cms_WV
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250 rows where "filedate" is on date 2015-10-01
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9513 | 9513 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2012-10-03 | 241 | D | 1 | 0 | YH2U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, family interview, medical record review, and staff interview, the facility failed to ensure residents' personal items were not used for other residents. Family members had reported witnessing roommates wearing one another's items of clothing, and/or finding items of clothing in their loved ones' closets labeled with names of other residents. Resident identifiers: #26 and #24. Facility census: 114. Findings include: a) Resident #26 During an interview with the family member of Resident #26, on 10/01/12, at approximately 1:00 p.m., she said a couple of weeks ago she visited and found him wearing the shoes and socks of his roommate. She said the roommate's name was clearly written on the items, and suspected staff must not have known the residents' identities. She said Resident #26 was not able to don his own shoes and socks, and staff had even been feeding him. Record review found this resident was admitted to the facility approximately six (6) weeks ago with [MEDICAL CONDITION] related to a stroke. b) Resident #24 During a random observation, on 10/03/12 at 9:50 a.m., a family member of Resident #24 approached the nurses' station, and spoke with a nurse, Employee #30. He held up a black pair of trousers, clearly labeled with the name of the roommate of Resident #24, Resident #97. The family member said he found Resident #97's trousers in Resident #24's closet. He said he would not have mentioned it, except this had occurred several other times recently, and it was getting to be a habit. During an interview with the director of nursing and administrator, on 10/03/12, at approximately noon, these scenarios were discussed, with no further information obtained. | 2015-10-01 |
| 9514 | 9514 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2012-10-03 | 280 | D | 1 | 0 | YH2U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise a care plan for one (1) of six (6) sampled residents. A resident sustained [REDACTED]. The previous fall had occurred when the resident attempted to transfer himself from his wheelchair to his bed, the second one was when he slid from his wheelchair in the dining room. Resident identifier: #19. Facility census: 114. Findings include: a) Resident #19 Review of incident and accident reports revealed Resident #19 sustained a fall from his wheelchair on 09/03/12. A general progress note for this date stated Resident attempted to transfer self to bed, and slid out of his wheelchair to the floor. Review of incident and accident reports revealed that on 09/25/12, Resident #19 sustained another fall from his wheelchair. A general progress note for this date stated Resident slid out of wheelchair in dining room eating PM (evening) meal. Review of the care plan, on 10/03/12, found the care plan had been revised on 07/18/12, for being at risk for falls due [MEDICAL CONDITION], limited functional mobility, cognitive loss, and history of falls. The care plan was most recently revised on 09/04/12 to wear hipsters at all times due to his history of falls. During an interview with the Director of Nursing, on 10/03/12, at approximately 12:40 p.m., she said she believed they had discussed during a meeting after his 09/25/12 fall, about making a referral to therapy related to evaluating wheelchair safety and positioning. When asked for a copy of an order for [REDACTED]. Interview with occupational therapy staff, Employees #21 and #80, on 10/03/12, at approximately 1:15 p.m., revealed that Resident #19 had most recently been on the occupational therapy case load from 07/19/12 through 09/13/12. They said they had tried several chairs, including a special order Broda chair he did not like as he was unable to self-propel himself. They returned to a high back chair, with a different type of cu… | 2015-10-01 |
| 9515 | 9515 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2012-10-03 | 372 | F | 1 | 0 | YH2U11 | Based on observations, staff interview, and the waste management service agreement review, the facility failed to dispose of garbage and refuse properly, as evidenced by dumpsters left uncovered and overflowing with garbage. This could potentially allow harborage and feeding of vermin, pests, and animals, resulting in a potentially unsafe environment. Employee identifiers: Registered Nurse #28, Administrative Assistant #33, and Maintenance Director #128. Facility census: 114. Findings include: a) Observation on 10/02/12 at 2:55 p.m., revealed four (4) dumpsters outside the facility, three (3) of which had opened lids. Both lids on dumpster #2 were open, exposing clear plastic bags that contained yellow disposable isolation gowns. One lid was open on dumpster #3, which was full, and cardboard boxes were exposed. Dumpster #4 was the largest dumpster, had no lids or coverings of any type, and mattresses were visible. Also observed was one (1) gray cat and one (1) orange cat walking around the dumpster area. On 10/02/12 at 2:55 p.m., Employee #28 confirmed that dumpster #2 was uncovered, was full of bagged garbage, including yellow isolation gowns. On 10/02/12 at 2:55 p.m., Employee #128 confirmed the dumpsters were uncovered, with garbage bags and bagged yellow isolation gowns visible. He stated that the dumpsters were used by the facility, and usually housekeeping and dietary empty the garbage into the dumpsters. He further stated that dumpsters were to always have the lids closed, and possibly staff did not take the time to close the lids since it was raining. He stated that dumpsters #1 and #2 were for garbage, dumpster #3 was for recyclable material, and dumpster #4 was for larger items. Waste pick up was scheduled for four (4) times a week, on Monday, Wednesday, Friday, and Saturday. b) Observation on 10/03/12 at 8:15 a.m., revealed dumpster #1 was full with visible yellow disposable isolation gowns inside clear garbage bags. The lids were down, but not closed due to the overflowing amount of garbage bags. One … | 2015-10-01 |
| 9516 | 9516 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2012-10-03 | 428 | D | 1 | 0 | YH2U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to take action in response to drug irregularities identified by the consultant pharmacist during review of the drug regimen for one (1) of six (6) residents whose medication regimens were reviewed. Following the pharmacist's recommendation to consider discontinuing an antianxiety medication, the facility failed to ensure a clinical rationale for the benefit of, or necessity for, the continued use of this medication. Resident identifier: #58. Facility census: 114. Findings include: a) Resident #58 Resident #58 was a [AGE] year old resident with advanced dementia, history of frequent falls at home, and history of a fractured hip repair which led to her March 2012 admission. Medical record review revealed a pharmacy consultation report, dated 06/13/12, to consider discontinuing the use of an anti-anxiety medication, Ativan. Below the pharmacy recommendation, was an area for the physician to either accept the recommendation, or to decline the recommendation with the rationale for any declination. This space was left empty and unsigned by the physician. On this form was a place provided for the signature of the director of nursing and her comments. This, too, was left blank and unsigned by the director of nursing. Review of physician's progress notes, dated 07/01/12, 07/10/12, and 08/22/12, revealed no mention of the pharmacist's recommendation to consider discontinuing the Ativan, or of any rationales for continuing the medication. Further medical record review revealed the most recent recapitulation of physician's orders [REDACTED]. orally twice daily was 03/28/12, and had continued since. Review of the Medication Administration Records (MARs) for 06/13/12, through 10/03/12, revealed the continued active order for Ativan 0.5 mg. twice daily prn (as needed). Interview with nurses, Employees #100 and #101, on 10/02/12 at 4:30 p.m., revealed that neither could locate in the medical rec… | 2015-10-01 |
| 9517 | 9517 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2012-10-17 | 157 | D | 1 | 0 | L6DP11 | Based on record review, staff interview, and policy review, the facility failed to notify the physician and responsible party of a change in condition related to the worsening of a resident's pressure ulcer. One (1) of four (4) sampled residents was affected. Resident identifier: #83. Facility Census: 92 Findings include: a) Resident #83 At 7:45 a.m. on 10/17/12, the facility's Pressure Ulcer Documentation Form was reviewed. A stage one (1) pressure ulcer to the right hip was identified for this resident. It had an onset date of 09/30/12. On 10/02/12, the same form indicated three (3) Stage II pressure ulcers were identified to the right hip. The notification of change was left unchecked, although the number of pressure ulcers had increased, and had progressed from Stage I to stage II. (Note: A Stage II is defined as a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed.) An interview with multiple employees was conducted on 10/17/12 at 10:30 a.m. in the Director of Nursing's (DON) office. 1) The Unit Coordinator (Employee #74) reviewed the resident's chart and confirmed no interdisciplinary notes were present to indicate the physician or responsible party had been notified. After reviewing the Pressure Ulcer Documentation Form, she agreed the notification of change was not marked. 2) The Minimum Data Set (MDS) Coordinator (Employee #1) confirmed notification was not made because the areas never opened. Employee #1 performed the staging of the pressure ulcers. Further corroboration was given by the Regional Director of Clinical Operations (Employee #108). A review of the risk management system (RMS) by her further established the absence of notification. Employee #108 and the DON (Employee #12) informed Employee #1 and Employee #74 of the need to notify the physician and responsible party when a change in condition occurred. On 10/16/12 at 8:00 p.m., the facility Skin Care and Pressure Ulcer Management Program policy was reviewed. The policy specifically stated any new sk… | 2015-10-01 |
| 9518 | 9518 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2012-10-17 | 279 | D | 1 | 0 | L6DP11 | Based on medical record review, staff interview, and policy review, the facility failed to ensure a comprehensive care plan was developed for one (1) of four (4) sampled residents. The actual presence of a pressure ulcer and a measurable goal were absent from the current care plan. In addition, there was no evidence the resident's care plan for turning and repositioning every two (2) hours, as noted on the care plan, was implemented. The care plan intervention was not placed on the treatment administration record (TAR) for implementation of the service. This affected one (1) of four (4) sampled residents. Resident identifier: #20. Facility census: 92. Findings include: a) Resident #20 The facility Pressure Ulcer Documentation Form, reviewed on 10/16/12 at 2:45 p.m., revealed the presence of two (2) pressure ulcers. Noted were a Stage II to the coccyx developing on 09/05/12 and a Stage I to the left ankle developing on 09/22/12. Review of the medical record, on 10/16/12 at 3:00 p.m., found the care plan contained a focus related to a high potential for skin breakdown had been initiated on 05/31/11. The presence of the two (2) pressure ulcers was not noted in the care plan. The goal for this focus stated, Resident skin will be kept free of breakdown through next review. A staff interview was conducted with the Unit Coordinator (Employee #74) on 10/16/12 at 3:15 p.m. She verified an updated care plan should be in place following development of pressure ulcers. She further agreed the stage of the pressure ulcers should be present on the care plan. An interview with the Director of Nursing (DON - Employee #12), on 10/17/12 at 10:05 a.m., resulted in confirmation of the missing pressure ulcer focus on the care plan. The regional director of clinical operations (Employee #108) was present during this conversation. On 10/17/12 at 10:15 a.m., Employee #108 provided evidence of a pressure ulcer that had been handwritten on a care plan in the thinned chart. However, this information was not transferred onto the current care… | 2015-10-01 |
| 9519 | 9519 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2012-10-17 | 282 | D | 1 | 0 | L6DP11 | Based on record review, staff interview, and policy review, the facility was unable to verify the care plan for one (1) of four (4) sampled residents had been implemented. There was no evidence the care plan for turning and repositioning every two (2) hours was implemented for this resident. The care plan intervention for this service was not placed on the treatment administration record (TAR) for implementation. Resident identifier: #20. Facility census: 92. Findings include: a) Resident #20 Record review, on 10/16/12 at 3:00 p.m., revealed an intervention on the care plan to turn and reposition the resident every two (2) hours. The TAR review, on 10/16/12 at 3:10 p.m., found no evidence of a turn and repositioning sheet. A staff interview, conducted on 10/16/12 at 3:15 p.m., with the Unit Coordinator (Employee #74) verified if a resident had a care plan in place for turning and repositioning every 2 hours, then the TAR should reflect this. The TAR required nurses' initials acknowledging the completed treatment. Employee #74 confirmed the TAR was the only evidence of implementation of the turning and repositioning intervention. On 10/17/12 at 8:00 p.m., the facility Skin Care and Pressure Ulcer Management Program policy was reviewed. The policy implementation section stated, It is important to be 'vigilant' in regards to care plans. It further noted the team . must ensure that all planned interventions and treatment are carried out as written in the Care Plan. | 2015-10-01 |
| 9520 | 9520 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2012-10-17 | 314 | D | 1 | 0 | L6DP11 | Based on record review, staff interview, policy review, and resident observation, the facility failed to provide the necessary services to monitor the impact of interventions used to promote wound healing and to modify interventions upon worsening of a pressure ulcer. This affected two (2) of four (4) residents on the sample. Resident identifiers: #83 and #18. Facility census: 92 Findings include: a) Resident #18 Resident #18 was noted to have a Stage III pressure ulcer to the left hip, with an onset date of 05/29/12, requiring weekly skin audits. The Pressure Ulcer Documentation Form, reviewed on 10/15/12 at 3:00 p.m., revealed the following information. -- On 10/15/12 at 3:00 p.m., a Y (yes) or N (no) was not visualized on the 10/07/12 weekly skin audit. In order to provide an accurate assessment, a complete weekly skin audit needed to include this information as indicated on the treatment administration record (TAR). -- At 7:15 a.m. on 10/17/12, the Licensed Practical Nurse (LPN - Employee #55) acknowledged, during an interview, weekly skin audits should contain a Y or N. She further stated if an N was entered on the TAR, as it should be for pressure areas, then a narrative should be entered in the notes to describe skin assessment findings. Within the weekly evaluations section of the Skin Care and Pressure Ulcer Management Program policy, reviewed on 10/16/12 at 8:00 p.m., directives were provided to place a Y or N during the head-to-toe skin check followed by a description of the area on the TAR. In adherence with the policy, accurate documentation following identification of compromised skin integrity allowed the process to move into the wound management phase. b) Resident #83 Review of the treatment administration record (TAR), on 10/17/12 at 6:00 a.m., revealed an incomplete weekly skin audit. The Y or N to indicate whether or not skin was intact on 10/11/12 was absent. At 7:00 a.m. on 10/17/12, the Pressure Ulcer Documentation Form was reviewed. A Stage I pressure ulcer to the right hip was identified w… | 2015-10-01 |
| 9521 | 9521 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2012-10-17 | 441 | E | 1 | 0 | L6DP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure a sanitary environment which was free from the risk of infection through cross contamination. During medication administration observations, a nurse touched medications with her bare hands. Additionally, the nurse did not wash her hands after performing a glucose finger stick. She also failed to wash her hands prior to preparing and administering an insulin injection. This practice affected one (1) of twenty-four (24) sample residents, and had the potential to affect all residents on the back section of the West Hall. Resident identifier: #91. Facility census: 92. Findings including: a) Resident #91 On 10/17/12 at 5:40 a.m., Employee #68, a licensed practical nurse, was observed during medication administration. She removed each medication from its packaging with bare hands. With her bare hands, Employee #68 opened [MEDICATION NAME] 100 mg and [MEDICATION NAME] 10 mg and poured the contents of these capsules into a medication cup. With her bare hands she placed [MEDICATION NAME] HCl 5 mg and [MEDICATION NAME] 0.5 mg into a plastic pouch, crushed them, and placed the contents in the medication cup. Employee #68 donned gloves and completed a glucose finger stick. She removed her gloves and left the resident's room to prepare an insulin injection of Novalog. Observation revealed Employee #68 did not wash her hands, or otherwise sanitize her hands, prior to preparing the injection. She returned to the room, donned gloves, and gave the injection. This information was discussed with the director of nurses (DON), Employee #12, on 10/17/12 at 10:30 a.m. She stated gloves should have been worn when the medications were touched. The DON also said the nurse should have washed her hands after she removed her gloves. The medication administration policy and hand washing / hygiene policy were reviewed on 10/17/12 at 10:15 a.m. Section P of the medication administration … | 2015-10-01 |
| 9522 | 9522 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2012-10-17 | 514 | D | 1 | 0 | L6DP11 | Based on medical record review and staff interview, the facility failed to maintain clinical records which were complete. A resident's turning and repositioning schedule, as noted on the care plan, was not placed on the treatment administration record (TAR) for implementation of the service. This affected one (1) of four (4) sampled residents. Resident identifier: #20. Facility census: 92. Findings include: a) Resident #20 Record review, on 10/16/12 at 3:00 p.m., revealed an intervention on the care plan to turn and reposition the resident every two (2) hours. The TAR review, on 10/16/12 at 3:10 p.m., found no evidence of a turning and repositioning sheet. A staff interview, conducted on 10/16/12 at 3:15 p.m., with the Unit Coordinator (Employee #74) verified if a resident had a care plan in place for turning and repositioning every 2 hours, then the TAR should reflect this. The TAR required nurses' initials acknowledging the completed treatment. Employee #74 confirmed the TAR was the only evidence of a completed turning and repositioning intervention. | 2015-10-01 |
| 9523 | 9523 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 279 | D | 0 | 1 | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure that resident-specific care needs identified in the most recent comprehensive assessment were addressed in the care plan by identifying goals and planning interventions to meet these goals to enhance the resident's ability to meet his objectives for one (1) of eighteen (18) sampled residents. Resident identifier: #5. Facility census: 98. Findings include: a) Resident #5 A review of the medical record for Resident #5 revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her initial capacity determination, completed on 08/06/09, stated she had the capacity to understand and form her own health care decisions. Her care plan meeting notes all identified Resident #5 as being alert and oriented, including the notes to a meeting held on 11/20/10, when the resident and the family were present for a discussion of her hospice options. In her comprehensive admission assessment with an assessment reference date (ARD) of 08/13/09, the assessor encoded Section B4 as 0, indicating she was independent with cognitive skills for daily decision making. No resident assessment protocol (RAP) was triggered with respect to cognitive loss, and the resident's comprehensive care plan did not address cognitive problems, as none were indicated. On 05/22/10, the resident's attending physician reversed his initial decision and determined the resident did not possess the capacity to understand and make informed health care decisions. In the most recent abbreviated quarterly assessment with an ARD of 08/11/10, the assessor encoded Section B4 as 1, indicating the resident's cognitive skills for daily decision making were now modified independence. This change in cognitive skills was not addressed in the resident's care plan. There were no goals established for preventing future cognitive decline, and no interventions were introduced to address any care needs resulting f… | 2015-10-01 |
