigations will be prompt, comprehensive and responsive to the situation ... g. Interviews and written statements from individuals, whether residents, visitors, or staff, who may have first hand knowledge of the incident. (Written statements should include name, title, date and time statement is being w… | 2015-07-01 |
| 10046 | 10046 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2012-03-13 | 226 | E | 1 | 0 | 0FUR11 | . Based on facility policy review, review of personnel training records, and staff interview, the facility failed to ensure two (2) of five (5) newly hired employees received training related to the facility's policy on abuse, neglect, and misappropriation of resident property. This deficient practice had the potential to affect more than an isolated number of residents currently residing in the facility. Employee identifiers: #35 and #3. Facility census: 55. Findings include: a) Employees #35 and #3 Review of the facility's policy prohibiting abuse, neglect, and misappropriation of resident property found a section entitled "Training". Review of this section found newly hired employees were to receive training in "Patient Advocacy Protocols" as part of their orientation. Review of the training agenda found it included: -- definitions of abuse, neglect and misappropriation of property -- Identification of potential victims of abuse or neglect and those at high risk for abuse -- Appropriate interventions for resident behavior such as aggression or resistance -- Staff responsibility to immediately report any violation or alleged violations -- Measures to be taken to protect the residents --The consequences for failure to report any and all allegations. Review of five (5) randomly chosen training records for newly hired employees found the facility had not ensured Employee #35 (a nursing assistant) and Employee #3 (a licensed practical nurse) received training in these areas prior to providing care to residents. An interview with Corporate Employee #66 confirmed the employees had not received the training required by facility policy. . | 2015-07-01 |
| 10047 | 10047 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2012-03-13 | 241 | E | 1 | 0 | 0FUR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and review of the facility's dress code policy, the facility failed to ensure five (5) direct care staff members displayed a name tag which would enable residents and visitors to identify those providing care. The failure to wear this identification failed to promote an environment of respect and dignity for residents in that they were not afforded the right to identify those providing the most intimate of care. This deficient practice had the potential to affect more than an isolated number of residents currently residing in the facility. Facility census: 55. Findings include: a) During random observations of the resident environment, conducted upon entrance to the facility on [DATE] at 12:45 p.m., it was noted that five (5) direct care staff members did not wear name badges to inform residents and visitors of their identity. Nursing assistants (NA) #1, #55, #61, #6, and licensed practical nurse (LPN) #17 identified themselves verbally when asked. An interview with NA #6 revealed this staff member was aware of the requirement to wear a name tag. Review of the personal appearance and dress requirements for the facility (2009) found the following language, "Name tag is to be worn and clearly visible at all times, if required for your position". . | 2015-07-01 |
| 10048 | 10048 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2012-03-13 | 246 | D | 1 | 0 | 0FUR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, and review of facility documents, the facility failed to ensure call bells remained within the reach of dependent residents. The failure to provide this reasonable accommodation affected three (3) of seven (7) sampled residents. Resident identifiers: #36, #33, and #31. Facility census: 55. Findings include: a) Resident #36 Random observations of the resident environment, conducted upon entrance to the facility on [DATE] at 12:45 p.m., noted Resident #33's call bell was not within his reach. The call bell was located on the floor approximately two (2) feet from his bed. b) Resident #33 A random observation conducted in Resident #33's room found her call bell on the floor behind an oxygen concentrator. The resident was alert and oriented and stated she utilized the call bell if she needed assistance. When asked what she would do if her call bell was in the floor, she stated she would have to yell until someone came to help her. c) Resident #31 Review of facility documents found an allegation had been made by Resident #31 on 02/17/12. The resident alleged her call bell was not within reach and she was left with unmet incontinence care needs for an extended period of time. Further review found a typed narrative, signed by the administrator, Employee #63, on 02/22/12 related to the resident's allegation. The typed narrative contained the following language, "I also informed the charge nurse to have the entire staff watch and make sure that all residents have their call lights within reach at all times." . | 2015-07-01 |
| 10049 | 10049 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2012-03-13 | 278 | F | 1 | 0 | 0FUR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview and position description review, the facility failed to ensure a registered nurse conducted or coordinated each assessment with the appropriate participation of health professionals. The facility employed and utilized the services of a licensed practical nurse (LPN) to act as the minimum data set (MDS) coordinator. This practice had the potential to affect all residents currently residing in the facility. Employee identifier: #13. Facility census: 55. Findings include: a) During random observations of the facility, on 03/13/12 at 11:15 a.m., a staff member approached and introduced herself as the minimum data set (MDS) coordinator. The employee wore a name badge identifying her as an LPN. A comprehensive interview with this LPN (Employee #13) concerning her role as MDS coordinator was conducted following the introduction. Employee #13 stated she coordinated the schedule for quarterly, annual, and significant change assessments. She stated she completed the MDS, conducted the Care Area Assessment (CAA) and, along with the interdisciplinary team (IDT), made the decision to care plan the Care Area Triggers (CAT). When asked what other members made up the IDT, she identified the social worker, the dietary manager, activities, therapy, etc. When asked if a registered nurse (RN) attended the IDT meetings, LPN #13 stated that no RN attended the IDT meetings. When asked what role an RN plays in the assessment process, LPN #13 stated she had to have an RN sign the MDS was complete. LPN #13 stated she had done this job for [AGE] years and had been the full time MDS coordinator for this facility as of October 2010. She denied RN participation in completing the CAA, making care plan decisions, or development of the care plans for residents. A copy of LPN #13's position description was obtained from the facility following the interview. -- Review of the POS [REDACTED]. --The Accountability Objective included, "Supervise and coor… | 2015-07-01 |
| 10050 | 10050 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2012-03-13 | 323 | D | 1 | 0 | 0FUR11 | . Based on observation, staff interview, and review of manufacturer's information, the facility failed to ensure a restraint-free alarm was properly applied to alert staff should Resident #18 try to exit the bed without assistance. Additionally, staff applied a padded lap tray restraint to Resident #3's wheelchair in an unsafe manner and not in accordance with manufacturer's instructions. Staff utilized a tightly knotted gait belt to secure the padded lap tray to the resident's wheelchair. This placed Resident #3 at risk should a medical or environmental emergency exist which required the restraint to be quickly released. Two (2) of seven (7) sampled residents were affected. Resident identifiers: #3 and #18. Facility census: 55. Findings include: a) Resident #3 During random observations of the resident environment, on 03/12/12 at 1:30 p.m., Resident #3 was noted to be seated in the lounge area adjacent to the nursing station. Observation revealed a padded lap tray was affixed to her wheelchair by use of a tightly knotted gait belt. The gait belt had been placed through the openings on the back of the lap tray, wrapped around the back of the resident's wheelchair, and securely tied with a knot. It was noted the lap tray did not remain securely in line with the arms of the resident's wheelchair, allowing a large gap between the edge of the lap tray and the arms of the wheelchair. The gap was of sufficient width to have enabled the resident to insert an arm or leg in the opening. Physical therapy assistant (PTA) Employee #65 was present in the lounge. At 1:30 p.m. on 03/12/12, he was asked to provide information concerning the use of a knotted gait belt to secure the resident's lap tray to her wheelchair. Employee #65 stated staff had come to the therapy department to inform them the straps utilized to secure the lap tray to Resident #3's wheelchair were missing. Employee #65 stated the staff members were instructed to order new ones. He agreed the lap tray was not secured in a safe manner, as the tray moved latera… | 2015-07-01 |
| 10051 | 10051 | BRIER, THE | 515144 | 601 ROCKY HILL ROAD | RONCEVERTE | WV | 24970 | 2009-10-16 | 371 | F | 0 | 1 | EVU911 | Based on observation and staff interview, the facility store and prepare milk and food under sanitary conditions. The temperature of milk was measured at 45 degrees Fahrenheit (F), and a dietary employee closed the lid to the trash can and then went back to food preparation without washing her hands. This had the potential to affect all residents. Facility census: 89. Findings include: a) Observation, with the certified dietary manager on 10/13/09 at 4:55 p.m., found the temperature of the milk carton, stored on ice in a bin in the food preparation area, to be 45 degrees F. This was just prior to the evening meal service. The temperature of another carton of milk taken from the milk cooler was found it to be 40 to 42 degrees F. The temperature on the milk cooler registered at 40 degrees F. The dietary manager indicated the temperature of the milk cooler should have been about 38 degrees F and that a repair person would be called. b) During preparation of the evening meal on 10/13/09 at 4:45 p.m., a dietary staff person (Employee #45) washed and dried her hands with a paper towel. After using a second paper towel to turn off the faucet, the employee threw the paper towel into the trash can. The lid on the trash can did not close, and the employee used her hand to close the trash can lid. She then went back to the food prep area and began touching food items. . | 2015-07-01 |
