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149 rows where "filedate" is on date 2016-01-01
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9163 | 9163 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-01-23 | 224 | G | 1 | 0 | 71W211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents were free of neglect by failing to assess, monitor, and provide medical intervention timely, for an [AGE] year old resident with diabetes and an existing pressure ulcer when she developed a blackened area on her right great toe. There was no evidence of assessments or interventions until six (6) days after the initial identification. This delay had the potential to adversely affect the progression of the wound and comfort of the resident. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 This [AGE] year old resident had [DIAGNOSES REDACTED]. She also had a had been receiving treatment for [REDACTED]. A progress note, dated 12/13/12, by Employee #126, a licensed nurse, identified the family's concern with the resident's great toe on the right foot. The nurse assessed the area, and noted a dark purple hematoma on toe. No evidence of any additional assessment or monitoring of the changes to the right great toe were found until six (6) days later on 12/19/12 at 5:47 a.m. On 12/19/12 at 5:47 a.m., a registered nurse (Employee #1), documented Resident has blackened area on right great toe and 4th great toe, her foot is [MEDICAL CONDITION] and cool. Skin of foot is red with striation . No dorsal or post tibia pulse appreciated with Doppler. Left foot has sore on 2nd toe . Will report to MD (doctor). In an interview with Employee #126, on 01/23/13 at 8:50 a.m., she said she had faxed the physician about the right great toe on 01/13/12, and verbally passed the information to the oncoming shift. She said the right great toe looked purple, it seemed to have been a sudden change, and had given the appearance of perhaps having been bumped. Employee #82 (registered nurse) was interviewed on 01/23/13 at 9:05 a.m. She said they kept copies of faxes sent to the physician in the physicians' mailboxes until they received a response. They would r… | 2016-01-01 |
| 9164 | 9164 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-01-23 | 280 | D | 1 | 0 | 71W211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise an eight-five year old diabetic resident's care plan following a change in condition of her skin. One (1) of nine (9) sampled residents was affected. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 Record review revealed a nursing progress note, dated 12/13/12, that identified the family's concern with the resident's right great toe. The nurse documented Noted dark purple hematoma on toe. Record review revealed the next documentation related to the right great toe occurred on 12/19/12 at 5:47 a.m., when Employee #1 (a nurse) identified in a nursing progress note, Resident has blackened area on right great toe and 4th toe, her foot is [MEDICAL CONDITION] and cool. Skin of foot is red with striation . No dorsal or post tibial pulse appreciated with doppler. Left foot has sore on 2nd toe. A nursing entry, dated 12/19/12 at 9:16 a.m., noted the wound care nurse, Employee #136, had inspected the resident's toe. An appointment with a podiatrist was then requested on 12/19/12, and was obtained for 4:45 p.m. later that day. Review of the podiatrist's progress note for the 12/19/12 visit, revealed a [DIAGNOSES REDACTED]. A nurses' note indicated the medical power of attorney had secured an appointment with an orthopedic surgeon for 12/27/12. However, due to an escalation in the resident's level of pain, she was transferred to the emergency roiagnom on [DATE], where she was admitted . Review of the resident's care plan revealed the absence of any revisions related to the new problems identified with the skin, and/or circulation to the resident's right foot and toe. During an interview with the Director of Nursing (DON), on 01/23/13 at 1:45 p.m., she agreed the care plan for this resident had not been revised to include the change in condition of the right great toe first identified on 12/13/12. | 2016-01-01 |
| 9165 | 9165 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-01-23 | 309 | G | 1 | 0 | 71W211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide medical intervention timely, and/or ongoing monitoring and assessments, to a resident who had a change in condition. An [AGE] year old resident with diabetes developed a change in condition to her right great toe, with no known interventions and/or assessments until six (6) days after the initial assessment. This delay in treatment had the potential to adversely affect the progression of the wound and comfort of the resident. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 This [AGE] year old resident had [DIAGNOSES REDACTED]. According to the resident's medical record, this resident had been treated for [REDACTED]. A progress note, dated 12/13/12, by Employee #126, a licensed nurse, identified the family's concern with the resident's great toe on the right foot. The nurse assessed the area, and noted a dark purple hematoma on toe. Record review found no evidence of assessment or monitoring of the changes to the right great toe until six (6) days later on 12/19/12 at 5:47 a.m. A progress note, dated 12/19/12 at 5:47 a.m., by a registered nurse (Employee #1), revealed a change of condition note that assessed the Resident has blackened area on right great toe and 4th great toe, her foot is [MEDICAL CONDITION] and cool. Skin of foot is red with striation . No dorsal or post tibia pulse appreciated with Doppler. Left foot has sore on 2nd toe . Will report to MD (doctor). During an interview with Employee #126 on 01/23/13 at 8:50 a.m., she said she faxed the physician about the right great toe on 01/13/12, and verbally passed the information to the oncoming shift. She said the right great toe looked purple, it seemed to have been a sudden change, and had given the appearance of perhaps having been bumped. During an interview with Employee #82 (registered nurse) on 01/23/13 at 9:05 a.m., she said they keep copies of faxes sent to the physi… | 2016-01-01 |
| 9166 | 9166 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-01-23 | 314 | E | 1 | 0 | 71W211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to provide all necessary treatment or services to promote and monitor wound healing. This had the potential to affect any resident in the facility with pressure ulcers. The facility failed to observe and/or measure pressure ulcers at regular intervals, as evidenced by omission of a weekly wound measurement for six (6) of eight (8) sampled residents with pressure ulcers. The facility also failed to complete body audits every week for one (1) of nine (9) sampled residents. Resident identifiers: #119, #1, #2, #108, #107, and #4. Facility census: 88. Findings include: a) Resident #119 Record review found that Resident #119 was admitted to the facility in November 2012 with a Stage II pressure ulcer to the right heel. Record review found the absence of a weekly body audit on 12/11/12, with the most recent body audit having occurred on 12/04/12, and the next on 12/17/12. Record review also found the absence of a weekly measurement and assessment of the pressure ulcer to the right heel on 12/20/12, with the most recent one having occurred on 12/13/12, and no other prior to her transfer to the hospital on [DATE]. Interview with licensed nurse Employee #81, on 01/22/13 at 9:30 a.m., found that every resident is to have a skin audit done weekly. Although they are usually done by the treatment nurse, the floor nurses do them in the absence of the treatment nurse. During an interview with the Director of Nursing (DON), on 01/22/13 at 2:45 p.m., she produced weekly body audit sheets dated 12/04/12 and 12/17/12 for Resident #119. She was unable to locate a body audit sheet for 12/11/12 at this time, or prior to exit. She said that body audits were to be done weekly. During an interview with the DON, on 01/22/13 at 3:30 p.m., she said pressure ulcer assessments/PUSH scores are to be completed weekly for residents with pressure ulcers. After reviewing the Pressure Ulcer Healing C… | 2016-01-01 |
| 9167 | 9167 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-01-01 | 272 | D | 1 | 0 | 8XAM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the accuracy of Section J of the Minimum Date Set (MDS) assessment, related to the number of falls and type of injury, for two (2) of five (5) sample residents identified as having falls. Resident identifiers: #32 and #111. Facility census: 110. Findings include: a) Resident #32 Review of the facility's Resident/Patient Incident Reports found Resident #32 had two (2) unwitnessed falls. These occurred on 10/04/12 and 10/16/12. The MDS review found a five (5) day Medicare MDS with an assessment reference date (ARD) of 10/23/12. Section J, item J1800, regarding health conditions, asked Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent? The assessor of the MDS coded the resident as having no falls between this assessment and the prior significant change MDS with an ARD of 09/12/12. Employee #15, the clinical care reimbursement coordinator, was interviewed on 12/31/12 at 3:30 p.m. She verified the MDS, with an ARD of 10/23/12, did not capture the resident's falls which occurred on 10/04/12 and 10/16/12. The director of nursing (DON), Employee #126, was also interviewed on 12/31/12 at 4:00 p.m. The DON provided no further information. b) Resident #111 Medical record review revealed Resident #111 was admitted to the facility on [DATE]. A review of the incident reports, nurses' notes, and the emergency room report revealed Resident #111 had fallen from bed, on 09/06/12 at 9:30 p.m., at the facility. Injuries sustained as a result of the fall were: hematoma and swelling on the left forehead and left upper and lower eyelids. A flap laceration was noted on the left elbow/forearm which was deep, involving muscle. Sutures to this area were attempted, but the resident's frail skin was unable to sustain the sutures. Review of the admission MDS, with an assessment reference date of 09/07/12,… | 2016-01-01 |
| 9168 | 9168 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-01-01 | 279 | D | 1 | 0 | 8XAM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility's interdisciplinary team failed to develop a comprehensive care plan to address the care needs and to describe the services needed for one (1) of five (5) sample residents regarding accidents/falls. There was no care plan for fall prevention for this resident who had a history of [REDACTED].#111. Facility census: 110 Findings include: a) Resident #111 Review of Resident #111's medical record revealed this resident was admitted to the facility on [DATE]. According to the hospital discharge summary provided on admission, this resident had generalized weakness and a documented fall which occurred during her hospitalization . Facility admission orders [REDACTED]. A fall risk assessment, completed by the facility, on 09/01/12, noted the resident was at risk for falls. According to nursing notes and an incident report, dated 09/06/12 at 9:30 p.m., Resident #111 was sitting up on the side of the bed. Staff heard her fall. Upon entering the resident's room, she was found lying on her back. She had a bruise on her left forehead, and her left upper and lower eyelids were [MEDICAL CONDITION]. A deep skin tear was noted on her left elbow and left forearm. The resident stated she hit her head when she fell . She was transferred to the hospital for evaluation due to the deep laceration on her left elbow/forearm and possible head injury. The resident returned to the facility on [DATE] a 1:20 a.m. The hospital had been unable to suture the laceration on the left elbow/forearm. Review of the resident's care plan revealed no interim or immediate care plan regarding the resident's risk for falls at the time of the residents's fall on 09/06/12. The information was available in the hospital discharge summary provided on admission on 08/31/12. In addition, the facility completed a fall risk assessment, on 09/01/12, and noted the resident was at risk for falls. On 01/01/13 at 10:00 a.m., Employee #1… | 2016-01-01 |
| 9169 | 9169 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-01-01 | 280 | D | 1 | 0 | 8XAM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to review and revise a resident's comprehensive care plan to address changes in condition and needs for one (1) of five (5) sample residents. This resident's care plan was not updated to reflect a [MEDICAL CONDITION] with surgical repair when the resident was readmitted to the facility from the hospital. Resident identifier: #87. Facility census: 110. Findings include: a) Resident #87 review of the resident's medical record revealed [REDACTED]. The resident was admitted to the hospital on [DATE], with a [DIAGNOSES REDACTED]. The resident was readmitted to the facility, on 11/08/12, after the surgical repair of the fracture. Review of the current comprehensive care plan revealed it had not been updated to include the [MEDICAL CONDITION]/femur until 12/18/12. This was nearly six (6) weeks after the resident was readmitted from the hospital after the surgical repair of the fracture. During an interview with Employee #126, the director of nursing (DON), on 01/01/13 at 10:00 a.m., she was unable to provide evidence the care plan, regarding care and services required related to the [MEDICAL CONDITION]/femur, was updated prior to 12/18/12. The DON agreed the care plan should have been updated upon the resident's readmission to facility on 11/08/12. | 2016-01-01 |
| 9170 | 9170 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-01-01 | 282 | D | 1 | 0 | 8XAM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure implementation of established care plans for one (1) of five (5) sample residents. The resident's care plan identified a specific intervention regarding the use of a soft helmet for this resident. This approach was to be implemented by the direct care staff (nursing assistants), but was not implemented. Resident identifier: #87. Facility census: 110. Findings include: a) Resident #87 Medical record review found an order written [REDACTED]. It read, Soft helmet at all times when OOB (out of bed). Review of the resident's current comprehensive care plan revealed the resident refused to wear the helmet as ordered. One of the interventions regarding this was, Staff to continue to encourage patient to wear soft helmet when awake. A confidential interview, conducted on 01/01/13 at 9:00 a.m., discovered nursing assistant (NA) communication regarding care plans was found in the activity of daily living (ADL) book. Each resident had a form known as a Kardex, which was located in front of their ADL flow sheets. This Kardex provided the NAs with information from the resident's care plan, which NAs were to implement when caring for the resident. Review of the ADL book containing Resident #87's ADL flow sheet revealed there was no Kardex. An interview conducted with Employee #126, the director of nursing (DON), confirmed there was no Kardex in front of Resident #87's ADL flow sheet. On 01/01/13 at 9:20 a.m. a Kardex for Resident #87 was provided by the DON. Review of the Kardex revealed there was no information regarding the soft helmet. At that time, the DON confirmed this care plan information was not on the Kardex for implementation by the NAs. | 2016-01-01 |
| 9171 | 9171 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-01-01 | 309 | D | 1 | 0 | 8XAM11 | br>Based on closed medical record review, review of the facility's policy and procedure for neurological assessment, review of incident reports, and staff interview, the facility failed to monitor and assess neurological vital signs in accordance with facility policy after a resident fell out of bed and hit her head on the floor. This affected one (1) of five (5) sample residents reviewed who fell and hit their heads. Resident identifier: #111. Facility census: 110. Findings include: a) Resident #111 Review of incident reports revealed a report, dated 09/06/12 at 9:30 p.m., which described this resident had fallen. The report included, Resident sitting up on side of bed prior to fall. Aide heard resident fall to floor. Resident found on floor beside bed. Resident alert and states hit head. One bruise on forehead and another on eye and cheek of left side. Skin tear (deep) on left elbow. Floor free of clutter. Head placed a foot away from night stand and resident between bed and sink. Lying on back. Resident denies pain and sat up to be put back to bed. fell out of right side of bed (side facing door). No mats in place. Bed low. Review of Resident #111's neurological assessment flow sheet, revealed neurological checks were completed as follows: -09/06/12- 9:30 p.m.-completed -09/06/12- 9:45 p.m.- completed -09/06/12-10:00 p.m.- completed -09/06/12-10:15 p.m.- Out of facility to acute care facility for evaluation -09/07/12-completed- Back in facility from acute care facility -09/07/12- completed No further entries were noted on the form. A review of facility's policy and procedures for neurological assessment revealed the following: Policy- Neurological assessment will be performed as indicated or ordered. When a patient sustains an injury to the head and/or has an unwitnessed fall, neurological assessment will be performed: -every 30 minutes x two hours, then -every one hour x four hours, then -every four hours x 24 hours Purpose- To monitor patient for neurological compromise. An interview with Employee #126, the … | 2016-01-01 |
