cms_WV
Data source: Big Local News · About: big-local-datasette
175 rows where "filedate" is on date 2015-11-01
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Suggested facets: facility_name, facility_id, address, city, zip, eventid, inspection_date (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9338 | 9338 | PRINCETON CENTER LLC | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-06-30 | 225 | E | 0 | 1 | QU2H11 | Based on review of sampled personnel files, review of the facility's abuse policy, and staff interview, the facility failed to make reasonable efforts to uncover past histories of individuals prior to employing them, in an effort to uncover any past criminal convictions that would indicate the individuals are unsuited to work in a nursing home. Criminal background checks were not conducted outside the State of West Virginia (WV) for eight (8) individuals who identified on their employment applications having lived, worked, or attended school outside of WV. This practice has the potential to affect more than an isolated number of residents. Employee identifiers: #76, #100, #49, #42, #47, #142, #123, and #48. Facility census: 65. Findings include: a) Employees #76, #100, #49, #42, #47, #142, #123, and #48 On 06/28/11, sampled employee personnel files were reviewed. This review revealed eight (8) employees who had listed past employment, residency, or college attendance in States other than WV. Employee #42 (activities coordinator) listed residency and employment in Ohio (OH) and North Carolina (NC). Employee #76 (registered nurse) listed employment in Virginia (VA). Employee #47 (nurse aide) listed employment, residency ,and school attendance in OH. Employee #48 listed college attendance in VA. Employee #49 listed employment and residency in VA. Employee #100 (registered nurse) listed employment in VA. Employee #142 listed employment and residency in VA. Employee #123 (dietary aide) listed employment in MD and residency in Rhode Island (RI) and Maryland (MD). - The facility's abuse policy, when reviewed on 06/30/11, revealed the following: 5. All requests for Criminal History Record Checks under the Central Abuse Registry are to be directed to the West Virginia State Police. - On 06/29/11 at approximately 10:00 a.m., Employee #11 (vice president of resources) reported the facility had not conducted any criminal background searches outside of the State of West Virginia for the employees listed above. Employee #11 ag… | 2015-11-01 |
| 9339 | 9339 | PRINCETON CENTER LLC | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-06-30 | 226 | E | 0 | 1 | QU2H11 | Based on review of sampled personnel files, review of the facility's abuse policy, and staff interview, the facility failed to develop and implement a policy which ensures the facility made reasonable efforts to uncover past histories of individuals prior to employing them, in an effort to uncover any past criminal convictions that would indicate the individuals are unsuited to work in a nursing home. Criminal background checks were not conducted outside the State of West Virginia (WV) for eight (8) individuals who identified on their employment applications having lived, worked, or attended school outside of WV, and the facility's policy did not address the need to do so. This practice has the potential to affect more than an isolated number of residents. Employee identifiers: #76, #100, #49, #42, #47, #142, #123, and #48. Facility census: 65. Findings include: a) Employees #76, #100, #49, #42, #47, #142, #123, and #48 On 06/28/11, sampled employee personnel files were reviewed. This review revealed eight (8) employees who had listed past employment, residency, or college attendance in States other than WV. Employee #42 (activities coordinator) listed residency and employment in Ohio (OH) and North Carolina (NC). Employee #76 (registered nurse) listed employment in Virginia (VA). Employee #47 (nurse aide) listed employment, residency ,and school attendance in OH. Employee #48 listed college attendance in VA. Employee #49 listed employment and residency in VA. Employee #100 (registered nurse) listed employment in VA. Employee #142 listed employment and residency in VA. Employee #123 (dietary aide) listed employment in MD and residency in Rhode Island (RI) and Maryland (MD). - The facility's abuse policy, when reviewed on 06/30/11, revealed the following: 5. All requests for Criminal History Record Checks under the Central Abuse Registry are to be directed to the West Virginia State Police. - On 06/29/11 at approximately 10:00 a.m., Employee #11 (vice president of resources) reported the facility had not conducted… | 2015-11-01 |
| 9340 | 9340 | PRINCETON CENTER LLC | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-06-30 | 280 | D | 0 | 1 | QU2H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, and medical record review, the facility failed to assure one (1) of twenty-one (21) Stage II sampled residents was afforded the right to participate in the care and treatment provided. Resident #89 (who was alert and oriented) was placed on a diet consisting only of spoonfuls of thickened water without consulting her or obtaining her consent. Resident identifier: #89. Facility census: 65. Findings include: a) Resident #89 During random observations of the evening meal beginning at 5:10 p.m. on 06/27/11, it was noted that staff members did not deliver a meal tray to Resident #89. At 6:00 p.m., Resident #89 had still not been provided a meal tray. The nursing assistant (NA) assigned to care for the resident that shift (Employee #73) was interviewed at 6:00 p.m. on 06/27/11. When asked if Resident #89 received a tray for the evening meal, the NA stated the resident did not get a meal tray due to being NPO (nothing by mouth). The NA stated he had not been in the resident's room during his shift. Review of the medical record found a 06/23/11 physician's orders [REDACTED]. The medical record contained no evidence that the resident was notified of this change in diet, nor that she was allowed to participate in this decision. Further review found, on 03/19/11 and on 03/22/11, the physician determined the resident retained the capacity to make her own informed medical decisions. Review of the minimum data set (MDS) with an assessment reference date (ARD) of 05/15/11 found the assessor noted Resident #89 to be usually able to make herself understood and usually able to understand verbal content. In the area of activities of daily living, the resident was assessed as requiring the total assistance of staff for eating. The resident's room was entered at 6:30 p.m. on 06/27/11. Resident #89 was alert and answered questions appropriately by nodding her head in the positive or negative. The resident'… | 2015-11-01 |
| 9341 | 9341 | PRINCETON CENTER LLC | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-06-30 | 309 | G | 0 | 1 | QU2H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to adequately assess / monitor and obtain timely medical intervention for one (1) of twenty-one (21) Stage II sample residents who was experiencing an acute change in condition. Resident #10, who was assessed upon admission on [DATE] as being continent of bowel, had twenty-seven (27) bowel movements (BMs) between her date of admission on [DATE] (with the first loose stool recorded on [DATE]) and until she expired on the early morning of [DATE]. Of those, twenty-one (21) BMs were described as loose and fourteen (14) of them were described as incontinent. There was no evidence of any recognition by licensed nurses of the resident's frequent episodes of diarrhea until it was brought to their attention by therapy staff on [DATE], and no evidence of any assessment / monitoring of the resident's bowel elimination status (after it was identified by the therapy staff) until [DATE], when a nurse noted the resident had a recurrent fever and episodes of diarrhea and the physician gave orders for a stool culture and sensitivity. When the lab results came back positive for [MEDICAL CONDITION] (C diff) in her stool on [DATE], Resident #10 was placed in contact isolation and started on an antibiotic ([MEDICATION NAME]) to treat the infection. This lack of assessment / monitoring resulted in a delay in treatment for [REDACTED]. Facility census: 65. Findings include: a) Resident #10 Record review revealed this [AGE] year old female resident was admitted to the nursing facility [DATE] and expired [DATE]. Her [DIAGNOSES REDACTED]. The resident had been hospitalized for [REDACTED]. The antibiotic therapy continued at the nursing facility until [DATE]. According to her hospital history and physical examination [REDACTED]. There was no mention of any diarrhea or hyperactive bowel sounds in her hospital discharge summary dictated by the physician on [DATE]. According to the hospital discharge summary, … | 2015-11-01 |
| 9342 | 9342 | PRINCETON CENTER LLC | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-06-30 | 314 | D | 0 | 1 | QU2H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to assure one (1) of three (3) Stage II sampled residents with pressure ulcers received care and treatment necessary to promote healing and prevent infection. Resident identifier: #31. Facility census: 65. Findings include: a) Resident #31 Review of the medical record noted Resident #31 developed Stage III and Stage IV pressure ulcers to her left heel, right heel, and right ankle. Review of physician's orders [REDACTED]. Review of the treatment administration record (TAR) noted the nurses were documenting utilizing tender wet dressings with non-bordered foam to the wounds to the resident's right outer ankle and left heel. The order for the resident's right inner heel had been defaced in such a manner as to render the order indecipherable. An observation of the wound treatment was conducted with a licensed practical nurse (LPN - Employee #97) at 9:26 a.m. on 06/30/11. The LPN was noted to prepare a clean field and place supplies for the wound dressings on it. She then removed a pair of scissors from her right uniform pocket and placed them on the clean field without cleansing or sanitizing them. She utilized the contaminated scissors to cut the non-bordered foam utilized on two (2) of the resident's wounds. The nurse dressed the wound to the resident's left heel with a tender wet dressing covered with the contaminated non-bordered foam. She dressed the wound to the resident's right outer ankle utilizing the tender wet dressing covered with the contaminated non-bordered foam. She utilized the correct treatment of [REDACTED]. After completing the treatments, the nurse returned the scissors to her right uniform pocket without cleaning or sanitizing them. The discrepancy noted between the physician's orders [REDACTED].#76) at 10:05 a.m. on 06/30/11. The RN called the wound treatment center to clarify the treatment for [REDACTED]. She agreed that she could not dec… | 2015-11-01 |
| 9343 | 9343 | PRINCETON CENTER LLC | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-06-30 | 327 | G | 0 | 1 | QU2H12 | Deficiency Text Not Available | 2015-11-01 |
| 9344 | 9344 | PRINCETON CENTER LLC | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-06-30 | 371 | E | 0 | 1 | QU2H11 | Based on observation and staff interview, the facility failed to ensure snack foods were stored in safe and sanitary conditions. The thermometer in the nourishment pantry refrigerator was not working, which did not allow for monitoring to ensure foods were stored in safe temperature range. This had the potential to affect more than an isolated number of residents. Facility census: 65. Findings include: a) On 06/28/11 at approximately 3:00 p.m., Employee #15 (environmental services supervisor) accompanied this surveyor during the tour of the building's general environment. Observation of the nourishment pantry refrigerator revealed the thermometer did not function properly. Employee #15 took the thermometer out of the refrigerator and replaced it with one (1) that worked. The facility used this refrigerator to store perishable food items for resident consumption. | 2015-11-01 |
| 9345 | 9345 | PRINCETON CENTER LLC | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-06-30 | 431 | F | 0 | 1 | QU2H11 | Based on observation and staff interview, the facility failed to assure that only authorized personnel were provided access to drugs and biologicals stored in the locked medication room. This deficient practice had the potential to affect all residents residing and receiving medication in the facility. Facility census: 65. Findings include: a) During observations of the nursing station on 06/29/11 at 8:00 a.m., two (2) members of the housekeeping staff were noted to enter the closed door of the nursing station. A member of the housekeeping staff (Employee #34) asked this surveyor to step out of the nursing station. She stated that everyone had to leave the nursing station so that housekeeping could clean. When asked how housekeeping cleaned the medication storage room, she stated the nurses leave the keys for them. The vice president of health services (Employee #67) was immediately informed of the housekeeper's statement and assisted this surveyor to identify what areas of the medication storage room allowed unsupervised access to members of the housekeeping staff. Employee #67 utilized the set of keys left by the nurse for the housekeeping staff to utilize and determined that the housekeepers would have access to cabinets full of medications as well as the controlled substances slated for destruction by the pharmacist. | 2015-11-01 |
| 9346 | 9346 | PRINCETON CENTER LLC | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-06-30 | 441 | F | 0 | 1 | QU2H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to establish and maintain an infection control program designed to help prevent the development and transmission of disease and infection. The facility failed to utilize a cleaning solution effective in killing Clostridium difficile (C diff) spores, failed to assure a nurse provided wound care free from contamination, failed to assure staff members washed their hands when indicated, and failed to assure staff members were educated concerning isolation procedures for equipment utilized in[DIAGNOSES REDACTED] isolation rooms. These deficient practices affected Residents #65 and #67, when nursing staff members failed to wash their hands prior to instilling eye drops, and had the potential to affect all residents residing in the facility. Resident identifiers: #65 and #67. Facility census: 65. Findings include: a) During the initial tour of the facility on 06/21/11 at 1:50 p.m., observation found Rooms #10 and #11 displayed signs on the doors directing visitors to go to the nursing station prior to entering the rooms. The registered nurse (RN - Employee #76), when asked why the signs were posted on the doors, stated the residents in both rooms were on contact isolation for[DIAGNOSES REDACTED]. Review of the medical records for each of the two (2) residents found that both were receiving treatment for [REDACTED]. The resident in room [ROOM NUMBER] was assessed as being always incontinent of bowel. In an interview on 06/21/11 at 2:04 p.m., a member of the housekeeping staff (Employee #20) stated she cleaned Rooms #10 and #11 and was aware that they were isolation rooms. When asked to describe the procedure she utilized in order to clean the rooms, Employee #20 stated she utilized a particular cleaning agent for all surfaces and floors in both rooms. In a subsequent interview conducted at 2:30 p.m. on 06/21/11, the vice president of environmental ser… | 2015-11-01 |
| 9347 | 9347 | PRINCETON CENTER LLC | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-06-30 | 502 | D | 0 | 1 | QU2H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility did not ensure one (1) of twenty-one (21) Stage II sample residents received timely laboratory services. The physician had ordered a laboratory test in May 2011, which had not been obtained by the facility as of 06/27/11. Resident identifier: #62. Facility census: 65. Findings include: a) Resident #62 On 06/27/11 at approximately 9:00 a.m., review of the medical record for Resident #62 revealed a physician's orders [REDACTED]. The resident had a [DIAGNOSES REDACTED]. The vice president of health services (Employee #67) verified the facility had not obtained the laboratory test. | 2015-11-01 |
| 9348 | 9348 | PRINCETON CENTER LLC | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-06-30 | 514 | D | 0 | 1 | QU2H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized for three (3) Stage II sample residents. The facility did not complete documentation each month regarding Resident #72's behaviors which necessitated the use of antipsychotic and benzodiazepine medication. The facility did not ensure physician's orders [REDACTED].#31. The nurses did not record explanations on the reverse side of the medication administration record (MAR) or the nursing notes to explain when medications were not administered as ordered by the physician for Resident #10. Resident identifiers: #72, #31, and #10. Facility census: 65. Findings include: a) Resident #72 The medical record review for Resident #72 conducted on 06/30/11 at approximately 11:00 a.m. revealed the resident received [MEDICATION NAME] 0.25 for agitation and [MEDICATION NAME] .25 for anxiety. Resident #72 had a [DIAGNOSES REDACTED]. Employee #83 (registered nurse) reviewed the resident's medical record and determined the facility had not documented the resident's behaviors of attempting elopement and crying in May 2011. The behavior tracking form for May 2011 had not been filled out. -- b) Resident #31 Review of physician's orders [REDACTED]. Review of the treatment administration record (TAR) noted that licensed nurses were documenting utilizing tender wet dressings with non-bordered foam to the wounds to the resident's right outer ankle and left heel. The order for the resident's right inner heel had been defaced in such a manner as to render the order indecipherable (last order on page 2 of the TAR). The discrepancy noted between the physician's orders [REDACTED].#76) at 10:05 a.m. on 06/30/11. The RN called the wound treatment center to clarify the treatment for [REDACTED]. She also agreed that she coul… | 2015-11-01 |
| 9349 | 9349 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2011-10-04 | 156 | C | 0 | 1 | 4F0I11 | Based on observation and staff interview, the facility failed to prominently display in the facility written information about how to apply for and use Medicare benefits and how to receive refunds for previous payments covered by Medicare benefits. This deficient practice had the potential to affect any resident or family member wishing to view the information. Facility census: 51. Findings include: a) On the morning of 09/29/11, observation revealed a bulletin board in the main corridor leading to the kitchen area. The bulletin board contained information on how to apply and use Medicaid benefits and how to receive refunds for previous payments covered by Medicaid, but it failed to contain the same information pertaining to Medicare benefits. On 09/29/11 at 9:20 a.m., the above deficient practice was discussed with the director of nursing, who stated the situation would be corrected. | 2015-11-01 |
| 9350 | 9350 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2011-10-04 | 225 | E | 0 | 1 | 4F0I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel file review, staff interview, and review of the facility's abuse / neglect policy, the facility failed to make reasonable efforts to uncover information about individuals' past histories that would indicate unfitness for employment in a nursing facility for three (3) of five (5) sampled employees. Employee identifiers: #90, #89, and #53. Facility census: 51. Findings include: a) Employees #90, #89, and #53 On 09/29/11 at approximately 1:00 p.m., the human resource assistant (Employee #94) assisted in the personnel file review. Three (3) of five (5) sampled employees who were hired within the past three (3) months did not receive thorough background screenings. These screenings included reference checks, nurse aide registry checks, and criminal background checks. - Employee #90 (housekeeping), hired on 06/13/11, did not have evidence of a nurse aide registry screening. This employee's file also did not have evidence of attempted or completed reference checks. - Employee #89 (laundry), hired on 06/27/11, did not have evidence of a nurse aide screening, nor were there any attempted or completed reference checks present in her file. - Employee #53 (nurse aide), hired on 06/06/11, had listed on her application her last state of residence as Ohio. She had also listed employment in Ohio. The facility had not completed any criminal background screenings in the state of Ohio for this employee. - The facility's policy titled Abuse / Neglect of Residents (with an effective date of 07/11/10), when reviewed on 09/29/11 at approximately 2:00 p.m., revealed the following in the section titled Screening (quoted as typed): 1. The facility shall not knowingly employ individuals who have been found guilty by a court of law of abusing, neglecting or mistreating residents; or have had a finding entered into the State Nurse Aid Registry concerning abuse, neglect mistreatment of [REDACTED]. 2. Prior to a nursing assistant being hires, the West Vi… | 2015-11-01 |
| 9351 | 9351 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2011-10-04 | 241 | E | 0 | 1 | 4F0I11 | Based on observation, staff interview, and medical record review, the facility failed to assure care for residents was provided in a manner and in an environment that maintains or enhances each resident's dignity. One (1) of twenty-five (25) Stage II sample residents (#36) was placed in the dining room facing a wall and not within line of sight of her husband (another resident) during the evening meal on 09/26/11, and a nursing assistant fed her in an undignified manner during the noon meal on 09/29/11 A housekeeper carried large transparent bags of garbage through the dining room during the evening meal on 09/26/11, such that the contents of the bags was visible to the eleven (11) residents who were eating in the dining room at the time of the occurrence. Additionally, staff did not serve one (1) of five (5) residents (#41) who were seated together at the same table a meal tray at the same time during the evening meal on 09/26/11. Facility census: 51. Findings include: a) Resident #36 1. Random observations were conducted of the evening meal service in the main dining room during the first day of this Quality Indicator Survey (QIS) on 09/26/11. Viewing of the main dining room, at 5:30 p.m., noted a female resident seated perpendicular to the dining table in a geriatric chair with her back to the other diners and facing the wall. Her geriatric chair was leaned back slightly, and the foot rest was up. A practical nursing student was noted to be unsuccessfully attempting to get the resident to take a bite of food. An interview with the social worker (Employee #102) elicited that the female resident was Resident #36 and the male resident seated next to her was her husband, Resident #30. Resident #30 was seated with the back of his wife's geriatric chair facing him. Neither Resident #30 nor Resident #36 could see each other. When asked why the residents had been seated this way, the social worker made arrangements for the residents to be able to view each other while eating. Review of Resident #36's medical record fo… | 2015-11-01 |