| 9524 | 9524 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 280 | D | 0 | 1 | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to involve one (1) of eighteen (18) sampled residents in the formulation of her advance directives. Resident identifier: #5. Facility census: 98. Findings include: a) Resident #5 A review of Resident #5's medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE]. At that time, she had been determined by her physician to possess the capacity to understand and make her own health care decisions and was described in the nursing admission history and the social services admission note as being alert and oriented. On 08/06/09, the physician orders [REDACTED]. (2) medical power of attorney representatives (MPOAs). In Section E of the POST form, there was a checkmark indicating contents of the form were discussed with the MPOA representative and the area for Patient / Resident was blank. The resident did not sign the POST form, although there were other informed consents in the record signed by her. During an interview with the social worker (Employee #142) at 12:00 noon on 11/15/10, she acknowledged, after reviewing the record, there was no evidence the resident had been included in the formulation of her advance directives, although she stated the resident was there. She had no explanation why the resident had not signed the POST form. | 2015-10-01 |
| 9525 | 9525 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 329 | D | 0 | 1 | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to assure one (1) of eighteen (18) sampled residents did not receive a medication ([MEDICATION NAME]) for an excessive duration, as indicated by a 90-day limit included in the physician's orders [REDACTED]. Facility census: 98. Findings include: a) Resident #112 A review of Resident #112's medical record revealed, on 07/12/10, her attending physician ordered: [MEDICATION NAME] 50 mg bid (twice daily) po (by mouth) x 90 days and evaluate. Review of Resident #112's Medication Administration Record [REDACTED]. Observation of the medication cart found a quantity of the medication labeled for Resident #112's use consistent with the twice daily administration. During an interview with the unit manager (Employee #21) at 4:00 p.m. on 11/15/10, she stated, after reviewing the resident's MAR, physician's orders [REDACTED]. | 2015-10-01 |
| 9526 | 9526 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 371 | F | 0 | 1 | TRO311 | Based on observation, staff interview, and policy review, the facility failed to properly store, prepare, distribute, and serve food under sanitary conditions as evidenced by staff not employing adequate hygienic practices during the preparation and service of food on the tray line, and by storing, opening, and using a milk product when it was beyond the expiration date. This had the potential to affect all residents who receive nourishment from the facility's kitchen. Facility census: 98. Findings include: a) Initial observation tour of the kitchen, on 11/08/10 at approximately 1:30 p.m., revealed in the refrigerator an opened, partially used, half-gallon carton of buttermilk with expiration date of 10/30/10 and an open date of 11/05/10. Upon this finding, the corporate dietician discarded the buttermilk. She later stated the outdated buttermilk was opened by someone who did not first check the expiration date; she stated they rarely use buttermilk, and this was inadvertently overlooked. -- b) Observation of the evening meal tray line preparation on 11/08/10 found Employee #37 picked up a noodle that fell on to the stove and popped it into her mouth at 4:35 p.m.; she did not wash her hands but donned gloves and proceeded to check food temperatures. She picked up an ink pen from the floor with her gloved hands and used it several times to record food temperatures into the log book, then laid the dirty pen on the wooden work space of the tray line. In addition to the bottoms of the dishes that touched the wooden work space (which had not been cleaned after the ink pen had been laid upon it), a white-handled knife used to slice open biscuits and a ladle were also laid on that same work space. At approximately 4:40 p.m., Employee #37 dropped a long, green oven mitt on the floor, then immediately picked it up and donned it as she took out hot metal trays of food and carried them to the steam table. When she was finished with the mitts, she laid them on the silver metal workspace just to the right of the wooden servin… | 2015-10-01 |
| 9527 | 9527 | HOLBROOK NURSING HOME | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2011-05-24 | 161 | E | 0 | 1 | OXPS11 | Based on facility record review and staff interview, the facility failed to obtain a surety bond of an amount sufficient to guarantee payment for any loss of residents' funds held, safeguarded, and/or managed by the facility. This has the potential to affect sixty-four (64) residents who have personal funds managed by the facility. Facility census: 103. Findings include: a) A review of the financial records of the facility reveal that they have a surety bond in the amount of $40,000.00. A review of the sixty-four (64) residents' accounts (which were active on 04/30/11) revealed a cumulative total account balance of $17,164.12. At 3:45 p.m. on 05/18/11, this amount was verified by Employees #141 and #142, who were responsible for overseeing the accounts. A review of the bank statement for the month ending on 04/30/11 revealed the residents' funds were deposited in a pooled account. The Daily Balance Summary revealed the following daily balance amounts: - 04/26/11 - $53,278.93 - 04/27/11 - $53,244.37 - 04/29/11 - $53,384.24 - 04/30/11 - $53,389.06 On these dates, the account balance exceeded the total coverage afforded by the surety bond. During an interview at 3:45 p.m. on 05/18/11 with Employees #141 and #142 (responsible for overseeing the accounts) and Employee #140 (assistant administrator), Employee #141 explained that all of the residents' incoming funds were deposited into this floating account and held there usually for several days before the facility withdrew the portion of funds required to pay the monthly bills. She stated this was done this way to ensure maximum interest accumulation and verified these daily balances were typical for each month. Employees #140, #141, and #142 acknowledged that, on these four (4) days, the total account balance exceeded the amount of the surety bond. | 2015-10-01 |
| 9528 | 9528 | HOLBROOK NURSING HOME | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2011-05-24 | 225 | D | 0 | 1 | OXPS11 | Based on record review and staff interview, the facility failed to immediately report an allegation of neglect. This was found for one (1) of six (6) self-reported allegations reviewed. Resident identifier: #55. Facility census: 103. Findings include: a) Resident #55 The facility's reports of abuse and neglect allegations were reviewed on at 1:54 p.m. on 05/17/11 and again at 11:15 a.m. on 05/19/11. This review disclosed an allegation of neglect involving Resident #55 that was self-reported to State agencies on 05/05/11. During an on-site investigation on 05/04/11 by the State's Nursing Assistant Program (NAP) of an allegation of neglect by a nursing assistant involving Resident #5 on 04/01/11, the NAP's investigator discovered that Resident #55 may also have been neglected on 04/01/11 by the same nursing assistant. This allegation was overlooked in the facility's internal investigation and was not reported until 05/05/11. A summary of the full investigation by facility's director of nursing (DON - Employee #1), dated 05/17/11 stated, . Upon my investigation, (Resident #5) and (Resident #55) were not changed per S******* A******* (former employee, nursing assistant). In an interview at 10:05 .m. on 05/23/11, the DON confirmed there was sufficient evidence available to the facility from their initial investigation of 04/01/11 to have prompted an immediate reporting of alleged neglect of both Residents #5 and #55. A written statement from a nursing assistant (Employee #55), dated 04/01/11, stated she found Resident #55 had a large brown urine stain on his incontinence pad which the facility concluded was the result of neglect by a nursing assistant on the 11:00 p.m. - 7:00 a.m. shift of 04/01/11. | 2015-10-01 |
| 9529 | 9529 | HOLBROOK NURSING HOME | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2011-05-24 | 242 | D | 0 | 1 | OXPS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed, for one (1) of thirty-seven (37) Stage II sample residents, to honor personal choices when determining daily activities in which the resident participated. The resident made her own bed upon rising each morning and, when interviewed, stated she did this because staff would not make her bed for her. Resident identifier: #65. Facility census: 103. Findings include: a) Resident #65 During an interview with Resident #65 on 05/12/11 at approximately 10:30 a.m., the resident stated she made her own bed every day and that she had put the bedspread on wrong side out that morning. When questioned as to why she made her own bed, the resident replied, They won't make it for me. The medical record for Resident #65, when reviewed on 05/16/11, revealed this [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent minimum data set assessment (MDS), a quarterly MDS with an assessment reference date of 04/11/11, contained a score of 14 out of a possible 15 on her brief interview for mental status (BIMS). This would indicate she was cognitively intact. A facility nurse (Employee #16), when questioned on the morning of 05/22/11 as to why this resident made her own bed, stated it was the resident's choice to make her own bed; that she had hopes of returning home and wanted to remain as independent as possible, and she physically able to do things for herself. The resident's most recent care plan, dated as having last been reviewed by the facility's interdisciplinary team on 04/20/11, made no mention of the resident's choice to make her own bed. The nurse designated at unit manager for the unit where Resident #65 resided (Employee #6), was interviewed on the morning of 05/24/11. When asked about Resident #65's practice of making her own bed, Employee #6 also stated the resident wanted to make her own bed. This employee co… | 2015-10-01 |
| 9530 | 9530 | HOLBROOK NURSING HOME | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2011-05-24 | 248 | D | 0 | 1 | OXPS11 | Based on observation, record review, resident interview, and staff interview, the facility failed, for two (2) of thirty-seven (37) Stage II sample residents, to provide a program of activities to meet the stated interests of the residents, in accordance with the comprehensive assessment. The comprehensive assessment process identified activities the residents felt were very important to them when interviewed by staff. The activity programs designed for these residents did not include these activities. Resident identifiers: #120 and #85. Facility census: 103. Findings include: a) Resident #120 During intermittent observations of Resident #120 on 05/11/11 and 05/12/11, the resident was noted to be out of bed in a reclining geri-chair; his was sitting in the hall on one occasion and sitting in the dining room asleep during bingo on another occasion. All other observations of the resident were of him in bed in his room. The resident's most recent minimum data set (MDS), a significant change in status assessment with an assessment reference date (ARD) of 04/07/11, was reviewed. Section F of this document preferences for customary routine and activities was completed with information obtained by staff through interview of the resident. When asked, While you are in this facility. and then given several options of activities and asked to rate how important those activities were to him, this resident's responses included that it was very important to keep up with the news and very important to go outside to get fresh air when the weather is good. The resident's current care plan was last reviewed / revised by the interdisciplinary team on 04/13/11, following completion of the significant change in status MDS of 04/07/11. The care plan made no mention of either assisting the resident to keep up with the news or of assisting the resident to go outdoors as weather permits. The activity director (Employee #93), when interviewed on 05/10/11 at 10:30 a.m. related to this concern, stated Resident #120's likes changed from day t… | 2015-10-01 |
| 9531 | 9531 | HOLBROOK NURSING HOME | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2011-05-24 | 279 | D | 0 | 1 | OXPS11 | Based on record review and staff interview the facility failed, for one (1) of thirty-seven (37) Stage II sample residents, to develop an activity care plan which integrated the results of the resident's comprehensive assessment. Resident #120's care plan made no mention of activities stated by the resident to be very important to him and his life in the facility. Facility census: 103. Findings include: a) Resident #120 During intermittent observations of Resident #120 on 05/11/11 and 05/12/11, the resident was noted to be out of bed in a reclining geri-chair; his was sitting in the hall on one occasion and sitting in the dining room asleep during bingo on another occasion. All other observations of the resident were of him in bed in his room. The resident's most recent minimum data set (MDS), a significant change in status assessment with an assessment reference date of 04/07/11, was reviewed. Section F of this document preferences for customary routine and activities was completed with information obtained by staff through interview of the resident. When asked, While you are in this facility. and then given several options of activities and asked to rate how important those activities were to him, this resident's responses included that it was very important to keep up with the news and very important to go outside to get fresh air when the weather is good. The resident's current care plan was last reviewed / revised by the interdisciplinary team on 04/13/11, following completion of the significant change in status MDS of 04/07/11. The care plan made no mention of either assisting the resident to keep up with the news or of assisting the resident to go outdoors as weather permits. The activity director (Employee #93), when interviewed on 05/10/11 at 10:30 a.m. related to this concern, stated Resident #120's likes changed from day to day but confirmed the current care plan did not include activities the resident had stated were important to him, as mentioned in the comprehensive assessment. | 2015-10-01 |
| 9532 | 9532 | HOLBROOK NURSING HOME | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2011-05-24 | 329 | D | 0 | 1 | OXPS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed, for one (1) of thirty-seven (37) Stage II sample residents, to provide physician-ordered monitoring following a change in her medication regimen. The resident's diuretic medication was decreased, an antidepressant was added, and the attending physician ordered orthostatic vital signs to be monitored twice daily for three (3) days. This monitoring was not completed as ordered. Resident identifier: #65. Facility census: 103. Findings include: a) Resident #65 The medical record review, on 05/16/11, revealed this [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed a physician's progress note, dated 04/07/11, stating: Staff report decline in amb (ambulation) function. On this date, the physician wrote orders for a decrease in the dosage of the resident's [MEDICATION NAME] (a diuretic) and added the medication [MEDICATION NAME] (an antidepressant) to her medication regimen. Along with the medication changes, the physician ordered: Orthostatic VSS (vital signs) BID (twice daily) x 3 days. The medical record revealed no evidence these orthostatic vital signs had been monitored as ordered. The director of nurses (DON - Employee #1), when interviewed on 05/17/11 at 3:35 p.m., reviewed the resident's medical record and other facility records and confirmed this monitoring had not been completed as ordered. | 2015-10-01 |
| 9533 | 9533 | HOLBROOK NURSING HOME | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2011-05-24 | 356 | C | 0 | 1 | OXPS11 | Based on observation, review of the facility's staff posting, and staff interview, the facility's nursing staff posting did not follow the acceptable format. The total number of licensed nursing personnel included nursing personnel that did not provide direct care to residents. This had the potential to affect all residents and visitors. Facility census: 103. Findings include: a) Nursing staffing information, observed as posted daily by the facility throughout the survey, included the director of nursing (DON), minimum data set (MDS) nurse, and the staff development nurse. The posting requirement is that the numbers and hours of licensed and unlicensed nursing staff directly responsible for resident care per shift be clearly posted and readily accessible to residents and visitors. The hours worked by the DON, MDS nurse, and staff development nurse should not have been included in these totals. During an interview with the DON (Employee #1) on 05/23/11 at 10:05 a.m., she confirmed that, although the hours worked by the DON, MDS nurse, and staff development nurse were not being included in the posted direct care hours, they were included in the posted total numbers of licensed staff. | 2015-10-01 |
| 9534 | 9534 | HOLBROOK NURSING HOME | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2011-05-24 | 364 | E | 0 | 1 | OXPS11 | Based on observation and staff interview, the facility failed to ensure the palatability and attractiveness of pureed foods being served to residents. This has the potential to affect any resident receiving pureed consistency foods. Facility census: 103. Findings include: a) During observation of the food service in the kitchen at 11:45 a.m. on 05/16/11, the pureed food offerings were of varying consistencies. Many of the residents were served their food items in individual bowls, and this surveyor observed there was no form to some of the foods. When the first plate was used for a resident receiving pureed foods, the pureed chicken held form and was of an acceptable pureed consistency, but the bread was loose and held no form, and the green beans were of the consistency of a thick soup and spread out over the plate running into the meat and bread. When this was pointed out to the dietary manager (Employee #101), who was present, she stated the thinness was preferred by the speech therapist (Employee #161), but she did agree the food items were thin and, when placed on a plate, lacked visual appeal. During an interview with the speech therapist (Employee #161) at 1:00 p.m. on 05/17/11, she stated the pureed foods should have the consistency of mashed potatoes and should definitely have a visual appearance that reminds the resident of the foods they have eaten during their life. She stated there were a few residents who needed thinner foods and, for these residents, she requested a thinned-pureed diet which was to be served in individual bowls. There had only been one (1) consistency of each of the pureed foods during observation of the noon meal service on 05/16/11. In a follow-up visit to the kitchen during the noon meal service at 11:40 a.m. on 05/23/11, the pureed foods were green beans, meatloaf, bread, and mashed potatoes. They were all of acceptable consistency and did not run together on the plates. Employee #101 agreed that the food's appearance on the plate was improved. She also acknowledged there were … | 2015-10-01 |
| 9535 | 9535 | HOLBROOK NURSING HOME | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2011-05-24 | 371 | F | 0 | 1 | OXPS11 | Based on observation and staff interview, the facility failed to assure the proper sanitation and food handling by not dating the opening of bulk dry food and by not resealing the packages after opening. This had the potential to affect all residents. Facility census: 103. Findings include: a) During the initial tour of the dietary department at 12:45 p.m. on 05/11/11, observation found a 5-pound paper package of cornbread mix and a 5-pound paper package of spice cake mix on shelves in the dry storage area. These packages had been opened and not closed / re-sealed or dated. These observation were pointed out to the dietary manager (Employee #101), who was present at the time. She offered no excuse and removed both packages and discarded them. | 2015-10-01 |
| 9536 | 9536 | HOLBROOK NURSING HOME | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2011-05-24 | 431 | E | 0 | 1 | OXPS11 | Based on observation, record review, policy and procedure review, and staff interview, the facility failed to assure resident medications were stored under proper temperature control. Medication refrigerator temperatures were not being monitored by staff as mandated by facility policy. This practice has the potential to affect any resident on the 100-200 hall who may receive a medication that requires a controlled storage temperature. Facility census: 103. Findings include: a) Observation of the 100-200 Hall medication storage refrigerator, on 05/19/11 at 8:51 a.m., found facility staff was not monitoring the temperatures of this refrigerator on a consistent basis. At the time of this observation, the thermometer inside the refrigerator read 40 degrees Fahrenheit (F), and the contents of the refrigerator included multi-dose vials of insulin for several residents as well as Phenergan rectal suppositories. Refrigerated medications are to be maintained in a temperature range of 36 to 46 degrees F. The temperature monitoring log on the 100-200 Hall revealed the following entries: - On 05/12/11 - a temperature of 32 degrees F with no corrective action. - On 05/13/11 at 1:45 p.m. - a temperature of 40 degrees F. There were no other temperatures recorded in the month of May 2011, and there were no other log sheets available in the medication room. Review of the facility's policy and procedure titled Medication Room (revised May 2011) found, under the heading Procedure, the following: 4. The medication refrigerator is for medications only and must be monitored to assure that medications are stored at a proper temperature. a. Temperatures will be monitored daily on the night shift and recorded on the temperature log. b. Any temperature that cannot be maintained within range must be adjusted and, if necessary, reported to the maintenance department. In an interview conducted at 9:25 a.m. on 05/23/11, the director of nursing (DON - Employee #1) agreed the staff did not follow the facility's Medication Room policy and proced… | 2015-10-01 |