| 9172 | 9172 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-01-01 | 323 | D | 1 | 0 | 8XAM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to implement physician ordered safety interventions to prevent injuries in the event of a fall for one (1) of five (5) sample residents reviewed, who had fallen at the facility. The resident was known to be at risk for falls. She had a physician's orders [REDACTED]. The mats were not in place at the time of a fall on 09/06/12. The resident sustained [REDACTED]. Resident identifier #111. Facility census: 110. Findings include: a) Resident #111 Review of the resident's discharge summary, dated 08/31/12, from an acute care hospital revealed the resident had fallen from bed while in the hospital. Review of the resident's medical records revealed a physician's orders [REDACTED]. The facility also completed a fall risk assessment on 09/01/12, which indicated the resident was at risk for falls. Review of an incident, dated 09/06/12 at 9:30 p.m., for this resident, included the following information: Resident sitting up on side of bed prior to fall. Aide heard resident fall to floor. Resident found on floor beside bed. Resident alert and states hit head. One bruise on forehead and another on eye and cheek of left side. Skin tear (deep) on left elbow. Floor free of clutter. Head placed a foot away from night stand and resident between bed and sink. Lying on back. Resident denies pain and sat up to be put back to bed. fell out of right side of bed. No mats in place. Bed low. During an interview with Employee #126, the director of nursing (DON) on 01/01/13 at 10:00 a.m., she was informed of the findings related to this resident's fall. The DON was unable to provide evidence the mats were in place at the time of the fall on 09/06/12. | 2016-01-01 |
| 9173 | 9173 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 221 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, policy review, and staff interview, the facility failed to ensure each resident was free from any physical restraints not required to treat the resident's medical symptoms. One (1) of thirty-six (36) Stage II sample residents was placed in a beanbag chair (which prevented him from rising) without a written physician's order for its use to treat a medical symptom. Resident identifier: #62. Facility census: 90. Findings include: a) Resident #62 1. At approximately 3:00 p.m. on 01/24/11, observation found Resident #62 to be sliding out of his positional chair while located in the living room area. Only one (1) aide was present in the room, and she placed a beanbag chair that had been positioned adjacent to his chair under him, so that he slid out of the positional chair and onto the beanbag chair. At 4:30 p.m. on 01/24/11, this surveyor observed the resident still reclining in the beanbag chair receiving one-on-one (1:1) supervision by a nursing assistant (Employee #80) while a licensed practical nurse (LPN - Employee #43) worked nearby. The resident was very confused, making snoring sounds, and hitting out (ineffectively) at staff. During an interview with Employee #43 at this time, she stated they use the beanbag chair when the resident is so agitated that they cannot get him in any other chair without fear that he will throw himself out or turn the chair over. A subsequent review of incident reports verified this behavior. The incident reports indicated the falls were usually from his positional chair with a safety belt harness in place. The resident was strong and would shift his weight to one (1) side and, then, upset chair. He had six (6) reported falls of this type in the last two (2) months (on 01/24/11, 01/18/11, 12/15/10, 12/13/10, 12/05/10, and 12/01/10). A follow-up visit, at 5:45 p.m., revealed Resident #62 was in a positional chair being fed by a nurse aide. When he had finished eating, he was m… | 2016-01-01 |
| 9174 | 9174 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 272 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the accuracy of an initial physical assessment and a minimum data set assessment (MDS) for two (2) of thirty-six (36) Stage II sample residents. Resident #109's admission nursing assessment was inaccurate related to the absence of skin breakdown, and two (2) of Resident #34's MDS assessments were inaccurate related to the absence of contractures. Resident identifiers: #109 and #34. Facility census: 90. Findings include: a) Resident #109 When reviewed on 01/31/11, the medical record of Resident #109 divulged the resident had been admitted to the facility from an acute care hospital on [DATE], following surgery for [REDACTED]. Assessment by a facility nurse on the day of admission (12/22/10) stated the resident has had no foot problems or care in past seven (7) days. Review of the resident's care plan revealed that, shortly after admission on 01/05/11, a problem statement was added to address the presence of stage II pressure areas. (A Stage II pressure area is described by the National Pressure Ulcer Advisory Panel at www.npuap.org as a partial thickness of dermis presenting as a shallow open ulcer with a pink wound bed, without slough. May also present as an intact or open / ruptured serum filled blister.) A facility nurse (Employee #135), when interviewed on 02/01/11 at approximately 10:00 a.m., was asked why this skin breakdown was not recognized prior to progressing to Stage II. Another facility nurse (Employee #139) presented a written document, which identified as having been acquired from the hospital from where the resident had been discharged immediately preceding his admission to the nursing home. Employee #139 stated the information had been received upon request by the facility on the previous evening (01/31/11). This document included an evaluation of the resident dated 12/22/10 at 7:50 a.m., which noted patient heels pink and spongy bilat (bilaterally). The… | 2016-01-01 |
| 9175 | 9175 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 279 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan that describes the services to be furnished to attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being, for two (2) of thirty-six (36) Stage II sample residents. One (1) resident (#109) had a [MEDICAL CONDITION] with no mention of this device and its associated care needs in the resident's care plan. Another resident (#97) acquired an eye infection that was not included in the care plan. Resident identifiers: #109 and #97. Facility census: 90. Findings include: a) Resident #109 When reviewed on 02/01/11, the medical record for Resident #109 divulged she had been admitted to the facility from an acute care hospital on [DATE], following surgery for [REDACTED]. Review of the resident's physician orders [REDACTED]. The resident's care plan, when reviewed on 02/01/11, contained no mention of the resident's [MEDICAL CONDITION] or care needs related to it. Employee #135, a facility nurse and assistant director of nurses, when interviewed related to the resident's care plan to address [MEDICAL CONDITION] care on 02/01/11 at 9:35 a.m., confirmed the [MEDICAL CONDITION] and its care needs were not included in the resident's plan of care. Employee #135, later on 02/01/11, provided evidence that, although the [MEDICAL CONDITION] and its care were not included on the resident's care plan, the information related to its care was available to facility nursing assistants by way of their kiosk (computer terminal) system. -- b) Resident #97 When reviewed on 01/31/11, the medical record of Resident #97 revealed a lab report dated (as reported to the facility) at 4:10 p.m. on 10/08/10. This lab report of a culture of the resident's eye identified the presence of [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA), scant growth. The resident's care plan in effect at that time (October 2010) was reviewed, and ther… | 2016-01-01 |
| 9176 | 9176 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 280 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the care plans for two (2) of thirty-six (36) Stage II sample residents when changes occurred in their healthcare status and/or service needs. Resident identifiers: #62 and #55. Facility census: 90. Findings include: a) Resident #62 1. At approximately 3:00 p.m. on 01/24/11, observation found Resident #62 to be sliding out of his positional chair while located in the living room area. Only one (1) aide was present in the room, and she placed a beanbag chair that had been positioned adjacent to his chair under him, so that he slid out of the positional chair and onto the beanbag chair. At 4:30 p.m. on 01/24/11, this surveyor observed the resident still reclining in the beanbag chair receiving one-on-one (1:1) supervision by a nursing assistant (Employee #80) while a licensed practical nurse (LPN - Employee #43) worked nearby. The resident was very confused, making snoring sounds, and hitting out (ineffectively) at staff. During an interview with Employee #43 at this time, she stated they use the beanbag chair when the resident is so agitated that they cannot get him in any other chair without fear that he will throw himself out or turn the chair over. A subsequent review of incident reports verified this behavior. The incident reports indicated the falls were usually from his positional chair with a safety belt harness in place. The resident was strong and would shift his weight to one (1) side and, then, upset chair. He had six (6) reported falls of this type in the last two (2) months (on 01/24/11, 01/18/11, 12/15/10, 12/13/10, 12/05/10, and 12/01/10). A follow-up visit, at 5:45 p.m., revealed Resident #62 was in a positional chair being fed by a nurse aide. When he had finished eating, he was moved away from the other residents and was provided a 1:1 caregiver (Employee #60). He was still very awake and trying to rise, although the nurse (Employee #43) stated he had r… | 2016-01-01 |
| 9177 | 9177 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 282 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to implement the plan of care for one (1) of thirty-six (36) Stage II sample residents, by failing to ensure staff applied a hand roll to the resident's hand and provided passive range of motion (PROM) exercises to the resident's knees and ankles in accordance with physician orders. Resident identifier: #55. Facility census: 90. Findings include: a) Resident #55 1. Observation, at 2:00 p.m. on 01/24/11, found Resident #55 sitting up in a chair in her room. There was no hand roll (foam or rolled washcloth) in either hand, nor was any hand roll observed to be present in her room. She was observed again at 10:00 a.m. on 01/25/11, at 4:15 p.m. on 01/25/11, and at 11:00 a.m. on 01/31/11, with no hand roll in place. A review of Resident #55's medical record revealed this [AGE] year old female had [DIAGNOSES REDACTED]. Further review of the medical record found the treatment administration records (TARs) for December 2010 and January 2011 were filled out daily indicating, by the nurse's initials, that a hand roll was applied to the resident's right hand on each shift. Review of the resident's therapy note, dated 01/11/11, revealed the following: Received a screen request from nursing to look at pt's (patient's) L (left) hand for contracture management and consider orthotic placement. Informed nursing that pt has been looked at twice in the past for same issue and that she will NOT leave any orthotic in that hand. She uses her other hand to remove it. Therefore, there is a recommendation still in pt.'s care plan to place hand rolls (or rolled gauze) in pt's hands AS SHE TOLERATES, which this therapist agrees with continuing. Review of the resident's physician orders [REDACTED]. If unable to put foam roll in hand you may use a rolled up washcloth. Review of the resident's current care plan found the following problem statement: Needs Total Assist with ADL's (activities of d… | 2016-01-01 |
| 9178 | 9178 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 309 | D | 0 | 1 | IEXL11 | Based on observation, record review, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care, by not consistently using hand rolls as specified in the resident's active care plan. This was found for one (1) of thirty-six (36) Stage II sample residents. Resident identifier: #34. Facility census: 90. Findings include: a) Resident #34 1. During daily observations of Resident #34 each morning and each afternoon on 01/24/11, 01/25/11, 01/26/11, and the morning of 01/27/11, there were no hand rolls or splints observed. Resident #34, when observed on 01/25/11 at 9:30 a.m., appeared to be unable to execute virtually any voluntary movement. During an interview with a facility registered nurse (RN - Employee #142) at 10:15 a.m. on 01/25/11, she was asked whether Resident #34 had any contractures. Employee #142 responded in the affirmative, stating she had contractures in both hands. When asked if hand rolls or splints were being used, she replied they were no longer, used because they were no longer helpful. She explained that the resident was nearly incapable of any voluntary movement and was totally dependant upon staff for all activities of daily living (ADLs) and movement. When observations were attempted on 01/31/11, it was found that resident was moved to another wing. Subsequent observation of the resident this revealed, again, no hand rolls or splints in place. On 01/31/11 at 4:20 p.m., a nursing assistant (Employee #143) was asked about use of splints or hand rolls for the resident. She stated she knew they sometimes used to use wash cloths. On 02/01/11 at 8:00 a.m., resident was observed in the dining room for breakfast with hand rolls in place. Observation of resident, on 02/01/11 at 9:45 a.m., revealed no breakdown on fingers or insides of hands. Resident #34 now had Posey hand rolls in place. -- The resident's MDS 3.0… | 2016-01-01 |
| 9179 | 9179 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 314 | G | 0 | 1 | IEXL11 | **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-six (36) Stage II sample residents, to provide care and services to prevent the development of pressure ulcers for a resident who entered the facility without pressure ulcers, but who was at risk of developing pressure ulcers. Resident #109 was admitted to the facility following hospitalization and surgery for [REDACTED]. This incorrect assessment delayed implementation of care to the areas which resulted in the development of Stage II pressure sores. These Stage II pressure sores subsequently worsened to Stage III pressure sores. Resident identifier: #109. Facility census: 90. Findings include: a) Resident #109 When reviewed on 01/31/11, the medical record for Resident #109 divulged this [AGE] year old male was admitted to the facility from an acute care hospital on [DATE], following surgery for [REDACTED]. Review of the discharge summary received at the facility from the acute care hospital revealed, under Discharge Disposition, We will have the patient up with assistance, weight bearing as tolerated, decubitus precautions up in chair at bedside, QPI's (unknown abbreviation) off bed and abduction pillows at all times. The resident's admission minimum data set assessment (MDS), with an assessment reference date (ARD) of 12/29/10, stated in the areas of Functional Status that the resident required the extensive physical assistance of two (2) or more persons for bed mobility and transferring to/from bed, chair, wheelchair, standing position. The resident had no ability to reposition himself. A nursing assessment completed on the day admission to the facility (dated 12/22/10 at 7:12 p.m.), stated the resident has had no foot problems or care in past seven (7) days. The resident's physician orders, when reviewed, disclosed orders for no pressure ulcer treatment or preventive measures at the time of admission. A nursing assessment entry, dated on 01/02/11 at 11… | 2016-01-01 |
| 9180 | 9180 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 318 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to provide physician-ordered therapeutic measures intended to prevent further decline in range of motion (ROM) and failed to periodically re-evaluate the resident's status and revise the plan of care as needed for one (1) of thirty-six (36) Stage II sample residents. Resident identifier: #55. Facility census: 90. Findings include: a) Resident #55 1. A review of Resident #55's medical record revealed this [AGE] year old female had [DIAGNOSES REDACTED]. The resident's annual minimum data set assessment (MDS), with an assessment reference date (ARD) of 08/31/10, stated the resident had limited ROM of all extremities and that this was no change from the previous MDS. The quarterly MDS, with an ARD of 11/14/10, indicated the resident had functional limitations of all extremities. The resident received therapy until 11/01/10, when she was discharged with a note stating, Discharge planned following completed staff education for restorative PROM (passive range of motion) program. -- 2. Review of the resident's therapy note, dated 01/11/11, revealed the following: Received a screen request from nursing to look at pt's (patient's) L (left) hand for contracture management and consider orthotic placement. Informed nursing that pt has been looked at twice in the past for same issue and that she will NOT leave any orthotic in that hand. She uses her other hand to remove it. Therefore, there is a recommendation still in pt.'s care plan to place hand rolls (or rolled gauze) in pt's hands AS SHE TOLERATES, which this therapist agrees with continuing. Review of the resident's physician orders [REDACTED]. If unable to put foam roll in hand you may use a rolled up washcloth. Review of the resident's current care plan found the following problem statement: Needs Total Assist with ADL's (activities of daily living). Has flexion contractures Rt (right) hand. The goal associated with this … | 2016-01-01 |
| 9181 | 9181 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 323 | E | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility incident and accident reports, and staff interview, the facility failed to provide an environment that was free from accident hazards over which the facility had control, by having room heating units in five (5) randomly observed resident rooms with surface temperatures exceeding 150 degrees Fahrenheit (F); by storing hazardous chemicals in an unlocked storage cabinet in the bathing room on the D Hall of the facility; and by failing to provide adequate supervision to one (1) of thirty-six (36) Stage II sample residents on B Hall of the facility to prevent reoccurring accidents. These practices had the potential to affect Residents #85, #69, #62, #70, and #65 (who had excessive heater temperatures), all cognitively impaired residents who wandered in the unsecured areas of the facility and had access to the unlocked chemicals on D Hall, and Resident #62 who was provided inadequate supervision to prevent reoccurring accidents. Facility census: 90. Findings include: a) Residents #85, #69, #62, #70 and #65 1. During an interview with Resident #85 in her room on D Hall at 5:30 p.m. on 01/24/11, testing found the surface temperature of the resident's heater, near the baseboard of her outside wall on the right side of her bed, was very hot to touch. The surface temperature, when measured with a thermometer, was found to be 162.9 degrees F. The resident, who currently occupied the bed nearest the heater, stated she knew it was hot and did not go over there. Observation found the thermostat which controls the heater in this room was set on 72 degrees F. This resident stated she did not adjust the thermostat herself. Following this observation, a random tour of the facility was conducted, and excessive surface temperatures were noted in rooms on each hallway of the facility as follows: 2. The heater in the room of Resident #69 (located on D Hall) was very warm to the touch. The surface temperature,… | 2016-01-01 |