| 9352 | 9352 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2011-10-04 | 250 | D | 0 | 1 | 4F0I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview, the facility failed to have well-defined, non-conflicting directives the administration of cardiopulmonary resuscitation (CPR) in the event of a cardiac or respiratory arrest for one (1) of twenty-five (25) Stage II sample residents. The code status form, signed by the medical power of attorney representative (MPOA) for a resident who lacked capacity (#10), gave conflicting directives regarding CPR. Additionally, physician's orders from the resident's admitted through the current date contained no orders related to CPR, and the resident's care plan noted she was a full code status. Resident identifier: #10. Facility census: 51 Findings include: a) Resident #10 Record review revealed the code status form signed by Resident #10's MPOA, dated [DATE], contained conflicting statements. In one (1) place on the form, the MPOA initialed indicating her desire for the resident to receive CPR in the event the resident's heart stopped beating or she ceased to breath. In another place on the form, the MPOA initialed indicating consent to the following statement: If I (the resident) am too sick to make medical decisions for myself, I do not want CPR. Record review revealed the absence of any physician's orders directing the resuscitation status for Resident #10. Review of the care plan revealed Resident #10 was a FULL CODE, meaning she would receive CPR in the event her heart stopped beating or she ceased to breath. Interview with a licensed practical nurse (LPN - Employee #40), on [DATE] at 12:00 p.m., revealed she could find no physician orders related to CPR for Resident #10, and she agreed the directives related to the resident's code status were in conflict. Employee #40 stated the physician orders always contain directives related to code status, but this one did not. A face-to-face interview with Resident #10's MPOA, on [DATE] at 1:25 p.m., found she had returned to the facility, per sta… | 2015-11-01 |
| 9353 | 9353 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2011-10-04 | 253 | E | 0 | 1 | 4F0I11 | Based on observation and staff interview, the facility failed to provide services necessary to maintain a sanitary, orderly, and comfortable interior for the residents. This was true for sixteen (16) of thirty-three (33) rooms: C-102, C-105, C-103, B-105, A-110, A-103, A-106, A-105, A-109. A-104, A-108, B-107, B-108, B-106, B-103, and B-101. Corridor and bathroom doors and walls were in disrepair due to gouges, holes, scrapes, and broken edges; cove base and corner molding were missing and/or was not attached to the walls; chips and holes were noted in the floor coverings; a window screen was torn, a wall unit heater was rusted; closet doors were in disrepair; paint was pealing from door facings; an outlet cover was broken. Facility census: 51. Findings include: a) Beginning at approximately 3:20 p.m. on 09/26/11, an environmental tour for the facility's interior revealed the following issues on C-wing and B-wing: - Room C-102 - the cove base was loose from the wall around the sink, and the metal corner bead was loose on the corner between the closet and the sink. - Room C-105 - the cove base was loose from around the wall, and deep scratches and gouges were observed on the wooden door leading into the room. - Room C-103 - scrapes and scratches were visible on the walls, deep gouges were seen on the bathroom door, and a hole was observed in the tile on the floor in front of the door leading to the bathroom. - Room B-105 - the wooden door leading into the room was scratched and with deep gouges, and a hole was observed in the tile in the floor. An interview was conducted with Employee #89 (a maintenance worker) on 09/29/11 at 1:15 p.m., who was advised of the room numbers in which each of the above deficient practice was observed. -- b) The following issues were found on A-wing: - Room A-110 - scratches and scuff marks were seen on the corridor and bathroom doors. - Room A-103 - paint was peeling from the facings on the corridor and bathroom doors. - Room A-106 - observation found dirty windows, torn window screen… | 2015-11-01 |
| 9354 | 9354 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2011-10-04 | 280 | D | 0 | 1 | 4F0I11 | Based on staff interview, medical record review, and care plan review, the facility failed to review and revise the care plan of one (1) of twenty-five (25) Stage II sample residents to address unique aspects of the resident's behaviors. The facility had not care planned a resident's potentially unsafe behaviors of attempting to climb under his Merry Walker. Resident identifier: #48. Facility census: 51. Findings include: a) Resident #48 During an interview on 09/28/11 at approximately 3:15 p.m., Employee #40 (a licensed practical nurse - LPN) reported Resident #48 had a tendency to climb out of one (1) side of his Merry Walker's safety strap. She said he had done this on more than one (1) occasion. A review of the resident's care plan, on 09/28/11 at approximately 4:00 p.m., revealed the Merry Walker was used to assist the resident with independent ambulation. The care plan addressed the resident's opening of the latch on the Merry Walker but did not address the resident coming out from one (1) side of the Merry Walker's safety strap. On 10/03/11 at approximately 2:00 p.m., the director of nursing (DON - Employee #55), when made aware of this issue, stated the facility could revise the resident's care plan to address this potential safety hazard. | 2015-11-01 |
| 9355 | 9355 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2011-10-04 | 323 | K | 0 | 1 | 4F0I11 | Based on observation of an emergency egress door, review of the facility's evacuation plan, review of National Fire Protection Association (NFPA) guidelines, and staff interview, the facility failed to assure the emergency egress door located in the A-wing dining room was maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. A test of this emergency egress door found it to be equipped with a magnetic locking system with a timed emergency egress function of 30 seconds. The test, conducted on 09/29/11 at 2:30 p.m., found the alarm sounded when pressure was applied to the door, with the magnetic lock disengaging after approximately 30 seconds. The release of the magnetic locking system did not allow opening of the emergency egress door, as it had been sealed shut from accumulated rust and corrosion of the threshold plate located at the bottom of the door. This egress door displayed emergency exit signage and was designated as an exit on the facility's evacuation plan posted on the wall outside the A-wing dining room. Additionally, interview revealed staff identified this as a door to be used in the event of an evacuation. The program manager of the life safety program of the Office of Health Facility Licensure and Certification (OHFLAC) was contacted at 2:50 p.m. on 09/29/11. He was apprised of the findings related to the emergency egress door located in the A-wing dining room. The life safety program manager determined that if the door was designated as an emergency egress, and this door could not be opened, this constituted a finding of immediate jeopardy. The director of support services (Employee #95) and the director of nursing (DON - Employee #55) were informed by the team leader at 3:05 p.m. on 09/29/11, that the failure to assure the emergency egress doors were operational placed any residents and staff who may be in the dining area and/or nursing station in immediate jeopardy of harm or death, should a fire or other disaster require evacuation. The im… | 2015-11-01 |
| 9356 | 9356 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2011-10-04 | 328 | D | 0 | 1 | 4F0I11 | Based on random observation, staff interview, and medical record review, the facility failed to provide oxygen in accordance with physician's orders to one (1) of twenty-five (25) Stage II sample residents, to prevent shortness of breath and low blood oxygen levels. Resident identifier: #36. Facility census: 51. Findings include: a) Resident #36 Random observations were conducted of the evening meal service in the main dining room during the first day of this Quality Indicator Survey (QIS) beginning at 5:30 p.m. on 09/26/11. Viewing of the main dining room noted a female resident seated perpendicular to the dining table in a geriatric chair with her back to the other diners and facing the wall. Her geriatric chair was leaned back slightly and the foot rest was up. A practical nursing student was noted to be unsuccessfully attempting to get the resident to take a bite of food. Observation found Resident #36 was panting through her open mouth and using accessory muscles to breathe. An oxygen concentrator was noted to be sitting beside her chair; the oxygen concentrator was turned off. The resident's nasal cannula and tubing were laying in her lap. When asked if Resident #36 was supposed to be on oxygen, the student stated the staff had brought the resident in that way. - The director of nursing (DON - Employee #55), when informed of the resident's condition following this observation, stated the resident was ordered continuous oxygen. Facility staff applied the resident's nasal cannula and turned on the oxygen concentrator, and the resident was noted to have a decrease in respiratory effort. During a follow-up interview on 10/04/11 at approximately 2:30 p.m., the DON was asked what the resident's pulse oximetry had been after being left without her oxygen in the dining room on 09/26/11. The DON called the nurse who assessed the resident and reported that, after her oxygen had been applied, her pulse oximetry reading was 90%. Subsequent record review found the nurse who had assessed the resident's pulse oximetry had… | 2015-11-01 |
| 9357 | 9357 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2011-10-04 | 371 | F | 0 | 1 | 4F0I11 | Based on observation and staff interview, the facility failed to serve and distribute food under sanitary conditions. Staff transported open carts of meal trays (intended for service to residents in the dining room) past a trash barrel that was overflowing with bags of soiled briefs and garbage. This deficient practice had the potential to affect eleven (11) of eleven (11) residents eating in the main dining room for the evening meal on 09/26/11. Additionally, the facility failed to assure an open container of liquid eggs was dated. This deficient practice had the potential to affect more than an isolated number of residents receiving an oral diet in the facility. Facility census: 51. Findings include: a) During the evening meal service on 09/26/11 at 5:15 p.m., random observation found a large trash barrel located outside the doors of the main dining room. The trash barrel was overflowing with clear plastic trash bags filled with soiled briefs and other garbage. Facility staff was observed to wheel the open carts containing the meal trays of the eleven (11) residents seated in the dining room directly past this barrel, then distribute them to the residents. -- b) On 09/26/11 at approximately 3:00 p.m., the dietary manager (Employee #84) accompanied this surveyor on a tour of the kitchen. Observation of the contents of the reach-in refrigerator revealed a carton of liquid eggs that was open but not dated. The dietary manager said she expected the kitchen staff to date items when they opened them. She reported the staff normally uses all opened items (such as liquid eggs) within three (3) days of opening them. | 2015-11-01 |
| 9358 | 9358 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2011-10-04 | 428 | D | 0 | 1 | 4F0I11 | Based on medical record review, staff interview, and consultant pharmacist interview, the facility failed to assure drug irregularities were reported to the physician and the director of nursing (DON) in a timely manner. This deficient practice affected one (1) of twenty-five (25) Stage II sample residents prescribed an antipsychotic medication. Resident identifier: #47. Facility census: 51. Findings include: a) Resident #47 Review of the medical record found a consultant pharmacy recommendation to reduce the dosage of Zyprexa Resident #47 was receiving to 5 mg at bedtime; this recommendation was made as part of a medication regimen review (MRR) conducted on 04/30/11. Further review noted the DON (Employee #55) did not act upon the recommendation until 08/26/11, with the physician acting upon it on 08/31/11. The physician agreed to reduce the antipsychotic per the pharmacist's recommendation. The DON was interviewed at 1:11 p.m. on 10/03/11. When asked why she did not act upon the pharmacist's recommendation for more than four (4) months, she stated the consultant pharmacist reported he had a problem getting the recommendations printed out. The consultant pharmacist, when interviewed on the afternoon of 10/03/11, stated that around April 2011, the company went with a different computer program, and he did not realize that the recommendations were not printing out until the end of July 2011. He stated he tries to have a turn-around time of getting his recommendations to the unit within about one (1) week after completing an MRR. | 2015-11-01 |
| 9359 | 9359 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2011-10-04 | 441 | E | 0 | 1 | 4F0I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observation, staff interview, and policy review, the facility failed to establish and maintain an infection control program to prevent the potential development and transmission of disease and infection. The facility failed to assure housekeeping staff cleaned and disinfected contact isolation rooms occupied by residents with Clostridium difficile (C. diff) infections, to prevent the potential spread of disease-causing spores. This deficient practice had the potential to place more than an isolated number of residents at risk of exposure to this infectious organism. Facility census: 51. Findings include: a) Random observations, conducted on 09/29/11 at 12:20 p.m., noted a housekeeping cart outside the room of a resident in contact isolation related to a [DIAGNOSES REDACTED] infection. The room was posted with signage directing staff and visitors to see the nurse before entering the room. - A housekeeper (Employee #100) was asked to describe how to clean this particular room. She stated she would use Virex to clean the surfaces and floors. She further stated she would clean that room, then clean one (1) or two (2) more rooms, before changing her mop head or mop water. She was unable to provide information concerning training in disinfecting rooms and/or preventing the spread of [DIAGNOSES REDACTED] spores within the facility. - An interview with the housekeeping lead (Employee #91) was conducted at 2:00 p.m. on 09/29/11. When informed of the observation and interview conducted with Employee #100 at 12:20 p.m. on 09/29/11, Employee #91 verified that the cleaning product Employee #100 utilized to clean rooms contaminated with [DIAGNOSES REDACTED] spores was not effective against the spores. He further stated that the mop head, mop water, and cleaning cloths were to be changed immediately after cleaning a room contaminated with [DIAGNOSES REDACTED] spores. - Review of the facility's policy titled Cleaning of rooms with Clostridium… | 2015-11-01 |
| 9360 | 9360 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2011-10-04 | 490 | E | 0 | 1 | 4F0I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the governing body failed to ensure the facility was administered in an efficient and effective manner as evidence by the presence of system failures in the areas of housekeeping services (to prevent the spread of infectious organisms) and maintenance of the resident environment. This failure affected more than an isolated number of residents at risk for development of [MEDICAL CONDITION] (C. diff) infections, as evidenced by poor sanitary practices by the housekeeping department and the failure to develop adequate policies and procedures related to the cleaning of [MEDICAL CONDITION] isolation rooms to prevent the spread of infection. This failure also affected residents residing on all three (3) wings of the facility due to the provision of inadequate maintenance services, as evidenced by holes, scratches, gouges in doors and walls and missing and/or chipped and broken tiles in resident rooms. The administrator of this facility was ultimately responsible for the operation of this facility, as this individual alone possessed the authority to manage the facility and make needed changes to facility systems. Facility census: 51. Findings include: a) Random observations, conducted on 09/29/11 at 12:20 p.m., noted a housekeeping cart outside the room of a resident in contact isolation related to a [DIAGNOSES REDACTED] infection. The room was posted with signage directing staff and visitors to see the nurse before entering the room. - A housekeeper (Employee #100) was asked to describe how to clean this particular room. She stated she would use Virex to clean the surfaces and floors. She further stated she would clean that room, then clean one (1) or two (2) more rooms, before changing her mop head or mop water. She was unable to provide information concerning training in disinfecting rooms and/or preventing the spread of [DIAGNOSES REDACTED] spores within the facility. - An interv… | 2015-11-01 |
| 9361 | 9361 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2011-10-04 | 514 | D | 0 | 1 | 4F0I11 | Based on random observation, staff interview, and medical record review, the facility failed to assure the clinical record, for one (1) of twenty-five (25) Stage II sample residents, contained an assessment of the resident and what actions were taken following an episode of shortness of breath, which occurred in the main dining room when Resident #36 was not supplied with continuous oxygen as ordered by the physician. Resident identifier: #36. Facility census: 51. Findings include: a) Resident #36 Random observations were conducted of the evening meal service in the main dining room during the first day of this Quality Indicator Survey (QIS) beginning at 5:30 p.m. on 09/26/11. Viewing of the main dining room noted a female resident seated perpendicular to the dining table in a geriatric chair with her back to the other diners and facing the wall. Her geriatric chair was leaned back slightly and the foot rest was up. A practical nursing student was noted to be unsuccessfully attempting to get the resident to take a bite of food. Observation found Resident #36 was panting through her open mouth and using accessory muscles to breathe. An oxygen concentrator was noted to be sitting beside her chair; the oxygen concentrator was turned off. The resident's nasal cannula and tubing were laying in her lap. When asked if Resident #36 was supposed to be on oxygen, the student stated the staff had brought the resident in that way. - The director of nursing (DON - Employee #55), when informed of the resident's condition following this observation, stated the resident was ordered continuous oxygen. Facility staff applied the resident's nasal cannula and turned on the oxygen concentrator, and the resident was noted to have a decrease in respiratory effort. During a follow-up interview on 10/04/11 at approximately 2:30 p.m., the DON was asked what the resident's pulse oximetry had been after being left without her oxygen in the dining room on 09/26/11. The DON called the nurse who assessed the resident and reported that, after h… | 2015-11-01 |
| 9362 | 9362 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2011-10-04 | 520 | K | 0 | 1 | 4F0I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the facility's evacuation plan, review of National Fire Protection Association (NFPA) guidelines, and policy review, the facility's quality assessment and assurance committee failed to develop and implement appropriate plans of action to correct deficiencies of which its members should have been aware in the areas of maintenance and housekeeping services. The QAA committee failed to implement a plan to ensure all doors identified as emergency egresses were able to be opened without impediment, especially in view of staff's awareness that a door identified as an emergency egress in the A-wing dining room had, once or twice before in past years, been sealed shut door due to corrosion at the threshold. This same door, which was labeled an emergency exit, was identified as an emergency exit on the facility's emergency evacuation plan, and was identified by staff as an exit to be used if it were necessary to evacuate this part of the facility, was unable to be easily opened when tested on [DATE], resulting in a finding of immediate jeopardy. The QAA committee also failed to identify quality deficiencies, and implement plans of action to correct these quality deficiencies, related to housekeeping services that were inadequate to prevent the spread of an infectious organism and maintenance services that failed to maintain a clean, comfortable, and sanitary interior for the residents. Facility census: 51. Findings include: a) During an interview with a family member who wished to remain anonymous, an allegation was made that staff members were smoking outside the A-wing dining room doors, causing smoke to enter the dining room. Following receipt of this complaint, an attempt was made, on 09/29/11 at 2:20 p.m., to exit the A-wing egress doors to inspect for evidence of smoking outside this door. The egress door failed to open after multiple attempts by this surveyor. - Assistance was sought from two (2)… | 2015-11-01 |
| 9363 | 9363 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-02-25 | 156 | D | 0 | 1 | 2RPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to inform the responsible parties of two (2) of thirty-two (32) Stage II sampled residents when Medicare-covered skilled treatments were discontinued and/or the reason(s) for the services being discontinued. Resident identifiers: #102 and #63. Facility census: 87. Findings include: a) Resident #102 A review of the medical record revealed that resident #102, who was admitted on [DATE], had received therapy services from 10/19/09 through 11/28/09. Althought the responsible party was notified by letter that the resident's Medicare Part A benefit days had exhausted on 11/28/09, there was no evidence in the medical record to show that the responsible party had been notified which services had been discontinued and no medical reason was given for the stoppage. The physical therapy (PT) notes written on 11/18/09, state: d/c (discontinue) PT - all goals met, and the occupational therapy (OT) notes written on 11/26/09, stated that the goals were partially met; but, neither indicated that this had been discussed with the family. The nurses notes from 11/24/09 - 12/03/09 were reviewed without any evidence of discussion with resident and/or family regarding the changes in the resident's care. During an interview with the director of nursing and the assistant director of nursing at 2:00 p.m. on 02/24/10, they stated that they could find no documentation that an explanation of which services were being discontinued and the reason for this had been given to the family, although they stated that they were sure it had been done. b) Resident #63 A review of the medical record revealed that resident #63, who was admitted on [DATE], received physical therapy (PT) and occupational therapy (OT) services from 09/15/09 - 12/21/09. A review of the nurses notes from 12/15/09 - 01/06/10 and of the PT and OT discharge notes failed to reveal any evidence that the resident and/or family had been notified of w… | 2015-11-01 |