| 9537 | 9537 | HOLBROOK NURSING HOME | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2011-05-24 | 441 | F | 0 | 1 | OXPS11 | Based on observation and staff interview, the facility failed to implement infection control measures to prevent the development and transmission of disease and infection related to the handling of soiled linen and soiled resident equipment and the storage of an ice scoop. These practices had the potential to affect the entire resident population. Facility census: 103. Findings include: a) During the initial tour of the facility at 12:45 p.m. on 05/11/11, observation found Resident #41 sitting on his bed eating lunch in his room. At the foot of his bed were urine-soaked linens. Immediately following this observation, a nursing assistant (NA - Employee #41) was asked about the resident and why he was eating with soiled linens on his bed. The NA stated, Yes, we did a complete change because he was soaking wet, and the trays came out, and we can't take linen out when the trays are on the floor. At 1:00 p.m. on 05/11/11, two (2) additional NAs were interviewed (Employees #55 and #88), and these employees confirmed the soiled linens were on the resident's bed and stated soiled linens cannot be removed when trays are on the floor, but they are to be placed in a plastic bag for removal until that time. In an interview conducted at 9:25 a.m. on 05/23/11, the director of nursing (DON - Employee #1) agreed the NAs were not to leave soiled linens in the residents' rooms for any reason. -- b) During initial tour of the facility at 1:15 p.m. on 05/11/11, in the bathroom shared by rooms #110 and #112, a urine measuring device was found on the back of the toilet with crystallized dried urine in the bottom of the urine measuring device. Immediately following this observation, Employee #41 was shown the urine measuring device. The NA stated she did not know why it was there and would get gloves and remove it. In an interview conducted at 9:25 a.m. on 05/23/11, the DON agreed the device should have been disposed of following use. -- c) A facility nutrition room adjoining 300 and 400 wings of the facility was observed during a rand… | 2015-10-01 |
| 9538 | 9538 | WEIRTON MEDICAL CENTER, D/P | 515077 | 601 COLLIERS WAY | WEIRTON | WV | 26062 | 2011-02-15 | 164 | D | 0 | 1 | PL2X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide privacy to one (1) of eighteen (18) sampled residents during a medical treatment. Employee # was doing a medical treatment to the elbows of Resident #194. During the treatment observation, the resident's room door to the public hallway was not closed, and the privacy curtain was not pulled to ensure personal privacy and confidentiality. Resident identifier: #194. Facility census: 27. Findings include: a) Resident #194 During a treatment observation on 02/08/11, at 11:15 a.m., a licensed practical nurse (LPN - Employee # ) applied treatments to [MEDICAL CONDITION] on the elbows of Resident #194, prior to which the LPN failed to provide privacy and confidentially by failing to close the door to the public hallway or pull the privacy curtain. Also during this observation, other residents were noted to be ambulated in the hall way by physical therapy, and visitors were passing the resident's room door. During an interview on 02/09/11 at 1:30 p.m., the director of geriatric services (Employee #5291) confirmed the nurse should have provided privacy for the resident when doing these treatments. | 2015-10-01 |
| 9539 | 9539 | WEIRTON MEDICAL CENTER, D/P | 515077 | 601 COLLIERS WAY | WEIRTON | WV | 26062 | 2011-02-15 | 272 | E | 0 | 1 | PL2X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the interdisciplinary team completed comprehensive assessments, to include the care area assessment summaries (CAASs - Section V0200), for five (5) of twenty-two (22) Stage II sample residents. Resident identifiers: #19, #79, #172, #185, and #190. Facility census: 27. Findings include: a) Residents #185 and #19 1. Resident #185 During a Stage I staff interview on 02/07/11 at 9:37 a.m., the minimum data set (MDS) assessment nurse (Employee # ) indicated Resident #185 fell at home and sustained a subdural hematoma before entering the facility. Review of the face sheet in the resident's medical record found the resident fell around 01/09/11 but could not remember exactly when. Review of the MDS, with an assessment reference date (ARD) of 01/30/11, found in Section G0110 the assessor indicated the resident required the limited assistance of two (2) or more persons for walking in the room / corridor found. In Section G0300, the assessor encoded 2, indicating the resident's balance was not steady (only able to stabilize with human assistance) for walking, turning around, and surface-to-surface transfers. In Section J1700, the assessor indicated the resident fell within the last month prior to admission and within the last two (2) to four (4) months of admission. In Section J1800, the assessor indicated the resident had falls since admission or prior assessment, but during the above interview with Employee # , the nurse reported the resident had not had any falls since his admission to the facility on [DATE]. Review of Section V0200 found the care area for Falls had triggered for further assessment, but the person completing this section did not indicate that Falls would be addressed on the resident's care plan, and there was no information to indicate the location and date regarding the Falls CAA information. Additionally, the signature lines for registered nurse (RN)… | 2015-10-01 |
| 9540 | 9540 | WEIRTON MEDICAL CENTER, D/P | 515077 | 601 COLLIERS WAY | WEIRTON | WV | 26062 | 2011-02-15 | 356 | C | 0 | 1 | PL2X11 | Based on observation and staff interview, the facility failed to ensure that accurate nursing staffing information was posted for the 3-11 shift on 02/06/11, as required. This had the potential to affect any resident or visitor wishing to access nursing staffing data on the skilled nursing unit (SNU). Facility census: 27. Finding include: a) Observations, on 02/06/11 at 6:00 p.m., found the nursing staffing data sheet posted by the elevator of the SNU for the afternoon shift was blank. An interview with the unit secretary (Employee # ) at this time confirmed that the posting had not been updated. | 2015-10-01 |
| 9541 | 9541 | WEIRTON MEDICAL CENTER, D/P | 515077 | 601 COLLIERS WAY | WEIRTON | WV | 26062 | 2011-02-15 | 371 | F | 0 | 1 | PL2X11 | Based on observation, staff interview, and facility policy review, the facility failed to ensure one (1) of six (6) dietary staff members, observed during the evening meal of 02/07/11, employed appropriate hand hygiene practices during meal preparation and service. This had the potential to affect all residents. Facility census: 27. Findings include: a) Observations made in the dietary department, during preparation of the evening meal at 5:00 p.m. on 02/07/11, found a food service worker (Employee # ) helping prepare the trays on the tray line. The employee sneezed several times into the sleeve of her uniform and then went to sink and washed her hands. She shut off the water with her bare hands without first obtaining a paper towel (thereby recontaminating her hands). She then obtained two (2) paper towels, dried her hands, and carried the paper towels with her back to her position at the end of the tray line. She put the used paper towels on a shelf (on which plates were stored) beside where she was standing and began to work on the tray line again. The director of support services (Employee # ) was interviewed on 02/14/11 at 11:55 a.m., and the findings of the observation were shared with her. A copy of the Department of Food and Nutrition Services Policy for Handwashing (dated 07/09/90 and reviewed on 08/10) stated, 1. Use soap and warm water; 2. Rub hands together for 20 seconds; 3. Rinse thoroughly and dry; 4. Turn faucet off with towel rather than clean hands. | 2015-10-01 |
| 9542 | 9542 | WEIRTON MEDICAL CENTER, D/P | 515077 | 601 COLLIERS WAY | WEIRTON | WV | 26062 | 2011-02-15 | 441 | E | 0 | 1 | PL2X11 | Based on observation, policy review, and staff interview, the facility failed to ensure a sanitary environment was maintained by failing to ensure nursing staff washed their hands after removing contaminated gloves in accordance with facility policy and after each resident contact for which hand washing is indicated by accepted professional practice. This practice had the potential to all residents who were assigned to Employee # on day shift on 02/07/11. Facility census: 27. Findings include: a) During the medication pass observation on 02/07/11 at 9:20 a.m. in the room of Resident #200, a nursing assistant (NA - Employee # ) was observed emptying a potty chair for Resident #200 while wearing gloves. The employee removed these gloves but failed to wash her hands with soap and water or use an alcohol-based hand sanitizer. The employee then made the resident's bed and arranged the bedside table of for the resident. The employee exited the room without washing or sanitizing her hands, removed clean linen from the linen cart in the hallway, and proceeded into another room and began making the bed of another resident. Employee # was assigned to provide care to seven (7) of eighteen (18) sampled residents on this unit. Review of the facility's policy on the use of gloves (dated January 1985) found Item #4 on page 3 which stated, Wash hands thoroughly, as soon as possible after glove removal. During an interview on 02/09/11 at 1:30 p.m., the director of geriatric services (Employee #5291) confirmed the NA should have washed her hands after removing the gloves and also before proceeding into another resident's room. | 2015-10-01 |
| 9543 | 9543 | WEIRTON MEDICAL CENTER, D/P | 515077 | 601 COLLIERS WAY | WEIRTON | WV | 26062 | 2011-02-15 | 463 | L | 0 | 1 | PL2X11 | Based on observation, family interview, staff interview, and a review of the facility's disaster plan and other records, the facility failed to provide a fully functional nurse call system (with both audible and visual signaling components of the system working as designed) and failed to provide an alternate means of communication to allow residents to summon nursing staff from their rooms, toilets, and bathing facilities when the facility disabled the audible signal component of the nurse call system due to a malfunction. This placed all of twenty-seven (27) residents on this skilled nursing unit (SNU) at in immediate jeopardy due to an inability to summon staff in the event of an emergency. Staff interview revealed the nurse call system went down during a power outage at 6:00 a.m. on 01/28/11. During this power outage, the unit director distributed tap bells to all residents on the SNU as an alternate means of summoning staff when the nurse call system. When the power was restored, these tap bells were collected from the residents after the power was restored at 6:30 a.m. on 01/28/11. After the power was restored on 01/28/11, the emergency nurse call system for two (2) bathrooms located on the SNU malfunctioned, causing the audible signal to the nurse call system for the SNU to sound continuously. The audible signal to the nurse call system was disabled due to its continuous ringing; however, tap bells were not redistributed to all residents as an alternate of summoning staff while the audible signal was disabled. The entire SNU was without a fully functioning nurse call system with an audible signal that would sound at the nurse's station (to alert staff of a resident's need for assistance) since 01/28/11, with no alternate means provided to residents to allow them to summon staff in the event of a resident need or an emergency. Family interview, staff interview, and direct observation, on 02/09/11, verified the audible signal component of the nurse call system was still disabled and no alternate means of comm… | 2015-10-01 |
| 9544 | 9544 | WEIRTON MEDICAL CENTER, D/P | 515077 | 601 COLLIERS WAY | WEIRTON | WV | 26062 | 2011-02-15 | 490 | L | 0 | 1 | PL2X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family interview, staff interview, and a review of the facility's disaster plan and other records, the facility's governing body failed to ensure the skilled nursing unit (SNU) was administered in an effective and efficient manner to maintain the highest practicable well-being of each resident. The facility failed to provide a fully functional nurse call system (with both audible and visual signaling components of the system working as designed) and failed to provide an alternate means of communication to allow residents to summon nursing staff from their rooms, toilets, and bathing facilities when the facility disabled the audible signal component of the nurse call system due to a malfunction. This placed all of twenty-seven (27) residents on this SNU at in immediate jeopardy due to an inability to summon staff in the event of an emergency. Staff interview revealed the nurse call system went down during a power outage at 6:00 a.m. on 01/28/11. During this power outage, the unit director distributed tap bells to all residents on the SNU as an alternate means of summoning staff when the nurse call system. When the power was restored, these tap bells were collected from the residents after the power was restored at 6:30 a.m. on 01/28/11. After the power was restored on 01/28/11, the emergency nurse call system for two (2) bathrooms located on the SNU malfunctioned, causing the audible signal to the nurse call system for the SNU to sound continuously. The audible signal to the nurse call system was disabled due to its continuous ringing; however, tap bells were not redistributed to all residents as an alternate of summoning staff while the audible signal was disabled. The entire SNU was without a fully functioning nurse call system with an audible signal that would sound at the nurse's station (to alert staff of a resident's need for assistance) since 01/28/11, with no alternate means provided to residents to allow them to … | 2015-10-01 |
| 9545 | 9545 | WEIRTON MEDICAL CENTER, D/P | 515077 | 601 COLLIERS WAY | WEIRTON | WV | 26062 | 2011-02-15 | 520 | L | 0 | 1 | PL2X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family interview, staff interview, and a review of the facility's disaster plan and other records, the facility's quality assessment and assurance (QAA) committee failed to identify quality deficiencies of which it should have been aware and failed to implement measures to remedy these quality deficiencies. The facility failed to provide a fully functional nurse call system (with both audible and visual signaling components of the system working as designed) and failed to provide an alternate means of communication to allow residents to summon nursing staff from their rooms, toilets, and bathing facilities when the facility disabled the audible signal component of the nurse call system due to a malfunction. This placed all of twenty-seven (27) residents on this skilled nursing unit (SNU) at in immediate jeopardy due to an inability to summon staff in the event of an emergency. Staff interview revealed the nurse call system went down during a power outage at 6:00 a.m. on 01/28/11. During this power outage, the unit director distributed tap bells to all residents on the SNU as an alternate means of summoning staff when the nurse call system. When the power was restored, these tap bells were collected from the residents after the power was restored at 6:30 a.m. on 01/28/11. After the power was restored on 01/28/11, the emergency nurse call system for two (2) bathrooms located on the SNU malfunctioned, causing the audible signal to the nurse call system for the SNU to sound continuously. The audible signal to the nurse call system was disabled due to its continuous ringing; however, tap bells were not redistributed to all residents as an alternate of summoning staff while the audible signal was disabled. The entire SNU was without a fully functioning nurse call system with an audible signal that would sound at the nurse's station (to alert staff of a resident's need for assistance) since 01/28/11, with no alternate means pro… | 2015-10-01 |
| 9546 | 9546 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 154 | D | 0 | 1 | 5V2011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to inform one (1) of twenty-one (21) sampled residents of the potential risks and available alternative treatments relating to bladder elimination. An alert and oriented resident, whose indwelling Foley urinary catheter continued to be used at her request (beyond the time-limited physician's orders [REDACTED]. Resident identifier: 25. Facility census: 157. Findings include: a) Resident #25 Resident #25's medical record, when reviewed on 11/19/09 at 1:30 p.m., revealed a [AGE] year old female who was admitted to the facility on [DATE]. The resident was alert and oriented and had been determined by her physician to possess the capacity to understand and make informed healthcare decisions. The resident was on bedrest due to a fall at home resulting in fractures to the lumbar spine. The physician ordered an indwelling Foley urinary catheter for seven (7) days on 11/01/09 due to excoriation. Resident #25, when observed in bed at 1:45 p.m. on 11/19/09, had in place an indwelling urinary catheter. The resident, when interviewed, reported she did not want the catheter removed until she was off of bedrest and able to ambulate. The director of nurses (DON - Employee #165), when interviewed on 11/20/09 at 3:15 p.m., reported it was the resident's choice to keep the catheter. However, the DON did acknowledge the facility failed to inform the resident of potential risks of continuing to use an indwelling catheter over an extended period of time or alternative treatments available. | 2015-10-01 |
| 9547 | 9547 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 156 | C | 0 | 1 | 5V2011 | Based on observation and staff interview, the facility failed to include the name, address, and telephone number of the State long-term care ombudsman together in its posting of information. This practice had the potential to affect all residents and visitors. Facility census: 157. Findings include: a) On 11/17/09, an observation of the facility's posting in the front lobby, which included names and addresses of individuals who could be contacted for questions related to long term care, revealed the facility had not listed the name of the State long term care (LTC) ombudsman. On 11/20/09 at 4:00 p.m., the administrator agreed the State ombudsman's name needed listed and agreed to change the posting to correct the issue. (NOTE: On 12/02/09, the administrator faxed to the State survey agency a copy of a posting titled Information Services located elsewhere in the facility. While it did contain the State LTC ombudsman's name and telephone number, it did not contain an address. Consequently, an individual who wanted the name, telephone number, and mailing address of the State LTC ombudsman would have had to locate and access both postings to obtain complete contact information.) | 2015-10-01 |
| 9548 | 9548 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 158 | C | 0 | 1 | 5V2011 | Based on review of resident funds, staff interview, and the confidential resident group interview, the facility failed to assure residents had access to petty cash on an ongoing basis. This practice had the potential to affect all residents for whom the facility handled funds. At the time of the survey, the facility handled funds for one hundred-twelve (112) residents. Facility census: 157. Findings include: a) On 11/19/09 at 2:30 p.m., residents' accounts were reviewed with the office manager and the staff member who handled resident funds. At that time, it was revealed residents only had access to their personal funds during the facility's regular business hours and for four (4) hours each Saturday and Sunday. This was confirmed during the confidential resident group meeting held on 11/18/09. | 2015-10-01 |
| 9549 | 9549 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 176 | D | 0 | 1 | 5V2011 | Based on observation and medical record review, the facility failed to assure one (1) of twenty-one (21) facility residents was safe to self-administer drugs prior to allowing the resident to keep medication at the bedside. Resident identifier: #112. Facility census: 157. Findings include: a) Resident #112 During observation of the medication administration pass on 11/17/09 at 10:00 a.m., Resident #112 was overheard telling to the licensed practical nurse (LPN - Employee #195) that the night shift nurse gave her Aspercreme to keep in her room. Employee #195 reported the resident's statement. The assistant administrator (Employee #74) retrieved two (2) used tubes of Aspercreme from the resident's nightstand with her permission. Review of the medical record found the current minimum data set (MDS) with an assessment reference date (ARD) of 09/15/09. Review of this MDS found, in Section S1, the assessor determined the resident was not capable of safe self-administration of medications. | 2015-10-01 |
| 9550 | 9550 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 221 | D | 0 | 1 | 5V2011 | Based on random observation and staff interview, the facility failed to assure each resident was free from physical restraints imposed for staff convenience. Facility personnel allowed a chair alarm to become a physical restraint for one (1) resident of random opportunity. Resident identifier: #32. Facility census: 157. Findings include: a) Resident #32 On 11/17/09 at 4:25 p.m., this resident was observed seated in front of Building 2's nursing station. At 4:26 p.m., the resident began rising from the wheelchair, and an alarm sounded. Employee #7 ( a licensed practical nurse - LPN) immediately looked up and across the nursing station. She loudly said, Ah! Ah! Sit back in your chair! Employee #7 did not attempt to ascertain why the resident wanted up and did not direct anyone else to attempt to determine his needs. Directing the resident to sit down, instead of ascertaining the resident's needs when an alarm sounds, results in that alarm becoming a restraining device for that resident. This information was provided to the director of nursing (DON - Employee #165) at 4:35 p.m. on 11/17/09. At that time, the DON confirmed that staff should have asked the resident what he needed instead of telling the resident to sit back down. | 2015-10-01 |