| 10052 | 10052 | BRIER, THE | 515144 | 601 ROCKY HILL ROAD | RONCEVERTE | WV | 24970 | 2009-10-16 | 166 | D | 0 | 1 | EVU911 | Based on resident group interview, staff interview, and review of reports of lost / missing items, the facility failed to ensure one (1) random resident had received information from staff, keeping her informed of the status of and progress toward finding / replacing her missing items. Resident identifier: #55. Facility census: 89. Findings include: a) Resident #55 During the resident group interview on 10/14/09 at 3:00 p.m., one (1) resident explained she was missing a couple of personal items. She explained she had moved to a different room in the facility and, after the move, she was not able to locate a calling card and a jar of "cold cream". She related the facility had not replaced these items and had not informed her if they had located the items. The two (2) social workers (Employees #89 and #90) were interviewed on 10/14/09 at approximately 5:00 p.m. and again on 10/15/09 at approximately 9:00 a.m., regarding this issue. The social workers provided a copy of the lost / missing item form that documented Resident #55's missing items. The form, dated 03/24/09, indicated the facility would replace the Ponds cold cream, a calling card, one (1) blue flat sheet, and two (2) gowns. The social workers indicated they thought all the items were replaced, but they were not positive. They agreed the documentation of the resolution on the lost / missing item form was unclear and could be more organized. The form contained several hand written notes and no complete / accurate conclusion summarizing what occurred. The administrator reviewed the lost / missing item form, on 10/14/09 at approximately 9:30 a.m., and agreed the form needed improvement. She said she had signed the form and, after signing, the social workers had continued to work on the issue. She said she would prefer the investigation be complete and a resolution reached prior to her signature. Employee #55 (maintenance / housekeeping / laundry) indicated she had no knowledge of the missing calling card or Ponds cold cream. She did talk about the replacemen… | 2015-07-01 |
| 10053 | 10053 | BRIER, THE | 515144 | 601 ROCKY HILL ROAD | RONCEVERTE | WV | 24970 | 2009-10-16 | 224 | D | 0 | 1 | EVU911 | Based on group interview, resident interview, and staff interview, the facility failed to ensure one (1) resident's personal care item was not removed from her room without her permission or without an explanation of the reason for the removal. Resident identifier: #55. Facility census: 89. Findings include: a) Resident #55 On 10/14/09 at approximately 3:00 p.m., a group interview was conducted with the residents at the facility. At this interview, Resident #55 related she was missing a can of hairspray. She indicated Employee #57 (a maintenance worker) came into her room and removed a can of hairspray given to her by the beautician as a Mother's Day gift. According to the resident, Employee #57 told her she could not have the hairspray because of the aerosol can and took it from her room. On 10/15/09 at approximately 3:00 p.m., Resident #55 was in the hallway of the facility, talking about the items the facility had replaced for her. She she commented that they still had not replaced her hairspray. She also recounted the story of how the beautician had given her the hairspray as a gift. The resident displayed emotions associated with being upset. On 10/15/09 at approximately 2:00 p.m., the administrator related she had no knowledge of the resident's missing hairspray. She said Employee #55 had not told her anything about the incident. The administrator also said her insurance policy recommended the facility not allow any aerosol cans in the building. She presented a page from the admissions contract that listed aerosol cans among items that could not be brought into the facility. On 10/16/09, the administrator called Employee #57 on the telephone, and he told her he did take the hairspray, because the resident could not have an aerosol can in her room. He also said he kept the hairspray locked up and that the resident could contact him when she needed to use it and he would bring it to her. Employee #57 had failed to tell his supervisor or the administrator that he had confiscated Resident #55's hairspray. He si… | 2015-07-01 |
| 10054 | 10054 | BRIER, THE | 515144 | 601 ROCKY HILL ROAD | RONCEVERTE | WV | 24970 | 2009-10-16 | 157 | D | 0 | 1 | EVU911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to notify the physician of a resident's repeated refusal to take the medication [MEDICATION NAME]. Additionally, this resident's nursing notes identified attempts to inform the resident's physician when her heart rate was 44 beats per minute, but it was not noted whether the physician was ever made aware, nor was the physician notified of the results of a positive urine culture or the recommendation that the urine culture be repeated. One (1) of fourteen (14) current residents on the sample was affected. Resident identifier: #42. Facility census: 89. Findings include: a) Resident #42 1. review of the resident's medical record revealed [REDACTED].e., the resident refused the medication, it was not available, etc. The MAR for October 2009 was also reviewed and, again, all documented doses had been circled. There was no evidence the physician had been informed of the resident's repeated refusal to take the stool softener. 2. This resident's [DIAGNOSES REDACTED]. (name) to advise of Resident's [MEDICAL CONDITION]. Apical heart rate remains @ 44 beats per minute. No other S/Sx (signs or symptoms) noted R/T (related to) heart rate." It was noted at 10:10 p.m., "Gave report to oncoming LPN (licensed practical nurse) - monitor closely - pg (paged) Dr. again to give report on Resident's Sx." The next entry was: "Pulse 45 @ 12 A (a.m.) Paged Dr. (name). Dr. (name) has not called back. No s/s (signs/symptoms) of distress or discomfort. . . . Will continue to monitor." Although the resident had a [DIAGNOSES REDACTED]. The resident was receiving [MEDICATION NAME] for hypertension, and a side effect of this medication is slow heart rate. There was no evidence the physician had ever been made aware of the resident's low heart rate. 3. Review of the resident's medical record noted she had been treated for [REDACTED]. coli at the emergency roiagnom on [DATE]. A physician's orders [RE… | 2015-07-01 |
| 10055 | 10055 | BRIER, THE | 515144 | 601 ROCKY HILL ROAD | RONCEVERTE | WV | 24970 | 2009-10-16 | 309 | D | 0 | 1 | EVU911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, staff interview, and observations, the facility failed to ensure each resident received the necessary care and services to attain or maintain his or her highest practicable level of well being in accordance with the plan of care. One (1) resident, who was observed at random, had support stockings on both legs while up in her wheelchair. The hose had wrinkled on the legs above the ankles. Another resident, who was on the sample of fourteen (14) current residents, had a physician's orders [REDACTED]. Resident identifiers: #82 and #42. Facility census: 89. Findings include: a) Resident #82 On 10/15/09 from 3:30 p.m. to 4:00 p.m., Resident #82 was observed sitting in the hall way in her wheelchair. She wore flesh colored support stockings that had wrinkled around her lower legs, causing significant indentations in her legs. At 4:00 p.m., Employee #41 was shown the condition of the stockings. She pulled the resident's stockings up, so they were wrinkle free. Indentations were apparent where the stockings had been wrinkled. These indentations persisted for at least one-half hour, when observations were ended for the day. Review of the resident's medical record found an order for [REDACTED]." The order had been received on 07/22/08. Her [DIAGNOSES REDACTED]." On 10/16/09 at 8:55 a.m., the resident was observed seated in her wheelchair in her room with her feet resting on the floor. The stockings were again wrinkled around the resident's lower legs. The resident was observed intermittently from 8:55 a.m. until 10:35 a.m., and the stockings remained wrinkled. At 10:35 a.m., Employee #41 was again informed of the wrinkled stockings. She said someone had [MEDICATION NAME] them earlier that morning, but the stockings would not stay [MEDICATION NAME]. b) Resident #42 Review of medical records found an order for [REDACTED]. Review of the resident's medical record found some vital signs had been recorded on the medication… | 2015-07-01 |
| 10056 | 10056 | BRIER, THE | 515144 | 601 ROCKY HILL ROAD | RONCEVERTE | WV | 24970 | 2009-10-16 | 441 | D | 0 | 1 | EVU911 | Based on observations and review of posted hand washing signs, the facility's infection control program failed to ensure staff practiced appropriate hand washing to prevent the spread of infection. Additionally, staff had not labeled a bottle of saline when opened to ensure it was not used more than forty-eight (48) hours after it was opened. Three (3) residents observed at random were affected. Facility census: 89. Findings include: a) Residents #89 and #14 1. Resident #89 On 10/14/09 at approximately 8:30 a.m., a nurse (Employee #8) washed her hands after administering the resident's medications. She washed her hands for approximately three (3) seconds and turned the water off with her bare hands, recontaminating them on the faucet handles. 2. Resident #14 On 10/14/09 at approximately 8:40 a.m., Employee #8 was observed administering medications to Resident #14. The nurse only washed her hands for approximately three (3) seconds, then turned the water off with her bare hands, thus recontaminating her hands. 3. Signage posted in the staff and public restrooms indicated the hands should be washed for at least ten (10) seconds and directed staff to use a dry paper towel to turn off the water. -- b) Resident #6 After lunch on 10/14/09, a nurse (Employee #88) was observed providing a treatment to the resident. Observation found a bottle saline for irrigation sitting on a cabinet in the resident's room. The bottle was open, but it had not been dated to indicate when it should be discarded. . | 2015-07-01 |