| 9364 | 9364 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-02-25 | 157 | D | 0 | 1 | 2RPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, record review, and staff interview, the facility failed to assure proper notification of the physician and the resident ' s responsible party when changes occurred in a resident's health care status and/or services. This was evident for one (1) of thirty-two (32) Stage II sampled residents. Resident identifier: #58. Facility census: 87. Findings include: a) Resident #58 During a family interview on 02/21/10 at 4:29 p.m., Resident #58's wife stated he was admitted to the hospital on [DATE], due to complications of a urinary tract infection [MEDICAL CONDITION]. At that time, she was allegedly told by the emergency room (ER) physician that his UTI, which had been diagnosed earlier that week at the facility (01/22/10), showed a colony count greater than 100,000. The wife stated she had signed the pink POST (Physician order [REDACTED]. The resident was subsequently hospitalized and treated for [REDACTED]. Review of the physician's progress note, dated 01/12/10, revealed, H/O (history of)[MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) UTI: monitor for symptoms. There is also a handwritten note stating, Family wants pt. (patient) to be kept comfortable and avoid re-hospitalization s. Medical record review revealed a nurse's note in the resident's electronic medical record, dated 01/19/10, stating the certified physician's assistant (PA-C) was in the facility and ordered a urinalysis, complete blood count, and other labs, and the wife was aware. The nurse (Employee #1) found this note in the computer on 02/24/10 at 10:10 a.m., but record review did not find the note had been printed and placed inside the medical record. The note did not say why the lab testing was ordered. A nurse's note, dated 01/21/10, stated the physician was notified of the lab results on 01/20/10, and culture results were pending. A urine culture and sensitivity (C&S) report, dated 01/22/10, noting [MEDICAL CONDITION] culture … | 2015-11-01 |
| 9365 | 9365 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-02-25 | 241 | D | 0 | 1 | 2RPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to provide care in a manner that maintained each resident's dignity during dining, as evidenced by one (1) of thirty-two (32) Stage II residents who did not receive proper set-up assistance with her utensils and was eating with her fingers prior to surveyor intervention. Resident identifier: #13. Facility census: 87. Findings include: a) Resident #13 Observation of the evening meal, on 02/22/10 at approximately 5:30 p.m., found Resident #13 sitting at the dining room table dipping her fingers into bowls of pureed green bean salad and pudding and eating from her fingers. Staff was lined up at the food cart approximately 10 feet from where Resident #13 was sitting, and other staff members were assisting other residents. After the fourth time Resident #13 was observed eating from her fingers, staff was asked if she was able to use eating utensils. An unidentified nursing assistant said, Yes, she does, if someone opens up her silverware for her. She then opened the silverware pack, and the resident began feeding herself with a spoon. Review of Resident #13's care plan revealed an intervention to set up tray, encourage 75 - 100% of food intake, as the resident was at nutritional risk with [DIAGNOSES REDACTED]. | 2015-11-01 |
| 9366 | 9366 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-02-25 | 278 | D | 0 | 1 | 2RPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview, the facility failed to ensure the accuracy of two (2) of thirty-two (32) Stage II residents with respect to bladder continence and the daily use of physical restraints. Resident identifiers: #80 and #122. Facility census: 87. Findings include: a) Resident #80 Interview with the resident, on during the mid-afternoon of 02/23/10, found the resident was aware of the need to void and did let staff know when she needed to use the rest room. Review of Resident #80's quarterly minimum data set (MDS), with an assessment reference date of 12/30/09, found, in Section H1, bladder incontinence was inaccurately assessed as 3 - frequently incontinent (tending to be incontinent daily, but some control present). Review of the Resident Continent Log, for the fourteen-day lookback period from 12/16/10 through 12/29/09, found the resident was only incontinent once each day on 12/17/09, 12/20/09, 12/25/09, 12/26/09, and 12/29/09, and twice on 12/23/09. During an interview with the MDS nurse (Employee #99) on 02/24/10 at 10 a.m., she said she made a mistake on the MDS and the resident was incontinent less than daily, with three (3) episodes of urinary incontinence during the first week of observation and four (4) during the second week. b) Resident #122 A review of the medical record revealed that Resident #122, who was admitted to the facility on [DATE], had been using a Vail enclosed bed system with zippered screened sides since admission, due to his constant movement. Additionally, whenever he was out of bed, he was in a Broda chair with either a pelvic or thigh restraint in place. These measures were confirmed by the nurse (Employee #9) at 3:00 p.m. on 02/22/10. His care plan addressed the daily use of these restraints, but his admission MDS indicated only that a trunk restraint was in use less than daily. When this was reviewed with the MDS nurse on 02/24/10, she agreed the resident use… | 2015-11-01 |
| 9367 | 9367 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-02-25 | 279 | D | 0 | 1 | 2RPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and medical record review, the facility failed to develop care plans to meet the known needs of two (2) of thirty two (32) Stage II sampled residents. Resident #80 had vision limitations due to [MEDICAL CONDITION] which were not addressed in her care plan, and Resident #127 was admitted with orders for outpatient [MEDICAL TREATMENT] three (3) times a week, and this was not addressed in her interim care plan. Resident identifiers: #80 and #127. Facility census: 87. Findings include: a) Resident #80 In interviews in her room on the mid-afternoon of 02/23/10 and again on 02/25/10 at 9:30 a.m., Resident #80 related she had [MEDICAL CONDITION] and her vision was limited. This limitation interfered with her ability to clearly see her food and to get about in the facility. She said she got around by feeling for most things. During an interview on 02/24/10, the director of nursing said Resident #80 liked to have the window blinds in her room closed due to her [MEDICAL CONDITION]. Review of Resident #80's most current care plan, dated 10/05/09, found the resident was noted to have [MEDICAL CONDITION], but there was no description of how the [MEDICAL CONDITION] limited the resident's ability to see, nor were there any interventions identified for staff to use to assist her with these limitations. b) Resident #127 A review of the medical record, on 02/24/10, revealed Resident #127 was admitted , on 02/17/10, with [DIAGNOSES REDACTED]. An interim care plan was present in the record, but it did not address the resident's [MEDICAL TREATMENT] needs, including nursing interventions for the monitoring and care of the venous access site and monitoring of the resident's fluid status. The care plan for Hydration / Fluid Maintenance Risk was marked N/A (not applicable) and left blank. In an interview with a licensed practical nurse (LPN - Employee #19) at 5:20 p.m. on 02/21/10, she stated the resident went to outpatie… | 2015-11-01 |
| 9368 | 9368 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-02-25 | 280 | D | 0 | 1 | 2RPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to revise a comprehensive care plan when a resident's status changed. The facility did not revise or update the care plan for a resident who developed two (2) Stage II pressure ulcers following admission to the facility. This was true for one (1) of thirty-two (32) Stage II sampled residents. Resident identifier: #10. Facility census: 87. Findings include: a) Resident #10 Resident #10's medical record, when reviewed on 02/23/10 at 3:00 p.m., revealed an [AGE] year old female who was admitted to the facility on [DATE], for care and rehabilitation therapy following a recent fall resulting in a fractured humerus. Review of the facility form titled Immediate Plan Of Care, dated 02/17/10, found the resident was a Pressure Ulcer Risk. The care plan was not revised or updated on 02/19/10, when the resident developed two (2) Stage II pressure ulcers on her buttocks. The care plan did not identify the presence of the pressure ulcers, nor did it contain the interventions currently ordered to promote wound healing. The care plan nurse (Employee #99), when interviewed on 02/24/10 at 9:15 a.m., confirmed the resident's current care plan did not address the presence or current treatment / interventions ordered to promote healing of the two (2) pressure ulcers. Resident #10 was observed on 02/24/10 at 10:35 a.m. while in bed. The registered nurse (RN - Employee #1) was observed providing treatment to the pressure ulcers. The resident was observed to have three (3) Stage II pressure ulcers - two (2) on the right buttocks and one (1) on the sacrum. The assistant director of nurses (ADON - Employee #59), when interviewed on 02/24/10 at 2:30 p.m., acknowledged the resident had developed a new Stage II pressure ulcer since the last weekly skin assessment on 02/22/10. The ADON notified the physician, and a new treatment to the sacrum was ordered. | 2015-11-01 |
| 9369 | 9369 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-02-25 | 281 | D | 0 | 1 | 2RPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, and observation, the facility failed to ensure physician's orders and the administration of medications met professional standards of care. This was true for three (3) of thirty-two (3) Stage II sampled residents. A physician's order for pain medication did not state the frequency the medication was to be administered. an order for [REDACTED]. Resident identifiers: #10, #44, and #80. Facility census: 87. Finding include: a) Resident #10 Resident #10's medical record, when reviewed on 02/24/10 at 10:00 a.m., revealed an [AGE] year old female with a history of a recent fall resulting in a fractured humerus. The resident's left arm was fractured, and she was admitted to the facility on [DATE] for care and rehabilitation services. Review of the admission physician orders, dated 02/17/10, revealed an order for [REDACTED]. Review of the February 2010 Medication Administration Record [REDACTED]. The assistant director of nurses (ADON - Employee #59), when interviewed on 02/24/10 at 3:35 p.m., acknowledged the current [MEDICATION NAME] order did not specify the frequency at which staff was to administer the medication. The ADON provided a computer-printed physician's telephone order, dated 02/17/10. The order, which was not signed by the physician, stated: [MEDICATION NAME] 50 mg tab 1 tab po Q6 hrs PRN for 812.41 Fractured humerus. A clarification order was subsequently obtained on 02/24/10. Review of the facility's medication policy titled LTC Facility's Pharmacy Services and Procedure Manual found: 1.1. A new order must include: . 1.1.3 Drug name, strength, dosage, time or frequency, and route of administration. b) Resident #44 Observation of the morning medication pass found Resident #44 in bed at 8:45 a.m. on 02/22/10. The medication nurse (Employee #13), when administering the resident's 8:30 a.m. medications, omitted a dose of [MEDICATION NAME] 500 mg. Review of the resident's current phy… | 2015-11-01 |
| 9370 | 9370 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-02-25 | 328 | D | 0 | 1 | 2RPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to assure all residents received respiratory treatment and care as ordered by the physician. This was evident for one (1) of thirty-two (32) Stage II sampled residents who was observed wearing a nasal canula connected to an empty oxygen tank. Resident identifier: #4. Facility census: 87. Findings include: a) Resident #4 Observation, on 02/21/10 at 5:17 p.m., found Resident #4 sleeping in his wheelchair in the dining room awaiting his evening meal. He was wearing a nasal canula which was connected to a portable oxygen tank attached to the back of his wheelchair. Inspection of the oxygen regulator found the tank was empty. When this situation was reported to the nurse (Employee #75) at this time, she sent a nursing assistant for a full tank of oxygen. Nine (9) minutes later (at 5:26 p.m.), the portable tank was replaced with a full tank of oxygen. Review of Resident #4's care plan revealed a problem area regarding injury risk related to hazards of oxygen administration; interventions included to keep oxygen on continuously and check especially during naps. Review of physician's orders [REDACTED]. | 2015-11-01 |
| 9371 | 9371 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-02-25 | 371 | F | 0 | 1 | 2RPR11 | Based on observation and staff interview, the facility failed to store or serve food under sanitary conditions. This was evident in the emergency food supply area, which contained dented canned food items and a dirty floor, and had the potential to affect all residents who received nourishment from the facility's kitchen. This was also evident by staff applying dirty table coverings onto the residents' dining room tables and had the potential to affect all residents who consumed meals in the restorative dining room. Facility census: 87. Findings include: a) Inspection of the emergency food storage area, on 02/24/10 at 12:00 p.m., revealed three (3) dented 6-pound cans of fruit in the plastic storage bins. One (1) can of pears was dented at the seam and had discoloration on the white label where something wet had soaked into or leaked onto the label. One (1) can of apricots also was dented at the seam. One (1) can of applesauce was dented horizontally on the side of the can about 3 inches wide which traversed the seam. The dietary manager, who was present during the inspection, removed those three (3) cans of food immediately. She said the emergency food supply was rotated every six (6) months. These three (3) cans were dated February 2010, indicating they had recently been restocked. Additionally, the floor in the emergency food supply area had an area of a brackish-colored, sticky substance. The dietary manager explained there previously had been a shelf that had been removed over that area. She obtained paper towels to cover the area to keep us from sticking in it until staff could come clean the floor. b) At 10:00 a.m. on 02/24/10, observation found a dietary worker (Employee #66) in the hallway pushing snack carts and carrying table cloths over one (1) arm, when she dropped a table cloth to the floor. She retrieved the cloth from the floor and returned it to the stack over her arm. She then continued to the North dining area, where she covered the tables with the table cloths in her arms. This observation was… | 2015-11-01 |
| 9372 | 9372 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-02-25 | 431 | E | 0 | 1 | 2RPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and a review of the facility's pharmacy manual, the facility failed to ensure drugs and biologicals used in the facility were labeled with expiration dates and failed to ensure outdated medications were discarded. This occurred for the intravenous (IV) cart and both treatment carts in the facility and had the potential to affect more than an isolated number of residents. Facility census: 87. Findings include: a) On [DATE] at 10:00 a.m., observation of the IV cart located at the South nursing station, with a licensed practical nurse (LPN - Employee #10) found the cart contained two (2) packages of Cipro IV, with a date of ,[DATE] on the bottom of the package and a date of [DATE] on the pharmacy label. Also found were a bag of Sodium Chloride 0.9% IV that expired in [DATE], four (4) bottles of Kefzol 1 gm powder with an expiration date of [DATE] on one (1) of the bottles and [DATE] on the other three (3) bottles, and a bottle of Heparin flush 100U per ml/30ml with an expiration date of [DATE]. At the same time, observation of the treatment cart at the South nursing station found a bottle of opened saline was observed without a date indicating when the bottle had been opened. These items were taken by Employee #10 and shown to the director of nursing at 10:30 a.m. on [DATE]. b) The treatment cart for the North nursing station, when observed on [DATE] at 10:45 a.m., held open containers of normal saline solution, hydrogen peroxide, and alcohol. The opened stock multidose containers of normal saline solution, hydrogen peroxide and alcohol were not properly labeled with the date initially opened. Additionally, Resident #76's Preparation H ointment was noted to have an expiration date of [DATE]. The treatment nurse (Employee #13), when interviewed on [DATE] at 10:50 a.m., acknowledged the normal saline solution, hydrogen peroxide, and alcohol solutions were opened and not properly labeled with a date opened. Th… | 2015-11-01 |
| 9373 | 9373 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-02-25 | 441 | D | 0 | 1 | 2RPR11 | Based on observation, policy review, and staff interview, the facility failed to ensure one (1) of two (2) nurses observed used good infection control techniques while obtaining blood sugars for Resident #19. Facility census: 87. Findings include: a) Resident #19 During observations on 02/21/10 at 3:21 p.m., the licensed practical nurse (LPN - Employee #18) donned a pair of gloves, opened the medication cart drawer, and removed a glucometer, lancet, and glucometer strip. The LPN then disinfected the glucometer and, without changing her gloves, checked the resident's blood sugar level using the lancet, the glucometer strip, and glucometer. A review of the facility's policy titled Blood Sampling - Capillary (Finger Sticks) (revised October 2009) found the nurse should have washed her hands and donned gloves just before utilizing the glucose monitoring device for the resident, and then washed her hands after cleaning the device. This observation was reviewed with the director of nursing at 2:30 p.m. on 02/24/10. | 2015-11-01 |
| 9374 | 9374 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-02-25 | 492 | F | 0 | 1 | 2RPR11 | Based on personnel record review, staff interview, and policy review, the facility failed to assure all currently employed dietary personnel had food handler's cards issued by the local health department prior to working in food service. This was evident for one (1) of fourteen (14) dietary employees and had the potential to affect all residents in the facility who received nourishment from the dietary kitchen. Employee identifier: #71. Facility census: 87. Findings include: a) Employee #71 Interview with dietary manager (Employee #61), on 02/24/10 at 2:40 p.m., revealed one (1) of fourteen (14) dietary employees listed on the employee roster, which was supplied to surveyors by the facility, had no food handler's card. Review of the employee roster revealed Employee #71 was hired 01/04/10 and was a full-time employee. Review of food handler's cards for all currently employed dietary personnel revealed the absence of a food handler's card for Employee #71. Interview with dietary manager, on 02/24/10 at 2:40 p.m., found Employee #71 had been scheduled to attend a food handler's class twice, but each time was cancelled due to inclement weather, and she has no valid card. Interview with a representative of the Monongalia County Health Department, on 02/24/10 at 2:50 p.m., confirmed there was no food handler's card or temporary card on file at the local health department for Employee #71. She stated all food service employees in Monongalia County must have a food handler's card before they can work in food service. She stated food service workers were allowed to come in and apply for a temporary card until they can procure a food handler's card, but Employee #71 did not do this. During interview with the dietary manager, on 02/24/10 at 3:00 p.m., she stated she just spoke with the Monongalia County Health Department, and they now have a date for Employee #71 to go to the health department to get her card. Interview with the administrator and the director of nursing, on 02/24/10 at 4:15 p.m., revealed they were made aw… | 2015-11-01 |
| 9375 | 9375 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-02-25 | 502 | D | 0 | 1 | 2RPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain physician-ordered laboratory testing for one (1) of thirty-two (32) Stage II sampled residents. Resident identifier: #6. Facility census: 87. Findings include: a) Resident #6 Record review revealed a physician's orders [REDACTED].#6, to monitor the effects of medications. Further record review revealed fasting glucose results for 06/15/09 and 12/14/09, but none for September 2009. Interview with the director of nursing (Employee #58), on 02/23/10 at 10:50 a.m., revealed that fasting glucoses were drawn and sent to the hospital for testing, and she could produce results for only 06/15/09 and 12/14/09. She stated they missed the September 2009 glucose blood draw. | 2015-11-01 |
| 9376 | 9376 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-02-25 | 514 | D | 0 | 1 | 2RPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain complete, accurate, and systematically organized medical records for two (2) of thirty-two (32) Stage II sampled residents, by continuing to document services that had been discontinued and/or by failing to assemble the nurses notes in an organized manner by date in the clinical record. Resident identifiers: #102 and #74. Facility census: 87. Findings include: a) Resident #102 A review of the clinical record revealed Resident #102, who was admitted on [DATE], had received therapy services from 10/19/09 through 11/28/09. The physical therapy (PT) notes, dated 11/18/09, stated, D/C (discontinue) PT - all goals met. The occupational therapy (OT) notes, dated on 11/26/09, stated these services were also discontinued with the goals partially met. However, an entry in the nursing notes by a nurse (Employee #3), dated 11/30/09, stated, Attends PT / OT / ST (speech therapy) regularly, see therapy notes for progress. On 12/01/09, this same nurse repeated the same entry, and on 12/03/09, another nurse (Employee #1) also recorded, Attended PT / OT / ST this AM (morning). During an interview with the director of nursing (DON) and the assistant director of nursing (ADON) at 2:00 p.m. on 02/24/10, they verified PT and OT services had been discontinued when the resident's benefit days were exhausted. They had no explanation for the contradictory entries in the nursing notes. b) Resident #74 A review of the clinical record for Resident #74 revealed nursing notes written by a nurse (Employee #16) on 09/25/09 were inserted between the notes written 09/13/09 and 09/14/09. During an interview with the DON at 9:15 a.m. on 02/25/10, she reviewed the notes and explained that each nurse was responsible for mounting her typed notes into the chart, and she confirmed the notes were entered in the wrong sequence. | 2015-11-01 |