| 9182 | 9182 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 329 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interview, the facility failed to ensure physician orders [REDACTED]. Resident identifier: #28. Facility census: 90. Findings include: a) Resident #28 1. A review of Resident #28's medical record revealed this [AGE] year old female had [DIAGNOSES REDACTED]. Her physician's orders [REDACTED].>- 04/07/10 - ([MEDICATION NAME]) [MEDICATION NAME] 2 mg/ml solution injection Dose Ordered: (0.5 ml/1 mg) intramuscular 1 mg q.6.h. (every 6 hours) p.r.n. first date 03/01/2010 FOR: Agitation. - 08/30/10 - ([MEDICATION NAME]) [MEDICATION NAME] 1 mg Tablet by mouth (1) 2 X wk. Sunday Wednesday 8:00 am first date: 09/01/2010 FOR: Agitation and restlessness due to dementia Notify Staff. - 09/14/10 - [MEDICATION NAME] 0.5 mg Tablet by mouth q.6.h. 8:00 am 2:00 pm 8:00 pm 2:00 am first date: 09/15/2010 FOR: Agitation and restlessness due to dementia Notify Staff. - 09/23/10 - ([MEDICATION NAME]) [MEDICATION NAME] 0.25 mg Tablet by mouth q.6.h. p.r.n. first date: 02/20/2010 FOR: Dementia-Related [MEDICAL CONDITION], organic mental syndrome, (Dementia-Related Psychoses) with behaviors of yelling out, spitting, screaming and resistive of personal care Notify staff. - 09/23/10 - ([MEDICATION NAME]) [MEDICATION NAME] 1 mg Tablet by mouth daily 8:00 am FOR: Dementia-Related [MEDICAL CONDITION] (Dementia-Related Psychoses) organic mental syndrome with psychotic or agitated behaviors first date: 07/01/2010. -- 2. The resident's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Also, there were no times or cumulative dosage limits set for giving either the PRN [MEDICATION NAME] or the PRN [MEDICATION NAME] along with the routine doses. -- 3. The facility policy entitled PRN MEDICATIONS, provided by the director of nurses at 8:00 a.m. on 02/02/11, stated: B. To assure the proper utilization of 'PRN' drug orders: 1. The frequency of normal use should be specified within the physician's … | 2016-01-01 |
| 9183 | 9183 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 371 | F | 0 | 1 | IEXL11 | Based upon observation, review of facility documents, and staff interview, the facility failed to store, prepare, distribute, and serve food under sanitary conditions, by not ensuring that staff was properly trained and equipped to monitor the sanitization process in the 3-compartment sink. This had the potential to affect all residents. Facility census: 90. Findings include: a) The clean-up of the morning meal was observed at 8:30 - 9:00 a.m. on 01/26/11. The facility's cook (Employee #157) was asked about procedure for test strips to test sanitizer levels in the 3-compartment sink, which was used for any manual dish washing. She stated she tests all three (3) sinks every time she washes. She indicated that she did not know what color the strips should be or what the acceptable values were following the test. She stated she will get the answer. When asked to demonstrate the procedure she follows, Employee #157 tested the third sink (sink containing sanitizing solution) by immersing a test strip for approximately 30 seconds in the hot water. (The heater had just been turned off.) The posting adjacent to the sink directed staff to allow the water to cool to 75 degrees Fahrenheit (room temperature) prior to testing. During an interview on 01/26/11 at 11:32 a.m., the dietary manager (Employee #16) was asked what the acceptable parts per million (PPM) concentration was for the sanitizer solution test. She did not know what the minimum acceptable levels were. She referred to the label on the jug of chemicals, which stated an acceptable range of 150 to 400 PPM. During an interview on 01/26/11 at 11:00 a.m., the dietary assistant (Employee #59) was asked about the correct procedure for testing the sanitizer solution in the 3-compartment sink. She stated she was not familiar with the use of the sinks or strips and that she had only been at the facility for about six (6) months. Observations also determined that the posted testing instructions located adjacent to the sink differed from the instructions found on the contai… | 2016-01-01 |
| 9184 | 9184 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 428 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to ensure one (1) of thirty-six (36) Stage II sample residents was free of the potential for excessive dosages of psychoactive medications due to duplicate therapy, when the pharmacist failed to recognize irregularities in his physician's orders [REDACTED]. Resident identifier: #28. Facility census: 90. Findings include: a) Resident #28 1. A review of Resident #28's medical record revealed this [AGE] year old female had [DIAGNOSES REDACTED]. Her physician's orders [REDACTED].>- 04/07/10 - (Ativan) Lorazepam 2 mg/ml solution injection Dose Ordered: (0.5 ml/1 mg) intramuscular 1 mg q.6.h. (every 6 hours) p.r.n. first date 03/01/2010 FOR: Agitation. - 08/30/10 - (Ativan) Lorazepam 1 mg Tablet by mouth (1) 2 X wk. Sunday Wednesday 8:00 am first date: 09/01/2010 FOR: Agitation and restlessness due to dementia Notify Staff. - 09/14/10 - Lorazepam 0.5 mg Tablet by mouth q.6.h. 8:00 am 2:00 pm 8:00 pm 2:00 am first date: 09/15/2010 FOR: Agitation and restlessness due to dementia Notify Staff. - 09/23/10 - (Risperdal) Risperidone 0.25 mg Tablet by mouth q.6.h. p.r.n. first date: 02/20/2010 FOR: Dementia-Related Psychosis, organic mental syndrome, (Dementia-Related Psychoses) with behaviors of yelling out, spitting, screaming and resistive of personal care Notify staff. - 09/23/10 - (Risperdal) Risperidone 1 mg Tablet by mouth daily 8:00 am FOR: Dementia-Related Psychosis (Dementia-Related Psychoses) organic mental syndrome with psychotic or agitated behaviors first date: 07/01/2010. -- 2. The resident's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Also, there were no times or cumulative dosage limits set for giving either the PRN Ativan or the PRN Risperdal along with the routine doses. -- 3. The facility policy entitled PRN MEDICATIONS, provided by the director of nurses at 8:00 a.m. on 02/02/11, stated: B. To assure the proper utilization of… | 2016-01-01 |
| 9185 | 9185 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 502 | D | 0 | 1 | IEXL11 | **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-six (36) Stage II sample residents, to obtain a physician-ordered laboratory procedure. Resident identifier: #32. Facility census: 90. Findings include: a) Resident #32 When reviewed on 01/26/11, the medical record of Resident #32 divulged the resident was receiving the medication [MEDICATION NAME] (an anti-platelet drug that helps to prevent the formation of blood clots). The record further disclosed a physician's orders [REDACTED]. The results of these lab tests, when reviewed, revealed they were provided to the facility on [DATE]. The report stated the quantity of the specimen was not sufficient for analysis of the CBC with diff and platelets. There was no evidence that a specimen had been resubmitted to carry out the physician's orders [REDACTED].>A facility nurse (Employee #28), when interviewed on 01/26/11 at approximately 2:00 p.m., confirmed staff had not resubmitted a sample in an attempt to carry out the physician's orders [REDACTED].> | 2016-01-01 |
| 9186 | 9186 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 514 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate clinical information in each resident's medical record, as evidenced by incorrectly recording nursing interventions in the care plan that differed from the physician's orders [REDACTED]. Resident identifiers: #55 and #62. Facility census: 90. Findings include: a) Resident #55 A review of Resident #55's medical record revealed an [AGE] year old female with [DIAGNOSES REDACTED]. Review of the resident's care plan found the following problem statement established 07/17/09: Needs Total Assist with ADL's (activities of daily living). Has flexion contractures Rt (right) hand. The nursing intervention stated: Wash / dry hands daily, apply foam roll to Rt hand, leave in hand until bedtime or as long as resident tolerates. The physician's orders [REDACTED]. The physician's orders [REDACTED]. During an interview with the administrator, director of nursing (DON), and a nurse (Employee #28) at 4:30 p.m. on 02/01/11, they acknowledged there was a difference in the wording of the care plan intervention versus the actual physician's orders [REDACTED]. -- b) Resident #62 A review of Resident #62's monthly recapitulation of the physician orders [REDACTED]. Notify Staff. This order was written on 04/09/10, when the resident was receiving physical therapy services. Further record review revealed Resident #62 had not been ambulatory or used a Merry Walker since at least August 2010, although the order continued to be recorded on the monthly recapitulations for the physician to sign. A review of the record revealed documentation by nursing assistants on the Activities of Daily Living forms, indicating the resident walk(ed) in room daily from 12/01/10 through 02/02/11 and required the assistance of one (1) person on eight (8) occasions. The physical therapist (Employee #17), stated in her documentation on 09/29/10: (Resident #62) is no longer able to ambulate. (mobility) Total Ass… | 2016-01-01 |
| 9187 | 9187 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2011-09-21 | 156 | B | 0 | 1 | 2WLP11 | Based on review of beneficiary liability notices and staff interview, the facility failed to complete the liability notices in accordance with CMS instructions. The facility was not documenting the reasons why Medicare-covered services were being discontinued and/or specific information regarding the delivery of the notices themselves. This was evident for three (3) of three (3) discharged residents whose beneficiary liability notices were reviewed. Resident identifiers: #147, #48, and #104. Facility census: 94. Findings include: a) Resident #147 Review of Resident #147's Notice of Medicare Provider Non-Coverage form found it did not contain any information regarding the reason the Medicare-covered services were being discontinued. The notice recorded the date the service was ending (05/08/11), and there was a note stating: Wife was notified by phone on 5-8-11. -- b) Resident #48 Review of Resident #48's Notice of Medicare Provider Non-Coverage form indicated the Medicare-covered services would end on 07/17/11. The notice also stated staff notified son (POA) (power of attorney) by phone on 7-17-11. -- c) Resident #104 Review of Resident #104's Notice of Medicare Provider Non-Coverage form found the Medicare-covered services were to be discontinued on 05/10/11. The only other notation was: Wife notified by phone 5-10-11. -- d) According to instructions from the Centers for Medicare & Medicaid Services (CMS), when completing the Generic Notice CMS- form, the facility is to insert the kind of services being terminated, such as skilled nursing, home health, hospice or comprehensive outpatient rehab. This information was not recorded on any of the forms reviewed. The instructions further stated that, if the provider is unable to personally deliver a notice of non-coverage to a person legally acting on behalf of a beneficiary, then the provider should telephone the representative to advise him or her when the beneficiary's services are no longer covered as follows: - The beneficiary's appeal rights must be explained to… | 2016-01-01 |
| 9188 | 9188 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2011-09-21 | 225 | E | 0 | 1 | 2WLP11 | Based on personnel record review, staff interview, and review of a newsletter issued to all nursing facilities in WV by the State survey and certification agency, the facility failed to conduct a thorough criminal background check prior to hiring five (5) of five (5) employees in the past four (4) months. There was no evidence to reflect the facility had conducted a statewide criminal background check for these individuals, in an effort to uncover personal histories of criminal convictions that would indicate these individuals may be unfit to provide services to residents in nursing facilities. This had the potential to affect more than an isolated number of residents. Employee identifiers: #69, #13, #39, #47, and #54. Facility census: 94. Findings include: a) Employees #69, #13, #39, #47, and #54 Review of five (5) personnel records of employees who had been hired by the facility in the past four (4) months revealed no evidence that statewide criminal background checks had been initiated for these individuals through the WV State Police. During an interview with the facility's administrator (Employee #2) on the afternoon of 09/19/11, she confirmed that criminal background checks were not obtained by the facility through the WV State Police. According to a newsletter sent to all WV Medicare / Medicaid certified nursing facilities and licensed nursing homes in November 2004: . Regarding criminal background checks, both the State licensure rule and the Federal Medicare / Medicaid certification requirements mandate screening of applicants for employment in a nursing home or nursing facility. The licensure rule specifically requires nursing homes to conduct a 'criminal conviction investigation' on all applicants; the certification requirements require that nursing facilities 'must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law'; facilities are expected to 'make reasonable efforts to uncover information about any past criminal prosecutions'. To sati… | 2016-01-01 |
| 9189 | 9189 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2011-09-21 | 279 | D | 0 | 1 | 2WLP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to use the results of a comprehensive assessment to develop a comprehensive care plan for two (2) of thirty-two (32) Stage II sample residents. Resident #33 had contractures of both hands, which had been identified in the comprehensive assessment, and a care plan had not been developed describing the services that were to be furnished to address these contractures. Resident #84 did not have a care plan to address the services to be furnished for urinary incontinence. Resident identifiers: #33 and #84. Facility census: 94. Findings include: a) Resident #33 Review of current physician orders [REDACTED]. An interview with the occupational therapist (OT - Employee #82), on 09/20/11 at 2:30 p.m., revealed this resident resisted having her hands opened and cleaned. The OT stated the resident yells, screams, and cries when staff works with her hands and tells staff she does not want to be bothered. The OT also reported that OT services were no being longer provided to this resident. Review of the resident's annual minimum data set assessment (MDS), with an assessment reference date (ARD) of 05/16/11, found the assessor encoded Section G to indicate the resident's upper extremities had impairment in range of motion on both sides. The assessor also encoded Section S of the MDS to reflect the resident had contractures of both hands. Review of the resident's current care plan, with a completion date of 08/18/11, found no plan had been developed to describe the care and services of the resident's contracted hands with goals and interventions developed, such as pain control, methods to relax the resident and the hands to make the treatment more acceptable to the resident. In an interview on 09/21/11 at 4:00 p.m., the facility's administrator (Employee #2) was informed of the lack of a comprehensive care plan for Resident #33's hand contractures. -- b) Resident #84 Review of the reside… | 2016-01-01 |
| 9190 | 9190 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2011-09-21 | 315 | D | 0 | 1 | 2WLP11 | Based on observation, record review, and staff interview, the facility failed to assure a resident received an appropriate toileting plan to restore as much normal bladder function as possible. Resident #84 had experienced urinary problems in the past and received services from a urologist. The facility failed to monitor his urinary elimination pattern and did not establish a toileting program based on the type of incontinence this resident was experiencing. This was observed for one (1) of thirty-two (32) Stage II sample residents. Facility census: 94. Findings include: a) Resident #84 Review of the medical record revealed this resident had been seeing a urologist for complications he was experiencing with his urinary elimination status. He previously had an indwelling Foley catheter present and also had previously had a temporary supra-pubic catheter which is a catheter inserted directly into the bladder through the abdomen. The most recent follow up appointment was with the urologist on 06/01/11. He stated in his report that he was following this resident for a stricture and his report indicated the resident was discharged with his Foley removed. The directions stated, Watch voiding pattern. A nursing note written on 06/01/11 stated, return to the facility. nno (no new orders). There was no care plan or evidence that it was communicated that the physician instructed them to watch his voiding pattern. An interdisciplinary care conference held on 06/16/11, revealed that this resident's Foley catheter was removed and he had no problems with voiding at that time. There was no evidence that there had been a discussion or review of the residents incontinence and no evidence he was evaluated for a toileting program or a voiding diary was initiated to further evaluated the type of incontinence her experienced or ways prevent incontinent episodes. The most recent minimum data set assessment (MDS), with an assessment reference date (ARD) of 09/05/11, revealed in Item H0200 that this resident was frequently incontinent o… | 2016-01-01 |