| 10057 | 10057 | BRIER, THE | 515144 | 601 ROCKY HILL ROAD | RONCEVERTE | WV | 24970 | 2009-10-16 | 514 | D | 0 | 1 | EVU911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, the facility failed to ensure medical records were accurate and complete. One (1) resident had expired, but there were no nursing entries regarding the resident's final hours or that there had been a cessation of vital signs. There was no documentation regarding the reason one (1) resident did not take her [MEDICATION NAME], nor was the effectiveness of her pain medication noted. Two (2) of seventeen (17) residents on the sample were affected. Resident identifiers: #91 and #42. Facility census: 89. Findings include: a) Resident #91 1. This resident was selected for closed record review as she had expired in the facility. Review of her medical record found a form entitled "Nursing Transfer / Discharge Note". The form noted the resident had died at 8:35 a.m. on [DATE]. There was information regarding the release of the body to the mortuary, but other sections were blank or marked as "N/A" (not applicable). Review of the nursing entries found an entry for [DATE] at 6:00 a.m., noting the resident had required suctioning three (3) times. The next entry was [DATE] at 1:00 p.m., which noted the physician had been in to see the resident and there were no new orders. From [DATE] at 1:00 p.m. through the time of death on [DATE] at 8:35 a.m., there were no further notes. The findings at the time of death (i.e., there was no heart beat, respirations were absent, etc.) were not identified. It was not noted whether the resident's family had been notified or whether the physician had been made aware of the resident's death. 2. During review of the resident's close medical record, a copy of a CMS-802 with the names of seven (7) other residents was found in Resident #91's file. This document included confidential information such as continence status, whether the individual was cognitively impaired, whether the resident had a [DIAGNOSES REDACTED]. Another document, including the names of thirty-one (31) other residents alon… | 2015-07-01 |
| 10058 | 10058 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2012-01-19 | 156 | D | 0 | 1 | ZNLH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . I. Based on record review and staff interview the facility failed to show evidence that one (1) of the two (2) persons who had been appointed "dual" medical power of attorney (MPOA) by one (1) of forty-nine (49) Stage II sampled residents had been included in the admission process and / or had been involved in treatment decisions since admission to the facility. Resident identifier: #102. Facility census: 118. Findings include: a) Resident #102 Review of the medical record revealed Resident #102 was an [AGE] year-old female admitted on [DATE], with [DIAGNOSES REDACTED]. She was determined by her attending physician to lack the capacity to make informed healthcare decisions. On 06/14/05, prior to the decision of incapacity, she had appointed her son and daughter to act jointly as her medical power of attorney (MPOA). Review of the admission process revealed the resident's son had signed all admission documents, including the "Advance Directive Acknowledgement Form" which indicated the resident was to be DNR (Do Not Resuscitate) status. On 12/27/11, he was also the sole MPOA signing the permission for admission of the resident into the Alzheimer's unit of the facility. Review of social service notes failed to reveal any evidence the daughter, who was a dual MPOA, had been consulted about placement or care decisions. In addition, a review of the nurse's notes revealed on 01/10/12, when the resident's health status declined, only the son was notified about her transfer to an acute care hospital. In an interview, at 1:00 p.m. on 01/17/12, the Memory Care director / social worker, Employee #114, stated she "was sure that the daughter was agreeable to the resident being here." She acknowledged, after reviewing the record, there was no evidence of her (the MPOA) involvement in the admission process nor of her permission to have the son complete the admission process. At 2:00 p.m. on 01/18/12, Employee #114 presented documentation indicating contact… | 2015-07-01 |
| 10059 | 10059 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2012-01-19 | 225 | D | 0 | 1 | ZNLH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . I. Based on review of self reported allegations of abuse / neglect, resident / family concern / grievance forms, staff interviews, and review of facility policies and procedures, the facility failed to immediately report (within no more than twenty-four (24) hours) all allegations of abuse / neglect to all applicable State officials as required. In the case in which the alleged perpetrator was a nurse aide, the facility also failed to report allegations of abuse / neglect to the Nurse Aide Program. Three (3) of thirteen (13) resident / family concern / grievance forms reviewed for the past six (6) months were found to have issues that should have been reported to the appropriate State agencies, but were not. Resident identifiers: #73, #101, and #134. Facility census: 118. Findings include: a) Resident #73 Review of the resident / family concern / grievance form found Resident #73 reported a concern to facility staff at 10:45 a.m. on 08/01/11. In Section I of the grievance form, the nature of the concern was reported as: "Resident expressed concern of staff members approach with her about care related to resident's incontinence." Further documentation, under Section II found, "Spoke /c (symbol for with) resident about her concern - stated her light was on - she wanted to go to the B/R (bathroom) - CNA's (certified nursing assistants) stated you can get up and go to the B/R - resident stated I'm dizzy - I can't get up. CNA's offered bed pan - but had observed Res. (resident) was incontinent. Removed dirty linen, placed on bed pan- res.(resident) not able to use - so CNA got res. (symbol for up) and took to B/R in w/c (wheelchair) - Res. feels that CNA's were upset because she was incontinent. States staff did nothing to hurt her - feels it was the tone of voice they used. Res. wants them to be aware of their response -Doesn't want an apology - not necessary - and states she doesn't mind if they cont. (continue) to care for her - Spoke /c 2 CN… | 2015-07-01 |
| 10060 | 10060 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2012-01-19 | 280 | D | 0 | 1 | ZNLH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, the facility failed to evaluate and revise the care plan when there was a change in the continence status for one (1) of forty-nine (49) Stage II sample residents. This resident had a decline in urinary continence for which the care plan was not revised to reflect the change. Resident identifier: #11. Facility census 118. Findings include: a) Resident #11 Review of the medical record revealed Resident #11 was an [AGE] year-old female with senile dementia who was originally admitted to the facility in 2008. She was admitted to the facility's Alzheimer's unit on 07/27/11. Her nursing admission assessment, on 07/27/11, indicated she was incontinent of urine. A significant change minimum data set (MDS), on 08/07/11, indicated, in section H0300, the resident was "Frequently Incontinent" of urine. The resident's care plan, present on the unit on 01/17/12, noted a problem, "Resident has potential for continence as evidenced by still has some continent episodes." The associated goal was, "Will have no more than one incontinent episode per shift." The interventions included: "... Check at least every two hours and change if wet or soiled." As of 01/17/12, the problem and the interventions remained the same as they had been since 06/29/11. The goal was altered, on 07/28/11, to: "Will have no incontinent episodes during waking hours," but was changed back to the original goal on 08/08/11. The quarterly MDS, of 10/25/11, indicated the resident was now "always" incontinent of urine, but the care plan problem and goal were not revised. During interviews with direct care staff, including a nursing assistant (Employee #61) and a nurse (Employee #70), at 11:30 a.m. on 01/17/12, both stated Resident #11 was always incontinent. Employee #61 stated the resident was taken to the bathroom every two (2) hours and was changed as needed. The Alzheimer's department director (Employee #114), a nurse (E… | 2015-07-01 |
| 10061 | 10061 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2012-01-19 | 364 | E | 0 | 1 | ZNLH11 | . Based on observation and staff interview, the facility failed to ensure meals were attractive. Two (2) of two (2) meals observed had little or no variety in color. Observation revealed most of the foods at these meals were white, or very light in color. They were also served on white plates. These meals were not attractive or appetizing in appearance. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 118. Findings include: a) On 01/16/12, at approximately 12:45 p.m., observation of resident dining revealed the meal consisted of chicken, cauliflower, and potatoes. When pureed, each of these items was white, or nearly white in color. These foods were served on a white plate. Substitutes for the meal included rice and pork chops, which were also white or nearly white in appearance when pureed. No garnishes were used to provide color to the plated meals. b) On 01/18/12 at 11:45 a.m., observation was conducted of foods for another noon meal. The consultant dietitian (Employee #168) was present at this observation. The foods on the menu for this meal were crunchy fish, macaroni and cheese, mashed potatoes, and cole slaw. All were white, or nearly white in color. Additionally, altering of the texture (ground / pureed) gave the appearance that all of these foods were white in color. Again, no garnishes were used to provide color to the plated meals. c) In an interview, on 01/18/12, at approximately 1:30 p.m., the administrator stated she had informed the home office some of the pureed meals on the menu lacked a variety of color. . | 2015-07-01 |