| 9551 | 9551 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 224 | E | 0 | 1 | 5V2011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure residents received treatments as prescribed by their physicians. This was true for three (3) of twenty-one (21) sampled residents and six (6) random residents. There was no evidence these nine (9) residents received their scheduled treatments on 11/14/09 (7:00 a.m. - 7:00 p.m. shift) as prescribed by the physician. Resident identifiers: #16, #15, #24, #33, #42, #76, #78, #111, and #112. Facility census: 157. Findings include: a) Resident #16 Resident #16 was observed on 11/17/09 at 9:35 a.m. in his room. The treatment nurse (a registered nurse - Employee #122) was observed changing the dressing on his left lower leg. The existing dressing was observed to be dated 11/11/09. The treatment nurse confirmed the date on the dressing to be 11/11/09 and then removed the dressing which had been covering a skin tear. The area was observed to be scabbed over and free from any redness or drainage. The treatment nurse reviewed the November 2009 treatment sheet and reported the dressing was scheduled to be changed on 11/14/09. The treatment nurse reported the treatment was not initialed on 11/14/09, which would have indicated the treatment was completed as ordered by the physician. Resident #16's medical record, when reviewed on 11/17/09 at 10:30 a.m., confirmed the physician had ordered the following treatments: Cleanse area to (L) Shin with NSS, pat dry, apply OpSite Q3days (every three days) and PRN (as needed), Moisture Barrier to coccyx BID (twice daily), Moisture Barrier to ABD fold BID, and Check O2 SAT QS (every shift) if below 90% notify MD. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator (Employee #78), when interviewed on 11/18/09 at 4:35 p.m., stated the treatment nurse (Employee #122) reported the omission of the treatments to … | 2015-10-01 |
| 9552 | 9552 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 241 | D | 0 | 1 | 5V2011 | Based on observation, resident interview, and staff interview, the facility failed to ensure the grooming needs of one (1) resident of random opportunity were promptly addressed. Resident identifier: #95. Facility census: 157. Findings include: a) Resident #95 On 11/18/09 at approximately 10:30 a.m., observation of Resident #95 revealed she had long hair on her chin. The resident related she had a broken left shoulder, which prevented her from doing things like trimming the hair on her chin. She said she would like to have the hair removed. On 11/18/09 at approximately 11:00 a.m., the registered nurse (Employee #146) was informed the resident wished to have the hair removed. She indicated they would assist the resident with the hair removal. | 2015-10-01 |
| 9553 | 9553 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 281 | D | 0 | 1 | 5V2011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of the West Virginia Nurse Practice Act, the facility failed to meet professional standards of care for one (1) of twenty-one (21) sampled residents. The facility's nursing staff failed to follow a physician's orders [REDACTED]. Facility census :157. Resident identifier: #25. Findings include: a) Resident #25 Resident #25's medical record, when reviewed on 11/19/09 at 1:30 p.m., revealed a [AGE] year old female who was admitted to the facility on [DATE]. The resident was alert and oriented and had been determined by her physician to possess the capacity to understand and make informed healthcare decisions. The resident was on bedrest due to a fall at home resulting in fractures to the lumbar spine. The physician ordered an indwelling Foley urinary catheter for seven (7) days on 11/01/09 due to excoriation. No additional physician's orders [REDACTED]. Resident #25, when observed in bed at 1:45 p.m. on 11/19/09, had in place an indwelling urinary catheter. The resident, when interviewed, reported she did not want the catheter removed until she was off of bedrest and able to ambulate. Staff interview with the director of nurses (DON - Employee #165), on 11/20/09 at 3:15 p.m., confirmed the resident did not have a current physician's orders [REDACTED]. According to the West Virginia Nurse Practice Act for Registered Professional Nurses (W.V.C. 30-70-1), Registered professional nursing shall mean the performance for compensation of any service requiring substantial specialized judgement and skill based on knowledge and application of principles of nursing derived from biological, physical and social sciences, such as responsible supervision of a patient requiring skill in observation of symptoms and reactions and the accurate recording of the facts, or the supervision and teaching of other persons with respect to such principles of nursing, or in the administration of medications and… | 2015-10-01 |
| 9554 | 9554 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 309 | D | 0 | 1 | 5V2011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed, for three (3) of twenty-one (21) sampled residents with orders to have their heels floated and/or the application of pressure relieving devices, to provide necessary care and services to assure their heels were free from unrelieved pressure. Resident identifiers: #19, #118, and #15. Facility census: 157. Findings include: a) Resident #19 Review of Resident #19's medical record found a physician's orders [REDACTED]. Observations, conducted with the assistance of a nursing staff member (Employee #187) on 11/17/09 at 3:40 p.m., found a pillow had been placed beneath Resident #19's feet. The resident's right heel was resting on the pillow, and the left heel was resting directly on the bed. Employee #187 agreed the resident's heels were not being floated. b) Resident #118 Review of Resident #118's medical record found a 10/28/09 physician's orders [REDACTED]. Further review found a physician's orders [REDACTED]. 1. Observations, conducted with the assistance of a nursing staff member (Employee #187) on 11/17/09 at 3:40 p.m., found a pillow had been placed beneath Resident #118's feet. The pillow had flattened and allowed the resident's right heel to rest on the bed. Employee #187 stated the facility was utilizing specialized pillows to float residents' heels and were doing away with the HeelzUp devices. She agreed the pillow in place at the time of this observation was not assuring the resident's heels were floated. 2. During random observations of the facility on 11/19/09 at 3:15 p.m., Resident #118 was found in a geriatric chair in the main dining room. No heel lift boot was on her left foot. A subsequent observation, in the main dining room at 12:00 p.m. on 11/20/09, found Resident #118 in a geri chair with no heel lift boot on the resident's left foot as ordered by the physician. c) Resident #15 Medical record review revealed this resident had a physician's … | 2015-10-01 |
| 9555 | 9555 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 315 | D | 0 | 1 | 5V2011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, policy review, and staff interview, the facility failed to assure one (1) of twenty-one (21) sampled residents received services to restore as much normal bladder function as possible. This resident's bladder incontinence was not assessed, and interventions were not implemented to assist the resident to restore or improve normal bladder function. Resident identifier: #57. Facility census: 157. Findings include: a) Resident #57 Medical record review, on 11/17/09, revealed this resident was admitted to the facility on [DATE]. The admission minimum data set noted the resident was frequently incontinent of bladder. Review of the medical record revealed a bladder patterning and analysis worksheet dated 10/26/09 - 10/28/09, which had been only sporadically completed. On 11/18/09, the director of nursing (DON) was asked if additional information might be available. At 12:00 p.m. on 11/18/09, the DON reported it was facility policy to begin a bladder assessment upon admission and that the appropriate form was included in the admission information for every resident. The policy was provided and reviewed with the DON. At that time, the DON confirmed the policy had not been implemented for Resident #57; she also confirmed the assessment, which was started on 10/26/09, had also not been completed as required by facility policy. During an interview with the resident at 3:15 p.m. on 11/18/09, the resident's bladder incontinence was discussed. The resident stated she usually could feel the urge to urinate. Further interview revealed the resident would like an opportunity to be evaluated to determine to what extent her continence might be restored. | 2015-10-01 |
| 9556 | 9556 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 332 | D | 0 | 1 | 5V2011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to assure residents were free of a medication error rate of five percent (5%) or greater. Nurses failed to give ordered medication or failed to give the correct dosage of medication to two (2) of seven (7) randomly observed residents. This resulted in five (5) medication errors with an opportunity for forty (40) errors. The medication error rate was twelve and eight-tenths percent (12.8%). Resident identifiers: #112 and #66. Facility census: 157. Findings include: a) Resident #112 During observations of the medication administration pass on 11/17/09, the licensed practical nurse (LPN - Employee #195), when preparing medications for Resident #112, skipped a page in the medication administration record (MAR). The LPN did not administer [MEDICATION NAME] 40 mg, [MEDICATION NAME] 17 GM, a multivitamin, and [MEDICATION NAME] 3000 units. She did, however, initial the MAR to indicate she had administered these medications. After observing the nurse administer medications to Resident #13, she was asked to review the MAR for Resident #112. She was shown the page with the five (5) medications which she had initialed but not administered. She agreed she had missed this page when preparing the medications. b) Resident #66 During observations of the medication pass on 11/17/09 at 7:30 a.m., the LPN (Employee # 54), while preparing Resident #66's 8:00 a.m. medications, poured one (1) 25 mg tablet of [MEDICATION NAME] into the medication cup. The LPN then administered the medication to the resident. Resident #66's medical record, when reviewed on 11/17/09 at 8:15 a.m., indicated the physician had ordered [MEDICATION NAME] 75 mg twice a day. Employee #54, when interviewed on 11/17/09 at 8:20 a.m., confirmed the resident did not receive 75 mg of [MEDICATION NAME] as ordered by the physician. The LPN stated, I am going to give her the other two tablets now. | 2015-10-01 |
| 9557 | 9557 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 356 | C | 0 | 1 | 5V2011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Review of the POS [REDACTED]. Additionally, the nurse staffing data was not posted in a clear and readable format. These deficient practices had the potential to affect all residents and visitors to the facility. Facility census: 157. Findings include: a) Random observations of the facility entrance, on 11/17/09 at 10:30 a.m., found the facility had posted the nurse staffing data in a locked display case. Review of the POS [REDACTED]. Further review revealed the nurse staff data included three (3) registered nurses (RNs) on the day shift. An interview with the staffing and scheduling coordinator (Employee #145) was conducted at 11:00 a.m. on 11/17/09. When asked about the nature of the job duties performed by the three (3) RNs listed on the posting, she relayed one (1) of the RNs did treatments and the other two (2) were unit managers. When prompted, Employee #145 was unable to state any resident direct care provided by these two (2) RN unit managers. An interview with the unit manager of building 2 (Employee #40), on the afternoon of 11/19/09, elicited what duties the unit manager routinely performed. Employee #40 stated when she first comes on duty, she checks physician's orders [REDACTED]. She relayed that a part of her shift consisted of any intravenous sticks, flushing ports, and occasional feeding of residents at lunch and dinner. The facility posting indicated all duties performed by these two (2) RN unit manager constituted direct care, which was not the case. Further Review of the POS [REDACTED]. When interviewed at 11:00 a.m. on 11/17/09, Employee #145 identified this posting to mean seven (7) LPNs and one (1) treatment nurse. Posting Tx to represent an additional LPN would not be clear to residents and visitors without medical backgrounds. The facility failed to assure that only nurse staffing hours devoted to direct care were posted as required, and failed to assure the staffing data was posted at the beginni… | 2015-10-01 |
| 9558 | 9558 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 364 | F | 0 | 1 | 5V2011 | Based on taste testing, recipe review, and staff interview, the facility failed to assure foods were flavorful. Seasoning was not added as required by recipes for three (3) food products which were sampled. This practice had the potential to affect all residents who were provided nourishment from the dietary department. Facility census: 157. Finding include: a) At 11:20 p.m. on 11/18/09, foods were sampled for seasoning. Mashed potatoes, pureed broccoli, and regular broccoli did not appear to be well seasoned. The assistant dietary manager (ADM) was asked to taste test these products. The ADM tasted the products and stated the products needed more salt. At that time the ADM directed the cook to add salt to the products. Review of the recipes for these food products revealed specific directives for seasonings. Upon inquiry, the cook confirmed the recipes for these food products had not been followed that day. | 2015-10-01 |
| 9559 | 9559 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 368 | F | 0 | 1 | 5V2011 | Based on observation, review of the facility's meal schedule, and staff interview, the facility failed to assure there were no more than fourteen (14) hours between a substantial evening meal and breakfast the following day. The span between these meals was actually greater than fifteen (15) hours. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 157. Findings include: a) On 11/18/09 at 4:25 p.m., residents who resided in Building #1 were observed to have already been served the evening meal in the dining room. Review of the facility's meal schedule revealed the meals had been served according to the schedule. Further review of the schedule revealed each area for meal service was scheduled for greater than fifteen (15) hours between the evening meal and breakfast the following day. Interview with the administrator, on 11/19/09 at 3:00 p.m., revealed she was not aware the meal span requirement was that each resident was to have no more than fourteen (14) hours between the evening meal and breakfast the following day without each resident receiving a nourishing snack and without agreement from a resident group. | 2015-10-01 |
| 9560 | 9560 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 371 | F | 0 | 1 | 5V2011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 157. Findings include: a) During the initial tour of the dietary department on 11/16/09 at 1:30 p.m., a dietary employee (#171) was observed [MEDICATION NAME] no sanitation techniques and was contaminating the kitchen area as follows: 1. She touched the inside of a waste can when she tossed something into the can and then did not wash her hands. She then walked to the area where the menu was kept and touched the menu. Next she walked over to a food cart containing foods ready to be served and pushed it to another area. 2. Employee #171 was then observed washing dishes. She washed her hands, but there was no waste can in the area. When it was not clear as to how she had disposed of the paper towels, an inquiry was made of her at 1:40 p.m. on 11/16/09. She stated she had thrown the paper towels into the large barrel just outside the dish room door. The barrel was noted to be covered. Upon inquiry, Employee #171 demonstrated that she had opened the cover with her plastic apron. After this demonstration, she was observed in the walk-in cooler pushing a cart containing food ready to be served while wearing the contaminated apron. Further inquiry revealed she had also not changed her apron the first time she lifted the trash barrel lid with the apron. b) At 1:50 p.m., another dietary employee was observed using a cleaning cloth which had been obtained from the cleaning cloth container. Upon inquiry, this person stated she had not prepared the solution in the container, so she did not know whether or not the water in it contained any t… | 2015-10-01 |
| 9561 | 9561 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 428 | E | 0 | 1 | 5V2011 | Based on record review and staff interview, the facility failed to ensure the pharmacist's report of irregularities was reviewed and acted upon by the attending physician in a timely manner. This was true for four (4) of twenty-one (21) sampled residents. Physicians were not notified of drug irregularities by the pharmacist in a timely manner. Resident identifiers: #77, #89, #57, and #95. Facility census: 157. Findings include: a) Resident #77 Resident #77's medical record, when reviewed on 11/16/09 at 4:00 p.m., indicated the consulting pharmacist reviewed the resident's drug regimen on 10/29/09 and identified a drug irregularity. The recommendation sheet was not found in the medical record. The director of nurses (DON - Employee #165), when interviewed on 11/20/09 at 11:25 a.m., confirmed the pharmacist's report of irregularities, dated 10/29/09, was not present and available for the physician to review in the medical record. The DON reported the pharmacist failed to send the report to the facility and attending physician in a timely manner. b) Resident # 89 Resident #89's medical record, when reviewed on 11/17/09 at 3:00 p.m., indicated the consulting pharmacist reviewed the resident's drug regimen on 10/28/09 and identified a drug irregularity. The recommendation sheet was not found in the medical record. The DON, when interviewed on 11/20/09 at 11:25 a.m., confirmed the pharmacist's report of irregularities, dated 10/28/09, was not present and available for the physician to review in the medical record. The DON reported the pharmacist failed to send the report to the facility and attending physician in a timely manner. c) Resident #57 Medical record review, on 11/17/09, revealed the consultant pharmacist indicated an irregularity had been identified on 10/28/09, and this information was recorded on the consultation report. This report had not been provided by the pharmacist until the DON asked for it upon request of the surveyor. d) Resident #95 The medical record review for Resident #95, conducted on 11/20/… | 2015-10-01 |
| 9562 | 9562 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 431 | E | 0 | 1 | 5V2011 | Based on observation, staff interview, and review of the manufacturer's package insert, the facility failed to date a multi-dose vial of Aplisol (Mantoux) when opened. This was true for one (1) medication refrigerator observed. One (1) multi-dose vial of Aplisol (Mantoux), was not labeled with the date the medication vial was initially opened. The manufacturer recommends the medication be discarded after thirty (30) days to ensure potency. This practice has the potential to affect all residents reside in the unit who received Aplisol (Mantoux) injections. Facility census: 157. Findings include: a) On 11/17/09 at 11:00 a.m., the medication refrigerator in building #1 was observed to have one (1) open multi-dose vial of Mantoux which was not labeled with the date the vial was initially opened. The director of nurses (DON - Employee #165), when interviewed on 11/17/09 at 4:30 p.m., observed the vial in the medication refrigerator and confirmed the Mantoux vial was opened and not labeled with the date opened. The DON discarded the vial. The DON, when interviewed on 11/20/09 at 2:30 p.m., reported the facility did not have a written policy regarding dating multi-dose vials of medications. The DON, when interviewed again on 11/20/09 at 3:00 p.m., provided a copy of the manufacturer's package insert. The manufacturer's package insert from JHP Pharmaceuticals states: Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. The DON confirmed multi-dose vials of Mantoux needed to be dated to ensure the medication's effectiveness. | 2015-10-01 |
| 9563 | 9563 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 441 | E | 0 | 1 | 5V2011 | Based on observation and staff interview, the facility failed to assure each staff member implemented practices to limit the potential spread of infections. A housekeeping aide did not utilize proper hand sanitization prior to completing ice pass. This practice had the potential to affect all residents who resided on B Hall. Facility census: 157. Findings include: a) At 3:40 p.m. on 11/18/09, a housekeeping aide (Employee #198) was observed passing ice on B Hall. Observation revealed she hugged a resident, then resumed passing ice without washing or otherwise sanitizing her hands. This information was immediately brought to the attention of the director of nursing (DON - Employee #165), who intervened and instructed the employee to throw out the ice, sanitize the ice chest and any affected water pitchers, then resume the ice pass with sanitized hands. Upon inquiry at 3:45 p.m. on 11/18/09, the DON confirmed the employee had not washed or hands or sanitized them by any other means. | 2015-10-01 |