| 9377 | 9377 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2012-11-09 | 309 | D | 1 | 0 | R50Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility's medication error reports, the facility failed to ensure two (2) of five (5) sample residents were provided the necessary care and services to attain or maintain their highest practicable physical well-being. Resident #130 was ordered [MEDICATION NAME], a medication for fungal infections of the nails, but was administered the medication [MEDICATION NAME], a [MEDICAL CONDITION] medication, for fifty-three (53) days. Resident #135 was administered the wrong inhaler. Resident identifiers: #130 and #135. Facility census: 159. Findings include: a) Resident #130 Review of the facility's medication error reports, on 11/07/12, at 1:30 p.m., found an incident dated 07/03/12. The medication error report identified Resident #130, was ordered [MEDICATION NAME] 250 mg every day for four (4) weeks. ([MEDICATION NAME] is a medication used to treat certain fungal infections of the nails.) The order was transcribed to the Medication Administration Record [REDACTED]. According to the medication error report, the correct medication was not received from the pharmacy. The pharmacy sent [MEDICATION NAME], a medication used to treat [MEDICAL CONDITION]. Review of the Medication Administration Record [REDACTED]. This medication error was identified when the pharmacist completed a review of the facility's medication cart on 07/03/12. The medication error report identified the error was discovered by a pharmacy cart check. During an interview with Employee #119 (director of nursing), on 11/07/12, at 1:45 p.m., it was confirmed the facility ordered the correct medication, [MEDICATION NAME], but the pharmacy sent [MEDICATION NAME] instead. Nursing staff administered the incorrect medication and did not identify the medication error. She stated, When medication is received from the pharmacy, the orders are checked with the Medication Administration Record [REDACTED]. On 11/07/12, at 2:30 p.m., … | 2015-11-01 |
| 9378 | 9378 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2012-11-09 | 425 | D | 1 | 0 | R50Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility's medication error reports, the facility failed to provide pharmaceutical services which ensured the accurate acquiring, receiving, dispensing, and administering of medications for one (1) of five (5) sample residents. Resident #130 was ordered the medication Lamisil, a medication for fungal infections of the nails. The pharmacy sent Lamictal, a seizure medication, instead. The resident received this incorrect medication for fifty-three (53) days. Resident identifier: #130. Facility census: 159. Findings include: a) Resident #130 Review of the facility's medication error reports, on 11/07/12, at 1:30 p.m., found an incident dated 07/03/12. The medication error report identified Resident #130, was ordered Lamisil 250 mg every day for four (4) weeks. (Lamisil is a medication used to treat certain fungal infections of the nails.) The order was transcribed to the Medication Administration Record [REDACTED]. According to the medication error report, the correct medication was not received from the pharmacy. The pharmacy sent Lamictal, a medication used to treat epilepsy. Review of the Medication Administration Record [REDACTED]. This medication error was identified when the pharmacist completed a review of the facility's medication cart on 07/03/12. The medication error report identified the error was discovered by a pharmacy cart check. During an interview with Employee #119 (director of nursing), on 11/07/12, at 1:45 p.m., it was confirmed the facility ordered the correct medication, Lamisil, but the pharmacy sent Lamictal instead. Nursing staff administered the incorrect medication and did not identify the medication error. She stated, When medication is received from the pharmacy, the orders are checked with the Medication Administration Record [REDACTED]. On 11/07/12, at 2:30 p.m., Employee #119 also confirmed the error was discovered during a pharmacy cart check. She… | 2015-11-01 |
| 9379 | 9379 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2010-06-15 | 157 | D | 0 | 1 | KN1V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, record review, and staff interview, the responsible party for one (1) of thirty-eight (38) sampled residents was not informed / consulted prior to the commencement of a Medicare Part B skilled service. Resident identifier: #112. Facility census: 112. Findings include: a) Resident #112 During an interview of the daughter / medical power of attorney representative (MPOA) of Resident #112 at 10:00 a.m. on 06/09/10, the MPOA stated that, for the last month, the therapist had been treating the resident for swallowing problems and she questioned why this had been done. When asked if anyone had spoken to her prior to starting this treatment, she said, No. and stated she only found out when she received a bill for $20.00 and another for $535.00. She stated there has been no change in the way her mother eats and swallows in over a year, and when she did ask the nurse about this last week, she was told that her mother was going to have her diet changed from all pureed foods and thickened liquids to chopped foods and regular liquids. She said she was very happy about this, because her mother does not always eat the pureed foods; she did not believe they were needed, because she brought the resident food from McDonalds which the resident ate with no problem. There was no mention of any swallowing difficulties in the nurses' notes and no evidence that the therapy evaluation and treatment had been discussed with the MPOA. During an interview with the speech language pathologist (Employee #110) at 9:30 a.m. on 06/10/10, she stated she had been asked to see the resident by the occupational therapist (OT - Employee #122) and had secured a physician's orders [REDACTED]. The evaluation was completed on 05/13/10. After reviewing the documentation on the Eating & Swallowing Evaluation form, she stated she believed she had spoken to the resident's granddaughter, who was visiting, about the evaluation. She acknowledged she had not spoken … | 2015-11-01 |
| 9380 | 9380 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2010-06-15 | 272 | D | 0 | 1 | KN1V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately identify a significant weight loss on the resident assessment instrument for two (2) residents of twenty-eight (28) Stage II sample residents. Resident identifiers: #151 and #141. Facility census: 112. Findings include: a) Resident #151 A review of Resident #151's clinical record revealed the resident had a significant weight loss which was not identified in Section K3A of the Medicare 30-Day MDS with an ARD of 04/09/10. His weight had been entered as 173, which was a 28# loss since the Medicare 14-Day MDS with an ARD of 03/30/10. During an interview with the director of care delivery (Employee #48) at 11:45 a.m. on 06/10/10, the nurse stated, after reviewing the record, that the weights were accurate and had been rechecked. She stated the resident had a lot of [MEDICAL CONDITION] and was receiving several diuretics. During an interview with the MDS coordinator (Employee #120) at 2:00 p.m. on 06/10/10, she stated she had spoken to the dietician, who stated she usually waited a full thirty (30) days to calculate a significant weight loss before indicating this on the MDS. She stated this would be rectified immediately. b) Resident #141 A review of Resident #141's clinical record revealed two (2) significant weight losses which were not identified in section K3A of the MDS. They were as follows: - The Medicare 14-Day MDS (ARD of 01/02/10) identified a weight of 166#, which was a loss of 35# since the admission MDS (ARD of 12/02/09), but the entry in K3A did not indicate a loss. - The Medicare 60-Day MDS (ARD of 02/02/10) identified a weight of 146#, which was a loss of 20# since the Medicare 30-Day MDS (ARD of 01/04/10), but the entry on K3A did not indicate a loss. During an interview with Employee #120 at 2:00 p.m. on 06/10/10, she stated she had spoken to the dietician, who stated she usually waited a full thirty (30) days to calculate a significant weight loss be… | 2015-11-01 |
| 9381 | 9381 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2010-06-15 | 279 | E | 0 | 1 | KN1V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to develop a care plan for each resident that adequately addressed all of the resident's needs based on the comprehensive assessment, for four (4) of twenty-eight (28) Stage II sampled residents. Resident identifiers: #112, #12, #63, and #83. Facility census: 112. Findings include: a) Resident #112 A review of Resident #112's clinical record revealed an [AGE] year old female with [DIAGNOSES REDACTED]. Her annual minimum data set assessment (MDS) contained the following information: - Section G1AB - she was totally dependent for transfers; - Sections G1AC and G1AD - she did not ambulate; - Section G4DA - she had limited range of motion in both legs; and - Section G9 - there had been no change in activities of daily living (ADL) since the last MDS. In Section V, staff indicated that care planning would be done to address the above issues. An observation of this resident, at 1:15 p.m. on 06/07/10, revealed she had contractures of both legs, with them curving inward when she was up in the wheelchair. During interviews with three nurses (Employees #142, #85, and #24) at 2:15 p.m. on 06/07/10, they all stated the resident could not stand and she had limited movement of both legs. In an interview at 2:30 p.m. on 06/07/10, the physical therapist (PT - Employee #49) verified the resident did have contractures of both legs which required special positioning when she was up in the wheelchair and with a strap added to the chair to assist her in maintaining that positioning. Neither the PT nor the nurses knew how long the contractures had been present. They knew they were not present on admission in 2008, and all agreed the contractures occurred over a year ago. (Subsequent to these interviews, no documentation of the onset of contractures was provided prior to the survey exit.) A review of the resident's current care plan (last revised on 05/13/10) did not find evidence of nurs… | 2015-11-01 |
| 9382 | 9382 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2010-06-15 | 280 | D | 0 | 1 | KN1V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, staff interview, and facility policy review, the facility failed, for three (3) of twenty-eight (28) Stage II sample residents, to ensure each resident's comprehensive care was was revised when changes occurred with the resident condition and/or treatment plan. Resident #23's care plan was not revised to reflect the presence of a second pressure ulcer. Resident #112's care plan was not revised to reflect changes made to her therapeutic diet. Resident #12's care plan was not revised when interventions to prevent falls / promote safety were no longer in use. Resident identifiers: #23, #112, and #12. Facility census: 112. Findings include: a) Resident #23 Medical record review, on 06/07/10, revealed Resident #23 two (2) Stage II pressure ulcers, one (1) on each buttock. A physician order, dated 06/01/10, directed staff to cleanse the area on the right buttock with sterile normal saline, apply Skin integrity to the wound, and cover with [MEDICATION NAME] foam every day, and check every shift for placement. Another physician's orders [REDACTED]. An observation of these ulcerations, on the morning of 06/10/09, found two (2) Stage II ulcerations - one (1) on the right side of the coccyx and one (1) on the left side of the coccyx; the surrounding tissue was pink, and serosanguinous drainage was seeping from the wounds. On 06/14/10 at 11:00 a.m., Resident #23 was interviewed in her room. During this interview, she reported she had pain when she sits up in the chair, especially if she sits up too long, and this was one (1) of the reasons why she did not like to get up into the chair. On 06/14/10 at 11:42 a.m., two (2) nurses (Employees #142 and #95) were interviewed at the nurses' station. They both identified the resident's family brings snacks to the facility, the resident often snacks in her room, and they have done a lot of education with the family to bring in healthy snacks. Additio… | 2015-11-01 |
| 9383 | 9383 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2010-06-15 | 281 | D | 0 | 1 | KN1V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record reviews, review of professional references and facility policies and procedures, and resident interview, the facility failed to meet professional standards in the administration and documentation of an ordered sliding scale insulin dose (based on blood glucose monitoring that occurred after, instead of before, a meal), failed to implement diet order changes timely, and failed to obtain a physician's order for passive range of motion (ROM) and the use of hand splints. These practices affected three (3) of twenty-eight (28) Stage II sample residents. Resident identifiers: #128, #112, and #63. Facility census: 112. Findings include: a) Resident #128 Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set assessment (MDS), with an assessment reference date (ARD) of 04/26/10, revealed the resident was moderately impaired for daily decision making, made self understood and sometimes understood others, and was dependent for activities of daily living (ADLs). Review of the annual MDS, with an ARD of 01/27/10, revealed the resident was moderately impaired for daily decision making, made self understood and sometimes understood others, and was dependent for ADLs. On 06/09/10 at 9:20 a.m., during observation of medication administration, Employee #70 (a licensed practical nurse - LPN) performed blood glucose (blood sugar) monitoring on Resident #128 by finger stick (pricking the finger with a lancet to obtain a drop of blood) using a glucometer. (A glucose meter or glucometer is a medical device for determining the approximate concentration of glucose in the blood ). The result of the blood glucose monitoring revealed the resident's blood glucose level was 300 mg/dl. Employee #70 then administered 4 units of [MEDICATION NAME](a fast acting insulin) by subcutaneous (under the skin) injection to Resident #128 in accordance with the sli… | 2015-11-01 |
| 9384 | 9384 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2010-06-15 | 309 | D | 0 | 1 | KN1V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record reviews, review of facility policies and procedures, and resident interview, the facility failed to follow the physician's order for blood glucose monitoring and the related administration of sliding scale insulin, and failed to provide for effective pain management, for two (2) of twenty-eight (28) Stage II sample residents. Resident identifiers: #128 and #23. Facility census: 112. Findings include: a) Resident #128 Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set assessment (MDS), with an assessment reference date (ARD) of 04/26/10, revealed the resident was moderately impaired for daily decision making, made self understood and sometimes understood others, and was dependent for activities of daily living (ADLs). Review of the annual MDS, with an ARD of 01/27/10, revealed the resident was moderately impaired for daily decision making, made self understood and sometimes understood others, and was dependent for ADLs. On 06/09/10 at 9:20 a.m., during observation of medication administration, Employee #70 (a licensed practical nurse - LPN) performed blood glucose (blood sugar) monitoring on Resident #128 by finger stick (pricking the finger with a lancet to obtain a drop of blood) using a glucometer. (A glucose meter or glucometer is a medical device for determining the approximate concentration of glucose in the blood ). The result of the blood glucose monitoring revealed the resident's blood glucose level was 300 mg/dl. Employee #70 then administered 4 units of [MEDICATION NAME](a fast acting insulin) by subcutaneous (under the skin) injection to Resident #128 in accordance with the sliding scale insulin dosage (an insulin dose ordered for a specific measured level of glucose in the blood) ordered for a glucose of 300 mg/dl. Observation in the resident's room at the time of the glucose monitoring and subsequent admi… | 2015-11-01 |
| 9385 | 9385 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2010-06-15 | 318 | D | 0 | 1 | KN1V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and resident interview, the facility failed to ensure one (1) of twenty-eight (28) Stage II sample residents received range of motion (ROM) for severe contractures. Resident #63 has a [DIAGNOSES REDACTED]. Facility census 112. Findings include: a) Resident #63 An observation of the resident, on 06/09/10 at 11:00 a.m., revealed the resident was contracted in all extremities. Record review revealed the resident's diagnoses, on admission to the facility on [DATE], included ALS. review of the resident's medical record revealed [REDACTED]. Resident wears splints up to two hours a day. PT was discontinued related to resident having a [MEDICAL CONDITION] disease causing paralysis progressively. Splints for 2-4 hrs a day to decrease further deterioration of contractures. Passive range of motion for extremities for the rest of her life to prevent further contractures. A review of the physician's orders found no orders for the passive ROM to all extremities or for the use of hand splints. An interview with a registered nurse (RN - Employee #142), on 06/09/10 at 11:00 a.m., revealed the resident would ask for splints to be placed on her hands usually everyday. She confirmed no physician orders were written for Resident #63 to use hand splints or to receive passive ROM. The resident came into the facility with the contractures, they had not changed, and she was no receiving passive ROM. She stated the facility no longer had restorative nursing assistants; the other nursing assistants were to assume the duties of providing restorative nursing services, and several residents in the facility continued to receive ROM as ordered. Interview with resident, on 06/09/10 at 2:10 p.m., revealed she asked for hand splints every day. | 2015-11-01 |
| 9386 | 9386 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2010-06-15 | 329 | D | 0 | 1 | KN1V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medication regimen of one (1) of twenty-eight (28) Stage II sample residents was free of unnecessary medication. Resident #63 received an order on admission to the facility for a [MEDICAL CONDITION] medication ([MEDICATION NAME] 0.5 mg) to be administered as needed. Review of the medical record found no documented indications for the use of this medication when it was administered on 02/02/10 and 06/02/10. Facility census: 112. Findings include: a) Resident #63 A review of Resident #63's physician's orders [REDACTED]. ([MEDICATION NAME] is used for anxiety.) These orders were received on the admission date of [DATE]. A review of the resident's February 2010 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A review of nursing notes for 02/02/10 also did not reveal the reason for the medication. On 06/02/10, the resident again received [MEDICATION NAME] 0.5 mg without any documented justification for its use. Behavior monitoring records indicated the resident was ordered [MEDICATION NAME] 0.5 mg as needed twice daily for anxiety attacks. Beginning on 01/15/10 and continuing to 06/10/10, the resident did not have any behaviors documented. An interview with a registered nurse (RN) supervisor (Employee #142), on 06/10/10 at 9:05 a.m., revealed the resident only received the [MEDICATION NAME] on 02/02/10 and 06/02/10. She came in from the hospital on [DATE], and the order came with the resident from the hospital. The RN stated this was something they should discontinue, because they were really not using the medication; it was given only twice since admission. An interview with the director of nursing (DON), on 06/10/10 at 10:40 a.m., revealed staff was told the resident needed to be given time to decide about her care and other things. She can get anxious at times, but if you talk with her and go slowly, this will work. The [MEDICATION NAME] is … | 2015-11-01 |
| 9387 | 9387 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2010-06-15 | 333 | D | 0 | 1 | KN1V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, clinical record review, and review of professional references and facility policies and procedures, the facility failed to ensure appropriate and timely administration of sliding scale insulin. The nurse administered fast-acting insulin based on a blood glucose measurement taken two and one-half (2-1/2) hours after the time it was ordered by the physician and after the resident had consumed a meal. This practice affected one (1) of twenty-eight (28) Stage II sample residents. Resident identifier: #128. Facility census: 112. Findings include: a) Resident #128 Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set assessment (MDS), with an assessment reference date (ARD) of 04/26/10, revealed the resident was moderately impaired for daily decision making, made self understood and sometimes understood others, and was dependent for activities of daily living (ADLs). Review of the annual MDS, with an ARD of 01/27/10, revealed the resident was moderately impaired for daily decision making, made self understood and sometimes understood others, and was dependent for ADLs. On 06/09/10 at 9:20 a.m., during observation of medication administration, Employee #70 (a licensed practical nurse - LPN) performed blood glucose (blood sugar) monitoring on Resident #128 by finger stick (pricking the finger with a lancet to obtain a drop of blood) using a glucometer. (A glucose meter or glucometer is a medical device for determining the approximate concentration of glucose in the blood ). The result of the blood glucose monitoring revealed the resident's blood glucose level was 300 mg/dl. Employee #70 then administered 4 units of [MEDICATION NAME](a fast acting insulin) by subcutaneous (under the skin) injection to Resident #128 in accordance with the sliding scale insulin dosage (an insulin dose ordered for a specific measured level of glucose in the blood) o… | 2015-11-01 |
| 9388 | 9388 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2010-06-15 | 428 | D | 0 | 1 | KN1V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) resident of twenty-eight (28) Stage II sample residents received a review of an as needed psychoactive medication ordered without adequate indications for use. Resident #63 was ordered a psychotropic medication (Ativan 0.5 mg) to be administered as needed. The resident received two (2) doses of the medication without evidence of any indication for its, and there was no evidence this was identified as an irregularity by the consultant pharmacist. Facility census: 112. Findings include: a) Resident #63 A review of Resident #63's physician's orders [REDACTED]. (Buspar is used for anxiety.) These orders were received on the admission date of [DATE]. A review of the resident's February 2010 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A review of nursing notes for 02/02/10 also did not reveal the reason for the medication. On 06/02/10, the resident again received Ativan 0.5 mg without any documented justification for its use. Behavior monitoring records indicated the resident was ordered Ativan 0.5 mg as needed twice daily for anxiety attacks. Beginning on 01/15/10 and continuing to 06/10/10, the resident did not have any behaviors documented. An interview with a registered nurse (RN) supervisor (Employee #142), on 06/10/10 at 9:05 a.m., revealed the resident only received the Ativan on 02/02/10 and 06/02/10. She came in from the hospital on [DATE], and the order came with the resident from the hospital. The RN stated this was something they should discontinue, because they were really not using the medication; it was given only twice since admission. An interview with the director of nursing (DON), on 06/10/10 at 10:40 a.m., revealed staff was told the resident needed to be given time to decide about her care and other things. She can get anxious at times, but if you talk with her and go slowly, this will work. The Ativan is something t… | 2015-11-01 |