| 10062 | 10062 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2012-01-19 | 441 | E | 0 | 1 | ZNLH11 | . Based on observation and staff interview, the facility failed to ensure one (1) dietary employee practiced effective hand hygiene during meal service to prevent the potential spread of infection. This had the potential to affect residents currently residing in the facility. Facility census: 118. Findings include: a) Observation, during the lunch meal, on 01/18/12 at 12:15 p.m., found the cook (Employee #92) washed her hands and then dried her hands with paper towels. After turning off the water faucet with the paper towels, she finished drying her hands with the same contaminated paper towels. She then proceeded to serve food from the steam table. Employee #92, at 12:40 p.m. on this same day, repeated this same process of washing her hands and then drying her hands with contaminated paper towels. The consulting dietitian (Employee #168) also observed Employee #92 wash her hands. The dietitian agreed Employee #92 had not practiced effective hand hygiene. . | 2015-07-01 |
| 10063 | 10063 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2012-01-19 | 502 | D | 0 | 1 | ZNLH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the consulting pharmacist's report, and staff interview, the facility failed to ensure one (1) of forty-nine (49) Stage II sampled residents received timely laboratory services. In August of 2011, the physician ordered a [MEDICATION NAME] level to be obtained every three (3) months. The lab study was not obtained until December 2011. Resident identifier: #18. Facility census: 118. Findings include: a) Resident #18 Medical record review revealed Resident #18 was receiving the medication [MEDICATION NAME] for a [DIAGNOSES REDACTED]. Further review found a physicians order, written on 08/31/11, for a [MEDICATION NAME] level to be obtained every three (3) months. The facility obtained the lab on 12/02/11. On 11/30/11, the consulting pharmacist reviewed the resident's medications and commented, "(name of resident) has orders for labs to be drawn, but at the time of this review they were not available in the resident record. The missing lab values include: [MEDICATION NAME] level every 3 months." During an interview with the director of nursing on 01/18/12 at 12:30 p.m., she stated: "The nurse just put the order on the wrong month, I don't know why." . | 2015-07-01 |
| 10064 | 10064 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2012-01-19 | 514 | B | 0 | 1 | ZNLH11 | . Based on medical record review and staff interview, the facility failed to ensure clinical records were accurate and kept in a systematically organized fashion for two (2) of forty-nine (49) Stage II sampled residents. A resident's therapy records were found in another resident's medical record. Resident identifiers: #137 and #34. Facility census: 118. Findings include: a) Residents #137 and #34 Review of the medical records found therapy notes for Resident #34 had been placed in Resident #137's record. This finding was reported to Employee #12 (medical records) at 2:24 p.m. on 01/18/12. . | 2015-07-01 |
| 10065 | 10065 | WYOMING NURSING AND REHABILITATION CENTER, LLC | 515164 | P.O. BOX 149 | NEW RICHMOND | WV | 24867 | 2009-10-23 | 502 | D | 0 | 1 | 0RO511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure that three (3) of thirteen (13) sampled residents received ordered laboratory testing in a timely manner. Resident identifiers: #26, #23, and #12. Facility census: 59. Findings include: a) Resident #26 Review of the medical record found a late entry nursing note at 1:00 p.m. on 10/15/09. The nurse documented that staff reported the resident had a loose stool with blood present. An order was obtained, at 1:45 p.m., to collect stool for [MEDICAL CONDITIONS] a stool culture and test for ova and parasites. Further review found a nursing note, dated on 10/16/09 at 4:30 a.m., which documented the stool specimen was obtained for testing related to [MEDICAL CONDITION] and parasite infestation. A thorough review found no evidence the facility had obtained the laboratory report. A registered nurse (Employee #84) was notified that the resident had this test ordered and the laboratory report could not be located Employee #84 and the director of nursing (DON, Employee #82), when interviewed about the missing laboratory results at 12:15 p.m. on 10/21/09, relayed the stool culture had been stored in a cabinet (for five (5) days) and had not been sent to the laboratory as ordered. Further interview elicited that the resident had been experiencing liquid stools on a daily basis from 10/1/09 through 10/21/09. The staff members obtained a stat stool culture, which was negative for [MEDICAL CONDITION], but had no results for possible parasitic involvement. b) Resident #23 Review of the medical record found a nursing note written on 10/17/09 at (unable to decipher handwritten time) to obtain a [MEDICAL CONDITION] stool culture due to two (2) reported bowel movements containing mucus, orange color, and odor. Further review found that the facility did not obtain the ordered stool sample until at 6:00 a.m. on 10/20/09. An interview with Employee #82, on 10/22/09 at 4:10 p.m., elicited … | 2015-07-01 |
| 10066 | 10066 | WYOMING NURSING AND REHABILITATION CENTER, LLC | 515164 | P.O. BOX 149 | NEW RICHMOND | WV | 24867 | 2009-10-23 | 371 | F | 0 | 1 | 0RO511 | Based on observation and staff interview, the facility failed to assure beverage glasses and bowls were free from moisture (wet nesting) and failed to assure garbage was properly secured during food service. These deficient practices had the potential to affect all resident receiving on oral diet. Facility census: 59. Findings include: a) Random observations of the dietary department, on 10/20/09 at 5:30 p.m., found racks containing bowls and beverage glasses stored in the dishwasher room. An inspection of the glasses and bowls noted drops of water present on the inside of randomly selected glasses and bowls. The dietary manager agreed that moisture was present and the glasses and bowls had not been properly air dried. b) On 10/19/09 at approximately 5:30 p.m., observation during meal service in the kitchen revealed an open trash can in the dishroom that did not have a lid on it. The dietary manager indicated the lid was probably left off by an employee who was preparing coffee. However, she agreed the employee needed to put the lid on the can after she it was used to discard trash. . | 2015-07-01 |
| 10067 | 10067 | WYOMING NURSING AND REHABILITATION CENTER, LLC | 515164 | P.O. BOX 149 | NEW RICHMOND | WV | 24867 | 2009-10-23 | 279 | D | 0 | 1 | 0RO511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop comprehensive care plans which contained measurable objectives, timetables, and relevant services to be provided to achieve the highest practicable physical, mental, and psychosocial well-being for two (2) of thirteen (13) residents currently residing in the facility. Resident identifiers: #5 and #36. Facility census: 59. Findings include: a) Resident #5 1. Review of the current care plan (with a resolution date of 11/20/09) found the facility identified the resident as demonstrating decreased cognitive ability related to dementia and confusion. The resident was refusing most invitations to group activity with some activity in room. The objectives (goals) developed by the facility were for the resident to participate in one-on-one activities two (2) times a seek and continue to do individual activities in the room. A review of the services to be provided in order to achieve the above goal included: "Do not correct resident try to redirect;" "Invite resident to go out of room for short periods of time just for a stroll;" and "When husband is visiting invite and encourage them to come and sing for peers and staff." None of the services to be provided were consistent with the goal of participating in one-on-one or in- room activities. 2. Further review of the care plan found the facility had identified the resident was at risk for falls. The objective was for the resident to have no falls requiring hospitalization through the next review. The services provided to obtain the stated objective included: "Administer Ambilify (sic) 20 mg po (by mouth) daily" and "Administer [MEDICATION NAME] 60 mg po daily". The care plan nurse could not state how the administration of antipsychotic and antidepressant drugs would assist the resident in not experiencing falls, during an interview on the afternoon of 10/21/09. b) Resident #36 1. The record review for Resident #36, conduc… | 2015-07-01 |
| 10068 | 10068 | WYOMING NURSING AND REHABILITATION CENTER, LLC | 515164 | P.O. BOX 149 | NEW RICHMOND | WV | 24867 | 2009-10-23 | 281 | D | 0 | 1 | 0RO511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of standing orders, facility staff interview, and review of West Virginia Nursing Code and Legislative Rules, Including Criteria for Determining Scope of Practice of Licensed Practical Nurses and Guidelines for Determining Acts That May Be Delegated or Assigned by Licensed Nurses (2009 Edition), the facility failed to assure licensed nurses acted within their respective scopes of practice while delivering care to two (2) of thirteen (13) sampled residents. Licensed practical nurses (LPNs) failed to notify the registered professional nurse (RN) or physician when Resident #26 had a change in condition, failed to act under the direction of the physician when ordering and administering medications for Resident #26, and failed to accurately document when Resident #23 refused medications. Resident identifiers: #26 and #23. Facility census: 59. Findings include: a) Resident #26 1. Review of the medical record found a nursing transfer / discharge summary with nursing notes written by a licensed practical nurse (LPN) on the night shift of 10/08/09. The LPN documented that the resident was nauseated and vomited a small amount at 3:30 a.m. At 4:30 a.m., the resident vomited a moderate amount. At 5:30 a.m., the resident vomited a large amount, his respirations were 30, and his oxygen saturation was 84%. Review of the facility's standing orders found the following: "IX. Acute Shortness of breath ...2. Check oxygen saturation via pulse oximeter PRN (as needed). If O2 (oxygen) SAT (saturation) less than 90, call physician." The nursing note written at 6:30 a.m. found the resident's oxygen saturation was only 87% with the use of oxygen. The documentation contained no evidence the LPN collected data related to the resident's breath sounds, bowel sounds, skin color, etc., nor was there evidence to reflect the LPN attempted to contact the physician or the RN for direction in providing care. The nursing transfer / discharge… | 2015-07-01 |