| 9564 | 9564 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 492 | F | 0 | 1 | 5V2011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on medical record review and staff interview, it was determined the facility failed to provide information regarding hospice to one (1) of twenty-one (21) sampled residents. This resident had an order for [REDACTED].C.16-5C-20. Resident identifier: #5. Facility census: 157. Findings include: a) Resident #5 Medical record review, on 11/19/09, revealed the physician had ordered comfort measures only on 09/25/09. At that time, the facility did not provide information regarding hospice. The resident's physical condition improved, and the health care surrogate decided not to continue with comfort measures only. The resident's physical condition subsequently declined again. A care plan meeting was held, with the surrogate present, on 10/09/09. At that time, the surrogate decided comfort measures only was in the best interest of the resident. On 10/13/09, the physician ordered, DNR, Comfort Care, and No labs. This information was brought to the attention of the social worker at 9:25 a.m. on 11/20/09. At that time, it was revealed that hospice information had not been provided to the resident / family on either occasion in which comfort measures were ordered. --- Part II -- Based on staff interview and review of individual food service worker's permits, the facility was not in full compliance with local laws regarding food handler's cards. Three (3) of nineteen (19) dietary personnel, who were currently working, did not have a food handler's card and/or a food handler's card from the county in which the facility is located. This practice has the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 157. Findings include: a) On 11/17/09, copies of food handler's cards were reviewed for the facility's dietary employees. The copies provided did not contain the cards for three (3) dietary staff, including the current dietary manager (Employees #13, #50, and #190). An inquiry was m… | 2015-10-01 |
| 9565 | 9565 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 514 | D | 0 | 1 | 5V2011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure each resident's medical record was accurate. An allergy was incorrectly identified for one (1) resident, and nursing notes did not reflect the current status of another resident. Resident identifiers: #15 and #89. Facility census: 157 Findings include: a) Resident #15 Medical record review, on 11/18/09, revealed this resident was admitted on [DATE]. Documentation in the record revealed the resident was allergic to plastic. It was unknown whether the allergy had been noted upon admission or at a later date. The noted allergy was of concern, because the resident had the potential to come in contact with plastic at the facility. The allergy was brought to the attention of the director of nursing (DON - Employee #165) on 11/18/09. The DON contacted the family. At 5:00 p.m. on 11/18/09, the DON reported the resident was not allergic to plastic. The resident's chart was then clarified to reflect this information. b) Resident #89 Resident #89's medical record, when reviewed on 11/17/09 at 10:00 a.m., revealed a [AGE] year old female who was readmitted to the facility on [DATE]. The resident was scheduled to receive [MEDICAL TREATMENT] three (3) times weekly at a renal center. Nursing notes, dated 11/01/09 at 6:25 p.m., stated, Sent to RGH Hospital for eval. Temp 102.5. Vomiting. Non responsive. IN an interview on 11/20/09 at 8:15 a.m., the DON acknowledged the documentation in the 11/01/09 entry was not complete and did not reflect an accurate and complete assessment of the change in the resident's condition. According to the American Health Information Management Association (AHIMA) Long Term Care (LTC) Guidelines, A complete record contains an accurate and functional representation of the actual experience of the individual in the facility. It must contain enough information to show that the facility knows the status of the individual, has adequate plans of care and … | 2015-10-01 |
| 9566 | 9566 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2012-10-09 | 441 | D | 1 | 0 | 9WM911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide signage at the entrance of rooms of residents who were to be isolated due to having infectious organisms. Failing to provide signage to alert visitors and/or staff to see the nurse before entering the room, and/or giving guidance as to what precautions are necessary when entering the room, created the potential to spread infectious organisms. Two (2) of six (6) isolation rooms observed had no signage present. Resident identifiers: #128 and # 59. Facility census: 148. Findings include: a) Resident #128 Observation on 10/08/12, at approximately 12:50 p.m., found a small cart in the hallway near the room of Resident #128. There was no signage at the door to see the nurse before entering, or instructions as to what precautions should be taken before entering the room. A speech therapy employee was observed sitting in the chair beside the resident's bed, watching him eat some food. She was not wearing gloves or a gown. A brief interview at the nurses' station, on 10/08/12, at approximately 1:00 p.m., with Employees #76 and #192 (nurses), found the isolation cart belonged to Resident #128 who was in a private room, but they were unsure why he was in isolation. Employee #192 stated Resident #128's nurse was in the dining room, and she would go ask her. Upon her return only minutes later, Employee #192 reported that his nurse said he had ESBL (extended-spectrum class A beta-lactamase), an infectious organism resistant to multiple antibiotics), in his urine. When asked if they typically post signage at the door to alert those wishing to enter his room, she applied in the affirmative. She then placed a sign instructing visitors to see the nurse before entering. Review of the medical record on 10/09/12, at approximately 2:00 p.m., found a new physician's orders [REDACTED]. However, at the time of the observation on the previous day, this had not been known. b) Resident #59 Observat… | 2015-10-01 |
| 9567 | 9567 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2012-10-09 | 514 | C | 1 | 0 | 9WM911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that all physicians' telephone and/or verbal orders for lab work, and orders to initiated if the resident spiked a fever, were complete and accurately dated and transcribed. This was evident for one (1) of six (6) sampled residents. Resident identifier: #151. Facility census: 148. Findings include: a) Resident #151 Medical record review, on 10/09/12, found a telephone order obtained by nurse Employee #51 from the physician, dated 07/16/12. The physician ordered a urinalysis and culture and sensitivity for Resident #151. On the same physician's orders [REDACTED]. Another physician's telephone order, obtained by Employee #51, dated 07/16/12, directed to begin [MEDICATION NAME] (an antibiotic), 500 milligrams (mg.) daily if the temperature spiked again to 101 degrees. There was no time inscribed on the latter physician's orders [REDACTED]. Review of the July 2012 Medication Administration Record [REDACTED]. one tablet daily if the temperature spikes again to 101 degrees, for urinary tract infection [MEDICATION NAME]. There was no indication on the MAR indicated [REDACTED]. There was no directive on the MAR indicated [REDACTED]. Further review of the MAR found that no doses of [MEDICATION NAME] had ever been administered in July. Review of a history and physical examination [REDACTED]complaint of cough and decreased oxygen saturation.of 56%, and was in respiratory distress. The physician noted in this report the resident had a temperature of 101 degrees two days before the hospitalization , and that he (the physician) had started him on oral [MEDICATION NAME]. The admitting [DIAGNOSES REDACTED]. During an interview with the director of nursing (DON) and the Administrator, on 10/09/12, at approximately 3:30 p.m., the DON said there was no documentation that Resident #151 had ever had a fever in July. She stated her belief was that the nurse, Employee #51, read communication … | 2015-10-01 |
| 9568 | 9568 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 156 | C | 0 | 1 | L3JB11 | . Based on observation and staff interview, the facility failed to provide a posting of names, addresses and telephone numbers of all pertinent state client advocacy groups; failed to display a written statement informing residents of their right to file a complaint with the State survey and certification agency concerning abuse, neglect and misappropriation of property and non-compliance with advance directives; and failed to prominently display written information about how to apply for and use Medicare and Medicaid benefits. These practices had the potential to all residents and visitors. Facility census: 114. Findings include: a) On 07/14/11 at approximately 11:42 a.m., observations of the facility's hallways and lobby failed to find postings of necessary information, such as the names, addresses, and telephone numbers of all pertinent state client advocacy groups, a written statement informing residents of their right to file a complaint with the State survey and certification agency concerning abuse, neglect and misappropriation of property and non compliance with advance directives, and written information on how to apply for and use Medicare and Medicaid benefits. At approximately 12:00 p.m., the maintenance supervisor (Employee #89) accompanied the tour of the building and could not locate the signs and postings. He reported these signs were taken down due to the facility's remodeling project. At approximately 2:45 p.m., these signs were located, and the maintenance director said he would ensure they were displayed in the facility. | 2015-10-01 |
| 9569 | 9569 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 167 | C | 0 | 1 | L3JB11 | Based on observation and staff interview, the facility failed to ensure survey results were accessible and available to residents. This practice had the potential to affect all residents and visitors. Facility census: 114. Findings include: a) On 07/11/11 at approximately 11:45 a.m., observation revealed the survey results were not accessible and available for review. The maintenance supervisor (Employee #89) also verified the survey results were not available for review. Employee #89 stated he would locate the survey results book and put it out in a prominent place for residents and others to review. On 07/14/11 at approximately 10:00 a.m., a visitor to the facility had requested to view the survey results book. The book was not accessible to the visitor, and the visitor had to ask someone at the facility to locate the survey results. The administrator said he would locate the survey results for the visitor. | 2015-10-01 |
| 9570 | 9570 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 225 | D | 0 | 1 | L3JB11 | Part I -- Based on review of the facility's patient / family concern forms, policy review, and staff interview, the facility failed to assure an allegation abuse / neglect was thoroughly investigated and immediately reported to other officials, including the State survey and certification agency, in accordance with State law. In addition, the facility allowed the alleged perpetrator to continue to work at the facility even though their resolution to the concern stated this employee would not be scheduled to work at the facility. This was true for one (1) of twenty (20) patient / family concern forms reviewed. Facility census: 114. Findings include: a) Review of the facility's patient / family concerns reports revealed a concern reported to a staff member on 06/03/11. On 06/03/11, an employee of the ambulance service reported the following: (Name of ambulance service employee) overheard a nurse, (name of nurse) interacting with the above resident. She states the (name of resident) was trying to tell (name of nurse) something and resident was stuttering. She states that the nurse told the resident to spit it out, I don't have time for you. Stated you need to get away. EMT (emergency medical technician) confronted nurse and told her that she didn't need to be rude. The staff member who recorded the concern also wrote: Spoke with EMT's partner, (name of partner). re. (regarding) incident. She states she cannot recall exactly what was said by the nurse but stated that it was basically - I don't have time to deal with you. She stated that the nurse was rude and disrespectful to the resident. Further review of the concern revealed the facility's steps to resolve the problem were: (Name of nurse) has not worked at (name of facility) since 05/20/11. Scheduling manager instructed not to utilize her services in the future. Review of the facility's abuse prohibition policy revealed: Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents o… | 2015-10-01 |
| 9571 | 9571 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 247 | E | 0 | 1 | L3JB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview, the facility failed to assure residents received prior notice before being moved to another room and/or failed to assure residents receiving a new roommate received prior notice. This was true for four (4) of four (4) residents who had room moves and/or received new roommates within the past two (2) months. Resident identifiers: #22, #76, #8, and #108. Facility census: 114. Findings include: a) Resident #22 During an interview with the resident on 07/07/11 at 9:44 a.m., she verified she was not given notice before receiving a new roommate and stated, They just bring one in. Review of the facility's computer-generated action summary revealed Resident #22 received a new roommate (Resident #76) on 06/16/11. Further review of nursing and social service notes found no documentation the resident was notified she was receiving a new roommate. Employee #118 (a social worker), when interviewed on 07/12/11 at 10:15 a.m., was unable to produce documentation the resident was notified she was receiving a new roommate. -- b) Resident #76 Medical record review revealed the resident was admitted to the facility on [DATE]. Further review of the facility's computer-generated action summary revealed Resident #76 was moved on 06/16/11, to share a room with Resident #22. Review of nursing and social service notes found no documentation the resident / responsible party was notified of the room move. Employee #118, when interviewed on 07/12/11 at 10:15 a.m., was unable to produce documentation the resident / responsible party was notified of the room move. Employee #118 reported the room move was completed by another facility employee. Employee #118 stated, It must have fell through the cracks. Employee #118 further explained the room moves were directed by the admissions coordinator, but the social workers were responsible for recording documentation of the room moves in the medical record, b… | 2015-10-01 |
| 9572 | 9572 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 253 | E | 0 | 1 | L3JB11 | Based on observation, record review, and staff interview, the facility failed to provide services necessary to maintain a sanitary, orderly, and comfortable interior. Several doors and walls were in disrepair due to gouges, holes, scrapes, and peeling coverings, with eleven (11) of the eighty-one (81) rooms in the facility having scrapes and gouges to the corridor doors. The floors in resident rooms were also unclean. Room numbers: #200, #203, #212, #201, #804, #409, #403, #405, #702, #706, and #410. Facility census: 114. Findings include: a) Observations throughout the day on 07/07/11 found the following: - The floor near the bed next to the window in Room #403 was dirty floor. - The floor behind the bed in Room #405 was soiled with debris from crackers / cookies. - The floors in Rooms #702 and #706 were soiled with debris. -- b) Review of the facility's patient / family concern forms, on 07/12/11, found the following concerns regarding the general cleanliness of the rooms. - 01/24/11 - 1. (Employee Name) only emptied trash in room. Did nothing else. 2. Not picking up dirty. - 01/27/11 - Room not getting mopped. - 04/10/11 - Resident and family very upset over the ants in the room. Also very upset that room is not thoroughly cleaned on a daily basis. Does not like dirty floors, toilet and bags hanging on doors. - 05/31/11 - Ants in her room. The floor is dirty in her room. Housekeeping staff just scoots stuff around when they sweep. They don't sweep it up, then they mop over it. - 06/24/11 - Ants in the room - a/c (air conditioner). (See citation at F469 related to inadequate pest control.) -- c) On 07/11/11 beginning at approximately 1:00 p.m., an environmental tour of the facility's interior revealed the following issues: - The corridor doors for Rooms #203, #200, #212, #405, #409, #410 and #201 were in disrepair due to gouges and/or scrapes - Border was observed peeling from bathroom door in the Blue Ridge shower room. - The wall near the floor in Room #804 was patched, but the patch job was not done well. Th… | 2015-10-01 |
| 9573 | 9573 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 257 | E | 0 | 1 | L3JB11 | Based on staff interview and family interview, the facility failed to ensure safe and comfortable temperature levels were maintained in the facility's only dining room. The temperatures in the dining room became too warm for the safety of residents; therefore, the facility suspended the evening meal in the dining room. Residents had to eat the evening meal in their rooms on at least two (2) occasions due to the excessive heat in the dining room. This had the practice to affect more than an isolated number of residents. Facility census: 114. Findings include: a) On 07/11/11 at approximately 2:00 p.m., Employee #89 (maintenance supervisor) reported the facility closed the dining room for the evening meal due to excessive heat and uncomfortable temperatures. Employee #89 also stated the director of nursing (Employee #121) had decided to close the dining room for the evening meal on 07/08/11. The administrator (Employee #83) reported the facility had a purchase order for new air conditioning units for the dining room and facility's administrative offices; however, the facility did not provide any written evidence showing they had ordered new air conditioning units. During an interview with Resident #152's family on 07/12/11 at approximately 2:00 p.m., they complained about the extreme heat in the dining room. Employee #142 (property manager) reported new air conditioning units were purchased and would arrive towards the end of July 2011. | 2015-10-01 |
| 9574 | 9574 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 272 | E | 0 | 1 | L3JB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, review of CMS's Resident Assessment Instrument (RAI) Minimum Data Set (MDS) 3.0 Manual, and staff interview, the facility failed to ensure accurate coding of required MDS assessments. Stage 2 pressure ulcers were coded as having granulation tissue; these pressure ulcers would have had to be at least a Stage 3 for granulation tissue to be present. Additionally, the presence of ulcers on prior assessments was not accurately coded for a resident, and Section S was not coded consistently with the coding of Section M for one (1) resident. Four (4) of seven (7) residents with Stage 2 pressure ulcers who were reviewed in Stage II of the QIS survey were affected. Resident identifiers: #167, #22, #145, and #17. Facility census: 114. Findings include: a) Resident #167 The resident's 30-day PPS (Medicare - Prospective Payment System) assessment, with an assessment reference date (ARD) of 03/0/11, indicated the resident had a Stage 2 pressure ulcer. This assessment was coded as 2 for granulation tissue in item M0700. Granulation tissue would not be present for a Stage 2 pressure ulcer. The ulcer would have had to be a Stage 3 or 4 for granulation tissue to be present. -- b) Resident #22 1. The resident's quarterly MDS assessment, with an ARD of 06/01/11, was coded to indicate the resident had two (2) Stage 2 pressure ulcers that developed in-house. In M0800, where the assessor was to indicate the number of current pressure ulcers that were not present or were present at a lesser stage on the prior assessment (OBRA or PPS), was coded as one (1) Stage 2 ulcer. No healed ulcers were coded in M0900, yet the prior quarterly MDS, with an ARD of 03/21/11, had been coded for no pressure ulcers at any stage. - 2. Her quarterly MDS, with an ARD of 06/01/11, was coded to indicate she had two (2) Stage 2 pressure ulcers that developed in-house; however, Section S was coded to indicate the resident had no new or reoccurring ulcers … | 2015-10-01 |
| 9575 | 9575 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 279 | D | 0 | 1 | L3JB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, and observations, the facility failed to develop a comprehensive care plan to address the specific care needs of three (3) of forty-six (46) Stage II sampled residents. No care plan was developed for a resident's who exhibited behaviors for which an antipsychotic and a benzodiazepine (drugs that are used to treat a variety of conditions, including anxiety) had been ordered. A resident who had contractures, and according to her assessments, had had contractures of varying locations, did not have a care plan to address prevention of new - or worsening of currently identified - contractures. No care plan was established for another resident who developed a Stage 2 pressure ulcer. Resident identifiers: #135, #22, and #17. Facility census: 114. Findings include: a) Resident #135 During the Stage I portion of the quality indicator survey (QIS), Resident #135 was identified as receiving the drug [MEDICATION NAME] (an antipsychotic) and the drug [MEDICATION NAME] (a benzodiazepine). Both of these medications must be used judiciously, especially in the elderly. The [AGE] year old resident was selected for Stage II by the QIS software for further review of the appropriateness of these medications. This included a review of the reasons the medications had been ordered, their effect on the resident, whether gradual dosage reductions had been attempted, and whether a care plan had been developed and implemented. Review of the physician's current orders found both medications had been ordered for pacing until exhausted and wringing her hands. Current nursing progress notes indicated she was an elopement risk and wandered the halls. She was noted to wander about talking to residents and staff. She was observed ambulating alone or with other residents on 07/12/11, 07/13/11, and 07/14/11. A copy of the resident's current care plan was requested and provided on 07/07/11. The care plan included a prin… | 2015-10-01 |