| 9191 | 9191 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2011-09-21 | 367 | E | 0 | 1 | 2WLP11 | Based on observation, menu review, and staff interview, the dietary staff did not serve therapeutic diets in accordance with the planned menus for those diets. Residents with orders for calorie-controlled diets received incorrect portion sizes for sweet potatoes and the wrong type of milk. This had the potential to affect thirty (30) residents with orders for 1200, 1500, 1800 and 2000 calorie-controlled diets. Resident identifiers: #49, #69, #99, #76, #67, #44, #9, #16, #93, #17, #64, #106, #31, #110, #22, #56, #114, #88, #20, #111, #132, #83, #45, #131, #92, #10, #102, #172, #156, and #100. Facility census: 94. Findings include: a) Residents #49, #69, #99, #76, #67, #44, #9, #16, #93, #17, #64, #106, #31, #110, #22, #56, #114, #88, #20, #111, #132, #83, #45, #131, #92, #10, #102, #172, #156, and #100. 1. Observations, during tray preparation for the noon meal on 09/12/11, found dietary staff placed cartons of 2% milk on the trays for the thirty (30) above-identified residents, all of whom were on calorie-controlled diets. According to a review of the facility's planned menu for the 1200, 1500, 1800 and 2000 calorie-controlled diets, these residents should have been served skim milk. As a result of being served 2% milk instead of skim milk, these residents would be receiving more fat exchanges than had been calculated into the menu pattern. When questioned, dietary staff reported the cartons of skim milk they had were out-dated and they could not serve the milk that was past its expiration date. - 2. Five (5) of these thirty (30) residents (#99, #44, #16, #31, and #88) had orders for 2000 calorie-controlled diets, which allowed them to receive 1/2 cup portions of sweet potatoes; there remaining twenty-five (25) residents were to have been served 1/3 cup portions of sweet potatoes. However, all thirty (30) of these residents were served 1/2 cup portions of sweet potatoes. The twenty-five (5) residents with orders for 1200, 1500, and 1800 calorie-controlled diets, consequently, were served more more carbohydrates t… | 2016-01-01 |
| 9192 | 9192 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2011-09-21 | 371 | E | 0 | 1 | 2WLP11 | Based on observation and staff interview, dietary staff failed to handle and serve food items in a sanitary manner. Staff was observed to handle food and non-food items with the same gloves while serving lunch on 09/12/11. This practice has the potential to affect all residents who consumed a diet of regular consistency on that date. Facility census: 94. Findings include: a) Observations, during tray preparation for the noon meal at 11:32 a.m. on 09/12/11, found a dietary staff member (Employee #91) wore food handlers gloves to serve food on the tray line. She then proceeded to the oven, retrieved a hand full of french fries from a pan, and carried them to the tray line area. She then placed the french fries on a plate for a resident. Those same gloves were worn when Employee #91 handled a wet rag that was lying on the steam table shelf, which was used to clean up spills. | 2016-01-01 |
| 9193 | 9193 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2011-09-21 | 502 | D | 0 | 1 | 2WLP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain laboratory services for one (1) of thirty-two (32) Stage II sample residents every three (3) months as ordered by the physician. Resident identifier: #88. Facility census: 94. Findings: a) Resident #88 Review of Resident #88's monthly recapitulation of physician orders [REDACTED]. Results of lab work completed in March 2011 were found, and the September lab work was scheduled to be obtained later in the week during the survey. However, no results could be found for lab work that should have been obtained in June 2011. Employee #111 reviewed the medical record, and at 2:20 p.m. on 09/20/11, she reported this lab had not been completed as ordered. | 2016-01-01 |
| 9194 | 9194 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2013-01-10 | 225 | D | 1 | 0 | UD9011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, review of the facility's reported allegations and associated investigations, and record review, the facility failed to immediately report an allegation of abuse to the appropriate authorities for one (1) of eight (8) sample residents. Resident #148 was identified as sustaining a second fracture to his left arm/shoulder on 12/17/12. The facility reported the incident to the Office of Health Facility Licensure and Certification (OHFLAC) as an injury of unknown origin. During the investigation it was found the resident had reported an allegation of abuse to two (2) employees who failed to immediately report the incident to the administrator. Also, the facility failed to thoroughly investigate all staff members working with the resident on the day of the incident, and failed to submit the five (5) day investigation report in a timely manner. Resident #148. Facility census: 147. Findings include: a) Resident #148 The nursing progress notes for this resident were reviewed on 01/08/13 at 2:15 p.m. The notes, dated 12/17/12, described the resident was complaining of pain in the left shoulder. According to the notes, Upon assessment, left shoulder noted to have swelling, little active range of motion, and possible deformity of upper arm. The physician was notified and ordered an immediate x-ray at first, but then the physician ordered the resident to be sent to the emergency room for evaluation. Resident #148 went to the emergency room where he was diagnosed with [REDACTED]. He returned to the facility with orders for his arm to remain in a sling, and to discontinue physical therapy (PT) until the attending physician gave approval to restart PT. The resident was to do no lifting, pulling, or use the left arm. During an interview with Employee #219 (administrator), on 01/09/13, it was discovered the facility immediately began an investigation after the second fracture was confirmed on 12/18/12. The facility reported the incide… | 2016-01-01 |
| 9195 | 9195 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2013-01-10 | 441 | D | 1 | 0 | UD9011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain infection control precautions for two (2) of seven (7) residents. Observation of two (2) rooms of residents on isolation revealed no signage to notify staff and visitors of isolation procedures. Facility census: 147. Resident identifiers: #129 and #54. Findings include: a) Resident #54 Observation of Room #E13, on 01/08/13 at 11:30 a.m., found an isolation cart outside of the room. No signage was found to identify the resident was on isolation precautions. Review of the medical record for this resident identified she was on reverse (protective) isolation for chronic [DIAGNOSES REDACTED] (a condition characterized by abnormally low levels of a certain white blood cell that plays an essential role in fighting bacterial infections). During an interview with Employee #73 on 1/10/13, at 10:26 a.m., it was confirmed the sign should have been posted on the door. b) Resident #129 Observation of Room #B4, on 01/08/13 at 11:20 a.m., found an isolation cart outside of the room. No signage was found to identify the resident was on isolation precautions. Employee #95 was asked what the cart was for she stated, We have to wear gloves when we go in there, she's got something. Review of the medical record identified Resident #129 was on isolation related to methicillin resistant staphylococcus aureus (MRSA - an organism that is resistant to many antibiotics). During an interview with Employee #73, on 1/10/13, at 10:26 a.m., it was confirmed the sign should have been posted on the door. | 2016-01-01 |
| 9196 | 9196 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 156 | C | 0 | 1 | MZQB11 | Based on observation and staff interview, the facility failed to prominently display required information and post the names, addresses and phone numbers of all pertinent State client advocacy groups and information concerning how to file a complaint with the appropriate State agency(ies) concerning abuse, neglect or misappropriation of resident property in the facility. This practice has the potential to affect all residents and families desiring to view this information. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Finding include: a) During the initial tour of the facility at the onset of the complaint investigation on 05/18/11, this surveyor attempted to view the posting of the required information. The entire first floor was toured, and there was no evidence of any posting containing contact information for the required State agencies. The director of nursing (DON), when questioned about the posting at 3:20 p.m. on 05/18/11, stated the facility had been remodeling and the posting must have been temporarily taken down while this was being done. During the initial tour of the facility at the onset of the annual Medicare / Medicaid certification resurvey at 11:00 a.m. on 05/24/11, observation found the State agency contact information had been posted on the front office door. Access to the front lobby through double doors from the nursing unit was also restricted for any resident wearing a Wanderguard bracelet, so this information would not have been readily available to all residents even if it were posted. | 2016-01-01 |
| 9197 | 9197 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 224 | G | 0 | 1 | MZQB12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, review of facility policies and clinical services notices, and staff interview, the facility failed to provide care and services necessary to avoid physical harm for two (2) of fourteen (14) sampled residents. - Resident #141, who was receiving an anticoagulant on a routine basis, had a witnessed fall at 10:45 a.m. on [DATE], during which he struck the left side of his head and left shoulder with force sufficient to cause a fracture to his upper arm. The licensed practical nurse (LPN) recorded the fall on the incident report and in the nursing notes, initially noting as the only injury a skin tear to the left elbow. Shortly after, the resident complained of left shoulder pain; a nurse notified the physician of the shoulder pain, and the physician ordered an in-house x-ray of the left arm. There was no evidence to reflect nursing staff, at the time of the fall or at any time thereafter, notified the physician that the resident had hit his head. After the fall occurred, staff did not follow facility policy, by not moving the resident until he was examined by emergency personnel or a head injury was ruled out. Although a neurological evaluation form was initiated for this fall, the assessments recorded were not complete / accurate (e.g., several entries identified limitations in motor movement to the wrong limb), and times were not always recorded; as a result, it could not be verified that these neuro checks were being completed at progressive intervals as specified in the directions on the form. After the fall on [DATE], the resident was noted to have a significant decline in the self-performance of activities of daily living, which was attributed to possible pneumonia with no consideration that a head injury may have caused or contributed to these declines. On [DATE], prior to the resident leaving the facility for an outpatient appointment with an orthopedist, the nurse was notified … | 2016-01-01 |
| 9198 | 9198 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 241 | D | 0 | 1 | MZQB11 | Based on observation, resident interview, and staff interview, the facility failed to provide care in an environment at meal time that provided and maintained each resident's dignity. Three (3) of thirty-eight (38) Stage II sampled residents were not treated in a dignified manner at meal time. Resident #228 was not provided with a bedside table for use during meals and was, instead, provided a small plastic isolation cart with wheels; the height of the isolation cart was not adjustable, and the resident spilled food on her gown and bed linens as she attempted to feed herself. Resident #70 was served her meal well after her roommate, was asked if she wanted a bib, and was not given adaptive utensils as per her tray slip. Resident #85 was also not served his meal in a timely manner. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #228 During the initial tour of the facility on 05/18/11 at 12:00 p.m., this resident was observed eating her lunch in her bed. Her tray was sitting on a plastic cart with wheels, which was located on the left side of her bed. This was noted to be her isolation cart with supplies in it required for maintaining contact isolation precautions. Resident #228 was feeding herself with her right hand, and her left arm was just lying on the bed. She was reaching over and getting chili on her spoon and was having difficulty getting it to her mouth without spilling it on her gown and bed linens. She said she could do it, but she just had to do a little bit at a time. When questioned about the cart her tray was sitting on, she stated she guessed that was all they had. She stated she ate on it earlier that morning. She stated someone fixed that up for her or she probably wouldn't have had anything to sit her tray on. She said, It doesn't look like much, but at least it works. She verified she could not use her left arm because she had a stroke and she was having a difficult time reaching o… | 2016-01-01 |
| 9199 | 9199 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 246 | D | 0 | 1 | MZQB11 | Based on observation, record review, resident interview, and staff interview, the facility failed to make reasonable accommodations to meet the individual needs of residents. The facility failed to ensure staff answered call lights within a reasonable period of time for two (2) of thirty-eight (38) residents on the Stage II sample and one (1) randomly observed resident. During a period of approximately one (1) hour, three (3) call lights were observed to be on for thirteen (13) to twenty-two (22) minutes without staff responding for more than ten (10) minutes. Additionally, Resident #228 was not provided with a bedside table for use during meals and was, instead, provided a small plastic isolation cart with wheels; the height of the isolation cart was not adjustable, and the resident spilled food on her gown and bed linens as she attempted to feed herself. Resident identifiers #60, #85, #155, and #228. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Residents #60, #85, and #155 1. On 06/08/11, while reviewing some information at the second floor nurses' station, it was noted at approximately 8:00 a.m., call lights were remaining on for extended periods of time. The display panel, the telephone display, staff in the halls, and the rooms were observed for staff's responses to the call lights. During this time, the following were noted on C hall: - Resident #60's call light rang for seventeen (17) minutes, - Resident #85's call light rang for twenty-two (22) minutes, and - Resident #155's call light rang for thirteen (13) minutes. Employee #58 (licensed practical nurse - LPN) was passing medication on the unit. Several nursing assistants (including, but not limited to, Employees #122 and #127) were also observed on C hall. No one answered the call lights in a timely manner. 2. Resident Council Meeting minutes Review of the Resident Council meeting minutes, dated 05/16/11, found under Nursing for Any requests (com… | 2016-01-01 |
| 9200 | 9200 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 250 | D | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide medically-related social services to one (1) of thirty-eight (38) Stage II sample residents who was approved for short-term placement at the facility, by failing to assess the resident's goals with respect to discharge and develop an appropriate discharge plan to accomplish those goals. Resident identifier: #148. Facility census: 144. Findings include: a) Resident #148 Medical record review revealed this [AGE] year old female was originally admitted to the facility on [DATE], and was discharged to home on 08/31/10. The resident was readmitted to the facility on [DATE] after she suffered a fracture of the right femur. Her current active [DIAGNOSES REDACTED]. Further record review revealed a social work assessment and history, dated 03/29/11. The sections addressing the resident's expected length of stay, anticipated discharge potential, anticipated discharge destination, and community resources potentially needed after discharge were not completed. Review of the resident's pre-admission screening (form PAS-2000) revealed the physician expected her to be able to return home in less than three (3) months. The PAS-2000 was signed by the physician on 03/21/11. Review of her minimum data set assessment (MDS 3.0), with an assessment reference date (ARD) of 04/01/11, found in Section Q0400 (Discharge Plan) that a determination for discharge had not been made. Employee #25 (physical therapy assistant), when interviewed on 06/02/11 at 11:05 a.m., stated he had treated the resident around this time last year and she was able to return home. He stated her son and husband had been very active in her treatment on her last admission, but he had not seen them this time around. He stated he was not sure what had happened. Employee #34 (licensed social worker), when interviewed on 06/02/11 at 10:35 a.m., stated she thought the resident was going to be a long term placement, but … | 2016-01-01 |