| 10069 | 10069 | WYOMING NURSING AND REHABILITATION CENTER, LLC | 515164 | P.O. BOX 149 | NEW RICHMOND | WV | 24867 | 2009-10-23 | 309 | D | 0 | 1 | 0RO511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure two (2) of thirteen (13) sampled residents received the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the plan of care. Facility nurses continued to administer laxatives to Resident #26 in the presence of multiple liquid stools. Additionally, the facility failed to assure Resident #57 received ordered antibiotics for treatment of [REDACTED]. Resident identifiers: #26 and #57. Facility census: 59. Findings include: a) Resident #26 Review of the medical record found a late entry nursing note on 10/15/09 at 1:00 p.m., documenting that staff reported the resident had a loose stool with blood present. The LPN wrote an order for [REDACTED].) Review of the Medication Administration Record [REDACTED]. Further review found licensed nurses administered both laxatives on 10/16/09, 10/17/09, 10/18/09, 10/19/09, and 10/20/09, and administered the [MEDICATION NAME] 8.6 mg/50 mg on the morning of 10/21/09. The facility utilizes a computer system to track resident bowel movements. The director of nursing (DON, Employee #82) accessed the information concerning Resident #26's bowel movements during an interview conducted at 12:15 p.m. on 10/21/09. Upon reviewing the electronic records, Employee #82 relayed the resident had large-to-extra-large liquid stools at the following times: 10/16/09 at 2:47 p.m., 10/17/09 at 2:50 p.m. and 9:50 p.m., 10/18/09 at 5:04 a.m., 10/19/09 at 2:14 a.m., 10/20/09 at 9:41 p.m., and 10/21/09 at 6:44 a.m. Following the above interview, the facility obtained an order to discontinue all the resident's laxatives due to loose stools. The nursing staff continued to administer laxatives to Resident #26 in the presence of liquid stools for a period of six (6) days. b) Resident #57 Review of the medical record found Resident #57 was prescribed the antibiotic [MEDICATION NAME] 875 mg every twelv… | 2015-07-01 |
| 10070 | 10070 | WYOMING NURSING AND REHABILITATION CENTER, LLC | 515164 | P.O. BOX 149 | NEW RICHMOND | WV | 24867 | 2009-10-23 | 364 | E | 0 | 1 | 0RO511 | Based on random observation, testing of food temperatures, and staff interview, the facility failed to assure each resident received food at the proper temperature for palatability. This deficient practice had the potential to affect more than an isolated number of residents receiving an oral diet. Facility census: 59. Findings include: a) During the evening meal service on the resident hallway on 10/20/09 at 5:50 p.m., random observations noted that undistributed resident trays were sitting on racks on an open cart. After the last resident on the hall was served their tray and began to eat, the dietary manager was asked to assist in obtaining food temperatures on the remaining tray. She obtained a thermometer and determined that the beans were 108.1 degrees Fahrenheit (F) and the hot dog chili was 109.9 degrees F. She agreed that both food items should have been at least 120 degrees at the point of service. . | 2015-07-01 |
| 10071 | 10071 | WYOMING NURSING AND REHABILITATION CENTER, LLC | 515164 | P.O. BOX 149 | NEW RICHMOND | WV | 24867 | 2009-10-23 | 328 | D | 0 | 1 | 0RO511 | Based on observation, policy review, and staff interview, the facility failed to assure a licensed nurse appropriately positioned one (1) of two (2) residents receiving medications via gastrostomy tube to avoid choking and potential aspiration. Resident identifier: #2. Facility census: 59. Findings include: a) Resident #2 During observation of the medication administration pass on 10/21/09 at 7:40 a.m., the nurse (Employee #13) was noted to prepare Resident #2's medications for administration via her gastrostomy tube. Observation found that, while the head of the resident's bed was raised approximately 30 degrees, the resident had slid down the bed until her chest and stomach were lying in a flat position. Employee #13 prepared the resident's medications individually. She checked for proper placement of the gastrostomy tube prior to flushing the tube with approximately 30 cc of water. The nurse then placed diluted medication into the tube followed by a 5 cc to 30 cc flush, administered another medication followed by a flush, administered another medication followed by a flush. After this, the resident began to make gurgling sounds. The nurse then administered a 350 cc flush, and the resident started to gurgle and cough. The nurse surveyor pointed out to Employee #13 that the resident's chest and stomach were flat in the bed and suggested the resident be pulled up in the bed, so she was in an elevated position. The resident continued to gurgle and cough until the nurse obtained assistance in pulling her up in the bed. The director of nursing (DON) was informed of the above observation. She provided the facility's policy, which stated the resident was to be assisted to a semi or high-Fowler's position (30 degrees to 45 degrees) if tolerated (policy titled Administering Medications through a Gastrostomy Tube, revised July 1, 2006). The DON agreed the resident should not have been administered medications when she was lying flat in the bed. . | 2015-07-01 |
| 10072 | 10072 | WYOMING NURSING AND REHABILITATION CENTER, LLC | 515164 | P.O. BOX 149 | NEW RICHMOND | WV | 24867 | 2009-10-23 | 441 | D | 0 | 1 | 0RO511 | Based on observation and review of facility policy, the facility failed to ensure licensed nursing staff sanitized or washed their hands prior to instilling medications via gastrostomy tubes for two (2) of two (2) randomly observed residents. Resident identifiers: #2 and #42. Facility census: 59. Findings include: a) Resident #2 During the medication administration pass on 10/21/09 at 7:40 a.m., observations found the nurse (Employee #13) preparing Resident #2's medications for administration via her gastrostomy tube. She was noted to touch her keys, the medication cart, the medication administration book, and the sink faucet handle prior to donning gloves without first washing or sanitizing her hands. b) Resident #42 During the medication administration pass on 10/21/09 at 8:20 a.m., the nurse (Employee #6) was observed to prepare Resident #2's medications for administration via her gastrostomy tube. She was noted to touch the medication cart, the medication administration book, and the sink faucet handle prior to donning gloves without first washing or sanitizing her hands. c) Review of the facility's policy related to "Administering Medications through a Gastrostomy Tube" (revised July 1, 2006), under the section entitled "Infection Control Protocol and Safety", found the following language: "1. Wash your hands thoroughly with soap and water at the following intervals: a. before the procedure;...". . | 2015-07-01 |
| 10073 | 10073 | OAK RIDGE CENTER | 515174 | 1000 ASSOCIATION DRIVE | CHARLESTON | WV | 25311 | 2012-03-01 | 164 | D | 1 | 0 | 0TSC11 | . Based on observation, the facility failed to ensure personal privacy was maintained during a nursing procedure for one (1) of nine (9) sampled residents. Resident identifier: #33. Facility census: 71. Findings include: a) Resident #33 During random observations, conducted on 02/29/12 at 11:15 a.m., a registered nurse (RN), Employee #31, was observed flushing Resident #33's gastrostomy tube. It was noted the roommate and two (2) visitors were in the room and were watching the procedure. The nurse exposed the resident's abdomen and failed to pull the curtain between the beds or close the door to the hallway. The resident's gastrostomy tube and abdomen were clearly visible from the hallway, as was the procedure performed by the RN. . | 2015-07-01 |
| 10074 | 10074 | OAK RIDGE CENTER | 515174 | 1000 ASSOCIATION DRIVE | CHARLESTON | WV | 25311 | 2012-03-01 | 225 | D | 1 | 0 | 0TSC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on facility document review and staff interview, the facility failed to ensure all allegations of neglect were reported to state agencies as required, and were thoroughly investigated. This deficient practice affected one (1) of nine (9) sampled residents. The resident's daughter made an allegation of neglect which was not investigated or reported by the facility. Resident identifier: #73. Facility census: 71. Findings include: a) Resident #73 Review of a facility document, dated 02/13/12, entitled "Record of Customer and Family Concerns," found the social worker, Employee #79, contacted the resident's daughter after the resident's admission to the hospital on [DATE]. Employee #79 documented the daughter "had some concerns about resident's condition prior to admission to hospital (sic)". Employee #79 further documented the nursing home administrator and director of nursing were informed. Employee #79 documented the daughter reported Resident #73 had bilateral pneumonia. Employee #79 further documented the daughter was upset with the facility "...because we did not check on her often because if we did this wouldn't have happened." Employee #79 documented the daughter stated, "...she came in on Wed. 01/31/12 and her mother appeared dehydrated, (her mouth was dry and tongue sticking to roof of mouth). (The Daughter) notified a nurse (couldn't recall name or identify), however nurse shrugged it off. (The daughter) gave her mother water and she seemed better. Monday 2/6/12, (the daughter) came to see (Resident #73) again (around end of dinner) and found her shaking and appearing dehydrated. (The daughter) also reports that her tube feed was dated for 2/4/12 and crusted around opening at stomach. (The daughter) reports that her mother was not talking or acknowledging her presence. (The daughter) went to get a nurse, but felt the nurse shrugged it off and ignored her concerns. (The daughter) continued to express concerns to nurse. (The daugh… | 2015-07-01 |