| 9576 | 9576 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 280 | E | 0 | 1 | L3JB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and resident interview, the facility failed to review and revise care plans for five (5) of forty-six (46) residents on the sample whose care plans were reviewed. The established care plan for Resident #19 was not followed / implemented with regard to pain management. The care plan for Resident #171 was not revised to reflect the worsening of her pressure ulcer. Residents #169 and #145 did not have their care plans revised to reflect the presence of Stage 2 pressure ulcers until two (2) weeks after the ulcers were identified. Resident #8's care plan for discharge was not revised. Resident identifiers: #19, #171, #145, #169, and #8. Facility census: 114. Findings include: a) Resident #19 This resident's care plan included a goal of: Ms. (name) will have no verbalization of pain x 90 days. The interventions included: Utilize pain scale. In addition to medications offer massage, attempt imagery techniques. Assess pain characteristics: quality, severity, locations, precipitating / relieving factors. Advise resident to request pain medication before pain becomes severe. Medicate resident as ordered for pain. Evaluate for side effects of medications. Monitor for non-verbal signs / symptoms of pain. The documentation on the Medication Administration Record [REDACTED]. The documentation on the MAR indicated [REDACTED]. In an interview with the director of nursing (DON) and Employee #19 (a registered nurse - RN) on 07/14/11 at 12:30 p.m., they stated the nurses are to document on the MAR indicated [REDACTED]. The nurses also are to document whether the medication was or was not effective on the back of the MAR. According to Employee #19, this determination was to be made one (1) hour after the medication is given. Review of the nursing progress notes for May, June, and July 2011 found no evidence of assessment of the resident's pain using a pain scale and no evidence of assessment of pain characteristic… | 2015-10-01 |
| 9577 | 9577 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 282 | D | 0 | 1 | L3JB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, review of medical records, staff interview, and policy review, the facility failed to ensure the care plan was implemented for one (1) of four (4) residents on the Stage II sample whose care plan was reviewed for the care area of pain. This resident had not been included in the Stage I sample. She was added to the three (3) residents selected by the software for review of the care area of pain in Stage II, after she was heard to voice a complaint of her legs hurting. Resident identifier: #19. Facility census: 114. Findings include: a) Resident #19 During the morning medication pass on 07/12/11, this resident was in the hall in her wheelchair. She was heard to complain of her legs hurting. When asked whether she had been given anything for pain, she said they gave her a pain pill every six (6) hours, but it did not always work or last long enough. On 07/12/11 at 2:10 p.m., a nursing assistant (Employee #39) was asked whether the resident often complained about her legs hurting. She said the resident does complain of pain often, especially when transferring. The nursing assistant said the resident complains mostly about her knee. The resident's [DIAGNOSES REDACTED]. ? 2009), and pain in the joints of the lower leg. On the resident's annual physical of 06/22/11, the physician documented the resident's pain was okay with meds. Under the section for the review of systems, Pain was checked and leg pain was written to the side. The current physician's orders [REDACTED].= 600 mg; the order date was 09/01/10. There was also an order [REDACTED]. ([MEDICATION NAME] is a medication used for [MEDICAL CONDITION], but can be used to change the way the body senses pain. It is sometimes used to relieve the pain of diabetic [MEDICAL CONDITION]. AHFS? Consumer Medication Information. ? Copyright, 2011.) - The most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 05/25/11 had the follo… | 2015-10-01 |
| 9578 | 9578 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 309 | D | 0 | 1 | L3JB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on medical record review, policy review, and staff interview, the facility failed to follow its policy to address constipation, which provided interventions for addressing no bowel movements (BMs) in three (3) days. This was true for one (1) of forty-six (46) residents reviewed. Resident identifier: #73. Facility census: 114. Findings include: a) Resident #73 Medical record review revealed this [AGE] year old female was admitted to the facility on [DATE]; her current [DIAGNOSES REDACTED]. Further review of the medical record review revealed a consultation summary from a local hospital dated 06/24/11. Documentation from the summary revealed, . X-ray was performed of the abdomen, showing a large fecal impaction and distention of the stomach. In addition, we will give her an enema to facilitate bowel emptying. Review of the x-ray report, dated 06/24/11, revealed: Large phlegm in the stools demonstrated over the level of the rectum. Consider fecal impaction. There is a dilated bowel loop over the upper abdomen, probably a dilated stomach. Review of the ADL (activities of daily living) flowsheet revealed the resident had regular BMs from 06/01/11 to 06/16/11, when the resident had a large BM. Documentation showed the resident did not have another BM until 06/22/11, when the resident had a small formed BM on day shift and a BM on the afternoon shift. The resident did not have a documented BM five (5) days - from 06/16/11 to 06/22/11. Further review of the ADL flowsheet revealed the resident was out of the facility during both day and evening shifts on 06/18/11. An interview with the director of nursing (DON), on the afternoon of 07/11/11, revealed the resident was out for a home visit with her husband on 06/18/11. Further review of the facility's standing orders for Episodes of constipation: no bowel movement in 3 days found the following protocol: Assess vital signs, bowel signs and document. If no bowel movement is 3 days give 30c… | 2015-10-01 |
| 9579 | 9579 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 314 | E | 0 | 1 | L3JB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, review of the facility's Wound Management Tracking Tool forms, review of the results of a database query of Section S for West Virginia, and staff interview, the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and / or did not have new pressure ulcers or recurrence of pressure ulcers. Two (2) of three (3) residents selected by the quality indicator survey (QIS) software were found to have a Stage 2 pressure ulcer develop after admission to the facility. One (1) of these was found have a high probability of the ulcer being unavoidable due to end-of-life conditions. One (1) was found to have developed the pressure ulcer prior to admission, and the third was found to have developed a pressure ulcer after admission. Another resident, who had triggered for other care areas, was found to have developed a pressure ulcer after admission and was added for pressure ulcer review. The original sample of three (3) was expanded to include a total of eight (8) residents. Four (4) of the eight (8) residents with pressure ulcers were found to have developed the ulcers after admission to the facility that were clinically avoidable. Resident identifiers: #171, #145, #17, and #169. Facility census: 114. Findings include: a) Resident #171 1. This resident was admitted to the facility on [DATE]. Her admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 03/02/11, indicated she did not have a Stage 1 or greater pressure ulcer present upon admission. She was coded as being at risk for developing pressure ulcers in Item M0150. Item M0210, regarding unhealed pressure ulcers was coded as No. Section I (Diagnoses) included hypertension, orthostatic [MEDICAL CONDITIONS] reflux, pneumonia, diabetes mellitus, [MEDICAL CONDITIONS], obesity, unspecified condition of brain, unspecified constipation, and [MEDICAL CONDITION] status. Section S… | 2015-10-01 |
| 9580 | 9580 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 318 | D | 0 | 1 | L3JB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of medical records, staff interview, and resident interview, the facility had not ensured a resident with limited range of motion (ROM) received services to increase ROM and / or to prevent further decrease in ROM. One (1) of forty-six (46) residents on the Stage II sample for care area reviews was found to have contractures with no plan to prevent a further decrease in ROM. Resident identifier: #22. Facility census: 114. Findings include: a) Resident #22 In Stage I of the quality indicator survey (QIS), the software selected this resident for a preliminary screening review for possible care area investigation. One (1) of the staff interview questions was whether the resident had contractures (a condition of fixed high resistance to passive stretch of a muscle). On 07/06/11 at 1:35 p.m., Employee #62, a unit charge nurse, said the resident had contractures of her feet. The nurse said the resident had developed foot drop while in the hospital before she had been admitted to the facility. The resident had been on a ventilator, and the contractures had developed at that time. She also stated the resident did not have splints / braces and had refused therapy. The resident was observed to have significant foot drop. Her admission minimum data set (MDS), with an assessment reference date (ARD) of 11/15/05, had noted limitations in ROM for both feet and legs and that she had full loss of voluntary movement of these extremities. She had subsequently improved in her functional abilities. Her annual MDS, with an ARD of 10/07/09, indicated she had limitation of ROM and partial loss of voluntary movement of one arm. She was coded as having limitation in ROM and partial loss of voluntary movement for both legs and feet. Her quarterly MDS, with an ARD of 06/01/11, indicated she had limitation in functional ROM on both sides of the upper and lower extremities. Section S of the assessment noted she had contractures of her should… | 2015-10-01 |
| 9581 | 9581 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 323 | E | 0 | 1 | L3JB11 | Based on observation, staff interview, and review of a material safety data sheet, the facility failed to assure a chemical disinfectant / deodorizing cleaner (Virex TB) was secured in a locked cabinet after use. This deficient practice had the potential to affect all residents who frequented the area in and around the 800 hallway of the facility. Facility census: 114. Findings include: a) During the initial tour of the facility on 07/05/11 at 2:30 p.m., two (2) bottles of the disinfectant cleaner Virex TB were observed in the shower room on the 800 hallway of the facility. The shower room door was open, and no residents or staff were occupying the shower room. Further observation of the shower room revealed a cabinet with a lock mounted on the right side of the wall in the shower room. Observation revealed a bright red sign on the cabinet door, When not using Virex it is to be stored in the locked cabinet. A licensed practical nurse (LPN - Employee #132), when summoned to the shower room at 2:30 p.m. on 07/05/11 by the surveyor, verified the Virex was to be locked in the cabinet when not in use. This employee placed the two (2) bottles of Virex in the cabinet and fastened the lock. Review of the material safety data sheet for Virex TB revealed, Warning: causes eye and skin irritation. Harmful if swallowed. | 2015-10-01 |
| 9582 | 9582 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 369 | D | 0 | 1 | L3JB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure a resident with a prior history of weight loss received her meals served in a scooped plate as ordered by the physician. This was true for one (1) resident sampled who received adaptive equipment for meals. Resident identifier: #73. Facility census: 114. Findings include: a) Resident #73 Medical record review revealed this [AGE] year old female was admitted to the facility on [DATE], and her current [DIAGNOSES REDACTED]. Review of the resident's current care plan revealed the following problem statement: (Name of resident) has dysphagia with loss of food and liquids from her mouth during meals. She is at risk for aspiration and leaves 25% or more uneaten. Wt. (weight) loss trend observed. An approach for resolution of the problem included: Resident attends lunch and dinner meals in dining room, she will attempt to feed herself, but will generally require ext. (extensive) assist to finish and ensure optimum po (oral) intake. Lipped plate to promote indep. (independence) w/ (with) meals. Further review of the medical record revealed a physician's orders [REDACTED]. Observation, on 07/11/11 at 2:00 p.m., revealed the resident was in her room eating with the assistance of a family member. Further observation revealed the resident's noon meal was not served in a scooped plate. On 07/11/11 at 2:00 p.m., a licensed practical nurse (LPN - Employee #8) verified the scooped plate was not present, and this employee stated she would tell the dietary manager. At approximately 4:00 p.m., the dietary manager stated Employee #8 had told her about the plate and she would take care of the problem. . | 2015-10-01 |
| 9583 | 9583 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 371 | F | 0 | 1 | L3JB11 | Based on observations and staff interview, the facility failed to store food items under sanitary conditions in the kitchen and in the nursing station nourishment pantries. Dietary equipment was in need of cleaning, and paper supplies were stored directly on the floor. In nourishment pantries, containers of food items were not labeled nor dated, no thermometer was in place to accurately determine temperature levels, refrigerators contained food spills that needed to be cleaned, and food items brought from outside the facility were not labeled nor dated. These practice have the potential to affect all residents who receive foods from the central dietary area and the unit nourishment kitchens. Facility census: 114. Findings include: a) During the initial dietary tour on 07/05/11 at 2:30 p.m., the following sanitation issues were noted: 1. In the storage supply closet, there were paper supplies sitting directly on the floor. Items need to be stored at least 12 inches off the floor for easy cleaning of the floor beneath them and to prevent the attraction of vermin. 2. The gaskets of the reach-in milk cooler were found to have grime and dirt which could prevent a tight seal and inhibit the maintenance of the internal temperature of the units. 3. Drip pans of the stove top had foil to catch the drippings. The foil was dated 6/26 and had several dried food spills and debris on it. This foil needed to be replaced on a more frequent basis. 4. Lids to plastic tubs used to hold sweet potatoes were found to be greasy to the touch and in need of cleaning. These items were found while a dietary aide (Employee #91) accompanied the surveyor on tour. She immediately began to correct the issues. -- b) On 07/12/11 at approximately 2:00 p.m., a tour of the nourishment pantries in the facility revealed problems with foods having no dates or labels, in addition restaurant foods being left in refrigerators with no names or dates. 1. In the Blue Ridge hall nourishment pantry, the refrigerator's freezer section had large amounts of ice b… | 2015-10-01 |
| 9584 | 9584 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 372 | F | 0 | 1 | L3JB11 | Based on observation by two (2) surveyors, the facility failed to properly dispose of garbage and refuse. Trash was spilled over the tops of trash cans stored outside the kitchen door, the door to the Dumpster was open with garbage falling out of it, and paper plates / cups, aluminum cans, and cigarette butts were strewn on the ground in this area. These unsanitary conditions could attract or harbor pests and rodents. Facility census: 114. Findings include: a) On 07/13/11 at approximately 9:00 a.m., a tour of the grounds behind the facility by two (2) surveyors revealed the following conditions outside of the kitchen door: - Trash cans with trash spilling out over the top were found outside the kitchen door. - The door to the Dumpster was open with trash falling out of it, and red potatoes were scattered on the ground around the Dumpster. - Paper plates / cups, aluminum cans, and cigarette butts were also strewn on the ground in this area. The facility found to have problems with effective pest control related to ants, roaches, and mice, and the above unsanitary conditions could attract or harbor pests and rodents. (See also citations at F465 and F469.) | 2015-10-01 |
| 9585 | 9585 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 428 | D | 0 | 1 | L3JB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the physician provided a rationale describing why a dose reduction of Ativan was clinically contraindicated after the pharmacist recommended a gradual dose reduction. This was true for one (1) of forty-six (46) Stage II sampled residents. Resident identifier: #38. Facility census: 114. Findings include: a) Resident #38 Medical record review revealed a [AGE] year old female whose current [DIAGNOSES REDACTED]. The resident was receiving Ativan 0.25 mg in the morning and Ativan 0.25 mg at bedtime for a [DIAGNOSES REDACTED]. Further review of the medical record revealed a consultation report from the pharmacist completed on 05/26/11. The pharmacist recommended the resident's Ativan be reduced from 0.25 mg twice daily to 0.25 mg at night. The physician responded to the pharmacist recommendation on 06/01/11 by documenting, Cont (continue) Ativan. An interview with the director of nursing (DON) was conducted on the afternoon of 07/06/11. The DON was unable to produce a documented rationale from the physician describing why a gradual dose reduction of Ativan was clinically contraindicated for this resident. | 2015-10-01 |
| 9586 | 9586 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 431 | E | 0 | 1 | L3JB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to dispose of narcotics prescribed to a resident who was discharged on [DATE] and outdated laboratory supplies. This deficient practice has the potential to affect more than an isolated number of residents. Facility census: 114. Findings include: a) Medication refrigerator storage Observation of the medication storage refrigerator on Blue Ridge hall, on the afternoon of [DATE], found a full package of Marinol belonging to Resident #180 who was discharged from the facility on [DATE]. On [DATE] at 1:20 p.m., the unit manager (Employee #102) said the pharmacist comes every month to destroy medications with the director of nursing (DON - Employee #121). On [DATE] at 1:30 p.m., The DON stated she was not aware the medication was still here. -- b) Outdated lab materials 1. Observation of the medication storage room on Shady Garden hall, at 1:13 p.m. on [DATE], revealed forty-six (46) expired Vacutainers and three (3) expired heparin lock flushes. A licensed practical nurse (LPN - Employee #19) was present when the expired Vacutainers and heparin lock flushes were discovered. - 2. Observation of the medication storage room for Cherry Blossom hall on [DATE], at 1:32 p.m., revealed four (4) outdated Vacutainers. The unit manager (Employee #62) immediately disposed of the outdated materials. - 3. During an interview with the DON on [DATE] at 2:15 p.m., she stated, The employees from the lab are responsible for checking the dates on the lab supplies and discarding any products that are expired. No further explanation was given related to the expired products. | 2015-10-01 |
| 9587 | 9587 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 441 | D | 0 | 1 | L3JB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the facility's policy, and staff interview, the facility failed to dispose of contents of a sharps container. Additionally, the facility failed to assure a nurse implemented hand hygiene consistent with the accepted standards of practice when administering eye drops. This deficient practice has the potential to affect more than isolated number of residents. Resident identifier: #32. Facility census: 114. Findings include: a) On 07/13/11 at 1:13 p.m., during observation of the medication storage unit on Shady Garden hall, a sharps container was found to be full. Used needles and intravenous supplies were found in the sharps container. The licensed practical nurse (LPN - Employee #19) immediately emptied the sharps container. Findings for this observation was reported to the director of nursing (DON - Employee #121) at 1:30 p.m. on 07/13/11. Review of the facility's policy titled Needle Handling and Sharps Injury Prevention revealed the sharps containers are to be replaced routinely and when 3/4 full. -- b) Resident #32 Employee #114, a registered nurse (RN), was observed administering medications to Resident #32 on 07/12/11 during the morning medication pass. The nurse did not wash her hands prior to donning gloves to administer artificial tears in the resident's left eye. After donning gloves, the nurse retrieved the bottle of eye drops from the table located on the right side of the resident's bed. As she went to the left side of his bed, she had to move a wheelchair with her gloved hands. After administering the eye drop to the left eye, she removed her gloves. She donned a clean pair of gloves to administer the eye drop to the resident's right eye without washing her hands. After an appropriate interval, the nurse administered [MEDICATION NAME] eye drops to the resident's eyes. Again, handwashing was not performed immediately prior to instilling the eye drops to both eyes. Review of the facility's policy and… | 2015-10-01 |