| 9201 | 9201 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 272 | E | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility's interdisciplinary team failed to complete assessments to accurately reflect each resident's health status / condition for six (6) of thirty-eight (38) Stage II sample residents. Complete and accurate assessments were not conducted for Resident #223's pressure ulcer, Resident #129's indwelling catheter, Residents #116 and #199's bladder continence, Resident #155's dental status, and Resident #125's complaints of a sore toe. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #223 During a review of Resident #223's initial Medicare 5-Day minimum data set assessment (MDS), with an assessment reference date of 04/14/11, found this resident had a pressure ulcer measuring 2.5 cm x 3.4 cm. This pressure ulcer, which was noted to have been present on admission to the facility, was identified on the MDS as being unstageable due to the presence of slough or eschar. Further review of the MDS found in Section V that the care area of Pressure Ulcer was then triggered and addressed in the care plan. The assessor noted that the further information for this care area could be found in a worksheet dated 04/18/11. The Care Area Assessment (CAA) worksheet dated 04/18/11, when reviewed, found in the analysis of this ulcer that this represented a potential problem. The nature of the problem was stated: At risk for pressure ulcers. The end note stated: (Resident #223) could be at risk for a pressure ulcer related to impaired mobility and incontinent. See the plan of care documentation for 4/11/2011. The staff will continue to assist her as needed for frequent position changes as well as prompt incontinence care. Any concerns with her skin will be reported to the MD promptly. Will proceed to care plan. This CAA did not reflect the resident's actual condition or evaluate the caus… | 2016-01-01 |
| 9202 | 9202 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 278 | D | 0 | 1 | MZQB12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure minimum data set assessments (MDSs) accurately reflected the health and functional status of two (2) of fourteen (14) sampled records. Resident identifiers: #141 and #21. Facility census: 140. Findings include: a) Resident #141 Record review revealed Resident #141 was admitted to the facility on [DATE]. Review of Resident #141's discharge MDS, with assessment reference date (ARD) of 08/04/11, found the assessor noted the number of falls since the prior assessment (which was a quarterly MDS with an ARD of 07/13/11) as follows: - Fall with no injury - none - Fall with injury (except major) - none - Fall with major injury - 1 - A review of the incident reports, nursing notes, and the significant event reporting in the computer revealed that Resident #141 had sustained falls as follows: - On 07/20/11 at 5:00 p.m., he was found on the floor and had sustained a scratch to his right hand measuring approximately 5 cm long. - On 07/22/11 at 7:30 p.m., he slid down the side of a chair after missing the seat, and an assessment found no apparent injuries. - On 07/24/11 at 10:45 a.m., he fell , hitting his left arm and the left side of his head against a door frame; he subsequently was found to have sustained a fractured humerus and a subdural hematoma. - The above assessment was inaccurate with respect to the numbers and types of falls that had occurred since his prior MDS with an ARD of 07/13/11. -- b) Resident #21 A review of a significant change in status MDS with an ARD of 05/02/11 found the assessor indicated, in Item M0300F, that Resident #21 had one (1) unstageable pressure ulcer. In a quarterly MDS with ARD of 07/27/11, the assessor again indicated the presence of one (1) unstageable pressure ulcer (measuring 0.4 cm x 0.5 cm) in Item M0300F. - Review of the resident's nursing notes revealed an entry, at 9:50 a.m. on 06/21/11, stating: Note necrotic tissue to L (left… | 2016-01-01 |
| 9203 | 9203 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 279 | E | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, staff interview, and family interview, the facility's interdisciplinary team failed to develop comprehensive care plans to address the care needs and to describe the services needed for residents to maintain a safe environment, prevent further condition decline, and prevent complications in their condition. The care plans were not complete and/or did not provide instructions to provide care in the areas of accidents / falls, activities of daily living, dental needs, hospitalization , nutrition, behaviors, the use of psychoactive medications, pressure ulcers, range of motion, contractures, indwelling urinary catheters, and management of urinary incontinence. The care plans did not address specific care needs for thirteen (13) of thirty-eight (38) stage II sampled residents. Resident identifiers: #228, #223, #129, #116, #199, #169, #138, #5, #148, #55, #3, #155, and #215. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #228 A complaint investigation was initiated at this facility at 12:00 p.m. on 05/18/11. Review of Resident #228's medical record revealed this [AGE] year old female was admitted to the facility at 8:30 p.m. on 05/17/11. According to hospital records provided on admission, this resident had dementia and a history of falls. That she had frequent falls was also noted on her physician's admission orders [REDACTED] According to the nursing notes dated 05/18/11 at 2:30 a.m., Resident #228 was found face down in the floor in her room with blood on her right hand and on the left side of her forehead; she was subsequently transferred to the hospital for evaluation due to complaints of pain in her left leg. The resident was in this facility for a total of six (6) hours prior to falling and being transferred to the hospital. She subsequently returned to the facility at 6:… | 2016-01-01 |
| 9204 | 9204 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 280 | D | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, family interviews, and review of medical records, the facility's interdisciplinary team failed to periodically review and revise residents' care plans to address changes in their conditions and needs. One (1) resident's care plan was not updated to reflect her discharge from hospice or the change in her functional abilities. Another resident had an indwelling urinary catheter that was noted to be in place for excoriation; the care plan had not been updated to plan for removal of the catheter after resolution of the excoriation. Two (2) of thirty-eight (38) residents on the Stage II sample were affected. Resident identifiers: #116 and #129. Facility census: 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #116 A copy of the resident's current care plan was requested. The copy was noted to have a print date of 06/01/11. A second copy was provided in response to a request for information regarding another issue. The second copy had a print date of 06/07/11. The resident had been discharged from hospice early in May 2011. The actual physician's orders [REDACTED]. A significant change in status assessment (SCSA), with an assessment reference date (ARD) of 05/02/11, was signed as complete on 05/12/11. The care plan should have been updated to address the results of the comprehensive assessment within seven (7) days of the assessment completion date. 1. The care plan printed on 06/01/11 still referenced receipt of hospice care in the interventions for two (2) goals. - 2. According to the assessment, the resident was totally dependent for bed mobility, locomotion on the unit, locomotion off unit, dressing, eating, toilet use, and personal hygiene. She required extensive assistance for transfers. The walk in room and walk in corridor items were coded as the activity having not occurred. Both of the care plans included interventions that included: Resident wonders (sic) around the… | 2016-01-01 |
| 9205 | 9205 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 281 | D | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to assure staff adequately assessed the patency of a gastrostomy tube prior to administering the medications and tube feeding. The nurse did not verify the placement of the tube by aspirating for residual per physician order. The physician's orders [REDACTED]. This did not occur for one (1) of one (1) resident observed during medication administration by gastrostomy tube. Resident identifier: #76. Facility census: 144. Findings include: a) Resident #76 During medication administration on 05/31/11 at 1:30 p.m., a licensed practical nurse (LPN - Employee #100) prepared to administer a medication to Resident #76 via gastrostomy tube. Employee #100 stated it was also time to turn on the resident's tube feeding, so she would do that too as soon as she gave his medication. Employee #100 administered the resident's medication in his enteral gastrostomy tube and then turned on his feeding of [MEDICATION NAME] 1.5 at a rate of 66 ml/hour as ordered. She stated this was ordered to run until 1320 cc of the tube feeding had infused. After administering this medication and turning on the feeding, the nurse then checked the Medication Administration Record [REDACTED]. If 400 ml of residual, hold the feeding and call the MD. The nurse, when questioned about verifying placement of the tube, stated, I know I forgot to aspirate to verify placement and check the residual. She verified that this should have been checked prior to administering the medication and starting the feeding. . | 2016-01-01 |
| 9206 | 9206 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 282 | D | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and resident interview, the facility failed to ensure implementation of established care plans for three (3) of thirty-eight (38) residents on the Stage II sample. The residents' care plans identified specific approaches direct care staff was to employ to address each identified problem, but these approaches were not consistently implemented. For example, a resident, who had a physician's orders [REDACTED]. This individual also had interventions identifying she enjoyed watching westerns on television, enjoyed listening to county music in her room, and for her glasses to be worn due to impaired vision. These interventions were not noted to be implemented until near the end of the third week of the survey. Other residents had care plans identifying hygienic needs, but these needs were not being met prior to identification of deficits by a survey team member. Resident identifiers: #5, #40, and #125. Facility census: 144. Findings include: a) Resident #5 1. Review of the resident's care plan found a problem of At risk for respiratory impairment related to risk for aspiration d/t (due to) dysphagia. Three (3) goals had been established for this problem: - Maintain patent airway - Will have no acute respiratory distress - Will exhibit no S&S (signs and symptoms) of aspiration such as coughing, fever, etc. One (1) of the interventions was: Position as upright as possible for meals and 30 minutes afterwards. The speech therapist had noted, in an evaluation dated 02/15/11, the resident needed to be in upright position. On 05/26/11, the resident was observed drinking her afternoon supplement while in bed in her room. The head of the resident's bed was elevated at only approximately 30 degrees. On 05/31/11 at approximately 2:00 p.m., observation found the resident lying in bed holding a carton of supplement. The head of her bed was elevated at only approximately 30 degrees. On 06/01/11 at 11:… | 2016-01-01 |
| 9207 | 9207 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 309 | G | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, resident interview, and staff interview, the facility failed to ensure residents received the services and care necessary to promote their highest level of well being. The facility failed to provide services to promote comfort and relieve pain and failed to communicate the recommendations of a consulting physician to a resident's attending physician related to lab studies for three (3) of thirty-eight (38) Stage II sample residents. The failure to provide these services caused actual harm to Resident #228, with the potential for more than minimal harm for Residents #227 and #125. Resident #228 suffered a fall with injuries and was sent to the emergency room six (6) hours after her admission to this facility. Her wound was treated, and she was sent back to the nursing home with instructions from the emergency room physician for follow up care of her injuries and measures for pain relief. This resident verbalized that she was experiencing pain at 3:15 p.m. on 05/18/11. She said she would like to have ice on her eye but they told to they did not have any. Observation found she had a hematoma, a laceration, and facial swelling around her left eye, as well as a large area of bruising. There was no evidence that any pain assessments or any pain relief interventions had been initiated for this resident since her return from the emergency room at 6:30 a.m. on 05/18/11. Resident #227 was admitted to the facility with wounds on his coccyx and was going to the wound healing center every week for treatment. On his visit to the wound center on 05/26/11, the following recommendation was communicated in writing to the facility by the wound center's physician: If he has not had a PT ([MEDICATION NAME] Time) / INR (International Normalized Ratio) recently, please check. Patient bled during assessment and cleaning. (These are blood test to assess the clotting tendency of the blood and are also used to detect bleedi… | 2016-01-01 |
| 9208 | 9208 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 312 | D | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observations, medical record review, and staff interview, the facility failed to provide necessary services to maintain good grooming and personal and oral hygiene for two (2) of thirty-eight Stage II sample residents. Each of these residents, who required assistance with activities of daily living (ADLs), were not provided this assistance. There were care plans to provide and/or assist the residents; however, the staff failed to implement the care plans. One (1) resident needed personal hygiene and oral care; the other resident needed assistance with grooming. Resident identifiers: #40 and #125. Facility census: 144. Findings include: a) Resident #40 During Stage I of the survey on 05/25/11 at 1:19 p.m., Resident #40 was asked, Does staff help you as necessary to clean your teeth? The resident said staff did not. The resident further stated he had not asked them to brush his teeth. The next question asked was: How often are your teeth / mouth cleaned? The resident answered his teeth had not been brushed for a month or more, because he was no longer able to brush them due to his [MEDICAL CONDITION] (MS). He stated no one had brushed them for him. The resident said he would really like to have his teeth brushed. When asked if he had a toothbrush, the resident said, Look in that drawer and see. There was an unopened toothbrush and an unopened box of toothpaste in the drawer. At 9:00 a.m. on 06/01/11, Employee #58 (licensed practical nurse - LPN), when asked if this resident was compliant with the provision of care, responded, Oh yes, he allows care needs to be met. He is very compliant with care. On 06/01/11, review of the resident's medical record revealed [REDACTED]. An intervention to assist the resident in achieving this goal was: Assist with daily hygiene, grooming, dressing, and oral care as needed. At 2:45 p.m. on 06/01/11, the resident was visited with the director of nursing (DON - Employee #12). Upon inqui… | 2016-01-01 |
| 9209 | 9209 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 314 | D | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide the necessary services to promote wound healing. This was found to be true for one (1) of thirty-eight (38) Stage II sample residents. A resident was assessed by the facility's registered dietitian (RD) on 04/11/11, at which time the RD recommended a multivitamin and Pro-Mod (a protein powder) to promote wound healing. These interventions were not initiated until 04/27/11 - sixteen (16) days after the recommendation was made. Resident identifier: #223. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #223 Review of Resident #223's closed record revealed she was admitted to the facility on [DATE] with a pressure area on her left buttock. This area was identified as an unstageable area and described as having dark necrotic tissue present. Review of the RD's assessment and progress note, dated 04/11/11, found the RD assessed the resident's nutritional needs and recommended a multivitamin (MVI) and ProMod twice daily (BID) to promote healing of the wound on the left buttock. There was no evidence to reflect these recommendations were communicated to nursing or that these supplements were ordered by the physician. On 04/19/11, the RD wrote: Previously documented resident with pressure area on left buttock. - Incorrect. Resident without pressure area. No new dietary interventions. On 04/20/11, the RD wrote: Note 4/19/11 documented resident with no pressure area - incorrect - wrong resident. Resident admitted with pressure area on coccyx which has increased in size this week. Will recommend ProMod 30 ml BID (100 kcal, 10 g pro) and MVI to promote wound healing. This was the same recommendation the RD had made on 04/11/11 but was never initiated. On 04/21/11, an interdisciplinary care plan meeting was held. The RD was present as well as all other disciplines and the… | 2016-01-01 |