| 10075 | 10075 | OAK RIDGE CENTER | 515174 | 1000 ASSOCIATION DRIVE | CHARLESTON | WV | 25311 | 2012-03-01 | 279 | D | 1 | 0 | 0TSC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, medical record review, resident interview, and staff interview, the facility failed to ensure a comprehensive care plan for one (1) of nine (9) sampled residents was developed to meet resident's medical and nursing needs. The facility failed to include a physician's orders [REDACTED].#60 was to have no water until her sodium levels normalized. Observations found the resident to have a pitcher of ice water at the bedside. Additionally, resident interview found the resident was unaware of this restriction. Resident identifier: #60. Facility census: 71. Findings include: a) Resident #60 Review of the medical record found a physician's orders [REDACTED]. An interview with the director of nursing (DON), Employee #6, on 02/29/12 at 3:40 p.m., elicited that "free water" meant plain water. Resident #60's room was entered at 3:41 p.m. on 02/29/12. Observation revealed a pitcher of ice water on her bedside table. The resident was alert and oriented. She was asked if she was allowed to have water. The resident responded, "I can have all the water I want." The facility provided no evidence the resident was educated concerning the physician's orders [REDACTED]. Further review of the medical record found the physician's orders [REDACTED]. . | 2015-07-01 |
| 10076 | 10076 | OAK RIDGE CENTER | 515174 | 1000 ASSOCIATION DRIVE | CHARLESTON | WV | 25311 | 2012-03-01 | 309 | G | 1 | 0 | 0TSC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, review of information from hospital records, observation, resident interview, and staff interview, the facility failed to assess a resident ' s clinical and mental status, failed to monitor the resident ' s response to treatment, and failed to obtain laboratory studies as ordered by the physician. These deficits in care resulted in a finding of actual harm to Resident #73. It was also determined a potential for more than minimal harm existed for Resident #60, by the facility ' s failure to implement a physician ordered fluid restriction. Two (2) of nine (9) residents on the sample were affected. Resident identifiers: #73 and #60. Facility census: 71. Findings include: a) Resident #73 1) Review of a facility document, dated 02/13/12, entitled "Record of Customer and Family Concerns," found the social worker, Employee #79, contacted the resident's daughter after the resident's admission to the hospital on [DATE]. Employee #79 documented the daughter "had some concerns about resident's condition prior to admission to hospital (sic)". Employee #79 further documented the nursing home administrator and director of nursing were informed. Employee #79 documented the daughter reported Resident #73 had bilateral pneumonia. Employee #79 further documented the daughter was upset with the facility "...because we did not check on her often because if we did this wouldn't have happened." Employee #79 documented the daughter stated, "...she came in on Wed. 01/31/12 and her mother appeared dehydrated, (her mouth was dry and tongue sticking to roof of mouth). (The Daughter) notified a nurse (couldn't recall name or identify), however nurse shrugged it off. (The daughter) gave her mother water and she seemed better. Monday 2/6/12, (the daughter) came to see (Resident #73) again (around end of dinner) and found her shaking and appearing dehydrated. (The daughter) also reports that her tube feed was … | 2015-07-01 |
| 10077 | 10077 | OAK RIDGE CENTER | 515174 | 1000 ASSOCIATION DRIVE | CHARLESTON | WV | 25311 | 2012-03-01 | 323 | E | 1 | 0 | 0TSC11 | . Based on medical record review, observation, and staff interview, it was found the facility failed to ensure the resident environment remained as free of accident hazards as possible. An LPN (licensed practical nurse), Employee # 75, was observed wearing long, dark painted fingernails with decorations that extended approximately one (1) inch beyond the fingertips. She also was wearing multiple rings on each hand. This practice constituted the potential for injury to residents when doing care. A stocked, unlocked treatment cart was left unsupervised in the hallway. Medicated ointments and dressing and treatment supplies on this cart were left unsupervised and accessible to residents who were in close proximity. Residents were observed near and around the nursing station. No staff members were present at the nursing station which was accessed by swinging doors. On the counters of the nursing station were several medications as well as a local anti-infective antiseptic. Each item present on the counter had the potential for harm to any resident who accessed them. These practices had the potential to affect more than an isolated number of residents. Facility census: 71. Findings include: a) Employee # 75 During observations in the 300 hallway, on 02/28/12, at approximately 9:45 a.m., this LPN was observed preparing medications for a resident. Observation revealed the nurse's fingernails were long, approximately one (1) inch beyond the fingertips. The nails were painted a dark color with decorations. It was also observed the nurse was wearing multiple rings on each hand. During a brief interview with the nurse, it was revealed nurses did their own treatments on residents on Tuesday, Thursday, Saturday and Sunday. During an interview with the director of nursing (Employee #06), on 02/29/12, at 10:30 a.m., it was agreed wearing long fingernails and multiple rings created a potential for injury to residents during care. . . b) Treatment cart Random observations of the resident environment, on 02/29/12 at 11:30 a.m., no… | 2015-07-01 |
| 10078 | 10078 | OAK RIDGE CENTER | 515174 | 1000 ASSOCIATION DRIVE | CHARLESTON | WV | 25311 | 2012-03-01 | 441 | F | 1 | 0 | 0TSC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, review of Center for Disease Control (CDC) and World Health Organization (WHO) guidelines, and review of cleaning products, it was determined the facility failed to ensure an effective infection prevention and control program to maintain a safe, sanitary environment to help prevent the development and transmission of infections. This practice had the potential to affect all facility residents. Facility census: 71. Findings include: a) Employee #75 During observations in the 300 hallway, on 02/28/12, at approximately 9:45 a.m., the licensed practical nurse (LPN) was observed preparing medications for a resident. Observation revealed the nurse's fingernails were long, approximately one (1) inch beyond the fingertips. The nails were painted a dark color with decorations. It was also observed the nurse was wearing multiple rings on each hand. During a brief interview with the nurse, it was revealed nurses did their own treatments on residents on Tuesday, Thursday, Saturday and Sunday. Following the medication administration to the resident, this nurse applied sanitizing solution and rubbed her hands together but did not clean under the fingernails or under the rings. Review of literature from the WHO, dated 2009, revealed several studies have shown that skin underneath rings is more heavily colonized with infectious organisms than comparable areas of skin on fingers without rings. The recommendation of WHO is to strongly discourage the wearing of rings or other jewelry during health care. According to CDC recommendations, published 10/26/02, artificial nails are noted to contribute to transmission of healthcare-associated infections. Health care workers who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than are those who have natural nails, both before and after hand washing. The studies referenced in the CDC recommendations provide evidence that wearing artifi… | 2015-07-01 |
| 10079 | 10079 | OAK RIDGE CENTER | 515174 | 1000 ASSOCIATION DRIVE | CHARLESTON | WV | 25311 | 2012-03-01 | 492 | F | 1 | 0 | 0TSC11 | . Based on review of the staffing worksheet completed by the facility for the pay period 02/12/12 through 02/25/12, and staff interview, it was determined the facility failed to operate in compliance with state regulations by failing to maintain a daily staffing ratio at the State required minimum of 2.25 nursing hours per resident. The staffing ratio on Sunday 02/12/12 was 1.89 nursing hours per resident. This practice had the potential to affect the care and well-being of all residents who resided in this facility. Facility census: 71. Findings include: a) During the course of the investigation, the facility was requested to complete a staffing worksheet which showed the nursing hours per resident for the pay period of 02/12/12 to 02/25/12. Review of the completed staffing worksheet revealed the facility staff-to-resident ratio fell below the state required minimum on 02/12/12. The staff-to resident ratio on that day was 1.89 hours. According to the State nursing home licensure rule 64-13-8.14a., the minimum hours per resident per day is 2.25 hours. During an interview with the scheduling manager, Employee #78, on 03/01/12 at 9:15 a.m., it was confirmed the facility staffing dropped below the required staffing ratio on 02/12/12. Employee #78 explained the facility utilized agency staffing services and overtime for facility staff when their nursing hours per resident dropped below their desired hours. Employee #78 said the facility was unable to bring the ratio up to desired levels on that day due to call offs and no availability of agency staff. . | 2015-07-01 |
| 10080 | 10080 | OAK RIDGE CENTER | 515174 | 1000 ASSOCIATION DRIVE | CHARLESTON | WV | 25311 | 2012-03-01 | 502 | D | 1 | 0 | 0TSC11 | . Based on medical record review and staff interview, the facility failed to obtain physician ordered laboratory services for one (1) of nine (9) sampled residents. A urinalysis with culture and sensitivity, a complete blood count (CBC), and a comprehensive metabolic panel was not obtained for the resident. Resident identifier: #73. Facility census: 71. Findings include: a) Resident #73 Review of the medical record found a physician's telephone order, written at 7:45 p.m. on 02/01/12, to obtain a urinalysis with culture and sensitivity, a complete blood count (CBC) and a comprehensive metabolic panel (CMP) in the morning. Review of the Medication Administration Record [REDACTED]. An interview was conducted with the director of nursing (DON), Employee #6, on 02/29/12 at 2:10 p.m. She was asked to provide the results from the laboratory work ordered by the physician on 02/01/12. She was unable to provide evidence the facility obtained the ordered laboratory services. . | 2015-07-01 |