| 9588 | 9588 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 463 | D | 0 | 1 | L3JB11 | Based on observation and staff interview, the facility failed to ensure that residents, when in their rooms had a means of directly contacting caregivers. One (1) of forty (40) residents in the census sample had a non-functional call system. When tested , Resident #76's call light did not light up outside her door. Facility census: 114. Findings include: a) Resident #76 On 07/05/11 during the census sample observation of Resident #76's room, her call light did not light up when tested . The maintenance supervisor (Employee #89) stated the facility had begun to work on the resident call system. The resident did have the capability of using her call system. | 2015-10-01 |
| 9589 | 9589 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 465 | F | 0 | 1 | L3JB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, staff interview, and other confidential interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The facility ' s interior and exterior were maintained in a manner that created an unsanitary and unsafe environment for residents, staff, and visitors due to an ineffective pest control program and improper storage and/or disposal on the sidewalks and the grounds outside of the facility of unused materials, equipment, and garbage / trash. Facility census: 114. Findings include: a) During a tour of the facility on 07/05/11 at approximately 3:00 p.m., observation found Resident #32 lying in his room with pizza on his chest. He ate some of the pizza and then tore off pieces of it and threw them on the floor. When asked, he reported there was a mouse in his room and he was throwing the pizza on the floor to feed the mouse. Resident #32 stated the mouse was inside of a wardrobe at the foot of his bed. On 07/06/11 at 8:00 a.m., food and debris were noted on the floor of Resident #32's room. Employee #23 (a licensed practical nurse - LPN) said she had seen mice in other rooms during the spring but not in Resident #32's room. Employee #42 (a housekeeping aide), when interviewed on 07/07/11 at 12:14 p.m., reported he had been in this resident's room and mopped the floor. He also cleaned out the closet. He denied finding any evidence of mice. He did say they placed a sticky trap in the room under a piece of furniture as a precaution. He also said that, during the spring, there had been mice in Resident #32's room. He said there was evidence of sheet rock being chewed through in the room when he mopped on 07/07/11. - On 07/07/11, a resident commented on noticing a roach on the floor of the 500 hallway. A surveyor observed the presence of a roach in the classroom at approximately 8:05 a.m. on 07/12/11. A third roach sight… | 2015-10-01 |
| 9590 | 9590 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 469 | F | 0 | 1 | L3JB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, staff interview, and other confidential interviews, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. During the survey, ants, roaches, and mouse droppings were observed in the facility. While the facility had a contracted pest control service to treat the interior of the facility for ants and mice, no treatment was provided for the roaches, and the facility failed to address the improper storage and/or disposal of unused supplies, equipment, and garbage / trash outside of the facility that could attract or harbor pests and rodents. Facility census: 114. Findings include: a) During a tour of the facility on 07/05/11 at approximately 3:00 p.m., observation found Resident #32 lying in his room with pizza on his chest. He ate some of the pizza and then tore off pieces of it and threw them on the floor. When asked, he reported there was a mouse in his room and he was throwing the pizza on the floor to feed the mouse. Resident #32 stated the mouse was inside of a wardrobe at the foot of his bed. On 07/06/11 at 8:00 a.m., food and debris were noted on the floor of Resident #32's room. Employee #23 (a licensed practical nurse - LPN) said she had seen mice in other rooms during the spring but not in Resident #32's room. Employee #42 (a housekeeping aide), when interviewed on 07/07/11 at 12:14 p.m., reported he had been in this resident's room and mopped the floor. He also cleaned out the closet. He denied finding any evidence of mice. He did say they placed a sticky trap in the room under a piece of furniture as a precaution. He also said that, during the spring, there had been mice in Resident #32's room. He said there was evidence of sheet rock being chewed through in the room when he mopped on 07/07/11. - On 07/07/11, a resident commented on noticing a roach on the floor of the 500 hallway. A surveyor observed the presence of… | 2015-10-01 |
| 9591 | 9591 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 507 | D | 0 | 1 | L3JB11 | **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 forty-six (46) Stage II sample residents, to file in the resident's medical record the results of laboratory reports completed in June 2011, to make them available for clinical management. Resident identifier: #158. Facility census: 114. Findings include: a) Resident #158 On 07/11/11 at approximately 1:00 p.m., review of the medical record for Resident #158 revealed a consultation report dated 06/15/11, stating, Scheduled for colonoscopy and removal of dome port. Scheduled for CT scan abd (abdomen/pelvis) - CBC (complete blood count), CEA (carcinoembryonic [MEDICATION NAME]), CMP (comprehensive metabolic panel). The CBC, CEA, and CMP were completed on 06/22/11. The colonoscopy with polypectomy (medical term for the removal of a polyp) were performed on 06/29/11. As of 07/11/11, the results from the CBC, CEA, and CMP, as well as the colonoscopy, were not part of the resident's medical record. (See also citation at F513.) On 07/11/11, Employee #62 verified these results were not on the resident's medical record. She contacted the medical records department of the local hospital, and the results were sent to the facility and made part of the medical record at that time. | 2015-10-01 |
| 9592 | 9592 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 513 | D | 0 | 1 | L3JB11 | **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 forty-six (46) Stage II sample residents, to file in the resident's medical record the results of diagnostic studies (colonoscopy) completed in June 2011, to make them available for clinical management. Resident identifier: #158. Facility census: 114. Findings include: a) Resident #158 On 07/11/11 at approximately 1:00 p.m., review of the medical record for Resident #158 revealed a consultation report dated 06/15/11, stating, Scheduled for colonoscopy and removal of dome port. Scheduled for CT scan abd (abdomen/pelvis) - CBC (complete blood count), CEA (carcinoembryonic [MEDICATION NAME]), CMP (comprehensive metabolic panel). The lab studies (CBC, CEA, and CMP) were performed on 06/22/11. The colonoscopy with polypectomy (medical term for the removal of a polyp) were performed on 06/29/11. As of 07/11/11, the results from the colonoscopy, as well as the results of the labs, were not part of the resident's medical record. (See also citation at F507.) On 07/11/11, Employee #62 verified these results were not on the resident's medical record. She contacted the medical records department of the local hospital, and the results were sent to the facility and made part of the medical record at that time. | 2015-10-01 |
| 9593 | 9593 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 520 | F | 0 | 1 | L3JB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, staff interview, and other confidential interviews, the facility's quality assessment and assurance (QAA) committee failed to develop and implement plans of action to correct quality deficiencies of which the committee was - or should have been - aware with respect to pest and rodent infestations. During the survey, ants, roaches, and mouse droppings were observed in the facility. While the facility had a contracted pest control service to treat the interior of the facility for ants and mice, no treatment was provided for the roaches, and the facility failed to address - in response to issues identified by the facility's contracted pest control service - the improper storage and/or disposal of unused supplies, equipment, and garbage / trash outside of the facility that could attract or harbor pests and rodents. Facility census: 114. Findings include: a) During a tour of the facility on 07/05/11 at approximately 3:00 p.m., observation found Resident #32 lying in his room with pizza on his chest. He ate some of the pizza and then tore off pieces of it and threw them on the floor. When asked, he reported there was a mouse in his room and he was throwing the pizza on the floor to feed the mouse. Resident #32 stated the mouse was inside of a wardrobe at the foot of his bed. On 07/06/11 at 8:00 a.m., food and debris were noted on the floor of Resident #32's room. Employee #23 (a licensed practical nurse - LPN) said she had seen mice in other rooms during the spring but not in Resident #32's room. Employee #42 (a housekeeping aide), when interviewed on 07/07/11 at 12:14 p.m., reported he had been in this resident's room and mopped the floor. He also cleaned out the closet. He denied finding any evidence of mice. He did say they placed a sticky trap in the room under a piece of furniture as a precaution. He also said that, during the spring, there had been mice in Resident #32's room. He said t… | 2015-10-01 |
| 9594 | 9594 | COLUMBIA ST. FRANCIS HOSPITAL | 515110 | 333 LAIDLEY STREET | CHARLESTON | WV | 25322 | 2011-02-16 | 272 | D | 0 | 1 | Q8EN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to assure the accuracy of initial nursing assessments for two (2) of eighteen (18) residents reviewed. Resident #100 ' s admitting nursing assessment incorrectly stated the resident had no skin impairment, and Resident #77 had two (2) areas of necrotic tissue on the right heel that were present on admission, but nursing documentation failed to identify one (1) of these areas. Resident identifiers: #100 and #77. Facility census: 19. Findings include: a) Resident #100 Record review revealed Resident #100 was admitted to the facility on [DATE]. Upon admission to the facility, a registered nurse (RN - Employee #12) completed an admission report which stated Resident #100 had no skin problems, recording no impairment on the skin risk assessment. On 02/03/11, the occupational therapist gave Resident #100 a bath. The occupational therapist subsequently documented the following: SKIN: Some breakdown on buttocks and LE's (abbreviation for lower extremities). Nursing is treating. Prior to 02/06/11, no documentation could be found to support that nursing was treating the pressure areas. No evidence was found for further assessment of Resident #100 ' s skin integrity until 02/06/11, when an employee documented the following: Location of Wound #1 Right / Left Buttocks Type: Blister / Excoriation Stage: II - Break In Skin - Blister Margins: Pink Wound Bed: Pink Drainage: None Allevyn adhesive dressing was applied. A Stage II pressure area is described by the National Pressure Ulcer Advisory Panel (www.npuap.org ) as a partial thickness of dermis presenting as a shallow open ulcer with a pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. On 02/07/11, another RN (Employee #21) documented the following: Wound Location: RT (right) BUTTOCK Type: PRESSURE ULCER Stage: II - BREAK IN SKIN - BLISTER Margins: RED Wound Bed: RED Drainage: Y … | 2015-10-01 |
| 9595 | 9595 | COLUMBIA ST. FRANCIS HOSPITAL | 515110 | 333 LAIDLEY STREET | CHARLESTON | WV | 25322 | 2011-02-16 | 314 | G | 0 | 1 | Q8EN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed, for one (1) of eighteen (18) Stage II sample residents, to provide care and services to prevent the development of pressure ulcers for a resident who entered the facility without pressure ulcers and/or to promptly identify and treat pressure sores after they developed, in order to promote healing. Resident #100, who was assessed as having no skin impairment upon admission to the nursing unit on 02/02/11, was identified by the occupational therapist as having skin breakdown on the buttocks and lower extremities on 02/03/11. However, there was no evidence of nursing documentation acknowledging the presence of any skin breakdown until 02/06/11, when Wound #1 (a Stage II pressure sore) was identified and first treated. Wound #2 (also a Stage II pressure ulcer) was identified and first treated on 02/07/11. When the resident's skin was observed in the presence of a facility nurse on 02/10/11, Wound #1 was dressed, Wound #2 had no dressing on it, and a third wound (also a Stage II) was found which had not previously been identified or treated by facility staff. Resident identifier: #100. Facility census: 19. Findings include: a) Resident #100 Record review revealed Resident #100 was admitted to the facility on [DATE]. Upon admission to the facility, a registered nurse (RN - Employee #12) completed an admission report which stated Resident #100 had no skin problems, recording no impairment on the skin risk assessment. On 02/03/11, the occupational therapist gave Resident #100 a bath. The occupational therapist subsequently documented the following: SKIN: Some breakdown on buttocks and LE's (abbreviation for lower extremities). Nursing is treating. Prior to 02/06/11, no documentation could be found to support that nursing was treating the pressure areas. No evidence was found for further assessment of Resident #100's skin integrity until 02/06/11, when an employee documente… | 2015-10-01 |
| 9596 | 9596 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-10-05 | 152 | D | 1 | 0 | D8F011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the West Virginia Code, the facility failed to ensure a third evaluation of the resident's ability to make health care decisions was completed after the facility obtained two conflicting statements regarding the resident's ability to make health care decisions. The unresolved conflict resulted in various individuals making health care decisions for the resident. This was true for one (1) of six (6) medical records reviewed for resident rights exercised by a representative. Resident identifier: #81. Facility census: 89. Findings include: a) Resident #81 Review of the medical record found the resident's physician had determined the resident demonstrated capacity to make medical decisions on 07/17/12. Further review of the medical record found the local Department of Health and Human Services (DHHR) had completed the admission paper work on 07/19/12, two (2) days after the resident's physician determined the resident had the capacity to make his own medical decisions. The DHHR had also completed a, West Virginia Physician order [REDACTED]. The admissions director, Employee #56, was interviewed at 10:00 a.m. on 10/2/12. He stated the resident had lacked capacity upon admission. On 10/02/12 at 10:25 a.m., the facility social worker, Employee #62, presented a physician's determination of capacity from a local hospital, dated 06/27/12, which determined the resident lacked capacity to make medical decisions and appointed the DHHR as the resident's health care surrogate. According to the West Virginia Code (16-30-22), .shall have two physicians, one of whom may be the attending physician, or one physician and a qualified psychologist, or one physician and an advanced nurse practitioner, certify that the principal has regained capacity. Further review of the physician's orders [REDACTED]. The director of nursing (DON), Employee #88, and the corporate nurse, Employee #89, were made aware of … | 2015-10-01 |
| 9597 | 9597 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-10-05 | 225 | D | 1 | 0 | D8F011 | Based on review of the facility's request / concern forms, staff interview, review of resident / visitor incident reports, and the facility's policy and procedure for Resident Advocacy Protocols, the facility failed to report allegations of abuse / neglect to the appropriate State authorities. This was true for two (2) of five (5) residents reviewed for possible neglect / abuse. Resident identifiers: #50 and #90. Facility census: 89. Findings include: a) Resident #50 Review of the facility's Request / concern forms found an allegation made by Resident #50's wife on 09/16/12. (Name of resident's wife) upset that when she arrived about 12pm (sic) that her husband was still in gown, food on mouth (unable to read) gown. Also HOB (head of bed) (symbol for up). Brief wet. Apparent had not been cared for. This is not the first incident per (name of wife). Under the heading of other actions: Assigned CNA (certified nursing assistant) has been disciplined and was sent immediately to care for resident. During an interview with the director of nursing (DON), Employee #88, and the corporate nurse, Employee #89, at 2:45 p.m. on 10/03/12, the DON verified the allegation was not reported to the State agencies as required. b) Resident #90 Review of a resident incident report, dated 06/29/12, found a valet held the resident's wheelchair, as the resident requested, to assist the resident with a transfer from his bed. The resident fell resulting in sheering to the upper distal portion of the left above the knee amputation site. Further review of the minimum data set (MDS), with an assessment reference date (ARD) of 05/18/12, found the resident was totally dependent upon staff for transfers. The resident's care plan, dated 04/25/12, identified the resident required staff to transfer the resident with a mechanical lift and an extra-large sling. On 10/03/12, the DON and Employee #89 were interviewed at 3:00 p.m. Employee #89 verified a valet was not a member of the nursing staff. Valets were not trained and certified to provide reside… | 2015-10-01 |
| 9598 | 9598 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-10-05 | 279 | D | 1 | 0 | D8F011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility's interdisciplinary care team failed to develop a comprehensive care plan with realistic goals and interventions to address care of [MEDICAL CONDITIONS]. Additionally, the care plan did not include parameters to make the goal measurable. This was true for one (1) of five (5) residents whose records were reviewed for care planning. Resident identifier: #91. Facility census: 89. Findings include: a) Resident #91 Medical record review found the resident was admitted to the facility on [DATE]. Further review of the medical record found the physician's admission history and physical, dated 03/29/12, describing a hypo-pigmented area and large [MEDICAL CONDITION] to left side of the resident's nose. Review of the resident's care plan found a problem statement: (Name of resident) has an (sic) lesion to left side of nose. The goal associated with this problem was, (name of resident) will not have any unidentified complications related to skin integrity issues through (date was absent). Interventions included: Reposition (name of resident) every 2-3 hours and as needed, (name of resident) needs treatments as ordered by physician. Employee's #15 and #52, the minimum data set (MDS) coordinators, were interviewed at 4:00 p.m. on 10/03/12. The employees were questioned regarding the relevance of repositioning to heal [MEDICAL CONDITION] lesion to the nose and the fact a treatment was not being provided when the care plan was written on 03/29/12. These employees were asked how the goal could be measured when the goal failed to include a time frame. No further information was received from the employees. | 2015-10-01 |
| 9599 | 9599 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-10-05 | 309 | D | 1 | 0 | D8F011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a treatment for [REDACTED]. The original order for treatment contained no frequency for the treatment, in addition there was no evidence any treatment was initiated until eleven (11) days after the original order. This was true for one (1) of three (3) residents whose treatments were reviewed during the survey. Resident identifier: #91. Facility census: 89. Findings include: a) Resident #91 The resident was admitted to the facility, on 03/23/12, with a [DIAGNOSES REDACTED]. Review of the medical record found no documentation of a description of the lesion, the dimensions of the lesion, or whether it was draining or not. Review of the physician's history and physical, completed on 03/29/12, found the physician had noted the resident had a large [MEDICAL CONDITION] to left nose. On 03/26/12, an order was written to cleanse the left side of the nose with normal saline, pat dry, and leave open to air. The order contained no parameters for frequency of the treatment. There was no evidence this treatment was provided from the date it was ordered until 04/06/12. Review of the treatment administration record (TAR) found an order dated 04/06/12 to Cleanse left side of nose (lesion) with sodium chloride 0.9% solution, pat dry and leave open to air. There was nothing to indicate with what frequency the treatment was to be provided. Review of the resident's care plan, completed on 03/29/12, found a problem statement of (name of resident) has a lesion to left side of nose. The intervention associated with this problem referenced providing treatments as ordered and a weekly evaluation of wound healing. The director of nursing (DON), Employee #88, and the corporate nurse, Employee #89, were interviewed on 10/03/12 3:00 p.m. The DON verified the original order lacked parameters for treatment. No further information was provided to explain the delay in treatment. The DON was una… | 2015-10-01 |