| 9389 | 9389 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2011-06-07 | 279 | D | 0 | 1 | Z5E911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility did not develop care plans for residents who were at risk for falls with measurable and individualized interventions for fall prevention. This was found for two (2) of twenty-two (22) residents whose records were reviewed. Resident identifiers: #30 and #22. Facility census: 40. Findings include: a) Resident #30 Resident #30's medical record, when reviewed during the afternoon of 06/02/11 and again on the morning of 06/06/11, revealed this [AGE] year old woman was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #30 had falls documented by incident reports and nurses' notes on 01/09/11, 03/25/11, 03/30/11, and 04/29/11. The fall on 04/29/11 resulted in a [MEDICAL CONDITION] hip. Resident #30 went to hospital that day, and returned on 05/10/11. She was not ambulatory upon her return. Her quarterly minimum data set assessment (MDS 3.0), with an assessment reference date (ARD) of 02/06/10, indicated the resident ambulated independently at that time. She was assessed as having a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. She was assessed as at risk for falls. Her MDS 3.0 with an ARD of 05/19/11, encoded for a significant change in condition, also indicated the resident was severely cognitively impaired. She was assessed, at that time, assessed as being totally dependent upon staff for ambulation with the assistance of two (2) or more staff. Resident #30's care plan prior to the fracture contained a problem identified for the risk for falls, and the goal for this identified problem was: Will have no falls. The intervention to accomplish the goal was: 11/12/10 Observe and report change in ambulation. No other interventions were found in the care plan. There were no additions or revisions noted to the care plan following any of the falls until the resident returned from hospitalization . Her care plan following the fracture… | 2015-11-01 |
| 9390 | 9390 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2011-06-07 | 280 | D | 0 | 1 | Z5E911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility did not review and revise care plans for residents who were identified as being at risk for falls after they had actually sustained subsequent falls. This was found for two (2) of twenty-two (22) Stage II sample residents whose records were reviewed. Resident identifiers: #30 and #22. Facility census: 40. Findings include: a) Resident #30 Resident #30's medical record, when reviewed during the afternoon of 06/02/11 and again on the morning of 06/06/11, revealed this [AGE] year old woman was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #30 had falls documented by incident reports and nurses' notes on 01/09/11, 03/25/11, 03/30/11, and 04/29/11. The fall on 04/29/11 resulted in a [MEDICAL CONDITION] hip. Resident #30 went to hospital that day, and returned on 05/10/11. She was not ambulatory upon her return. Her quarterly minimum data set assessment (MDS 3.0), with an assessment reference date (ARD) of 02/06/10, indicated the resident ambulated independently at that time. She was assessed as having a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. She was assessed as at risk for falls. Her MDS 3.0 with an ARD of 05/19/11, encoded for a significant change in condition, also indicated the resident was severely cognitively impaired. She was assessed, at that time, assessed as being totally dependent upon staff for ambulation with the assistance of two (2) or more staff. Resident #30's care plan prior to the fracture contained a problem identified for the risk for falls, and the goal for this identified problem was: Will have no falls. The intervention to accomplish the goal was: 11/12/10 Observe and report change in ambulation. No other interventions were found in the care plan. There were no additions or revisions noted to the care plan following any of the falls until the resident returned from hospitalization . Her care… | 2015-11-01 |
| 9391 | 9391 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2011-06-07 | 309 | D | 0 | 1 | Z5E911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility did not ensure one (1) of twenty-two (22) Stage II sample residents was adequately assessed for injuries following a fall. Resident identifier: #29. Facility census: 40. Findings include: a) Resident #29 Review of the facility's accident reports revealed Resident #29 sustained a fall on 12/18/11 at 3:45 p.m. as follows: Lost her footing while standing in front of the toilet. Next to the heading Condition of Resident was written: Stable. Next to the heading Describe Injuries was written: 3 bruised areas to right elbow on (sic) of which was raised. This report contained no other assessment data, to include no vital signs, no assessment for pain, and no assessment for limitations in range of motion in extremities. -- Review of Resident #29's quarterly minimum data set assessment (MDS 3.0), with an assessment reference date (ARD) of 12/05/10, revealed this [AGE] year old female, who was admitted on [DATE], had the following Diagnoses: [REDACTED]. In Section C (Cognitive Patterns), the assessor noted the resident was alert and oriented with no cognitive impairment. In Section G (Functional Status), the assessor noted limited assistance from one (1) person with bed mobility, transferring, and toilet use, and she was independent with ambulation both in her room and in the corridor. -- A progress note, signed by the nurse on 12/18/10 at 20:17 (8:17 p.m.), stated (quoted as typed): Summoned to resident's room by HSW at 3:45PM. Resident was sitting on the floor in front of the toilet. She stated that she lost her footing and that her right leg became weak and she sat down on the floor. Temp. 100.4 Pulse 148 Resp. 24 B/P 148/76 SPO2 93% on room air. Resident was moved by hoyer lift from floor to her recliner. 3 bruises were noted to her right elbow. Aside from the resident's vital signs, this note contained no other assessment data, such as an assessment for pain and/or limitations in the resident… | 2015-11-01 |
| 9392 | 9392 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2011-06-07 | 364 | E | 0 | 1 | Z5E911 | Based on observation, staff interview, and policy review, the facility failed to provide pureed food the was attractive in appearance, caused by thinning the pureed foods to the extent that they were more liquid than solid. This had the potential to affect all six (6) residents who were ordered pureed consistency diets. Facility census: 40. Findings include: a) During the observation of food service for the noon meal at 11:32 a.m. on 06/06/11, this surveyor observed pureed foods being placed into divided plates. The mixed vegetables were the consistency of broth and the spaghetti with sauce was only slightly thicker. Both were definitely liquid. At 11:50 a.m. the food service supervisor (Employee #34), who was present, agreed these items were too thin and stated she had instructed the cooks that pureed foods should be thick enough to hold their shape when placed on a regular dinner plate. She agreed that these items would not hold their shape. The dietary policy manual also described pureed foods as having the consistency of mashed potatoes. The cook (Employee #36) stated there were presently six (6) residents receiving pureed diets. | 2015-11-01 |
| 9393 | 9393 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2011-06-07 | 371 | F | 0 | 1 | Z5E911 | Based on observation and staff interview, the facility failed to assure the proper sanitation and food handling practices of all the dietary staff during the preparation and/or serving of the residents' meals, by staff failing to perform mandatory handwashing when entering the kitchen and prior to taking part in the food handling processes. These practices represent a potential source of pathogen exposure for all residents. Facility census: 40. Findings include: a) While this surveyor was observing food preparation in the kitchen at 11:00 a.m. on 06/06/11, a dietary aide (Employee #35) entered through the kitchen door with another worker. The other worker proceeded to the sink to wash her hands, but Employee #35 came into the kitchen, picked up a tray and some utensil containers off a work top, and left the room through an exit door. At 11:15 a.m. on 06/06/11, Employee #35 reentered the room. She did not wash her hands before proceeding to a table where other employees were preparing raw chicken. She then went to the serving area and began assembling food for the serving line. At 11:50 a.m. on 06/06/11, Employee #35 was seen reentering the kitchen for the third time without washing her hands. Shortly after, a woman came to the door and held out a set of keys, saying: Did you leave these in the bathroom? Employee #35 took the keys from her, put them in her pocket, and proceeded to a table where food was being prepared and began wiping off surfaces. These observations were presented to the dietary supervisor (Employee #34) at 11:55 a.m. on 06/06/11, who assured this surveyor that she would rectify this situation. | 2015-11-01 |
| 9394 | 9394 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-11-16 | 225 | E | 1 | 0 | DEOF11 | Based on review of the facility's complaint/concern files, review of reported allegations of resident abuse/neglect, and staff interview, the facility failed to report all allegations of resident abuse/neglect to State agencies as required. Four (4) of twenty (20) reviewed Record of Customer and Family Concerns contained allegations of verbal abuse or neglect which were not reported to State agencies as required. Resident identifiers: #124, #121, #125, and # 95. Facility Census: 119. Findings Include: a) Resident #124 Review of a Record of Customer and Family Concerns form, dated 05/11/12, revealed this resident, on 05/10/12 around 7:00 p.m. or a little after 7:00 p.m., requested her water pitcher be filled with ice. The resident reported it took the staff an hour and a half to honor the request. The resident also reported the nurse aide was rude to her, stated she had never been talked to like that, treated so poorly, or made to feel so bad in her life. There was no evidence this allegation of neglect and verbal abuse was reported to the appropriate State agencies, which included the Office of health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the ombudsman. An interview with the administrator, on 11/14/12, verified the incident was not reported to the appropriate State agencies. An interview with Employee #42, a registered nurse (RN), nurse practice educator, at 12:55 p.m. on 11/14/12, revealed she was the employee who took the report from the resident. She said she did not feel it needed to be reported, because her opinion was the incident was not an allegation of abuse or neglect. Employee #42 reported she spoke to the resident, and the resident did not feel threatened nor did the nurse aide call her a name. Therefore, Employee # 42 felt like this was just a concern and not an allegation of abuse or neglect. b) Resident #121 Review of a Record of Customer and Family Concerns form, dated 06/27/12, revealed this resident complained of not having ice and water all day. The… | 2015-11-01 |
| 9395 | 9395 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2011-02-15 | 279 | D | 0 | 1 | NDLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop an interdisciplinary plan of care that described the individualized dietary interventions to be furnished to attain or maintain each resident's highest practicable physical well-being, to ensure the entire interdisciplinary team was aware of, consistently providing, and documenting those interventions. This was found for two (2) of eighteen (18) Stage II sample residents. Resident identifiers: #201 and #221. Facility census: 29. Findings include: a) Resident #201, admitted on [DATE] When reviewed on 02/09/11 at 2:00 p.m., the minimum data set (MDS) assessments for Resident #201 were found to be encoded for significant weight loss as follows: - MDS 3.0 with an assessment reference date (ARD) of 02/01/11 was encoded for weight loss (1 = yes) with a height of 67 and weight of 123#. - MDS 3.0 with an ARD of 01/23/11 was encoded for weight loss (1 = yes) with a height of 67 and weight of 122#. - MDS 3.0 with an ARD of 01/11/11 was encoded 0 = no or unknown weight loss with a height of 67 and weight of 137# - MDS 3.0 with an ARD of 12/29/10 was encoded 0 = no or unknown weight loss with a height of 67 and weight of 137#. - MDS 3.0 with an ARD of 12/20/10 was coded 0 = no or unknown weight loss with a height 67 and weight of 137#. The care plan for Resident #201, when reviewed on 02/09/11 at 4:00 p.m., contained a nutrition-related problem as follows: 2/8/11: Resident is currently 90% of her ideal body weight. The goal associated with this problem statement was: Resident will gain 1/2 - 1 pound per week. Approaches to achieve this goal were: 1. Provide resident's dietary preferences while adhering to dietary restrictions. 2. Weekly weights. Record review, on 02/09/11 at 4:30 p.m., found a dietary progress note dated 01/20/11, which stated: Will recommend ensure pudding. No further mention of nutritional interventions to address weight loss was found in dietary charting comple… | 2015-11-01 |
| 9396 | 9396 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2011-02-15 | 371 | F | 0 | 1 | NDLO11 | Based on observation and staff interview, the facility failed to store food under sanitary conditions, and failed to ensure that signs posted above all kitchen handwashing stations contained directions to perform handwashing in accordance with current accepted standards of professional practice. This had the potential to affect all residents who receive nourishment from the facility's dietary kitchen. Facility census: 29. Findings include: a) Initial tour of the kitchen, on 02/07/11 at 6:35 p.m., revealed numerous packages of condiments on the floor of the dry food storage area including four (4) packages of fat-free ranch dressing, three (3) packets of Sweet-N-Low artificial sweetener, one (1) packet of ketchup, four (4) packets of pepper, and a three (3) compartment packet of sugar, salt, and pepper. Also, a 20 ounce Styrofoam cup with approximately four (4) ounces of clear liquid was on a wire rack beside numerous boxes of instant mashed potatoes. Further observation revealed three (3) large plastic Rubbermaid canisters, one (1) which contained rice, another which contained flour, and another which contained rice; each of the three (3) canisters was found to have a plastic scoop inside each of the bins. Observation also revealed a 480 ounce cardboard carton of walnuts that was open to air and not covered. These findings were reported to a dietary staff member (Employee #58) on 02/07/11 at approximately 7:00 p.m., in the absence of the dietary manager. During an interview with the dietary manager in the early afternoon on 02/09/11, she stated the above-mentioned concerns had been corrected. When asked about the handwashing procedure posted above each of the handwashing stations in the kitchen which dictated a 15-second handwashing protocol, rather than the 20-second handwashing protocol advocated by the Centers for Disease Control and Prevention (CDC), she stated the signs posted above all the handwashing sinks in the kitchen were obtained in 2008, and she would replace them with updated signs. | 2015-11-01 |
| 9397 | 9397 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2011-02-15 | 425 | E | 0 | 1 | NDLO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure open multi-dose vials of insulin were discarded after one (1) month of the first entry into each vial in accordance with facility policy. This affected for four (4) of eighteen (18) Stage II sample residents and one (1) randomly observed resident. Resident identifiers: #207, #215, #214, #213, and #204. Facility census: 29. Findings include: a) Resident #207 Medication administration observation, on 02/09/11 at 4:27 p.m., revealed a licensed practical nurse (LPN - Employee #3) withdrew 6 units of Regular insulin and administered it to Resident #207. The vial of Regular insulin was tagged 12/15/10. When asked how long a vial of insulin can be kept in the drawer, the nurse said it should be good for six (6) months or a year. There was no other date on the vial. Review of the medical record found Resident #207 was admitted to the unit from the hospital on [DATE]. Observation of Resident #207's medication drawer in the medication cart, in the company of another LPN (Employee #35) on 02/10/11 shortly before 4:00 p.m., found two (2) vials of Regular insulin in the drawer, one (1) tagged 12/15/10 and another tagged 12/31/10. Another nurse (Employee #52) inspected these vials on 02/10/11 at approximately 4:00 p.m. and removed them from the medication cart. -- b) Resident #215 Medication administration observation, on 02/09/11 at 5:14 p.m., revealed a registered nurse (Employee #13) withdrew 4 units of Regular insulin and administered it to Resident #215. The vial of Regular insulin was tagged 12/12/10, with no other date inscribed. When asked how long insulin can be kept in the drawer, Employee #13 asked if that meant a month or something. She said she didn't know of any facility policy about how long Regular insulin could be stored in the medication cart. Review of the medical record found that Resident #215 was admitted to the unit from the hospital on [DATE]. Re… | 2015-11-01 |
| 9398 | 9398 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-11-15 | 224 | E | 1 | 0 | TJP411 | Based on medical record review, staff interview, and a review of the reportable allegations of abuse and neglect, the facility failed to ensure female residents were free from inappropriate sexual behavior by a male resident. Resident #89 had displayed inappropriate sexual behaviors toward four (4) female residents. Resident identifiers: #4, #24, #84, #74, and #89. Facility census: 89. Findings include: a) On 11/14/12 at approximately 10:00 a.m., a review of Resident #89's medical record revealed this resident had engaged in sexually inappropriate behavior toward four (4) female residents. A review of the general progress notes revealed a note from a registered nurse dated 10/05/12 at 2:20 p.m. The note stated, RN was notified by laundry staff at 7:07 pm that elder was observed by her touching a female resident in a sexual and inappropriate way in activities DR (dining room). RN (registered nurse) redirected elder to his room. Female elder was unable to verbalize situation or defend herself from it, however, she did not show any apparent signs of distress from it. While RN was escorting elder back to his room, elder would try to approach other female residents and attempt to show them his (genitals). Elder was left in his room, lying down at that time while RN went to get direction from policy/protocols for situation. By 7:45 pm both aides working that side of East Hall (Employee #9 and Employee #80 CNA), reported to RN that elder had been observed in 2 separate female resident's rooms undressing them. One of the lady's gown was pulled completely off and lying on her abd (abdomen) while he was attempting to get her bra off her. Elder was attempting to pull of the other lady's gown when aide walked in the room and noted situation. Both aides informed me that there was another female resident that is A&O (alert and oriented) to psn (person) & is very aware of her environment. Per aides, this lady verbalized and displayed fear towards elder, and stated elder tried to get in bed with her and was acting 'inappropriate… | 2015-11-01 |
| 9399 | 9399 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-11-15 | 225 | E | 1 | 0 | TJP411 | Based on a review of the reportable allegations of abuse and neglect, and staff interview, the facility did not ensure allegations of abuse were thoroughly investigated. The investigations did not contain statements from witnesses or others involved in the incidents. In addition they did not contain documentation showing the investigative process that led to the facility's determination of whether or not the facility substantiated the allegations. Resident identifiers: #4, #24, #74, #84, and #89. Facility census: 89. Findings include: a) Residents #4, #24, #74, #84 and #89 On 11/14/12, at approximately 10:00 a.m., the reportable allegations of abuse and neglect were reviewed. On 10/05/12 the facility reported four (4) allegations of abuse to the state survey/certification agency. The allegations listed Resident #89 as the perpetrator. Residents #4, #24, #74, and #84 were identified as victims of inappropriate sexual behavior by Resident #89. The social worker (Employee #72) completed the immediate reporting forms to the state survey/certification agency for each of the four (4) victims. However, in her initial reporting she did not describe the nature of the abuse. The report simply stated there was an allegation of sexual abuse without any further description of what had taken place. In addition, in the five (5) day follow up report to the state survey agency, the social worker did not describe how the facility reached a decision to substantiate the allegation of abuse. On 11/15/12, at approximately 9:00 a.m., Employee #96 (director of nursing) indicated the facility was in the process of changing the way they documented allegations of abuse/neglect. On 11/15/12, at approximately 11:00 a.m., Employee #98 (corporate registered nurse consultant) also verified the facility needed to change the way they documented their allegations when reporting to the state/survey agency. The social worker was not available for interview. Employee #96, Employee #98, and Employee #97 (administrator) did not locate any further infor… | 2015-11-01 |
| 9400 | 9400 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2010-04-08 | 156 | B | 0 | 1 | 85AT11 | Based on record review and staff interview, the facility failed to assure one (1) of one (1) applicable resident / responsible party was informed of the right to request a demand bill when the resident's Medicare-covered services were discontinued by the facility. This practice had the potential to affect any resident who was discontinued from Medicare-covered skilled services. Resident identifier: #60. Facility census: 97. Findings include: a) Resident #60 On 04/07/10 at 3:30 p.m., a review was conducted, with the facility's business office manager, of residents whose Medicare-covered skilled services had been discontinued by the facility. Three (3) of four (4) residents reviewed had met their rehabilitation potential and were discharged home. One (1) resident (Resident #60) was discontinued from Medicare-covered services but remained in the facility. He had not exhausted his allowable one hundred (100) Medicare days, but facility staff believed he had met his rehabilitation potential. Because of this, he should have been offered the opportunity to request a demand bill. Review of the notice provided to the resident revealed the form did not contain an option for the resident / responsible party to request a demand bill. There was a space to indicate no regarding submission of a demand bill, but no space to indicate yes requesting the facility to submit a demand bill. In an interview conducted with the social worker (Employee #103) at 4:00 p.m. on 04/07/10, Employee #103 stated she had no idea how this situation had happened but confirmed the form did not contain the required information to allow a resident / responsible party to request the facility submit a demand bill in the resident's behalf. | 2015-11-01 |