| 9210 | 9210 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 315 | D | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, medical record review, and staff interview, the facility failed to assess each resident's bladder function and develop / implement measures to restore as much normal bladder function as possible. Resident #129 had an indwelling Foley urinary catheter present without a [DIAGNOSES REDACTED]. She had a catheter change followed by a urinary tract infection, and the continued need for the catheter was not re-evaluated. There was no current [DIAGNOSES REDACTED]. Residents #116 and #199 did not receive services to improve their bladder function. There was no evidence to reflect efforts by the facility to ascertain the type of urinary incontinence each was experiencing, nor did the facility implement measures in an effort to improve their urinary incontinence. This deficient practice affected three (3) of thirty-eight (38) Stage II sample residents. Resident identifiers: #129, #116, and #199. Facility census: 144. Findings include: a) Resident #129 During an interview with Resident #129 on 05/25/11 at 1:00 p.m., observation revealed she had an indwelling Foley urinary catheter. When questioned about the presence of the catheter, Resident #129 stated the catheter had been inserted at the facility where she was prior to coming here. Record review revealed Resident #129 was admitted from a hospital to the facility on [DATE] with an order for [REDACTED]. Resident #129's admission minimum data set assessment (MDS), with an assessment reference date (ARD) of 03/11/11, revealed, in Section H, this resident had an indwelling urinary catheter. This triggered the care area Urinary Incontinence and Indwelling Catheter in Section V of the MDS, where the assessor recorded that the location and date of the CAA could be found in the worksheet dated 03/16/11. In Section M of the MDS, the assessor did not identify the presence of any pressure ulcers or open areas. The resident's CAA worksheet for Urinary Incontinence and Indw… | 2016-01-01 |
| 9211 | 9211 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 318 | D | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to assure two (2) of thirty-eight (38) Stage II sample residents received treatment and services, including preventive care, to increase range of motion (ROM) and/or to prevent further decrease in ROM. The facility had no individualized plans in place for these two (2) residents, each with a limited range of motion, which assured each resident was provided services to reach and maintain his or her highest level of range of motion, or to prevent decline of range of motion. Resident identifiers: #3 and #55. Facility census: 144. Findings include: a) Resident #3 During Stage I of this survey, this resident was identified with a contracture of the right hand. The resident did not have a splint / device or receive ROM activities. Medical record review, on 06/01/11, revealed no order for splints or other devices; however, the facility's current Patient Information Worksheet indicated the resident was to have hand palm protector on at all times. Observation of the resident, at 10:45 a.m. 06/01/11, revealed the resident was in bed and had no hand rolls in place. The resident was observed again at 1:30 p.m. on 06/01/11, and no hand rolls were in place. Medical record review, on 05/31/11, revealed a care plan, last revised on 02/02/11 with the following goal: Will exhibit no decline in ROM within confines of disease. There were no interventions regarding the contracture of the resident's right hand. Interview with the rehabilitation manager (Employee #110), on 06/01/11 at 1:30 p.m., revealed the resident's last rehabilitation evaluation occurred in November 2010. According to Employee #110, at that time, a palm protector for the right hand was recommended. On 06/02/11 at 11:00 a.m., the director of nursing (DON - Employee #12) stated the resident now had an order for [REDACTED]. The DON confirmed occupational therapy had evaluated the resident's need for a device in N… | 2016-01-01 |
| 9212 | 9212 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 323 | G | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record, and staff interview, the facility failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents and to promote resident safety. The facility failed to assess the immediate safety needs for Resident #228, a newly admitted resident who was identified in her admission information as having dementia and a history of falls. Failure of the facility to assess the resident upon admission for safety needs and to implement measures to prevent falls resulted in the resident falling only six (6) hours after she arrived at the facility and sustaining a head injury. She was transferred to the emergency room and treated for [REDACTED]. After safety measures were ordered upon her return to the facility (to include a low bed without side rails and mats on both sides of her bed), she was observed in her bed with a mat on only one (1) side of bed and tile floor on the other side. Resident #76, who had a [DIAGNOSES REDACTED]. He was in a low bed, and according to his treatment record, he was to have mats on both sides of the bed. Two (2) mats were stacked on top of each other on one (1) side of the bed with the tile floor on the other side. Resident #48 was observed to have Theraband used in a manner that was presented an accident hazard to this cognitively impaired resident. This band, which had been tied to the wheelchair to secure her leg secured to the chair, presented a hazard when the resident attempted to stand up from the chair without assistance. Resident #5 was observed at meal time to have straws in beverages, which were contrary to his physician's orders [REDACTED]. This was an accident hazard for this resident. Failure of the facility to assess the residents for safety needs and implement measures to prevent accidents and injuries affected three (4) of thirty-eight (38) Stage II sample residents. Resident identifiers: #228, #76, #48, and #5. Facility census: 149 at the onset of t… | 2016-01-01 |
| 9213 | 9213 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 325 | D | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview, the facility failed to assure the resident received nutritional supplements as ordered by the physician after the resident experienced a 7 pound weight loss in three (3) days. The facility failed to specify how often the resident would be weighed to monitor the effectiveness of the diet ordered. This was true for one (1) of thirty-eight (38) Stage II sample residents. Resident identifier: #215. Facility census: 144. Findings include: a) Resident #215 Medical record review revealed an [AGE] year old male admitted to the facility on [DATE]. The resident's admission weight was 129.8 pounds (#). On 03/21/11, the resident's weight was 122.8#. On 03/21/11, the physician added nutritional supplements to the resident's diet in an effort to address the resident's unplanned weight loss. Review of the nutrition risk assessment completed by the registered dietitian (RD) on 03/31/11 stated, . note 3/18/11 wt. (weight) 129.8# and 3/21/11 wt. of 122.8 #. ? (symbol for 'question') accuracy of these wts. - will monitor wt. status. Review of the June 2011 recapitulation of the monthly physician's orders [REDACTED]. On 04/07/11, the physician added one (1) house supplement with lunch. In total, the resident was now to receive three (3) house supplements and three (3) cans of Ensure daily, according to the physician's orders [REDACTED]. Observation of the resident's noon meal, on 06/06/11, found the resident was served lunch without the Ensure; however, the house supplement was present on the noon tray. Employee #24 (assistant dietary manager), when interviewed at 2:15 p.m. on 06/06/11, was unaware of the orders for Ensure to be served with each meal. She produced a copy of the resident's tray ticket, which verified the dietary department would send only a house supplement with the noon meal. Employee #81 (RD), when interviewed on 06/06/11 at 2:30 p.m., stated she thought the physician's orders [RE… | 2016-01-01 |
| 9214 | 9214 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 329 | D | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to: (1)identify the problem or need for a medication; (2) identify the targeted behaviors for use of a psychoactive medication; (3) implement non-pharmacological interventions before administering a psychoactive medication to control a resident's behavior; (4) monitor for potential adverse side effects of a psychoactive medication; (5) monitor the resident's response to medications; and (6) act upon recommendations made by the consultant pharmacist. This was true for two (2) of thirty-eight (38) Stage II sample residents. Resident identifiers: #215 and #73. Facility census: 144. Findings include: a) Resident #215 Review of Resident #215's medical record revealed this [AGE] year old male resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed an order, handwritten by the physician on 04/07/11, for: [MEDICATION NAME] 0.125 mg PO (by mouth) PRN (as needed) every evening for anxiety and agitation (family request). Review of the April 2011 Medication Administration Record [REDACTED]. On 04/24/11, the physician gave an order for [REDACTED]. Review of the nurses' notes from 04/24/11 through 04/30/11 revealed the following entries: - On 04/24/11: Resident has been to the desk several times c/o (complaining of) different things . - On 04/28/11: Resident has been at N.S. (nurses station) several times. c/o of different things. Wanting wife returned to bed then (symbol for 'up'). (Resident #215 shared a room at the facility with his wife.) Review of the May 2011 MAR found the PRN [MEDICATION NAME] was administered on eighteen (18) occasions. Review of the nurses notes from 05/01/11 through 05/31/11 revealed resident behaviors were documented on only two (2) occasions - 05/26/11 and 05/28/11. - On 05/26/11: Out in hallway demanding in loud voice that he pays for paper towels and he does not have any. Staff offered to get… | 2016-01-01 |
| 9215 | 9215 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 332 | E | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to assure the medications were administered as ordered by the physician and that the medication error rate was not greater than five percent (5%). The medication errors included omissions, the incorrect dosage, administration of the incorrect type of vitamins, and inadequate flushing of the gastrostomy tube when administering medications. There error rate for the facility was sixteen and seven one-hundredth percent (16.07%). There were medication errors observed for six (6) of eleven (11) residents observed during medication pass. Resident identifiers: #68, #142, #76, #169, #6, and #37. Facility census: 144. Findings include: a) Resident #68 During a medication administration on 06/02/11 at 1:13 p.m., a licensed practical nurse (LPN - Employee #100) was observed preparing the medications for Resident #68. During this preparation, she was observed to prepare a tablet of Multivitamin (MVI) with Iron. The medication administration record (MAR) did not indicate this resident was to receive a MVI with Iron. Prior to going in to the resident's room to administer these medications, the nurse was questioned about the medications. She stated this was all of them. She was stopped and asked to review the MAR with the nurse surveyor, who brought to her attention there was no MVI with Iron scheduled for this resident. She stated, That is what our House Supplement is. It was noted on the MAR this resident was to receive a house supplement TID (three-times-a day). This nurse surveyor again asked Employee #100 if she was sure this was what she should give, and the LPN stated, Yes. This surveyor told the LPN at that time that she was told earlier the house supplement written on the MAR was something sent from the kitchen for the residents to drink for extra calories. Employee #100 stated, If that is what it is, no one has ever told me. The LPN then proceeded in to the resident's ro… | 2016-01-01 |
| 9216 | 9216 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 356 | B | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, the facility failed to post the required nurse staffing information in an area readily accessible to the residents. The posting was observed in the front lobby on the office door, in an area not readily accessible to most of the residents. This practice has the potential to affect more than an isolated number of residents who may desire to view this information. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Upon entrance to the facility on [DATE] at 12:00 p.m., the nurse staffing posting was observed in the front lobby on the office door. During a tour of the facility, other areas of the facility were observed, and the front lobby was the only area where the nurse staffing posting was displayed. Access to the front lobby through double doors from the nursing unit was restricted for any resident wearing a Wanderguard bracelet. Observations were continued throughout the survey event from 05/24/11 to 06/08/11, and the front lobby was the only area in which the nurse staffing posting was displayed. According to the requirement, this posting must be in a prominent place readily accessible to residents and visitors. The front lobby area was readily accessible to visitors, but this area was not readily accessible to all residents. | 2016-01-01 |
| 9217 | 9217 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 369 | D | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of medical records, resident interview, and review of a resident's dietary slip, the facility failed to ensure each residents received special utensils at meal times as indicated. A resident did not have the specialized utensils provided for two (2) of four (4) meals observed. One (1) of thirty-eight (38) Stage II sample residents was affected. Resident identifier: #70. Facility census: 144. Findings include: a) Resident #70 Record review revealed this resident's [DIAGNOSES REDACTED]. On 05/24/11, the resident was observed sitting in her wheelchair in her room at lunch time. After she was served her meal and began to eat, observation found she had some difficulty in manipulating the standard flatware. When asked whether she had ever tried using large handled or other adaptive utensils, she reached for her communication board. Using her communication board, the resident spelled out: I got some in Kitchen. She then spelled out: They probably forgot. At the bottom of her tray slip was printed RED NAPKIN, which she got, and SPECIAL, SPOON, FORK, which she did not receive. She was provided the special utensils at lunch time on 06/01/11, but she did not receive them at lunch time on 06/02/11. She had them again at lunch time on 06/06/11, at which time she demonstrated how she used her spoon with the special handle that went around her hand. | 2016-01-01 |
| 9218 | 9218 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 371 | F | 0 | 1 | MZQB11 | Based on observation, information from the ServSafe Manual (Fifth Edition), and temperature measurement, the facility did not store the emergency food supply in a manner to assure food safety. The temperature of the outdoor emergency food storage area was higher than recommended, and it was not ventilated to help keep the interior temperature and humidity constant throughout the storage area as recommended. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 144. Findings include: a) At 1:15 p.m. on 05/31/11, the outside food storage area, where emergency foods were stored, was found to have an interior temperature of 78 degrees Fahrenheit (F). In addition, the area was not well ventilated to assist in keeping the temperature and humidity constant. According to the ServSafe Manual (Fifth Edition), To keep food at its highest quality and to assure food safety, the temperature of the dry-storage area should be between 50 (degree sign) F and 70 (degree sign) F. Additionally, the ServSafe Manual discussed the need to (m)ake sure dry-storage areas are well ventilated to help keep temperature and humidity constant throughout the storage area. | 2016-01-01 |
| 9219 | 9219 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 412 | D | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview, the facility failed to assess the resident's dental needs, resulting in a failure to arrange dental services. This was true for one (1) of thirty-eight (38) Stage II residents reviewed. Resident identifier: #155. Facility census: 144. Findings include: a) Resident #155 Medical record review revealed this [AGE] year old male resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. During two (2) interviews with the resident (on 05/25/11 at 8:46 a.m. and again on 05/31/11 at 11:20 a.m.), the resident stated his teeth hurt, especially when eating. He related he had about seven (7) teeth and they were rotted out. On 05/31/11 at 12:20 p.m., the director of nursing (DON) was interviewed regarding the resident's dental needs and was advised the resident had stated his teeth were hurting when he ate. On 06/01/11 at 2:00 p.m., the DON stated she could find no evidence of a dental assessment and no evidence the resident had been evaluated by a dentist since his admission on 11/18/09. She stated the facility had scheduled a dental consult for the resident. Review of the medical record, on 06/01/11, revealed a telephone order received on 05/31/11 at 6:15 p.m. for: Consult dentist due to toothache. Further review of the medical record revealed a nursing admission evaluation completed on 10/08/10. In Section F, regarding the resident's condition of teeth, the assessor indicated the resident had broken teeth. The resident's annual comprehensive minimum data set (MDS), with an assessment reference date of 11/10/10, did not indicate the resident had any oral problems in Section L (Oral / Dental Status). On 06/02/11 at 3:00 p.m., Employee #95, a registered nurse (RN), was asked to assess the resident's dental needs. Employee #95 assessed the resident's teeth and stated, Looks like he may have a cavity in that back tooth. | 2016-01-01 |
| 9220 | 9220 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 425 | E | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview, and a review of the facility's inservice records and procedures for ordering medications, the facility failed to assure medications were acquired timely and available for administration as ordered by the physician. Medications for newly admitted residents were not obtained in a timely manner, the emergency box was not checked to see if a medication was available when it was not found on the medication cart, and there was no evidence that staff notified the physician when medications were not administered in accordance with the orders. Review of residents' medication administration records (MARs) revealed medications were frequently not available and were not administered, with no interventions or follow-up actions evident. This practice was true for six (6) of thirty-eight (38) Stage II sample residents and one (1) resident of random opportunity. Resident identifiers: #228, #116, #112, #6, #40, #3, and #215. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #228 During a complaint investigation beginning at 12:00 p.m. on 05/18/11, a nurse surveyor found Resident #228 was admitted at 8:30 p.m. the prior evening (on 05/17/11). On admission, the physician ordered multiple medications for this resident. The orders were stamped STAT at that time, and someone had written on the orders: STAT meds (medications) please. The resident had orders to receive sixteen (16) medications on a daily basis, and she did not receive morning doses for any of these medications on 05/18/11. Her orders included six (6) medications to treat high blood pressure (Tenormin, Diovan, Lisinopril, Catapres, Apresoline, Zaroxolyn and Lasix). Her vital signs were recorded by staff at 8:00 a.m., and her blood pressure was not elevated (132/72). The resident's medication nurse - a licensed practic… | 2016-01-01 |