| 9600 | 9600 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-10-05 | 314 | G | 1 | 0 | D8F011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility's policy and procedure for, Introduction to Prevention and Management of Wounds, the facility failed to; accurately and timely assess the pressure areas, administer treatments as ordered by the physician to promote wound healing, evaluate the effectiveness of the treatments in place, and follow their policy for treatment of [REDACTED]. This was true for two (2) of three (3) residents reviewed for pressure ulcers. Resident identifiers: #81 and #18. Facility census: 89. Findings include: a) Resident #81 Resident #81 was admitted to the facility on [DATE] at 7:34 p.m. According to the nursing admission note, he was admitted with a stage II pressure ulcer to the coccyx. Upon admission, an order was present to clean the Stage II pressure area to the coccyx with normal saline solution, pat dry and apply Combiderm every day. Review of the treatment administration record (TAR) for July found the treatment was not provided as ordered from 07/13/12 through 07/24/12, when the resident was discharged from the facility and admitted to the hospital. On 07/27/12 the resident was readmitted to the facility at 3:50 p.m. admission orders [REDACTED]. On 07/27/12 a physician's order was present to, cleanse The Stage II pressure ulcer to coccyx with Saf-clens, AF wound cleanser, apply duoderm, change every three (3) days and as needed. Review of the TAR found the first treatment to the pressure area was not provided until 07/30/12. Review of the medical record found no assessment, including a measurement of the pressure area, or evaluation of the pressure ulcer from 07/13/12 until 08/02/12. There was no documentation present to verify the measurements of the pressure area on the 07/13/12 admission or the re-admission on 07/27/12. On 08/02/12 a, pressure ulcer evaluation, form was completed which included measurements, treatment, and a description of the wound. On 08/02/12 the Stage II pre… | 2015-10-01 |
| 9601 | 9601 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-10-05 | 323 | D | 1 | 0 | D8F011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's request/concern forms, and staff interview, the facility failed to follow orders for a safe transfer of a resident and failed to ensure the necessary equipment was available to facilitate a safe transfer. This was true for one (1) of three (3) residents whose medical records were reviewed for accident hazards. Resident identifier: #83. Facility census: 89. Findings include: a) Resident #83 Review of the facility, Request / concern forms, found Resident #83 had alleged that staff would not transfer him out of bed to the bed side commode with the lift because the lift pad (sling) was locked in the laundry room and there were no staff present to unlock the laundry door. The concern was dated 08/26/12 and was completed by the director of nursing (DON). Further review found a statement attached to the allegation and addressed to the director of nursing (DON) from a registered nurse, Employee #81. Per our phone call - I explained to (name of Resident #83) and his sister due to the lift pad being in laundry we would not be able to physically lift to bedside commode. Upset because on 08/25/12 three CNAs were instructed to assist to BSC (bedside commode), he is total lift. Bedpan offered several X's (times) refused. Verbalized comfort except wants on BSC. This statement was not dated. A follow up statement to the DON on the same paper, Laundry had sling clean and on shelf if open or access this entire ordeal could have been avoided. Included in the investigation was a statement from Employee #25, medical records staff. (Name of staff, Employee #80 a nursing assistant) came to me (name of medical records employee) and stated that (name of resident) needed to go to the bathroom, and that (first name of another employee) would not take him. I went to activities where (first name of employee) was feeding another resident (name of resident) and told her that when a resident ask (sic) to go to the bat… | 2015-10-01 |
| 9602 | 9602 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-10-05 | 356 | B | 1 | 0 | D8F011 | Based on observation and staff interview, the facility failed ensure the nurse staff posting was completed at the beginning of the shift and contained the total number and the actual hours worked for licensed and unlicensed nursing staff for the day shift of 10/01/12. This had the potential to affect more than an isolated number of residents and visitors. Facility census: 89. Findings include: a) During the initial tour of the facility, on 10/01/12 at 12:35 p.m., observation of the nurse staff posting found the number of licensed and unlicensed nursing staff for the day shift of 10/01/12 had not been completed. The nurse staffing posting was observed with the director of nursing (DON) on 10/01/12 at 12:35 p.m. The DON confirmed the information had not been completed. | 2015-10-01 |
| 9603 | 9603 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-10-05 | 364 | E | 1 | 0 | D8F011 | Based on observation and staff interview, the facility failed to ensure delivery of meal trays in a timely manner, resulting in unacceptable temperatures at the time of meal service. This practice had the potential to affect more than an isolated number of residents. Facility census: 89. Findings include: a) An open tray cart was observed sitting in the main dining room from 12:10 p.m. until 12:40 p.m. At 12:40 p.m., the open cart was taken to Dogwood Drive on the east wing with three (3) remaining trays. At 12:45 p.m. on 10/01/12 the last tray was being served from the cart. Employee #82, a dietary assistant, was asked to take the temperatures of the food items being served. Employee #82 verified the temperatures as follows: -- mashed potatoes, 102 degrees; -- meat loaf 114 degrees, -- greens 102 degrees -- milk 55 degrees. Generally accepted guidelines for palatability of cold foods is 50 degrees Fahrenheit or less, and hot foods at 120 degrees Fahrenheit or above, when served, The dietary manager, Employee #47, was interviewed at 9:00 a.m. on 10/02/12, as she was unavailable on 10/01/12. She stated she was aware of the situation and the staff should have heated the food in the microwave. She verified the food items served for the noon meal left the kitchen at acceptable temperatures. | 2015-10-01 |
| 9604 | 9604 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-10-05 | 465 | E | 1 | 0 | D8F011 | Based on observation and staff interview, the facility failed to maintain a safe functional and sanitary environment. A fire door was found to be closed and blocked with containers preventing entrance / exit to the hallway. This had the potential to affect more than an isolated number of residents. Facility census: 89. Findings include: a) Observation of the west wing, on 10/01/12 at 11:30 a.m., found one fire door on the right side hall closed. Behind this door were numerous items preventing usage of the door. Items included; a chucks only container, a garbage container, a biohazard container, a linen only container, a soiled linen cart, a portable oxygen tank in a wheeled cart, and a wet floor sign lying on its side. An interview, on 10/01/12 at 11:30 a.m., with Employee #33, a nursing assistant, revealed these items were placed behind the closed fire door because, Employee #40, a floor tech, was waxing the soiled utility room floor. Employee #33 then added another container to the items blocking the fire door. The housekeeping floor tech, Employee #40, confirmed he had placed the items in front of the fire door so he could clean the floor in the soiled utility room at 11:30 a.m. on 10/01/12. This situation was discussed with Employee #54, a register nurse on the west wing, who confirmed the fire door should not be blocked. At 12:10 p.m. on 10/01/12, these findings were discussed with the administrator, Employee #87 and the corporate registered nurse, Employee #89. | 2015-10-01 |
| 9605 | 9605 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-10-05 | 490 | G | 1 | 0 | D8F011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of citations and the associated plans of correction issued to the facility in 2012, staff interview, and the findings of the current complaint survey, the governing body failed to ensure all deficient practices cited during a combined quality indicator survey (QIS) and a complaint survey on 02/01/12, and a second complaint survey occurring on 06/01/12, were corrected, as alleged in the plan of correction. Non-compliance remained in the following groupings: Resident Behavior and Facility Practices, Quality of Care, Resident Assessment, and Nursing Services. This had the potential to affect more than an isolated number of residents who reside in the facility. Facility census: 89. Findings include: Repeat deficiencies were found in the following areas: a) The facility failed to ensure two (2) residents received timely treatments for pressure ulcers. Medical record review, staff interview, and review of the facility's policy and procedure for, Introduction to Prevention and Management of Wounds, found the facility had failed to assess pressure areas accurately and timely, had failed to provide treatments as ordered by the physician to promote wound healing, had failed to evaluate the effectiveness of the treatments in place, and had failed to follow their policy for treatment of [REDACTED]. (This was previously cited during the 02/01/12 complaint survey at a level of harm.) b) The governing body failed to ensure allegations of abuse/neglect were reported to the appropriate state authorities. Review of the facility's request / concern forms, staff interview, review of resident / visitor incident reports, and the facility's policy and procedure for Resident Advocacy Protocols, found the facility had failed to report allegations of abuse / neglect to the appropriate State authorities. (This was previously cited on the 02/01/12 QIS.) c) The governing body failed to ensure a comprehensive care plan was developed to address a resident w… | 2015-10-01 |
| 9606 | 9606 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-10-05 | 520 | G | 1 | 0 | D8F011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of citations and the associated plans of correction issued in 2012 , and staff interview, the facility's quality assessment and assurance (QAA) committee failed to implement and monitor actions to ensure previously cited deficient practices were corrected and did not recur. This visit found five (5) repeat deficiencies, including one (1) repeat deficiency with non-compliance at a severity level of harm. This had the potential to affect more than an isolated number of residents. Facility census: 89. Findings include: a) Quality Assurance and Assessment Committee During the complaint survey completed on 10/01/12, the survey team found non-compliance with four (4) regulatory requirements which were found to be deficient during the 02/01/12 survey and the 06/01/12 complaint survey. The facility's QAA committee did not ensure areas of deficient practice did not recur. Additionally, there was no evidence the QAA committee was aware these areas were out of compliance. The QAA committee did not ensure corrective actions were implemented and monitored to ensure on-going compliance. The following areas were identified: 1. Quality of Care -- Medical record review, staff interview, and review of the facility's policy and procedure for, Introduction to Prevention and Management of Wounds, found the facility had failed to assess pressure areas accurately and timely, had failed to provide treatments as ordered by the physician to promote wound healing, had failed to evaluate the effectiveness of the treatments in place, and had failed to follow their policy for treatment of [REDACTED]. (This was previously cited during the 02/01/12 complaint survey at a level of harm.) -- Medical record review and staff interview found the facility failed to ensure a treatment for [REDACTED]. The original order for treatment contained no frequency for the treatment, in addition there was no evidence any treatment was initiated un… | 2015-10-01 |
| 9607 | 9607 | HEARTLAND OF RAINELLE | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2010-03-05 | 160 | D | 0 | 1 | I2AU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to convey, within thirty (30) days, personal funds for a resident who had expired. This was noted for one (1) of five (5) residents reviewed for this aspect of personal funds. The resident expired on [DATE]. As of [DATE], the funds had not been conveyed to the resident's estate. Resident identifier: A. Facility census: 55. Findings include: a) Resident A On [DATE], review of the resident funds, with the administrator, found an account balance of $831.68 for this expired resident, who expired on [DATE]. At 2:00 p.m. on [DATE], the administrator confirmed these funds had not yet been conveyed to the resident's estate. | 2015-10-01 |
| 9608 | 9608 | HEARTLAND OF RAINELLE | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2010-03-05 | 225 | E | 0 | 1 | I2AU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review and staff interview, the facility failed to be thorough in their investigation of the past history for one (1) of ten (10) employees whom the facility hired. The facility failed to make an inquiry of the State nurse aide registry for Employee #11. This practice had the potential to affect more than an isolated number of residents. Facility census: 55. Findings include: a) Employee #11 On 03/04/10, ten (10) sampled employee personnel files, when reviewed with the facility's human resource director (HRD), revealed Employee #11 was hired on 05/26/09. There was no evidence an inquiry was made of the nurse aide registry, to identify findings concerning abuse, neglect, mistreatment of [REDACTED]. When this information could not be located by the HRD, the HRD contacted the director of nursing (DON), in case the DON had this information. At 3:00 p.m. on 03/04/10, the HRD and DON reported this screening had not been done for Employee #11. | 2015-10-01 |
| 9609 | 9609 | HEARTLAND OF RAINELLE | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2010-03-05 | 241 | D | 0 | 1 | I2AU11 | Based on random observations, the facility failed to each resident was treated with dignity. A volunteer insisted on a resident wearing a clothing protector despite the resident's repeated protestations. Resident identifier: #55. Facility census: 55. Findings include: a) Resident #55 At lunch time in the dining room on 03/04/10, observation found Resident #55 seated at a table with two (2) other residents. A staff member had placed clothing protectors on the other two (2) residents earlier, but Resident #55 had declined. A volunteer moved about the dining room interacting with residents. When she reached the table at which Resident #55 sat at 11:35 a.m., the volunteer picked up a clothing protector that had been lying folded on the table in front of an empty chair. She moved to place it on the resident, and the resident said, I don't want that. Despite the resident's repeated statements that she did not want the clothing protector, the volunteer persisted in trying to persuade the resident to allow her to put the clothing protector on her (the resident) in case she would spill her food. The volunteer tried to place the protector around the resident's neck, and the resident pulled it away. The volunteer then put it in the resident's lap. After the volunteer left the table, the resident again said, I don't want that, folded the clothing protector, and put it back on the table where it had been initially. This incident was reported to the social worker in late morning on 03/05/10. She said it was something that definitely needed to be addressed. . | 2015-10-01 |
| 9610 | 9610 | HEARTLAND OF RAINELLE | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2010-03-05 | 272 | E | 0 | 1 | I2AU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, resident interviews, and observations, the facility failed to ensure the interdisciplinary team provided documentation of summary information regarding the additional assessment performed through the resident assessment protocols (RAPs) which contained sufficient evidence areas to reflect triggered by the minimum data set (MDS) assessments had been fully explored for the individual. Additionally, the information documented in the RAPs did not demonstrate the rationale for the care planning decisions. Five (5) of twelve (12) current residents on the sample were affected. Resident identifiers: #32, #25, #17, #16, and #22. Facility census: 55. Findings include: a) Resident #32 Review of the Urinary Incontinence and Indwelling Catheter RAP found it had triggered due to Indwelling catheter having been coded on the admission assessment with an assessment reference date (ARD) of 12/14/09. The assessment also indicated the resident was continent of bowel. In the narrative section, the assessor documented the following, Problem - potential for infection Contributing factors - use of indwelling cath upon admission but was DC (discontinued) after 2 days and remains continent of urine thus far, has stage one pressure ulcer to coccyx upon admission to facility Risks - infection Referrals, catheter removal, toilet as ordered and provide incontinent (sic) care as needed, skin care as ordered, monitor labs and weights as ordered, offer fluids at and between meals. The physician ordered the catheter be removed on 12/09/09. The nurses' notes indicated the catheter had been removed and the resident was voiding. The RAP notation indicated the resident was voiding continently. The RAP also noted possible reversible problems to be reviewed in evaluating the need for a catheter or evaluating incontinence. Check marks had been placed beside of locomotion, [MEDICAL CONDITIONS], and psychoactive medications. There was no evide… | 2015-10-01 |
| 9611 | 9611 | HEARTLAND OF RAINELLE | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2010-03-05 | 279 | E | 0 | 1 | I2AU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, staff interviews, and family interview, the facility failed to develop a comprehensive care plan for each resident that included measurable objectives and described the services to be provided to assist the resident to attain his or her highest practicable level of well-being. Goals were not established for items identified on the assessment that would require the development of a program, i.e., no care plan was developed although a resident was assessed as being on a planned weight loss program. Goals were established without parameters to render them measurable and/or to provide guidance to caregivers. Rehabilitative goals were identified, but the care plan was primarily directed toward maintenance of current abilities and/or for staff to meet the resident's needs. Four (4) of twelve (12) current residents on the sample were affected. Resident identifiers: #11, #32, #25, and #21. Facility census: 55. Findings include: a) Resident #11 1. The quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/04/10, identified the resident was on a planned weight change program. No care plan had been established regarding what change was desired regarding the resident's weight. The interdisciplinary team established a goal, dated 10/12/09, for: Will consume / tolerate 75% of meals with no S/S (signs/symptoms) of aspiration this quarter. The interventions were related to positioning, honoring food preferences, to monitor and report her weight, etc. There was nothing to indicate how much weight the resident was to lose or gain and how fast the weight loss or gain was to occur. Neither her current nor target weights were identified in the care plan. For this item to be coded in K5h, the MDS manual instructs: On Planned Weight Change Program - Resident is receiving a program of which the documented purpose and goal are to facilitate weight gain or loss (e.g., double portions; high calorie… | 2015-10-01 |
| 9612 | 9612 | HEARTLAND OF RAINELLE | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2010-03-05 | 280 | D | 0 | 1 | I2AU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to review / revise care plans when there was clinical change in condition that impacted the resident's care needs. One (1) resident had an increase in episodes of bowel incontinence after admission, but the care plan was not revised. Another resident was admitted with an indwelling urinary catheter, which was discontinued shortly after admission; the care plan addressed urinary incontinence and was not revised when a catheter was reinserted. Two (2) of twelve (12) current residents were affected. Resident identifiers: #11 and #32. Facility census: 55. Findings include: a) Resident #11 The resident's admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/08/09, was coded to indicate the resident was occasionally incontinent of bowel. The quarterly assessment, with an ARD of 01/04/10, indicated she was incontinent of bowel all, or almost all, of the time. A care plan had been established based on the admission assessment. It included an intervention to toilet the resident upon arising, before / after meals, and at bedtime and as needed. The care plan had not been updated to address the increase in incontinence. There were no interventions established that would promote bowel continence. b) Resident #32 The resident was admitted to the facility on [DATE]. At the time of admission, she had an indwelling urinary catheter. The catheter was discontinued on 12/09/09. A care plan was established for no complications due to incontinence and for: Will be maintained in as clean and dry dignified state as possible within confines of urinary dysfunction. On 12/19/09, a catheter was reinserted. The care plan had not been revised, as of 03/05/10, to reflect the use of the catheter. c) These issues were discussed with the director of nursing in mid-morning, and the assessment coordinator (Employee 42) at 3:10 p.m. on 03/05/10. They agreed the care … | 2015-10-01 |
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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 );