| 10081 | 10081 | OAK RIDGE CENTER | 515174 | 1000 ASSOCIATION DRIVE | CHARLESTON | WV | 25311 | 2012-04-17 | 514 | E | 1 | 0 | 0TSC12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on treatment administration record (TAR) review, resident interview, and staff interview, the facility failed to ensure the medical records for four (4) of nine (9) residents on the sample were accurate. Four (4) residents had physicians' orders for scheduled treatments that were not recorded on the individual's TAR. Resident identifiers: #34, #17, #40, and #48. Facility census: 68. Findings include: a) Resident #34 Resident #34, an [AGE] year-old female, came to the facility on [DATE]. She had a physician's orders [REDACTED]. The physician had ordered the ostomy changed every three (3) days and as needed. The treatment administration record indicated the resident's ostomy appliance had not been changed on 04/07/12. b) Resident #17 Resident #17, a [AGE] year-old female, came to the facility on [DATE]. The skin integrity report revealed she had a stage II pressure ulcer to her right heel. The treatment administration record revealed a physician's orders [REDACTED]. The treatment administration record showed the facility had not completed this treatment on 04/05/12 on the 11:00 p.m. - 7:00 a.m. shift, as well as on the 7:00 a.m. - 3:00 p.m. shift. On 04/12/12, the treatment administration record indicated the treatment to the right heel had not been completed on the 3:00 p.m. - 11:00 p.m. shift. On 04/15/12, there was no evidence the treatment had been completed on the 11:00 p.m. - 7:00 a.m. shift or the 3:00 p.m.-11:00 p.m. shift. c) Resident #40 Resident #40, a [AGE] year old female, came to the facility on [DATE]. She had a current [DIAGNOSES REDACTED]. The treatment administration record revealed a physician's orders [REDACTED]. Apply [MEDICATION NAME] lotion to coccyx every shift. The treatment administration record revealed the facility did not complete the treatment on 04/05/12 during the 11:00 p.m. - 7:00 a.m. shift as well as the 7:00 a.m. - 3:00 p.m. shift. A second physician's orders [REDACTED]. There was no evidence the trea… | 2015-07-01 |
| 10082 | 10082 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2010-03-04 | 502 | E | 0 | 1 | FFCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure laboratory tests were completed as ordered by the physician. This was true for four (4) of twenty-three (23) sampled residents' records. The facility failed to obtain laboratory test timely for Residents #45, #92, #115, and #108. Facility census: 112. Findings include: a) Resident #45 Resident #45's medical record, when reviewed on 03/02/10 at 8:45 a.m., revealed a [AGE] year old female with a history of [MEDICAL CONDITION]. Review of the current physician orders, dated 02/17/10, revealed the physician ordered a complete blood count (CBC) test monthly. Review of the laboratory test results revealed the CBC test was not done as ordered. The registered nurse (RN - Employee #25), when interviewed on 03/02/10 at 9:30 a.m., confirmed the CBC was not completed for 02/2010 as ordered. b) Resident #92 Resident #92's medical record, when reviewed on 03/02/10 at 10:00 a.m., revealed a [AGE] year old female who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the current physician orders [REDACTED]. Review of the laboratory test results revealed the [MEDICAL CONDITION] level was not done as ordered. Employee #25, when interviewed on 03/2/10 at 3:30 p.m., confirmed the [MEDICAL CONDITION] test was not completed as ordered. c) Resident #115 Resident #115's closed medical record, when reviewed on 03/04/10 at 10:00 a.m., revealed a [AGE] year old resident with end stage [MEDICAL CONDITION]. The resident received outpatient [MEDICAL TREATMENT] treatments three (3) times a week at a [MEDICAL TREATMENT] center. Review of the 08/17/09 physician orders [REDACTED]. Review of the medical record noted there was no hematological laboratory results in the medical record. The director of nurses (DON - Employee #2 ), when interviewed on 03/04/10 at 11:37 a.m., acknowledged the PTT test were not completed as ordered by the physician. d) Resident #108 Review of Reside… | 2015-07-01 |
| 10083 | 10083 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2010-03-04 | 507 | D | 0 | 1 | FFCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure laboratory reports were maintained on file in each resident's medical record. This was true for two (2) of twenty-three (23) sampled residents. Resident identifiers: #115 and #28. Facility census: 112. Findings include: a) Resident #115 Resident #115's closed medical record, when reviewed on 03/04/10 at 10:00 a.m., revealed a [AGE] year old resident with end-stage [MEDICAL CONDITION]. The resident received outpatient [MEDICAL TREATMENT] treatments three (3) times a week. Review of the 08/17/09 physician orders [REDACTED]. Review of the medical record found no hematological laboratory results in the medical record. The director of nurses (DON - Employee #2), when interviewed on 03/04/10 at 11:40 a.m., acknowledged the laboratory tests were not maintained in the medical record as required. b) Resident #25 Record review revealed, on 06/02/09, the physician ordered a complete blood count (CBC) each month, magnesium every three (3) months, fasting blood sugars each month, and magnesium and transferrin every three (3) months. Review of the medical record only found a lab report for a CBC dated 08/31/09; reports for fasting blood sugars dated 10/29/09, 12/17/09, 01/14/10, and 02/14/10; and reports for magnesium and transferrin for 08/31/09 only. The DON, on 03/02/10 at 4:00 p.m., reported the missing labs were pulled from the computer. . | 2015-07-01 |
| 10084 | 10084 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2010-03-04 | 161 | E | 0 | 1 | FFCS11 | . Based on record review and staff interview, the facility failed to obtain a current surety bond to protect all personal funds of residents deposited with the facility. This had the potential to affect all residents who elected to have their funds managed by the facility. Facility census: 112. Findings include: a) Shortly after entrance to the facility, facility staff provided requested information regarding the surety bond. Review of the surety bond revealed an accompanying letter from the Office of Health Facility Licensure and Certification (OHFLAC - the State agency designated to serve as the holder of such bonds for nursing homes in WV) dated 01/11/10, relaying a request from the Attorney General's Office to make necessary corrections and return the surety bond to the OHFLAC. Furthermore, the letter instructed the facility to contact the Attorney General's Office for any further questions regarding the corrections. Interview with the business office director (Employee #3), on 03/04/10 at 9:30 a.m., revealed the surety bond was signed by the representative authorized by the corporation to do so, although he was neither the president or vice-president of the corporation nor owner or general partner of the company as specified by the Attorney General's office. She said the corporate office takes care of this, not the facility, and they were in the process of trying to clarify this. On 03/04/10 at 10:15 a.m., a representative from OHFLAC, when interviewed, reported that, as of this date, the facility's surety bond covering the period of 08/15/09 through 08/15/10 had not been approved by the Attorney General's Office. . | 2015-07-01 |
| 10085 | 10085 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2010-03-04 | 203 | E | 0 | 1 | FFCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review, the facility failed to provide correct contact information on its uniform transfer / discharge notice for the State long-term care ombudsman and the single State agency responsible for the protection and advocacy of persons with [DIAGNOSES REDACTED]. This had the potential to affect any resident who might need to contact these organizations. Facility census: 112. Finding include: a) Resident #114 Closed record review of Resident #114 revealed she was given a uniform transfer / discharge notice which contained inaccurate information. The notice she received directed persons with a developmental disability or mental illness to contact the "West Virginia Developmental Disabilities Council" for assistance. However, the single agency designated in West Virginia to provide protection and advocacy to individuals with both mental [MEDICAL CONDITION] and mental illness is "West Virginia Advocates, Inc." (not West Virginia Developmental Disabilities Council). Also, the appeals notice lacked the name of the State long-term care ombudsman, although it did list the name of the regional ombudsman. . | 2015-07-01 |
| 10086 | 10086 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2010-03-04 | 281 | D | 0 | 1 | FFCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and record review, the facility failed to ensure two (2) of twenty (20) sampled residents received medications in accordance with physician orders. Resident identifiers: #35 and #81. Facility census: 112. Findings include: a) Resident #35 Observation of the medication pass, on 03/02/10 at 8:45 a.m., with the licensed practical nurse (LPN - Employee #204), found she administered [MEDICATION NAME] 100 mg to Resident #35. Review of the March 2010 monthly recapitulation of physician's orders [REDACTED]. During the observation and review of the medication with the nurse on 03/02/10 at 9:00 a.m., she stated, "I owe her (Resident #35) a half tablet." b) Resident #81 Medication pass observation, on 03/01/10 at 4:20 p.m., found Resident #81 received Calcium 500 mg from a bottle of stock medication. At 5:00 p.m., the nurse (Employee #25) passing medications stated she should have given this resident Calcium 500 mg with 200 mg Vitamin D from a bottle of stock medication, but took from the wrong bottle. During reconciliation, the physician's orders [REDACTED]. . | 2015-07-01 |