| 9221 | 9221 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 428 | D | 0 | 1 | MZQB11 | Based on medical record review and staff interview, the facility failed to assure the pharmacist's recommendations of irregularities identified in the medication regimen were acted upon by the attending physician and the director of nursing in a timely manner. This was true for three (3) of thirty-eight (38) Stage II sample residents whose records were reviewed. Resident identifiers: #140, #5, and #73. Facility census: 144. Findings include: a) Resident #140 Review of consultation report from the pharmacist dated 02/10/11 revealed, (Name of resident) is on glimepiride / Amaryl 2 mg qd (every day) and sliding scale insulin QID (four times a day); morning fingerstick's range 78 to 103 mg/dl, excellent control; coverage seldom required as blood sugars seldom are over 150 mg/dl at any time of day. Recommendation: Please consider discontinuing use of sliding scale insulin and begin fingersticks with no coverage alternating mornings Mon, Wed, Fri and 4 p.m. Tues, Thurs, Sat. On 03/21/11, the physician responded to the recommendations from the pharmacist by documenting, Agree. On 03/10/11, the consultant pharmacist reviewed the resident's medication regimen and, again, made the same recommendation as made on the 02/10/11 visit. The resident's physician reviewed and signed this recommendation on 04/04/11. The order to discontinue the sliding scale insulin and previous fingersticks was not written until 04/04/11, after being recommended by the pharmacist on 02/10/11 and 03/10/11. The director of nursing (DON, when interviewed on 05/31/11 at 2:15 p.m., was unable to explain the delay in writing the orders in accordance with the pharmacist's recommendations. She verified the orders should have been written on 03/21/11, when the resident's physician agreed to the recommendations. -- b) Resident #5 On 05/11/11, the consultant pharmacist issued a report that included: Comment: (Resident #5's name) is on Remeron 15 mg qhs (every hour of sleep) since January 2011; due for review and documentation of continued need. This regimen … | 2016-01-01 |
| 9222 | 9222 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 431 | E | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure drugs and biologicals are labeled in accordance with currently accepted professional principles. Eye drops used for Resident #76 were not labeled to ensure the drops were not administered to another resident, especially in view of the fact this resident had recently been treated for [REDACTED]. This practice have the potential to affect more than an isolated number of residents. Resident identifier: #76. Facility census: 144. Findings include: a) Resident #76 During medication administration on 06/02/11 at 1:45 p.m., the licensed practical nurse (LPN - Employee #100) was observed preparing Resident #76's medications, which included eye drops (Natural Balance Tears 0.4%). Employee #100 removed a box of eye drops from the medication cart; however, there was no name written on the box to ensure these eye drops were administered only to Resident #76. Employee #100 applied her gloves and proceeded to administer eye drops as ordered for this resident. The eye drop container was observed to have direct contact with the resident's eyes. This action contaminated the eye dropper, as well as contamination the resident's eyes with any organisms that may have been on the dropper. (See also citation at F441.) Review of Resident #76's medical record found he had been treated for [REDACTED]. There was a potential for these eye drops to be administered to another resident after being contaminated when used for Resident #76. Employee #100 was questioned at 1:50 p.m. 06/2/11 about the eye drop box not having a label and she said, This is our facility's stock. When asked how she knew these were Resident #76's eye drops, she stated again, They are our facility stock. When the surveyor told the nurse there was no way to assure these eye drops were to be only administered to this resident and had not been used on someone else, she asked the surveyor, Do you want me to write his … | 2016-01-01 |
| 9223 | 9223 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 441 | E | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to establish and maintain an effective program in which practices of the facility prevent the spread of disease and infection. During medication pass for Resident #76, the nurse contaminated a bottle of eye drops by directly touching the tip of the eye dropper to resident's the eyes (which had been treated for [REDACTED]. The nurse, who was wearing gloves, then wiped the resident's eyes with a tissue. She did not change her gloves prior to administering medications via the resident's his gastrostomy tube. The contaminated bottle of eye drops was then placed back in the medication cart, potentially contaminating other items in the cart. Staff used an isolation cart from outside of Resident #228's room in lieu of an overbed table for serving this resident her meal. Resident #228 was in contact isolation for a multi-drug resistant organism. When staff provided an overbed table for the resident to use for the remainder of the meal, the contaminated isolation cart was placed back out in the hallway. Multiple observations were made of soiled linen and contaminated linen in red bags lying on the floors of residents' rooms and bathrooms. Isolation precautions were not implemented for Resident #3 (who resided on the second floor), when staff suspected she had a condition that could be spread to others. These deficient practices had the potential to cause more than minimal harm to more than an isolated number of residents. Resident identifiers: #76, #228, and #3. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #76 1. Eye Drop Technique During medication administration on 06/02/11 at 1:45 p.m., the licensed practical nurse (LPN - Employee #100) was observed preparing Resident #76's medications, which included eye drops (Natural Balance Tears 0.4%). Employee #100 re… | 2016-01-01 |
| 9224 | 9224 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 513 | D | 0 | 1 | MZQB12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain in a timely manner and file on the medical record the results of diagnostic services performed on one (1) of fourteen (14) sampled residents. The results of diagnostic procedures performed to evaluate Resident #33's urinary tract were not obtained and filed on the resident's medical record until thirteen (13) days after the procedures were completed. Resident identifier: #33. Facility census: 140. Findings include: a) Resident #33 Medical record review, on 08/22/11, revealed this [AGE] year old male with [MEDICAL CONDITION] and [MEDICAL CONDITION] bladder had an indwelling Foley urinary catheter in place for a long time. He also had experienced a history of urinary tract infections and [MEDICAL CONDITION]. Resident #33 had a history of [REDACTED]. Further medical record review revealed the resident, at a local hospital on [DATE], underwent a rigid cystourethroscopy (endoscopy of the urinary bladder via the urethra, carried out with a cystoscope). The resident also had a bilateral retrograde pyelography with interpretation (a procedure where the physician injects contrast into the ureter in order to visualize the ureter and kidney). These tests revealed no evidence of hydrouretero[DIAGNOSES REDACTED] (distension of the kidney and/or ureter caused by backward pressure on the kidney when the flow of urine is obstructed). (http://www.merckmanuals.com/home/kidney_and_urinary_tract_disorders/obstruction_of_the_urinary_tract/hydro[DIAGNOSES REDACTED].html#v 1) - When asked about the results of the above mentioned diagnostic procedures on 08/22/11 at 12:00 p.m., Employee #200 (a registered nurse) reported the facility had not yet received the report. She said she had this on a list of items she needed to get. On 08/23/11 at approximately 10:00 a.m., the facility obtained a copy of the diagnostic test results. - Review of the operative report for these two (2) procedures… | 2016-01-01 |
| 9225 | 9225 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 520 | E | 0 | 1 | MZQB11 | Based on the findings of the current survey, staff interviews, review of documentation of inservices, and review of medical records, the facility's quality assessment and assurance (QAA) committee failed to implement fully implement its action plan to correct identified quality deficiencies with respect to the availability of medications for administration to residents in a timely manner, and failed to implement monitoring activities to ensure the quality deficiencies were corrected going forward. All residents had the potential to be affected. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Availability of medications During a complaint investigation beginning at 12:00 p.m. on 05/18/11, a nurse surveyor found Resident #228 was admitted at 8:30 p.m. the prior evening (on 05/17/11). On admission, the physician ordered multiple medications for this resident. The orders were stamped STAT at that time, and someone had written on the orders: STAT meds (medications) please. The resident had orders to receive sixteen (16) medications on a daily basis, and she did not receive morning doses for any of these medications on 05/18/11. (See citation at F425 for additional details related to Resident #228 and additional examples of other residents affected by this deficient practice.) This lack of availability of medications for administration was further investigated during the Quality Indicator Survey (QIS) conducted between 05/24/11 and 06/08/11. It was learned the facility had identified a problem with the timely and / or consistent provision of the medications. Review of the corrective actions taken to correct the problem found inservices had been provided to the facility's licensed nurses beginning in the latter part of April 2011 and continuing into May 2011. The inservice documents included copies of the various forms that were to be used to order / reorder medications, a copy of the pharmacy's presentation slides c… | 2016-01-01 |
| 9226 | 9226 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2013-01-08 | 241 | E | 1 | 0 | C0IF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, care plan review, and observation, the facility failed to ensure four (4) of ten (10) residents, who were dependent in activities of daily living, received the assistance needed as indicated by their physical condition. All four (4) residents had unmet grooming needs which they were unable to attend to on their own. Resident identifiers: #114, #72, #57, and #37. Facility census: 114. Findings include: a) Resident #57 An observation of Resident #57, on 01/07/13 at 1:00 p.m., revealed this resident needed his facial hair shaved. He had several days beard growth and hair was growing out of his ears. He said he would like to have a shave and a hair cut as well as the hair trimmed from his ears. He said he had not had a hair cut or a shave in a long time. At 1:30 p.m. on 01/07/13, Employee #130, a licensed practical nurse (LPN) said the resident was on the list to have a hair cut from the beautician. On 01/07/13 at 4:00 p.m. the resident had received a hair cut. On 01/08/13 at 10:50 a.m. the resident was still not shaven. Employee #130 said the resident would get shaved this morning. The resident liaison (Employee #97) said she had noticed this resident needed shaved on the morning of 01/07/13. Employee #97 said she knew the facility needed razors on the morning of 01/07/13. b) Resident #72 An observation of Resident #72, on 01/07/13 at 12:30 p.m., revealed this female resident had long hairs on her chin. She said she was not scheduled for a bed bath today and she had forgotten to mention this to the staff over the weekend. On 01/07/13 at 12:45 p.m., Employee #101, a registered nurse (RN), stated he would make sure this hygiene need was addressed. c) Resident #37 Resident #37 was observed on 01/07/13 at 11:30 a.m. This female resident had chin hair that needed removed. d) Resident #114 On 01/07/13 at 1:15 p.m., this resident was observed. He was in need of a shave. Upon inquiry, Employee #130 sai… | 2016-01-01 |
| 9227 | 9227 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2013-01-08 | 280 | D | 1 | 0 | C0IF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and observation, the facility failed to update the care plan in a timely manner for one (1) of six (6) sample residents. The care plan for a resident who had experienced falls was not updated at the time of the falls. Resident identifier: #73. Facility Census: 114. Finding include: a) Resident #73 Resident #73 was first observed on 01/03/13 at 11:00 a.m. She was lying on her right side, sleeping. She was wearing an immobilizer related to a [MEDICAL CONDITION] humerus. Bruising was visible on her left upper arm and her left hand was [MEDICAL CONDITION]. Employee #60, nursing assistant (NA), was seated next to the bed. She stated she was providing one-on-one supervision, because the resident had fallen. During an interview with Employee #159, a registered nurse (RN), and Employee #9, director of nursing services (DNS), on 01/03/13, at approximately 2:00 p.m., they related Resident #73 had a history of [REDACTED]. They also stated the resident had a fall with an injury on 12/12/12. The DNS stated many of the resident's falls were due to attempts to obtain gum or candy from her over-the-bed table or bedside stand. Employee #159 said the resident was on fluid restrictions, which caused her to have a dry mouth. Both the DNS and the RN indicated the dry mouth increased the resident's desire for gum or candy. Employee #159 stated several interventions had been put into place. One of the interventions was a low over-the-bed table. She indicated the purpose was to ensure the gum and candy were within the resident's reach. The resident's medical record was reviewed on 01/04/13 at 12:00 p.m. The general progress note, dated 12/12/12 at 5:32 p.m., noted . notified at this time by cna that resident was lying at foot of bed with laceration noted to forehead . resident previously was sitting in wheelchair beside bed . send to ER for evaluation. The general progress note dated 12/13/12 at 2:37 p.m. included, . … | 2016-01-01 |
| 9228 | 9228 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2013-01-08 | 323 | D | 1 | 0 | C0IF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and resident comments, and staff interview, the facility failed to ensure one (2) of six (6) residents who had sustained past fractures were equipped with the assistance devices and accommodations necessary to prevent further accidents. Resident identifiers: #73 and #37. Facility census: 113. Findings include: a) Resident #37 The medical record review for Resident #37, conducted on 01/05/13 at 10:00 a.m., revealed this resident sustained [REDACTED]. She had fallen out of her wheelchair and hit her face and head. On 01/05/13 at 10:45 a.m., the director of nursing (DON), Employee #9, provided a copy of the resident's care plan which contained an intervention for her fall risk. The facility had developed a plan which included the use of a scoot chair when the resident was out of bed. An observation of Resident #37, on 01/05/13 at 11:30 a.m., revealed the resident sitting in a regular wheelchair in the dining room, eating lunch. She did not have a scoot chair. On 01/07/13 at 11:00 a.m., Resident #37 sat in the dining room participating in an activity. She sat in a wheelchair, not a scoot chair. On 01/07/13 at 11:15 a.m., the occupational therapy assistant (Employee #120) confirmed the resident was not sitting in a scoot chair. On 01/07/13 at 11:30 a.m., the licensed practical nurse (LPN), Employee #130, indicated the resident had used a scoot chair before, but did not know why she currently was not using one. She located the resident's scoot chair in a storage room. On 01/07/13 at 11:45 a.m., the director of care delivery (DCD) (Employee #121) indicated the facility had cleaned the resident's scoot chair last week. After the cleaning of the chair the resident was placed in a wheelchair instead of back in her scoot chair. On 01/08/13 at 12:00 p.m., a review of the cleaning schedule revealed scoot chairs were cleaned on Monday and Friday. b) Resident #73 Resident #73 was first observed on 01/03/13 at 11:… | 2016-01-01 |
| 9229 | 9229 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2013-01-08 | 511 | D | 1 | 0 | C0IF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and observation, the facility failed to promptly notify the attending physician of x-ray results for one (1) of eight (8) sample residents. The physician was not notified of x-ray results which indicated a dislocated left femoral prosthesis. Resident identifier: #49. Facility census: 114. Findings include: a) Resident # 49 During observation of Resident #49, on 01/03/13 at 12:00 p.m., he was in bed, lying on his back. His left leg was rotated inward. He did not respond to conversation. Another observation, on 01/04/13 at 9:30 a.m., revealed he was again on his back, with his left leg rotated inward. His family was present, and upon inquiry, stated he had broken his hip. Review of the medical record, on 01/04/13 at 11:00 a.m., revealed an x-ray was obtained on 06/15/12 related to constipation. The x-ray report was received by the facility at 9:22 p.m. on 06/15/12. Significant findings on the report included, The left femoral prosthesis appears to be dislocated .Impression 2) Dislocated left hip prosthesis. Further review of the medical record, on 01/07/13, revealed a note by the physician, dated 06/21/12, which stated, Sent to ER ,[DATE] for incidental finding of (L) left hip prosthesis dislocation on (abd) abdomen xray done for constipation a few days ago, just found out about this yesterday at 4 pm. This was five (5) days after the facility received the x-ray report. There was no evidence of notification of the physician prior to 06/20/12. Interview with Employee #86 (registered nurse), on 01/08/13 at 2:30 p.m., confirmed no evidence was available to indicate the physician was notified of the dislocated prosthesis between 06/15/12 and 06/20/12. | 2016-01-01 |