| 9401 | 9401 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2010-04-08 | 272 | E | 0 | 1 | 85AT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, observation, and staff interview, the facility failed to periodic pain assessments for one (1) of thirty-seven (37) Stage II sample residents, and failed to complete accurate assessments for three (3) of thirty-seven (37) Stage II sample residents, all of whom were erroneously coded as being on planned weight change programs. Resident identifiers: #55, #160, #111, and #94. Facility census: 97. Findings include: a) Resident #55 In an interview conducted at 3:00 p.m. on 04/06/10, Resident #55 stated he had pain in his left leg and that it often kept him awake at night. At that time, the resident was observed rubbing his left thigh. The resident's medical record, when reviewed on 04/07/10, contained a current physician's orders [REDACTED]. Based on this order, facility staff should have been aware of the possibility of leg pain and should have provided ongoing assessments for this resident's specific pain. Review of the care plan, at the same time, revealed no care plan or other mention of leg pain. In an interview at 10:45 a.m. on 04/07/10, a registered nurse (RN - Employee #136) revealed she had no knowledge of the resident experiencing left leg pain. Employee #136 reviewed the resident's pain scores (pain assessments) for April 2010 and reported there was no documentation of pain thus far in April. She confirmed that the pain score record did not specifically indicate assessment of left leg pain. Employee #136 then visited the resident in his room. At 11:00 a.m. on 04/07/10, the RN reported the resident stated to her that he has left leg pain at night and that the leg pain kept him awake at night. The resident's care plan was again reviewed, this time with Employee #136. At 5:30 p.m. on 04/07/10, Employee #136 confirmed the facility was not aware the resident was having pain and confirmed that ongoing assessments for left leg pain had not been occurring for this resident. Employee #136 state… | 2015-11-01 |
| 9402 | 9402 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2010-04-08 | 279 | E | 0 | 1 | 85AT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, observation, and staff interview, the facility's interdisciplinary team (IDT) failed to develop care plans for four (4) of thirty-seven (37) Stage II sample residents, which contained information necessary to provide appropriate care and services to assist each resident in attaining or maintaining his/her highest level of functioning and/or well being. Care plans were not developed for pain, weight loss, or activities, based on the assessed medical, nursing, or psychosocial needs for these four (4) residents. Resident identifiers: #55, #100, #158, and #76. Facility census: 97. Findings include: a) Resident #55 In an interview conducted at 3:00 p.m. on 04/06/10, Resident #55 stated he had pain in his left leg and that it often kept him awake at night. At that time, the resident was observed rubbing his left thigh. The resident's medical record, when reviewed on 04/07/10, contained a current physician's orders [REDACTED]. Based on this order, facility staff should have been aware of the possibility of leg pain and should have provided ongoing assessments for this resident's specific pain. Review of the care plan, at the same time, revealed no care plan or other mention of leg pain. In an interview at 10:45 a.m. on 04/07/10, a registered nurse (RN - Employee #136) revealed she had no knowledge of the resident experiencing left leg pain. Employee #136 reviewed the resident's pain scores (pain assessments) for April 2010 and reported there was no documentation of pain thus far in April. She confirmed that the pain score record did not specifically indicate assessment of left leg pain. Employee #136 then visited the resident in his room. At 11:00 a.m. on 04/07/10, the RN reported the resident stated to her that he has left leg pain at night and that the leg pain kept him awake at night. The resident's care plan was again reviewed, this time with Employee #136. At 5:30 p.m. on 04/07/10, Employee #1… | 2015-11-01 |
| 9403 | 9403 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2010-04-08 | 280 | D | 0 | 1 | 85AT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed, for three (3) of thirty-seven (37) Stage II sample residents, to update the plan of care to reflect current needs. Resident #153 experienced a decline in urinary continence with no update to the plan of care, Resident #158 experienced a fall with no update in the plan of care, and Resident #160 experienced a change in the status and treatment of [REDACTED]. Resident identifiers: #153, #158, and #160. Facility census: 97. Findings include: a) Resident #153 The medical record for Resident #153, when reviewed on 04/07/10, disclosed the resident was admitted to the facility on [DATE]. According to the Nursing Admission Evaluation completed on 11/23/09, as well as the Bladder Pattering and Analysis Worksheet completed on 11/24/09, the resident was continent of bladder function. An ADL (activity of daily living) Worksheet, completed during the month of January 2010, continued to note the resident as being continent of bladder function. ADL Worksheets for the months of February, March, and April 2010 disclosed the resident had declined in urinary continence to the current status of totally incontinent. The resident's current plan of care, when reviewed on 04/07/10, noted a focus area for this resident as: Occasional urinary incontinence related to hypertonicity bladder, physical limitations. This focus area was initiated on 12/08/09, and included interventions such as using absorbant products and adult briefs and providing incontinence care as needed. The care plan had been reviewed on 03/01/10, but no changes had been implemented to reflect the decreasing urinary continence as described on the ADL Worksheets for the period of time after mid-February 2010 to the present April 2010, when the resident was described as being totally incontinent of urine. A licensed practical nurse (LPN) assigned to the care of this resident on 04/08/10 (Employee #119), when qu… | 2015-11-01 |
| 9404 | 9404 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2010-04-08 | 309 | G | 0 | 1 | 85AT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, record review, and staff interview, the facility failed to provide care and services to assist each resident in attaining or maintaining the highest physical well being possible for three (3) of thirty-seven (37) Stage II sample residents. Resident #55 expressed experiencing pain in his leg that kept him awake at night, and he had an order for [REDACTED].#62 did not eat for three (3) days, and staff failed to assess for possible causes and failed to notify the physician, although the resident did not have a known terminal illness; the resident died twenty-four (24) hours after the physician was notified. Resident #153 was not appropriately assessed for fall risk and sustained two (2) falls. These actions resulted in actual harm to Resident #55 and #62. Resident identifiers: Residents #55, #62, and #153. Facility census: 97. Findings include: a) Resident #55 In an interview conducted at 3:00 p.m. on [DATE], Resident #55 stated he had pain in his left leg and that it often kept him awake at night. At that time, the resident was observed rubbing his left thigh. The resident's medical record, when reviewed on [DATE], contained a current physician's orders [REDACTED]. Based on this order, facility staff should have been aware of the possibility of leg pain and should have provided ongoing assessments for this resident's specific pain. Review of the care plan, at the same time, revealed no care plan or other mention of leg pain. In an interview at 10:45 a.m. on [DATE], a registered nurse (RN - Employee #136) revealed she had no knowledge of the resident experiencing left leg pain. Employee #136 reviewed the resident's pain scores (pain assessments) for [DATE] and reported there was no documentation of pain thus far in April. She confirmed that the pain score record did not specifically indicate assessment of left leg pain. Employee #136 then visited the resident in his room. At 11:00 a.m. on [DATE], the RN … | 2015-11-01 |
| 9405 | 9405 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2010-04-08 | 315 | D | 0 | 1 | 85AT11 | **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 assure timely and appropriate assessment for a resident who was continent of urine when admitted to the facility and who became totally incontinent within the four (4) months following admission, in an effort to determine the possible cause and to address the incontinence to the extent possible. Resident identifier: #153. Facility census: 97. Findings include: a) Resident #153 The medical record for Resident #153, when reviewed on 04/07/10, disclosed the resident was admitted to the facility on [DATE]. According to the Nursing Admission Evaluation completed on 11/23/09, as well as the Bladder Pattering and Analysis Worksheet completed on 11/24/09, the resident was continent of bladder function. An ADL (activity of daily living) Worksheet, completed during the month of January 2010, continued to note the resident as being continent of bladder function. ADL Worksheets for the months of February, March, and April 2010 disclosed the resident had declined in urinary continence to the current status of totally incontinent. The resident's current plan of care, when reviewed on 04/07/10, noted a focus area for this resident as: Occasional urinary incontinence related to hypertonicity bladder, physical limitations. This focus area was initiated on 12/08/09, and included interventions such as using absorbant products and adult briefs and providing incontinence care as needed. The care plan had been reviewed on 03/01/10, but no changes had been implemented to reflect the decreasing urinary continence as described on the ADL Worksheets for the period of time after mid-February 2010 to the present April 2010, when the resident was described as being totally incontinent of urine. A licensed practical nurse (LPN) assigned to the care of this resident on 04/08/10 (Employee #119), when question as to the urinary continence of this re… | 2015-11-01 |
| 9406 | 9406 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2010-04-08 | 319 | D | 0 | 1 | 85AT11 | **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 thirty (30) Stage II sample residents, to accurately assess the resident's increasing emotional distress / behaviors following a [DIAGNOSES REDACTED]. Resident identifier: #162. Facility census: 97. Findings include: a) Resident #162 When reviewed on [DATE], the closed medical record of Resident #162 disclosed she was 92-years old when admitted to the facility on [DATE] from a local acute care hospital with an admission [DIAGNOSES REDACTED]. The document Medical History / Physical Examination, completed by the resident's attending physician at the time of admission, stated the resident was recently diagnosed with [REDACTED]. Review of the resident's admission minimum data set assessment (MDS), dated as completed on [DATE], disclosed in the areas of Cognitive Patterns, Section B, the resident had long and short term memory problems but was able to recall the current season, staff names and faces, and that she was in a nursing home. In the area of emotional issues, Section E, the resident was described as experiencing [MEDICAL CONDITION] and repetitive physical movements. The document also stated that, although the indicators were present, they were easily altered. The next MDS, a Medicare 14-day assessment dated as completed on [DATE], described the resident as continuing to experience [MEDICAL CONDITION], having a sad / pained / worried / facial expression, and continuing to exhibit repetitive physical movements. Additionally, the resident had become physically abusive, resisted care, and indicators of [MEDICAL CONDITION] had surfaced. A social services note, dated [DATE], stated the resident had a decline in condition and was more confused, more restless especially at night, resisting care, and hitting at staff sometimes. The resident's care plan was reviewed. Staff had assessed the resident as having altered nutritional status related to terminal diagnos… | 2015-11-01 |
| 9407 | 9407 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2010-04-08 | 325 | D | 0 | 1 | 85AT11 | Based on record review and staff interview, the facility failed to administer nutritional supplements as care planned and/or ordered for two (2) of thirty-seven (37) Stage II sample residents meant to optimize each resident's nutritional status. Resident identifiers: #111 and #94. Facility census: 97. Findings include: a) Resident #111 A review of the medical record revealed Resident #111 had a significant weight loss in November 2009. His care plan interventions included monitoring the percentage consumed of snacks / nutritional supplements, but there was no evidence on either the treatment sheet or the activities of daily living (ADL) worksheet for April 2010 that he received and/or consumed snacks / supplements as planned. b) Resident #94 A review of the medical record revealed Resident #94 was a debilitated hospice resident who weighed 70# and had a Stage II pressure ulcer on her coccyx. The progress notes stated she was declining in all areas. According to her medical record, snacks and/or nutritional supplements were care planned and/or ordered, but there was no evidence to reflect she received and/or consumed them. The area on the ADL worksheet, where staff was to document the acceptance of evening snacks for April 2010, was incomplete, with only three (3) of seven (7) days marked. A review of the resident's treatment sheet found evidence of her having received and/or refused her nutritional supplement on thirteen (13) of twenty-one (21) occasions when it was offered. c) During an interview with a nursing assistant (Employee #46) at 9:10 a.m. on 04/08/10, she verified these were the two (2) locations staff was to record whether a resident had and/or consumed snacks and/or supplements - the ADL worksheet and the treatment sheet. She stated the nursing assistants were to document the percentage of intake on the ADL worksheet. These findings were shared with the director of nurses (DON) at 9:30 a.m. on 04/08/10. After she review the resident's record, she stated she would take care of the problem. | 2015-11-01 |
| 9408 | 9408 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2010-04-08 | 364 | F | 0 | 1 | 85AT11 | Based on confidential resident interviews, taste testing, menu review, observation, temperature measurement of test trays, and staff interview, the facility failed to assure foods were palatable and at the proper temperatures upon receipt by the residents. Additionally, the facility failed to assure menus were followed relative to planned foods, alternate foods, and use of garnishes. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 97. Findings include: a) Confidential Resident Interviews 1. Resident A On 03/29/10 at 3:29 p.m., this resident stated No when asked if the food tasted good and looked appetizing. 2. Resident B On 03/29/10 at 3:55 p.m., this resident stated No when asked if the food tasted good and looked appetizing. The resident also stated a sandwich was requested regularly because of the taste of the food. 3. Resident C On 03/29/10 at 3:13 p.m., this resident stated No when asked if the food tasted good and looked appetizing. The resident also stated, .wish they had a good cook. 4. Resident D On 03/30/10 at 10:00 a.m., this resident stated, .the milk was warm most of the time. On 03/29/10 at 3:30 p.m., this resident stated the food was often cold and the milk was always warm. 5. Resident E On 03/29/10 at 3:45 p.m., this resident said, The food is not good. You can get something else, but it's not good either. 6. Resident F During the afternoon of 03/31/10, this resident said, The food tastes bad, looks bad, some cooked too much, some not enough. 7. Resident G On 03/29/10 at 3:30 p.m., this resident stated the cold foods were always too warm. 8. Resident H On 04/05/10 at 2:36 p.m., this resident stated the food was not good and needed more seasoning. -- b) During the noon meal on 04/07/10, the green beans were tasted and did not appear to have been seasoned. Employee #62, who prepared the green beans, stated she had seasoned the green beans with garlic powder. No such flavoring was detectable upon taste testing. This was co… | 2015-11-01 |
| 9409 | 9409 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2010-04-08 | 371 | F | 0 | 1 | 85AT11 | Based on observations and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices had the potential to affect all facility residents who received nourishment from the dietary department. Facility census: 97. Findings include: a) On 04/07/10 at 11:55 a.m., observation revealed the rinse temperature of the dishwasher was 198 degrees Fahrenheit (F). According to the 2005 Food Code, the rinse temperature should not exceed a maximum of 194 degrees F., to assure proper cleaning and sanitization. This situation was brought to the attention of the dietary manager (DM) at the time of observation. The DM stated she was unaware that rinse temperatures greater than 194 degrees F were ineffective in sanitizing food service items. Additionally observations at the same time revealed a large coating of dusty debris on the walls around the dishwasher, on top of the dishwasher, and on the ceiling vent above the dishwasher. b) During observation of meal preparation and meal tray preparation at the noon meal on 04/07/10, steam table pans were observed stacked inside each other prior to air drying. Trapped moisture was observed inside each one, creating a medium for bacteria growth. Additionally, these pans, which were ready for use, contained debris which could be scraped off with a fingernail. Plate covers were stacked inside of each other prior to air drying. They also contained some type of white loose debris. c) At 11:25 a.m. on 04/07/10, a pan of cucumber salad made with Ranch dressing was observed at the serving area, ready for service. The temperature of the product was measured. It was being held for service at 50 degrees F. The temperature of pureed green beans, being held for service on the steam table, was measured at the same time. They were 120 degrees F. d) At 12:15 p.m. on 04/07/10, the tray line (with … | 2015-11-01 |
| 9410 | 9410 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2010-04-08 | 387 | D | 0 | 1 | 85AT12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the attending physician, for one (1) of thirteen (13) residents reviewed, completed visits to the resident every thirty (30) days for the first ninety (90) days following admission as required. Resident identifier: #68. Facility census: 105. Findings include: a) Resident #68 When reviewed on 06/15/10, the medical record for Resident #68 disclosed the resident had been admitted to the facility on [DATE]. Further review found no evidence the resident had been seen by her attending physician since that time. The facility's administrator, when interviewed on 06/15/10 at 3:15 p.m., could provide no evidence to reflect the resident had been seen by her attending physician since the time of his admission to the facility on [DATE]. | 2015-11-01 |
| 9411 | 9411 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2010-04-08 | 431 | E | 0 | 1 | 85AT11 | Based on observation and staff interview, the facility failed, for one (1) of two (2) medication refrigerators, to ensure the internal temperature was maintained in a safe range of 36 to 46 degrees Fahrenheit (F). Facility census: 97. Findings include: a) At 9:23 a.m. on 04/05/10, Employee #104 observed the refrigerator and identified it was above the upper limit of the safe zone at 50 degrees F. The employee adjusted the temperature control to a colder temperature. | 2015-11-01 |
| 9412 | 9412 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2010-04-08 | 441 | E | 0 | 1 | 85AT11 | Based on observation and staff interview, the facility failed to assure the surfaces of the hand rails in the hallways on one (1) wing of the facility, and the surfaces in an employee bathroom, were maintained in such a manner that they could be adequately cleaned and disinfected to prevent the spread of infection. This had the potential to affect more than an isolated number of residents. Facility census: 97. Findings include: a) On 03/30/10 and throughout the survey, the following observations were made: 1. The bathroom located adjacent to the 300-400 nursing station, which was used by employees providing direct care to the residents on these halls, was observed by this surveyor to have cracked and missing caulking around the toilet and sink, and plastic baseboards were loose in several areas with gaps that exposed dirt and debris. 2. The handrails along the 300 hall did not have a sealed surface, as there were many chinks out of the rail surface down into the bare wood. These conditions make it impossible to thoroughly clean and sanitize these areas. During an interview with the infection control nurse (Employee #32) at 9:00 a.m. on 04/08/10, she accompanied this surveyor to the areas in question and acknowledged they were not clean and probably could not be cleaned / sanitized. | 2015-11-01 |
| 9413 | 9413 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2010-04-08 | 456 | F | 0 | 1 | 85AT11 | Based on observation and staff interview, the facility failed to assure essential equipment in the kitchen was in safe operating condition. The rinse temperature of the dishwasher was at a temperature which did not effectively sanitize food preparation and service items. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 97. Findings include: a) On 04/07/10 at 11:55 a.m., observation revealed the rinse temperature of the dish washer was 198 degrees Fahrenheit (F). According to the 2005 Food Code, the rinse temperature should not exceed a maximum of 194 degrees F, to assure proper cleaning and sanitization. This situation was brought to the attention of the dietary manager (DM), at the time of observation. The DM stated she was unaware that rinse temperatures greater than 194 degrees F were ineffective. | 2015-11-01 |
| 9414 | 9414 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2012-11-07 | 282 | D | 1 | 0 | I0U011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, grievance review, resident interview, and staff interview, the facility failed, for one (1) of ten (10) sampled residents, to follow the care plan related to the time for transporting a resident to [MEDICAL TREATMENT] appointments. The facility also failed to follow the care plan related to a resident's preference for supplement for one (1) of ten (10) sampled residents who was identified as experiencing weight loss. Resident identifiers: #51 and #35. Facility census: 102. Findings include: a) Resident #51 Record review found that Resident #51 was a [AGE] year old individual, with [DIAGNOSES REDACTED]. Review of a grievance/concern, dated 10/29/12, revealed that Resident #51 had expressed a concern with having to gobble down breakfast before [MEDICAL TREATMENT], then being transported too early, approximately an hour before her [MEDICAL TREATMENT] appointment was scheduled. This caused her to incur a total of 6.25 hours out of the facility on that date. During an interview with Resident #51, on 10/31/12 at 5:00 p.m., she said her [MEDICAL TREATMENT] appointments were always scheduled for 10:30 a.m. on Mondays, Wednesdays, and Fridays, and it was only a 20 minute drive to the [MEDICAL TREATMENT] center. She said she was not supposed to leave the facility until 10:00 a.m. However, on 10/29/12, she left the facility around 9:00 a.m., then had to wait uncomfortably at the [MEDICAL TREATMENT] center for an hour before beginning her four-hour long [MEDICAL TREATMENT] treatment. She said she had to hurry and eat breakfast in order to get dressed and be ready for the 9:00 a.m. transport. The resident said she had barely gotten to touch her food before leaving the facility. She said it was too tiring for her to be up that long at one time. According to the resident this was not the first time this had happened, but she wished it to be the last time. Review of the current care plan found that she was care planned to be transport… | 2015-11-01 |