| 10087 | 10087 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2010-03-04 | 441 | F | 0 | 1 | FFCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on a review of the facility's hand hygiene procedure and staff interview, the facility failed to establish handwashing guidelines in accordance with current professional standards of practice as recommended by the Centers for Disease Control and Prevention (CDC). This had the potential to affect all residents. Facility census: 122. Findings include: a) Review of the facility's hand hygiene procedure found, at Step 6, "Rub hand together vigorously for 10-15 seconds, generating fraction on all surfaces of the hands and fingers." The policy was reviewed with the director of nursing on 03/03/10 at 12:00 p.m., at which time it was discussed that current CDC guidelines for hand washing indicate hands should be rubbed together for 15-20 seconds. --- Part II -- Based on record review, staff interview, and policy review, the facility failed to follow its own policy on [DIAGNOSES REDACTED] (TB) screening to assure all newly admitted residents were tested and found to be free of this communicable disease. This was evident for one (1) of three (3) residents' closed records. Resident identifier: #114. Facility census: 112. Findings include: a) Resident #114 Review of the facility's policy on TB screening (dated November 2008) revealed all new residents must have a 2-step Mantoux Purified Protein Derivative (PPD) on admission. The first step is to be completed within seven (7) days of admission or according State / Federal regulation, and the second step is to be completed within seven (7) to twenty-one (21) days after a negative result from the first step or according to State / Federal regulation, always following the more strict requirement. The administration and results are then to be documented on the TB Screening Record in millimeters (mm). Review of Resident #114's medical record, on 03/04/10, revealed the Step 1 PPD was administered on 09/21/09 in the left forearm to be read on 09/23/09; however, on 09/23/09, the results of the t… | 2015-07-01 |
| 10088 | 10088 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2010-03-04 | 309 | G | 0 | 1 | FFCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, resident interview, staff interview, and physician interview, the facility failed to provide necessary care and services to assist one (1) of twenty (20) sampled residents in attaining or maintaining her highest practicable level of physical well-being, by failing to obtain routine laboratory testing as ordered by the physician for a resident with a [DIAGNOSES REDACTED].#108, who was subsequently found to be dehydrated and hyperkalemic. Labs, obtained only after surveyor intervention, revealed the resident was dehydrated and hyperkalemic (elevated serum potassium level), and the physician discontinued the diuretic therapy and ordered the administration of intravenous IV fluids (to rehydrate the resident), medications to alter the resident's serum potassium level, and repeat labs. During this period of active physician intervention, the facility failed to document periodic nursing assessments (including vital signs) and the resident's response to treatment. Resident identifier: #108. Facility census: 112. Findings include: a) Resident #108 Review of Resident #108's medical record revealed an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. 1. Record review, on 03/02/10, revealed physician orders [REDACTED]. However, the most recent test results, dated 08/31/09, revealed the following abnormal lab values: - Potassium - high at 5.6 (normal range 3.5 - 5.2) - Chloride - high at 115 (normal range 97 - 108) - Carbon [MEDICATION NAME] - low at 17 (normal range 20 - 32) - BUN - high at 39 (normal range 5 - 26) - Creatinine - high at 3.02 (normal range 0.57 - 1.00) - Estimated Glomerular Flow Rate (eGRF - a test for monitoring kidney function) - low at 15 (normal range > 59) (Note: Abnormally high values of BUN, creatinine, and potassium are indicative of impaired kidney function; abnormally low values of eGFR are indicative of kidney damage. Abnormally high value… | 2015-07-01 |
| 10089 | 10089 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2010-03-04 | 225 | E | 0 | 1 | FFCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on personnel record review and staff interview, the facility failed to screen individuals, prior to permitting them to have resident contact, for convictions of abuse, neglect, or mistreatment residents by a court of law and/or findings entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. Five (5) of five (5) contracted nursing employees reviewed did not have evidence of a statewide background check (Employees #97, #103, #108, #111, and #113), and there was no evidence of screening against the State nurse aide registry for four (4) of five (5) contracted employees and one (1) of five (5) regular employee reviewed (Employees #38, #97, #108, #111, and #113). Facility census: 112. Findings include: a) Employees #97, #103, #108, #111, and #113 Review of sampled personnel files, with the payroll clerk at 4:00 p.m. on 03/03/10, failed to find evidence of statewide background checks for contracted Employees #97, #103, #108, #111, and #113, in an effort to uncover information about any past criminal prosecutions that would indicate unfitness for service in a nursing facility caring for vulnerable adults. On 03/04/10 at 10:00 a.m., the payroll clerk confirmed there were no statewide background checks completed for these individuals. b) Employees #38, #97, #108, #111, and #113 Review of sampled personnel files, with the payroll clerk at 4:00 p.m. on 03/03/10, failed to find evidence the State nurse aide registry was checked for Employees #38, #97, #108, #111, and #113. On 03/04/10 at 10:00 a.m., the payroll clerk confirmed the State nurse aide registry had not been checked for these individuals. . | 2015-07-01 |
| 10090 | 10090 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2010-03-04 | 156 | E | 0 | 1 | FFCS11 | . Based on observation and staff interview, the facility failed to post the correct names, addresses, and telephone numbers of all pertinent State agencies. Incorrect contact information was posted for the State survey and certification agency and the local Medicaid office. This had the potential to affect any resident who might need to contact these agencies. Facility census: 112. Findings include: a) Observation of the posted contact information for pertinent State agencies, in the company of the administrator at 10:30 a.m. on 03/04/10, found the following: 1. The address of the State survey and certification agency was incorrect. 2. The address and telephone number of the local Medicaid office address were incorrect. The administrator confirmed these errors at the time of the observation. . | 2015-07-01 |
| 10091 | 10091 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2010-03-04 | 329 | D | 0 | 1 | FFCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the drug regimen of one (1) of twenty (20) sampled residents was free from unnecessary drugs. Resident #28 was ordered [MEDICATION NAME] 0.5 mg on 01/15/10 for Mild Mental [MEDICAL CONDITION] in the absence of adequate indications for it use. Facility census: 112. Findings include: a) Resident #28 Record review revealed Resident #28 was admitted to the facility on [DATE], and the hospital discharge summary for that date indicated the resident was receiving [MEDICATION NAME] 0.5 mg prior to admission to the facility. Copies of hospital records on the resident's medical record, when reviewed, contained no information explaining why the resident required this medication. The resident's 01/15/10 admission physician's orders [REDACTED]. Review of the physician's progress notes from 01/15/10 forward failed to find any documentation of the indications for use of the [MEDICATION NAME]. Review of the resident's 01/26/10 care plan found the resident was receiving [MEDICATION NAME] for "MR with behaviors" and "Behavioral symptoms drug is intended to treat: Resists care". This information was reviewed with the director of nursing on 03/04/10 at 4:00 p.m., and she agreed the indications for giving this resident [MEDICATION NAME] were inadequate. She reported having reviewed the medical record and finding no additional information concerning this matter. . | 2015-07-01 |
| 10092 | 10092 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2010-03-04 | 248 | E | 0 | 1 | FFCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on confidential resident group interview, resident interview, and staff interview, the facility failed to provide an ongoing program of activities designed to meet the interests and psychosocial well-being of each resident. This was evident by six (6) of eight (8) residents in attendance at a confidential group meeting who reported they were unable to participate in outings as a group and for one (1) of twenty (20) sampled residents (#6) who reported being unable to participate in outings as desired. Facility census: 112. Findings include: a) During a confidential resident group meeting on 03/02/10 at 10:30 a.m., six (6) of eight (8) residents in attendance reported they had never been able to attend outings as a group outside the facility as they desired. When asked, several of the residents reported they would like to visit the local Senior Center but noted transporting more than one (1) or two (2) residents in wheelchairs on the transit bus would be a problem. Group members stated the facility had no van of its own. During a confidential interview with an employee on 03/03/10 at approximately 3:00 p.m., this employee confirmed no group outings had been held for residents for at least the past two (2) years. Interview with the assistant activity director (Employee #6), on 03/04/10 at 11:15 a.m. revealed, only a few residents over the past few years have asked her about having a group outing. She stated the activities department has contacted the Marion County Transit Authority to transport individual residents for such things as shopping at Wal-Mart when requested, but the facility has not requested the Transit Authority to transport a group of residents at the same time. Interview with the activity director (Employee #10), on 03/04/10 at 2:45 p.m., revealed there have been no group outings since she has been working at the facility in July 2009. She recalled last year, in August or September, residents mentioned wanting group outin… | 2015-07-01 |
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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 );