| 9415 | 9415 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2012-11-07 | 464 | D | 1 | 0 | I0U011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide tables of suitable height to meet the needs of three (3) of four (4) residents observed eating at a table in the Coral / Restorative dining room. Resident identifiers: #44, #98, and #83. Facility census: 102. Findings include: a) Resident #44 This resident was observed eating lunch on 10/30/12 at 12:15 p.m. in the Coral / Restorative dining room. The resident was being assisted by restorative nursing assistant Employee #104. The table was at the level of the resident's axilla, making it difficult for her to see her food and feed herself more independently. Resident #44 was a [AGE] year old, 102 pound female with [DIAGNOSES REDACTED]. Her minimum data set (MDS) notes she is rarely understood. The care plan stated she was to eat in the Coral / Restorative dining room for staff supervision and cueing. All meals were to be monitored, alternate choices were to be offered as needed, and staff were to alert the dietitian and physician if a decline in intake was noted. An additional observation was made on 10/31/12 at 12:30 p.m. Restorative nursing assistants, Employees #82 and #130 were observed assisting the resident during lunch in the Coral / Restorative dining room. During an interview with Employees #82 and #130 at that time, they agreed Resident #44 would benefit by the table being lowered further to allow the resident to see what she was eating and possibly improve her desire to eat. Employee #130 thought the table legs could be adjusted lower and stated she would contact maintenance and have them evaluate the table legs. A final observation on 11/07/12 at 12:30 p.m., found evidence the table had been lowered and Resident # 44 was more active in feeding herself. b) Resident #98 This was observed eating lunch on 10/30/12 at 12:15 p.m. in the Coral / Restorative dining room being assisted by restorative nursing assistant Employee #104. The resident was seated at a table th… | 2015-11-01 |
| 9416 | 9416 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2012-11-07 | 514 | B | 1 | 0 | I0U011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to document percentages or acceptance of supplement intake. This was evident for three (3) of ten (10) sampled residents. Resident identifiers: #35, #66, and #11. Facility census: 102. Findings include: a) Resident #35 Review of the physician's orders [REDACTED].#35 was to receive a house supplement three (3) times daily. Review of the snack, nourishment, supplements and pantry stock policy (3.14) on 11/07/12 found the nourishment list was printed from the tray tracker and used as a guide for delivery of supplements to residents and to record acceptance. Nourishment list records were reviewed for a sample of fourteen (14) days. The dates reviewed were 10/24/12 through 11/06/12. This afforded forty-two (42) opportunities for the resident to receive a supplement. An interview with Employee #102, the director of nurses, Employee # 92, the director of food services, and Employee #37, the assistant food director, revealed no evidence was available to indicate the resident had been offered the supplement on six (6) of fourteen (14) days. A nourishment list was not available for the dates of 11/03/12, 11/02/12, 10/30/12, 10/28/12, 10/27/12, and 10/25/12. The nourishment forms for this resident were blank for five (5) of forty-two (42) opportunities reviewed. These dates included 11/04/12, 11/01/12 and 10/29/12. Acceptance only, with no percentage of consumption noted, occurred on two (2) occasions. Additionally, consumption was unable to be identified on one (1) occasion due to the report indicated both acceptance and refusal of the same date and time of distribution. b) Resident #11 Review of the medical record indicated this resident had an order to receive a house supplement twice daily. This afforded twenty-eight (28) opportunities for consumption during the fourteen (14) days reviewed. The dates reviewed were 10/24/12 through 11/06/12. Review of the snack, nourishment, supplements … | 2015-11-01 |
| 9417 | 9417 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2011-03-02 | 225 | E | 0 | 1 | 3LT211 | Based on review of sampled personnel records, staff interview, and review of the facility's abuse policies and procedures, the facility failed to make reasonable efforts to uncover information that would indicate an individual was unfit for service as an employee of a nursing facility, by failing to adequately screen individuals, who reported having lived and/or worked in States outside of West Virginia (WV), for criminal convictions, adverse actions by applicable professional licensing boards, and/or findings entered into the State nurse aide registry concerning abuse, neglect, etc. in these other States. This occurred for five (5) of five (5) new employees, one (1) contracted employee, and two (2) of three (3) employees who were hired since January 2009 whose personnel records were reviewed. Employee identifiers: #13, #17, #20, #50, #88, #94, #110, and #111. Facility census: 56. Findings include: a) Employee #13 Employee #13, a licensed practical nurse (LPN) who was hired on 01/19/09, reported on her employment application having lived and worked in Ohio (OH) prior to her employment at this facility in WV. Review of the personnel file failed to find evidence of the following: - A statewide criminal background check for WV; - A check of the Nurse Aide Registry for OH; and/or - A check of the LPN licensing board for OH. -- b) Employee #88 Employee #88 was a nursing assistant (NA) who was hired on 11/17/09. Review of her personnel file failed to find evidence of a statewide criminal background check for WV. -- c) Employee #50 was a medical records employee who was hired on 11/13/10. Review of her personnel file failed to find evidence of verification that she had no findings of abuse / neglect on the WV nurse aide registry. -- d) Employee #110, a cook aide who was hired on 02/21/11, lived and worked in OH at the time of hire by this facility. Review of the personnel file failed to find evidence of the following: - A statewide criminal background check for WV; - A check of the Nurse Aide Registry for WV; and/or - A… | 2015-11-01 |
| 9418 | 9418 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2011-03-02 | 226 | E | 0 | 1 | 3LT211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of sampled employees' personnel files, staff interview, and review of the facility's policies and procedures, the facility failed to develop and/or implement policies and procedures that would ensure it did not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. This occurred for five (5) of five (5) new employees, one (1) contracted employee, and two (2) of three (3) employees who were hired since January 2009 whose personnel records were reviewed. Employee identifiers: #13, #17, #20, #50, #88, #94, #110, and #111. Facility census: 56. Findings include: a) Employee #13 Employee #13, a licensed practical nurse (LPN) who was hired on 01/19/09, reported on her employment application having lived and worked in Ohio (OH) prior to her employment at this facility in WV. Review of the personnel file failed to find evidence of the following: - A statewide criminal background check for WV; - A check of the Nurse Aide Registry for OH; and/or - A check of the LPN licensing board for OH. -- b) Employee #88 Employee #88 was a nursing assistant (NA) who was hired on 11/17/09. Review of her personnel file failed to find evidence of a statewide criminal background check for WV. -- c) Employee #50 was a medical records employee who was hired on 11/13/10. Review of her personnel file failed to find evidence of verification that she had no findings of abuse / neglect on the WV nurse aide registry. -- d) Employee #110, a cook aide who was hired on 02/21/11, lived and worked in OH at the time of hire by this facility. Review of the personnel file failed to find evidence of the following: - A statewide criminal background check for WV; - A check of the Nurse Aide Registry for WV; and/or - A check of the Nurse Aide Registry for OH. -- e) Employee #111, a data entry emp… | 2015-11-01 |
| 9419 | 9419 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2011-03-02 | 272 | D | 0 | 1 | 3LT211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and resident interview, the facility did not ensure two (2) residents of twenty-eight (28) Stage II sample residents received an accurate assessment for dental and weight loss. Resident #85 did not receive an accurate assessment for dental problems. Resident #75 did not receive an accurate assessment for weight loss. Facility census: 56. Findings include: a) Resident #85 Record review revealed this [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's dental assessment dated [DATE], the resident had three (3) teeth in the upper right quadrant, no teeth in the upper left quadrant, no teeth in the lower right quadrant, and two (2) teeth in the lower left quadrant. The resident had a lower partial. Additional comments indicated, Upper right tooth broken, denies any pain or discomfort, denies any chewing difficulties. A review of the resident's minimum data set (MDS), with an assessment reference date (ARD) on 01/11/11, found in Section L (Oral / Dental Status) directions to check all that apply. The assessor checked Item Z for None of the above were present, indicating the resident had no dental problems. Not checked was Item D which stated, Obvious or likely cavity or broken natural teeth, even though the dental assessment dated [DATE] indicated the presence of a broken tooth. An interview with the MDS coordinator (Employee #33), on 03/01/11 at 10:30 a.m., revealed the resident does not have any problems with chewing, according to the nursing assessment that was completed on admission, and the resident stated that she did not have a problem chewing. She further stated, The resident does not have any broken teeth and does not have a problem chewing her food. An observation of the resident's mouth, on 03/01/11 at 10:45 a.m., revealed the resident had a partial on the bottom which, with her own teeth, provided a full set of teeth on the … | 2015-11-01 |
| 9420 | 9420 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2011-03-02 | 280 | D | 0 | 1 | 3LT211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to recognize continued weight loss for one (1) of twenty-eight (28) Stage II sample residents. Resident #14 was admitted to this facility on 12/30/10 with a weight of 186 pounds (#). The resident experienced a weight loss of 10# (5.38%) from 12/30/10 to 02/12/11. Review of the resident's comprehensive care plan (dated 12/30/10 to 03/31/11) found the care plan had not been reviewed / revised to address the weight loss. Resident identifier: #14. Facility census: 56. Findings include: a) Resident #14 Medical record review disclosed this resident had been admitted to this facility from an assisted living facility on 12/30/10, with medical [DIAGNOSES REDACTED]. The resident had been receiving Hospice services prior to admission. Further review of the record revealed this resident was 69 inches in height and weighed as follows: - 12/30/10 - 186# with a body mass index (BMI) of 27 - 01/12/11 - 177# with a BMI of 26 - 02/12/11 - 176# with a BMI of 26 The resident sustained [REDACTED]. The certified dietary manager (CDM - Employee #64) recorded a nutrition note on the resident's date of admission (12/30/10), after which there were no further nutrition notes entered by the CDM. The resident was on a regular diet. A dietary assessment was performed by a registered dietitian (RD) on 01/03/11. An initial assessment note by the RD, dated 01/12/11, stated to continue with the plan of care and to monitor for changes by facility staff. Review of the resident's current comprehensive care plan (dated 12/30/10 to 03/31/11) disclosed a problem of altered nutrition. The goal associated with this problem was to maintain optional nutritional status AEB (as evidence by) no significant weight loss greater than 5% a month. The interventions intended to achieve this goal included offering substitutes for uneaten foods and encouraging 100% consumption, offering snacks between meals, and documenting t… | 2015-11-01 |
| 9421 | 9421 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2011-03-02 | 325 | D | 0 | 1 | 3LT211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide care and services to promote acceptable parameters of nutritional status for one (1) of twenty-eight (28) Stage II sample residents with unplanned weight loss. Resident #14 was admitted to this facility on 12/30/10 with a weight of 186 pounds (#). The resident experienced a weight loss of 10# (5.38%) from 12/30/10 to 02/12/11. Review of the resident's comprehensive care plan (dated 12/30/10 to 03/31/11) found the care plan had not been reviewed / revised to address the weight loss. The resident's nutritional status was at risk due to lack of monitoring and failing to identify an unplanned weight loss in a timely manner. Resident identifier: #14. Facility census: 56. Findings include: a) Resident #14 Medical record review disclosed this resident had been admitted to this facility from an assisted living facility on 12/30/10, with medical [DIAGNOSES REDACTED]. The resident had been receiving Hospice services prior to admission. Further review of the record revealed this resident was 69 inches in height and weighed as follows: - 12/30/10 - 186# with a body mass index (BMI) of 27 - 01/12/11 - 177# with a BMI of 26 - 02/12/11 - 176# with a BMI of 26 The resident sustained [REDACTED]. The certified dietary manager (CDM - Employee #64) recorded a nutrition note on the resident's date of admission (12/30/10), after which there were no further nutrition notes entered by the CDM. The resident was on a regular diet. A dietary assessment was performed by a registered dietitian (RD) on 01/03/11. An initial assessment note by the RD, dated 01/12/11, stated to continue with the plan of care and to monitor for changes by facility staff. Review of the resident's current comprehensive care plan (dated 12/30/10 to 03/31/11) disclosed a problem of altered nutrition. The goal associated with this problem was to maintain optional nutritional status AEB (as evidence by) no significan… | 2015-11-01 |
| 9422 | 9422 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2011-03-02 | 362 | F | 0 | 1 | 3LT211 | Based on observation, review of the facility's dish machine temperature logs, staff interview, and review of the facility's policy for glove use in the dietary department, the facility failed to employ sufficient competent support staff to carry out the functions of the dietary service, as evidenced by failure of the facility to ensure dishes were properly sanitized between uses and failure to ensure dietary staff employed appropriate techniques to maintain hand hygiene. These practices had the potential to affect all residents who consume an oral diet. Facility census: 56. Findings include: a) During a kitchen observation on 02/22/11 at 11:30 a.m., review of the facility's dish machine temperatures log found the rinse cycle temperature had not been reaching the required 180 degrees Fahrenheit (F) for the final rinse cycle since 02/16/11. During a test of the dish machine, performed by the facility's chef (Employee #51) on 02/22/11 at 11:40 a.m., observation found the water temperature of final rinse cycle reached 162 degrees F. A second test found the water temperature of the final rinse cycle to be 165 degrees F. The water temperature of the dish machine failed to reach the required 180 degrees F during the final rinse cycle. Review of the dish machine temperatures logs for the months of October 2010 through February 2011 found the dietary staff had not consistently recorded the dishwasher wash and rinse cycle temperatures every time the dish machine was used. Interview with the certified dietary manager (CDM - Employee #64), on 02/22/11 at 11:40 a.m., found the dish machine's heat booster (which heats the water during the rinse cycle to the required 180 degrees F) had not been working the previous week but had been repaired. The wash / rinse cycle temperatures had not been recorded on the dish machine temperature log for the noon meal since 02/14/11. The CDM reported the dietary employees responsible for running the dish machine had not informed her of the dish machine failing to reach the proper water tempera… | 2015-11-01 |
| 9423 | 9423 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2011-03-02 | 371 | F | 0 | 1 | 3LT211 | Based on observation, review of the facility's dish machine temperature logs, staff interview, and review of the facility's policy for glove use in the dietary department, the facility failed to ensure dishes were properly sanitized between uses and failed to ensure dietary staff employed appropriate techniques to maintain hand hygiene. These practices had the potential to affect all residents who consume an oral diet. Facility census: 56. Findings include: a) During a kitchen observation on 02/22/11 at 11:30 a.m., review of the facility's dish machine temperatures log found the rinse cycle temperature had not been reaching the required 180 degrees Fahrenheit (F) for the final rinse cycle since 02/16/11. During a test of the dish machine, performed by the facility's chef (Employee #51) on 02/22/11 at 11:40 a.m., observation found the water temperature of final rinse cycle reached 162 degrees F. A second test found the water temperature of the final rinse cycle to be 165 degrees F. The water temperature of the dish machine failed to reach the required 180 degrees F during the final rinse cycle. Review of the dish machine temperatures logs for the months of October 2010 through February 2011 found the dietary staff had not consistently recorded the dishwasher wash and rinse cycle temperatures every time the dish machine was used. Interview with the certified dietary manager (CDM - Employee #64), on 02/22/11 at 11:40 a.m., found the dish machine's heat booster (which heats the water during the rinse cycle to the required 180 degrees F) had not been working the previous week but had been repaired. The wash / rinse cycle temperatures had not been recorded on the dish machine temperature log for the noon meal since 02/14/11. The CDM reported the dietary employees responsible for running the dish machine had not informed her of the dish machine failing to reach the proper water temperature during the final rinse cycle. The CDM agreed the dietary staff had not been documenting the rinse cycle water temperatures on the te… | 2015-11-01 |
| 9424 | 9424 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2011-03-02 | 441 | D | 0 | 1 | 3LT211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy for administering medications via feeding tubes, and staff interview, the facility failed to ensure one (1) of four (4) nurses who administered medications used good infection control practices in order prevent the spread of infections. Employee #30 (a licensed practical nurse - LPN) administered medications to Resident #89 via a [DEVICE] using a syringe that had been stored in a bottle of water located next to the resident's bed. The nurse used the syringe and the water in this bottle to flush the resident's [DEVICE], after stirring the resident's liquid medications in a medicine cup, and then placed the syringe back into the same bottle of water for storage. The syringe was not rinsed before being stored in the bottle. Facility census: 56. Findings include: a) Resident #89 Observation, on 02/24/11 at 11:00 a.m., found Employee #30 administering liquid medications to Resident #89 via a [DEVICE]. A syringe was observed standing in a bottle of water at the resident's bedside. The nurse drew water from the bottle into the syringe and used the syringe to flush the resident's [DEVICE] several time throughout the observation. Each time, the nurse would draw water from the bottle. During the medication administration, the nurse inserted the syringe into the end of the resident's [DEVICE] and had also used the syringe to stir liquid medication in a medicine cup. After the medication administration, the nurse replaced the syringe back into the bottle of water and did not rinse it. The nurse, when interviewed at this time, reported the bottle and syringe were changed out each night. She also stated she had worked in a hospital, and this was a standard practice. Review of the facility's policy titled Administering Medication Through an Enteral Tube (dated 03/09) found it was not specific to the cleansing or storage of the syringe. It only indicated that disposable items should be thrown away. Interviews w… | 2015-11-01 |
| 9425 | 9425 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2012-11-07 | 323 | F | 1 | 0 | T1K611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and measurement of water temperatures, the facility failed to ensure the environment was as free of accident hazards as possible. Water temperatures in resident care areas were unsafe, the medication cart was unlocked and unattended on two (2) separate occasions, assistive devices to prevent accidents were not in place for two (2) residents, and toxic chemicals were improperly stored in the central shower room. These practices had the potential to affect all residents at the facility. Resident identifiers: #25 and #43. Facility census: 58. Findings include: a) Water Temperatures Water temperatures were obtained by Employee #60, the maintenance supervisor, using the facility's thermometer, beginning at 11:15 a.m. on 11/06/12. The following temperatures were measured in residents' rooms: -Room B1- hand sink-120 degrees Fahrenheit (F) -Room B3- hand sink-119 degrees F -Room B9- hand sink-115 degrees F -Room B16- hand sink-117 degrees F -Room A1 - hand sink-113 degrees F -Room A6 - hand sink-110 degrees F At 11:25 a.m. the women's public restroom water temperature was 120 degrees F. At 11:50 a.m. the resident shower room water temperature was 115 degrees F. On 11/06/12 at 1:30 p.m., Employee #60 presented logs of monthly water temperature monitoring through 10/05/12. Water temperatures were noted to be within acceptable ranges through 10/05/12. On 11/07/12 at 8:10 a.m., Employee #60 reported a problem with the, mixing valve. Employee #60 stated there was a part that needed to be ordered, and stated the mixing valve was adjusted to turn down the temperature to prevent spiking. On 11/07/12, beginning at 8:15 a.m., water temperatures were obtained by Employee #60 using the facility thermometer with the following results in residents' rooms: -Room B1- hand sink-95 degrees F -Room B3- hand sink-113 degrees F -Room B9- hand sink-106 degrees F -Room B16- hand sink-105 degrees F During A hall … | 2015-11-01 |
| 9426 | 9426 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2012-11-07 | 441 | F | 1 | 0 | T1K611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the facility's infection control records, review of policies and procedures, and consultation with the local health department, it was determined the facility failed to implement and maintain an effective infection control program when the facility became aware of an outbreak of a contagious communicable disease / condition. The facility failed to report the outbreak to the local health department and failed to provide evidence of control, prevention, and in-servicing of staff related to prevention of the communicable condition. Additionally the facility failed to ensure residents' personal care equipment was stored in a manner to prevent the spread of infections. This practice had the potential to affect all residents who resided at the facility. Resident identifiers: #11, #42, and #34. Facility census: 58. Findings include: a) Residents #11, #42, and #34 Medical record review found each of these residents had physician's orders [REDACTED].#11 was seen by a dermatologist who confirmed the scabies. Residents #42 and #34 were treated for [REDACTED]. Observation revealed all three (3) residents were clustered together on B-Hall. Review of the facility's infection control policies and procedures found no procedures which addressed interventions or treatment for [REDACTED]. The infection control log was reviewed with the director of nursing (DON), Employee #11, at 1:45 p.m. on 11/06/12. The residents who were treated for [REDACTED]. The DON also stated she had not reported the outbreak of scabies to the local health department. At that time, she verified the infection control policy and procedure did not address scabies interventions for prevention or treatment. The DON stated employees had received in-servicing on treatment of [REDACTED]. A representative of the local health department was contacted on 11/07/12 at 9:30 a.m. This employee verified the facility should have reported the confirmed and… | 2015-11-01 |
| 9427 | 9427 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2012-11-07 | 465 | F | 1 | 0 | T1K611 | Based on observation and staff interview, the facility failed to ensure a safe physical environment was provided for residents. Wiring for the alarm system at the exit door was exposed, the exterior of the facility was cluttered, the heater in the central shower room and the exhaust fan in the clean laundry room were covered with lint, and blankets and pillows were stacked to the ceiling in the clean laundry room. This practice had the potential to affect all residents who resided at the facility. Facility census: 58. Findings include: a) Wiring Observation of the B-Hall exit door with Employee #60, the maintenance supervisor, at 2:15 p.m. on 11/06/12, found the outside coating was frayed on the wiring leading to the door alarm. Green tape had been applied to the frayed area. There was an excess of wiring at the top of the door frame. Some of the wiring was enclosed in a plastic casing, but some wiring was still exposed. Employee #60 stated the wiring was like that when he came to work. He stated the alarm system was very low voltage and he would fix the problem. b) The exterior of the facility At 2:45 p.m. on 11/05/12, the area behind the facility found the following items were scattered around the facility's storage buildings: - Three (3) mattresses, - A ladder was propped in an upward position against one storage building, - A broken bench, - A broken over the bed table frame, - A piece of window glass approximately 3 feet by 5 feet, - A 50 gallon soiled linen barrel, - Parts of a metal bed frame, - Two (2) unsecured 20 pound propane gas tanks, - A rusted storage cart for storing oxygen cylinders. c) Observation of the clean laundry room and central shower The exhaust fan in the clean laundry room was observed with Employee # 68, a laundry worker, on 11/07/12 at 7:30 a.m. The blades of the fan and the casing around the fan were covered with lint. Pillows and blankets were observed touching the ceiling. Employee #68 stated she would find another place for these items. (According to the Life Safety Code- 101, K6… | 2015-11-01 |
| 9428 | 9428 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2012-11-07 | 505 | D | 1 | 0 | T1K612 | Based on medical record review and staff interview, the facility failed to promptly obtain and notify the attending physician of laboratory (lab) results. The physician was not notified of the results of a urinalysis and urine culture for one (1) of five (5) sample residents. Resident identifier: #25. Facility census: 51. Findings include: a) Resident #25 Review of the medical record, on 01/02/12, revealed a urinalysis and urine culture was obtained on 12/24/12 at the emergency room . There was no evidence of the lab reports in the medical record. Upon inquiry of the location of the lab results, at 4:00 p.m. on 01/02/12, Employee #15 (licensed practical nurse), reviewed the medical record and stated she was unable to locate the lab results for the urinalysis and urine culture. She looked in the physician's folder and requested Employee #14, the minimum data set nurse, look in medical records. On 01/02/12, Employee #9, the director of nurses (DON), was informed the lab results were unable to be located. She looked for the results and reported they had not been obtained. During a follow up with the DON, on 01/03/12 at 9:30 a.m., she stated she had called for the results and provided a copy of a faxed report from the hospital, which was dated 01/02/13. Further interview revealed the facility had no policy for follow up of lab results from hospital visits. During an interview, on 01/03/12 at 10:00 a.m., the physician stated he was unaware the urinalysis and urine culture had been obtained. He confirmed he had not been notified of the lab results. | 2015-11-01 |
| 9429 | 9429 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2011-07-28 | 152 | D | 0 | 1 | TF5T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview it was found that the Physician order [REDACTED]. This was evident for 1 (one) of 37 stage II sampled residents. Census: 57 residents currently in facility. Findings include: A) Resident #51 Review of the medical record for this resident revealed that there had been a previous POST form completed with a physician signature and date of 12/29/09. It stated the resident would want: Do Not Resuscitate (DNR), comfort measure only, antibiotics, IV (intravenous fluids)for a trial period and no tube feedings. Another POST form was noted which was dated by staff on 1/26/11. This document had listed that the resident would want DNR, no antibiotics, no IV, no tube feedings. It was not signed nor dated as to when the physician would have reviewed this information with the resident or responsible party and informed them of this change in treatment that would be provided. Spoke with director of nursing on 7/26/11 at mid afternoon regarding the lack of the signature and date by the physician. There was no further details submitted to the surveyor as of exit on 7/28/11 | 2015-11-01 |
| 9430 | 9430 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2011-07-28 | 314 | G | 0 | 1 | TF5T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, observations, review of the Weekly Skin Check Report of Pressure Areas, review of the facility policies and procedures, and staff interview, the facility had failed to ensure residents did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable; and failed to ensure a resident having pressure ulcers received the necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing. This resulted in actual harm to two (2) residents. Two (2) of three (3) residents, who were reviewed for the pressure ulcer care area in the Stage II sample of thirty-seven (37), were found to have developed unstageable pressure ulcers while in the facility. One (1) resident developed a pressure area on his left heel and had another area on the anterior aspect of his foot / ankle area that was thought to be related to pressure. Another resident developed an area of deep tissue injury on her buttock that developed in-house. Additionally, during the observation of treatments, breaches on infection control practices were noted. Resident identifiers: #32 and #10. Facility census: 57. Findings include: a) Resident #32 Medical record review revealed this [AGE] year old male was re-admitted to the facility on [DATE]. A Medicare 14-Day minimum data set assessment (MDS), with an assessment reference date (ARD) of [DATE], noted that no pressure ulcers were present. A comprehensive significant change in status MDS with an ARD of [DATE] also noted no pressure ulcers were present. Review of the list of MDS assessments completed for this resident found he had not been discharged to an acute care facility for at least for at least three (3) months. Review of the resident's medical record found a pressure ulcer was first noted on the resident's left heel on [DATE]. - A copy of the Weekly Skin Check Report of Pressure Areas was provided upon reques… | 2015-11-01 |
| 9431 | 9431 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2011-07-28 | 441 | E | 0 | 1 | TF5T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the facility's policies and procedures for handwashing and dressing changes, review of the Centers for Disease Control and Prevention (CDC) guidelines, and staff interview, the facility failed to ensure staff employed infection control practices to prevent the development and spread of infection. Nurses did not perform handwashing when indicated, and / or in a manner consistent with facility policy and CDC guidelines, during medication pass and treatments. Treatment supplies, a medication, and scissors were not handled in a manner to prevent the potential for transmission of microorganisms from one resident to another. These practices had the potential to affect more than a limited number of residents. Resident identifiers: #2, #32, and #38. Facility census: 57. Findings include: a) Resident #2 On 07/26/11 at 11:00 a.m., a licensed practical nurse (LPN - Employee #2) was observed administering a medication via gastrostomy tube. After completing the procedure, she took the piston syringe used to give the medications to the resident's bathroom to rinse. After rinsing the syringe and replacing it in the storage bag, she removed her gloves. She then returned to the medication cart without washing her hands. -- b) Resident #32 On 07/28/11 at 9:53 a.m., a dressing change to the resident's left heel and dorsal foot / ankle was observed. Employee #2 removed some bottles from a green plastic basket in the top drawer of the treatment cart. She placed unsterile 4 x 4's, gloves, Saf-Clens Spray, non-adherent dressings, Kling, and Medfix in the basket. After entering the resident's room, the nurse placed the basket directly on the resident's overbed table without benefit of sanitizing the table or using a barrier. She obtained paper toweling from the resident's bathroom and placed it on the overbed table to establish a clean field. The items were removed from the basket and placed on the paper towels. The box of Medfix (a … | 2015-11-01 |
| 9432 | 9432 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2011-07-28 | 522 | F | 0 | 1 | TF5T11 | Based on review of information provided to the Office of Health Facility Licensure and Certification (OHFLAC) and staff interview, the facility had failed to provide written notice to the State licensing agency at the time of change of the facility's administrator and director of nursing. The individuals in these positions had been changed for nearly a year and more than a year, respectively, prior to the survey. This had the potential to affect all residents residing in the facility. Facility census: 57. Findings include: a) Notification of change in the director of nursing During the course of the survey, it was identified by staff at OHFLAC that there had been a change of the individual serving as the director of nursing (DON). On the afternoon of 07/28/11, the administrator was asked whether OHFLAC had ever been notified of the current DON's name. He said he had just received a call from an OHFLAC staff member and had sent this information to the office. The individual currently serving as the DON had been in that position since 04/01/10. The notification to the State licensing agency had not been made at the time of the change in the DON. -- b) Notification of change in the identity of the administrator. On the afternoon of 07/28/11, the administrator stated he thought a corporate person had made the notification of the change in administrators to OHFLAC. This information was provided via e-mail to OHFLAC at 1:08 p.m. on 07/28/11. The administrator had been in place since 08/13/10. The notification to the State licensing agency had not been made at the time of the change in the administrator. | 2015-11-01 |
| 9433 | 9433 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2011-03-16 | 241 | E | 0 | 1 | R8P711 | Based on observations, review of the information provided on the CMS-802, and review of medical records, the facility failed to promote care for residents in an environment that maintained or enhanced each resident's dignity. Incontinence briefs were observed lying out where anyone passing by individual residents' rooms in the hall or entering the rooms could see the briefs. This conveyed to others the residents were incontinent. Additionally, one (1) resident who required assistance with eating was not served her tray until her roommate had finished eating. Six (6) of thirty-four (34) current residents on the Stage II sample were affected. Resident identifiers: #52, #2, #9, #6, #49, and #42. Facility census: 55. Findings include: a) On Sunday, 03/06/11, between approximately 4:00 p.m. and 6:30 p.m., residents on the C-hall were observed during the initial tour of the facility and during the evening meal. Not all rooms were entered as the residents were absent. There were thirty (30) residents residing on C-hall at that time. Sixteen (16) of the thirty (30) residents were identified on the CMS-802 as being incontinent. 1. Resident #52 On 03/06/11 at 4:06 p.m., a small stack of incontinence briefs were observed on the resident's overbed table. The overbed table was against the wall next to the door to the hall way. This placed the briefs in view of anyone passing by the room. 2. Resident #2 On 03/06/11 at 6:00 p.m., two (2) incontinence briefs were observed lying on the foot of the resident's bed. The briefs were visible from the hall way. 3. Resident #9 At 6:00 p.m. on 03/06/11, two (2) incontinence briefs were observed lying on the chair by bed of Resident #9. These could be seen from the hall. This resident's most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/09/11, identified the resident as being always incontinent of bowel and bladder. She could be understood and was coded as being able to sometimes understand others. Her hearing was assessed as highly impaired. This… | 2015-11-01 |
| 9434 | 9434 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2011-03-16 | 279 | D | 0 | 1 | R8P711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, and resident observation, the facility failed to develop a comprehensive care plan for each resident to include measurable objectives and/or interventions to address problems identified through the comprehensive assessment and/or to achieve established goals for three (3) of thirty-four (34) residents in the Stage II sample. Resident identifiers: #17, #9, and #5. Facility census: 55. Findings include: a) Resident #17 On 03/07/11 at 10:14 a.m., an interview with Resident #17 revealed she felt her gums were shrinking and her dentures did not feel right. The resident further stated she did not know if they could make her any more dentures or not. Review of Resident #17's medical record revealed she was evaluated by a dentist on 05/06/10, 08/16/10, and 09/10/10 for improper fitting dentures and sores on her gums. On 03/10/11 at 3:30 p.m., an interview with Resident #17 revealed she had mentioned to staff about her dental problems in the past, but she had not mentioned any dental problems to staff recently. The resident further stated she had had three (3) appointments and the dentist could not fix her dentures. The resident reported she was still having discomfort, but when asked if she would like staff to be made aware and to possibly see another dentist, she stated, I don't want to fool with it anymore. The resident further stated she was able to chew, but they had to grind her meat. review of the resident's medical record revealed [REDACTED]. The evaluation further stated she did not have any chewing / swallowing problems, and her diet included ground meats, no concentrated sweets, and regular liquids. A Nursing Evaluation dated 10/21/10 revealed the resident was on a regular diet at that time. Review of Resident #17's care plan found no mention of dental problems or difficulty chewing. On 03/16/11 at 9:30 a.m., an interview with the clinical care supervisor (Employee #78) re… | 2015-11-01 |
| 9435 | 9435 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2011-03-16 | 280 | D | 0 | 1 | R8P711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and resident interview, the facility failed to periodically review and revised each resident's care plan for changes in care and treatment. The facility failed to revise a care plan for Resident #45 regarding discharge planning. One (1) of thirty-four (34) residents on the Stage II sample was affected. Resident identifier: #45. Facility census: 55. Findings include: a) Resident #45 Review of Resident #45's medical record revealed the resident did not possess the capacity to understand and make her own health care decisions. On 03/10/11 at 11:30 a.m., an observation of the resident found her to be alert and ambulatory in her wheelchair. On 03/10/11 at 1:40 p.m. and 3:40 p.m., interviews with the resident revealed she was unable to answer questions asked by this surveyor regarding alleged missing clothing. Review of Resident #45's medical record revealed the following social discharge review assessments: - 11/30/10 - the discharge plan included short-term stay, the resident was planning to return home, and the resident had a support system available (e.g., resident lives with son, other sons are also involved with in home needs). Services at the time of discharge were to be determined, with the possibility that home health would be consulted depending upon the discharge orders. - 12/28/10 - the discharge plan was unknown, the resident was planning to return home, and the resident had a support system available. Discharge referrals were to be determined when / if the resident decided to return home. - 01/21/11 - the discharge plan was unknown, the resident was planning to return home, and the resident had a support system available (discharge was to be determined by the family within the next couple weeks). Discharge referrals were to be determined, and the facility stated it was possible that home health would be consulted depending upon the discharge orders. Further review of the resident's medi… | 2015-11-01 |
| 9436 | 9436 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2011-03-16 | 309 | D | 0 | 1 | R8P711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident comments, and medical record review, the facility failed to provide the necessary care and services to assist each resident in attaining or maintaining his or her highest practicable levels of well-being in accordance with the comprehensive assessment and plan of care. A resident, who had loss of voluntary movement in her lower legs, was observed throughout the survey to be in a wheelchair that did not provide support for her feet. Two (2) residents were observed at meal times to be positioned in poor body alignment and in a manner that did not facilitate their abilities to eat. Three (3) of thirty-four (34) Stage II residents were affected. Resident identifiers: #3, #9, and #5. Facility census: 55. Findings include: a) Resident #3 During the initial tour of the facility on 03/06/11 and throughout the survey, this [AGE] year old resident was periodically observed up in a wheelchair. Her feet did not fully touch the floor, and there were no footrests on the chair. She used her hands to wheel about the facility. The minimum data set assessment (MDS), with an assessment reference date (ARD) of 02/13/11, indicated she had loss of functional range of motion in both lower extremities. The assessment was also coded for the [DIAGNOSES REDACTED]. On 03/16/11 at 10:48 a.m., Employee #78, a registered nurse (RN) and the clinical care supervisor, was shown the resident's positioning. When asked whether a smaller wheelchair had ever been tried, she stated she did not know. Employee #87, a certified occupational therapy assistant (COTA), was in the area at that time. The lack of support for the resident's feet was pointed out to him. He looked at the wheelchair and said he could lower the chair. At 10:51 a.m., Employee #87 said the physical therapist had said a bearing needed to be fixed and her chair had been changed out last week until it could be repaired. He agreed the wheelchair she was currently using n… | 2015-11-01 |
| 9437 | 9437 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2011-03-16 | 323 | G | 0 | 1 | R8P711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on family interview, medical record review, and staff interview, the facility failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents with injuries for one (1) of thirty-four (34) Stage II sample residents. Record review revealed Resident #48 fell from her bed on the morning of 01/31/11 and sustained a compression fracture of the T-4 vertebra and a facial bone fracture. Further review of the record revealed she had sustained two (2) previous falls from her bed (on 08/23/10 and 11/07/10) with no injuries; however, the interdisciplinary team did not revise the resident's care plan after these falls to include interventions that would serve to either prevent the resident from falling out of bed and/or reduce the likelihood of serious injury from such a fall. The care plan interventions for falls remained essentially unchanged since 08/30/10, with a reliance on the use of bed and chair alarms to alert staff to unassisted self-transfers. The use of bed bolsters and floor mats was not added to her overall plan of care until after the 01/31/11 fall. Resident identifier: #48. Facility census: 55. Findings include: a) Resident #48 1. When interviewed on 03/07/11 at approximately 2:00 p.m., Resident #48's daughter stated she did not understand why the facility had not initiated the use of more safety devices (such as fall mats in her mother's room) after Resident #48 fell in November 2010. The resident had subsequently sustained a fall with injuries in January 2011. -- 2. Record review revealed Resident #48 was an [AGE] year old female originally admitted to the facility on [DATE], with her most recent admission occurring on 06/29/10. According to her most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 02/06/11, Resident #48 scored 4 on the Brief Interview for Mental Status (BIMS); a resident scoring between 0 and 7 is considered to hav… | 2015-11-01 |
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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 );