| 9230 | 9230 | ROANE GENERAL HOSPITAL, D/P | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2011-06-08 | 156 | C | 0 | 1 | O68G11 | Based on observation and staff interview, the facility failed to prominently displayed in the facility written information on how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. Additionally, information posted regarding various agencies' names and addresses contained the wrong address for the State survey agency and the wrong name of the State long-term care ombudsman. This had the potential to affect all residents and visitors. Facility census: 31. Findings include: a) Observations of information posted throughout the unit during the survey revealed a typed notice which contained the names, addresses and telephone numbers of various agencies which the residents may need to contact. On this list, the State survey agency's street address and the name of the State long-term care ombudsman were incorrect. b) Observations also found no notices of any kind which provided information regarding how to apply for Medicaid / Medicare benefits, nor was there information about how to receive refunds for previous payments covered by those benefits. c) These issues were discussed with the social worker (Employee #77) at 1:50 p.m. on 06/ 7/11. She accompanied the surveyor to observe the notices, and she verified the above findings. | 2016-01-01 |
| 9231 | 9231 | ROANE GENERAL HOSPITAL, D/P | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2011-06-08 | 167 | C | 0 | 1 | O68G11 | Based on observations and staff interview, the facility had failed to post a notice of the availability of the most recent survey results. This has the potential to affect all residents and visitors. Facility census: 31. Findings include: a) Observations by the surveyor, on 06/07/11 at 10:30 a.m., did not find any survey results of the most recent survey available for review by residents and visitors. When staff at the nursing station was asked where the survey results were posted, they were unaware of the location as well. At 10:40 a.m. on 06/07/11, a registered nurse (Employee #26) informed the surveyor that the information was in a notebook on a bookcase in the activity / dining room area. Subsequent observation of this area found all types of books, such as reading novels, etc., on this bookcase for resident access, including the survey results. There was no signage posted to inform residents or visitors where this information could be located for review. | 2016-01-01 |
| 9232 | 9232 | ROANE GENERAL HOSPITAL, D/P | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2011-06-08 | 241 | E | 0 | 1 | O68G11 | Based on observation, review of resident diet slips, and staff interview, the facility failed to provide care to eight (8) of thirty-one (31) residents in a manner and an environment that maintained or enhanced dignity and respect for residents who required assistance with eating. Facility staff and the dietary department referred to these residents as feeders both verbally in the dining room during meal service and in writing on the residents' diet slips. Resident identifiers: #26, #35, #27, #24, #16, #23, #12, and #32. Facility census: 31. Findings include: a) Residents #26, #35, #27, #24, #16, #23, #12, and #32 During random observation of the evening meal service in the main dining room on 05/31/11 at approximately 6:00 p.m., facility staff was overheard referring to residents as feeders. Review of the diet slips left on the tables by the residents' plates noted the slips were labeled with the residents' names and identified them as feeders. During an interview with the nurse manager (Employee #8), on 06/01/11 at 2:15 p.m., she provided a list of all residents with dietary slips which identified them as feeders. She stated that steps had been initiated to correct this practice. | 2016-01-01 |
| 9233 | 9233 | ROANE GENERAL HOSPITAL, D/P | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2011-06-08 | 279 | D | 0 | 1 | O68G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a care plan with goals and approaches addressing anxiety for two (2) of nineteen (19) Stage II sampled residents with orders for anxiolytic medications. Resident identifiers: #33 and #20. Facility census: 31. Findings include: a) Resident #33 Review of the medical record found this female resident was admitted to the facility on [DATE] with orders for [MEDICATION NAME] 0.25 mg twice-a-day (BID) for anxiety. Review of the behavioral monitoring sheets noted staff was not monitoring for signs and symptoms of anxiety. Staff was monitoring for social withdrawal and [MEDICAL CONDITION]. Review of the current care plan found the facility had not developed goals or approaches related to assisting the resident to reach her highest practicable level of functioning related to experiencing anxiety. The care plan merely addressed the dosage, side effects, and dosage reduction attempts for the use of [MEDICATION NAME]. The minimum data set (MDS) coordinator (Employee #8), when interviewed on the afternoon of 06/01/11, was unable to provide any further evidence that the facility had developed an appropriate care plan related to anxiety for this resident. -- b) Resident #20 Review of the medical record found Resident #20 was prescribed and had received [MEDICATION NAME] 10 mg BID and [MEDICATION NAME] 1 mg BID for a [DIAGNOSES REDACTED]. Review of the care plan found no care plan had been developed related to this resident experiencing anxiety. | 2016-01-01 |
| 9234 | 9234 | ROANE GENERAL HOSPITAL, D/P | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2011-06-08 | 309 | D | 0 | 1 | O68G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure one (1) of nineteen (19) Stage II sampled residents did not receive medications beyond the date the physician determined they should be discontinued. Resident identifier: #33. Facility census: 31. Findings include: a) Resident #33 1. Review of the medical record found a physician's progress note, dated 05/25/11, which documented the resident's potassium was mildly elevated and to stop K-Dur. Review of the Medication Administration Record [REDACTED]. An interview with the unit manager (Employee #8), on 06/07/11 at 2:00 p.m., revealed the physician had overlooked writing an order to stop the potassium for this resident. -- 2. Review of the medical record found the resident received [MEDICATION NAME] (antidepressant) 20 mg daily. A physician's orders [REDACTED]. Review of the MAR found nursing staff members gave the resident both the [MEDICATION NAME] 20 mg and the [MEDICATION NAME] 60 mg on 05/06/11. | 2016-01-01 |
| 9235 | 9235 | ROANE GENERAL HOSPITAL, D/P | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2011-06-08 | 329 | D | 0 | 1 | O68G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and and staff interview, the facility failed to assure the drug regimen, for one (1) of nineteen (19) Stage II sampled residents, was free from unnecessary drugs. Resident #33 was prescribed [MEDICATION NAME] 0.25 mg twice-a-day (BID) without adequate indications for its use. Resident identifier: #33. Facility census: 31. Findings include: a) Resident #33 Review of the medical record found Resident #33 was admitted to the facility on [DATE] with orders for [MEDICATION NAME] 0.25 mg BID for anxiety. Review of the behavior monitoring sheets found facility staff was not monitoring for anxiety or signs and symptoms of anxious behaviors. The behavior monitoring sheets indicated staff was monitoring for social withdrawal and [MEDICAL CONDITION]. Review of the current care plan found no goals or interventions related to the resident experiencing anxiety. Review of the 04/22/11 social worker progress note found the following documentation: . She also stated she feels that she is depressed and has been for several years. The progress note did not address nor give evidence to reflect the resident was experiencing anxiety. A subsequent social worker progress note, written on 05/05/11, contained the following language: . She usually refuses to get out of bed and come out of her room. She did indicate she has symptoms of depression and she gave them a frequency of 2 - 6 days over the past two weeks. Her daughters indicate that she has been depressed for a long time and has not been active This note was also devoid of any evidence that the resident was experiencing anxiety. An interview with the social worker (Employee #77), on 06/07/11 at 12:20 p.m., revealed that Employee #77 visited the resident regularly to encourage her to leave her room and participate in facility life and activities. Employee #77 discussed the resident's depression but could offer no indications of the resident experiencing or demonstrating signs and s… | 2016-01-01 |
| 9236 | 9236 | ROANE GENERAL HOSPITAL, D/P | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2011-06-08 | 332 | D | 0 | 1 | O68G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, the facility's medication delivery window policy, and medical record review, the facility failed to ensure a medication error rate less than five percent (5%). Resident identifier: #1. Facility census: 31. Findings include: a) Resident #1 During observation of the facility's medication passes on 06/06/11 and 06/07/11, a licensed practical nurse (LPN - Employee #5) failed to administer Resident #1's medication in a timely manner. Resident #1 had an order for [REDACTED]. On 06/07/11 at 1:13 p.m., Employee #5 again administered Resident #1'[MEDICATION NAME] 24 after the prescribed time. When interviewed on 06/07/11 at 1:30 p.m., the unit manager (Employee #8) could offer no explanation for the error, but she provided a copy of the facility's medication delivery window policy. Review of the medication delivery window identified medications will be delivered to the resident within a window of one (1) hour prior to or one (1) hour after the assigned delivery time. | 2016-01-01 |
| 9237 | 9237 | ROANE GENERAL HOSPITAL, D/P | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2011-06-08 | 354 | F | 0 | 1 | O68G11 | Based on review of facility information, observation, and staff interview, the facility failed to designate a registered nurse (RN) to serve as of the director of nursing (DON) on a full time basis. This deficient practice had the potential to affect all thirty-one (31) residents currently residing in the facility. Facility census: 31. Findings include: a) Review of the entrance information, provided by the facility on 05/31/11, found that Employee #000 was identified as the DON. Observations made throughout this two-week survey noted this individual was not present on the unit. An interview was conducted with Employee #000 at 10:51 a.m. on 06/07/11. She stated she did not work on the long term care unit, nor did she direct the provision of nursing care for the residents residing there. She stated the unit manager provides her with monthly reports related to budgetary and administrative concerns. | 2016-01-01 |
| 9238 | 9238 | ROANE GENERAL HOSPITAL, D/P | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2011-06-08 | 371 | F | 0 | 1 | O68G11 | Based on observation and staff interview, the facility failed to store food items in a manner that maintained sanitary conditions. Containers of food times were not dated when opened, and one (1) freezer unit was not equipped with a thermometer to ensure foods were being stored at the correct temperature. This practice has the potential to affect all residents who consume food by oral means as all residents are served from this location. Facility census: 31. Findings include: a) During a tour of the nourishment kitchen for the skilled unit at 1:05 p.m. on 06/07/11 with the unit manager (Employee #8), the following sanitation issues were noted: a plastic container of honey thickened water and two (2) plastic containers of nectar thickened products (one (1) filled with water and one (1) filled with cranberry juice) were found opened but not labeled with a date when they were opened. A specific label for recording the open date was attached to one (1) container, but it was blank. b) During this same time period, observation found a freezer unit did not have an internal thermometer nor any temperature device on the outside of the equipment. This freezer was located in the nourishment area where food was served from that room directly to the dining room. c) These issues were found with Employee #8, who accompanied the surveyor at the time of observations. | 2016-01-01 |
| 9239 | 9239 | ROANE GENERAL HOSPITAL, D/P | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2011-06-08 | 425 | D | 0 | 1 | O68G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medication administration records (MARs) and staff interview, the facility failed to assure medications ordered for residents were available for administration in a timely manner. Two (2) of nineteen (19) Stage II sampled residents did not receive their 5:00 a.m. medications. Resident identifiers: #1 and #12. Facility census: 31. Findings include: a) Resident #1 Review of the resident's MAR, on 06/07/11 at 10:30 a.m., found Resident #1 was ordered Sinemet 25/250 for a [DIAGNOSES REDACTED]. Review of the MAR indicated [REDACTED]. The medication had been circled, and on the reverse side of the MAR, the nurse documented: Sinemet not available. During an interview on 06/07/11 at 10:45 a.m., the unit manager (Employee #8) confirmed the Seroquel 25/250 was available via the hospital pharmacy. Employee #8 could offer no explanation why the medication was not obtained and given to Resident #1 as ordered. -- b) Resident #12 Review of the resident's MAR, on 06/07/11 at 10:30 a.m., found Resident #12 was ordered Seroquel 50 mg to be given twice a day. The morning dose was circled, and the nurse documented: Seroquel not given - not available. At 06/07/11 at 10:45 a.m., Employee #8 confirmed Seroquel was available via the hospital pharmacy. She further stated, The nurse would just need to request the medication from the hospital pharmacy, and it could be obtained. | 2016-01-01 |
| 9240 | 9240 | ROANE GENERAL HOSPITAL, D/P | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2011-06-08 | 428 | D | 0 | 1 | O68G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure the consultant pharmacist reported irregularities related to the drug regimen for one (1) of nineteen (19) facility residents. Residents #33 received an anxiolytic drug without adequate indications for its use, which was not identified by the pharmacist and reported to the attending physician and director of nursing (DON) as required. Resident identifier: #33. Facility census: 31. Findings include: a) Resident #33 Review of the medical record found this female resident was admitted to the facility on [DATE] with orders for Xanax 0.25 mg twice-a-day (BID). The record contained [DIAGNOSES REDACTED]. Review of the behavior monitoring sheets for April 2011 and May 2011 found the facility was monitoring the resident for social withdrawal and insomnia. The behavior monitoring sheets contained no evidence that nursing staff was monitoring for signs and symptoms of anxiety. An interview with the social services director (Employee #77), on 06/07/11 at 12:20 p.m., revealed Employee #77 was concerned that the resident did not come out of her room, she expressed no interest in out-of-room activities, and she exhibited no desire for conversation. Employee #77 stated the resident appeared very depressed. Employee #77 gave no examples of the resident displaying signs and/or symptoms of anxiety. The consultant pharmacist conducted a drug regimen review on 05/02/11 with documentation of .medications & labs reviewed. The drug regimen report contained no evidence the consultant pharmacist identified the absence of a clinical rationale for use of the Xanax to be communicated to the attending physician and DON. | 2016-01-01 |
| 9241 | 9241 | ROANE GENERAL HOSPITAL, D/P | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2011-06-08 | 431 | F | 0 | 1 | O68G11 | Based on observation and facility staff interview, the facility failed to store drugs in locked compartments which could be accessed only by authorized personnel. This deficient practice had the potential to affect all residents residing in the facility. Facility census: 31. Findings include: a) An inspection of the facility's medication storage, conducted on the morning of 06/09/11, found the facility maintained an unlocked emergency drug box in an unlocked cabinet at the nursing station. The drug box was accessible to all employees, unsupervised residents, and/or visitors. An interview with the unit manager (Employee #8), at 9:30 a.m. on 06/08/11, elicited the facility kept a list of medications stored in the emergency drug box. Review of this list found the following potentially hazardous medications listed: Digoxin, Geodon, Haloperidol, Nitroglycerin, and Warfarin. -- b) Random observations, conducted on the afternoon of 06/07/11, noted a pharmacy employee and nurse stocking medications in the nursing station. The employees were removing medications from three (3) large blue duffel bags. Further observations, during the medication storage inspection conducted the following day on 06/08/11 at 9:30 a.m., noted three (3) large blue duffel bags stacked in the nursing station in clear view from the dining room and resident hallway. With the assistance of a licensed practical nurse (LPN - Employee #27), an inspection of the three (3) large blue duffel bags revealed the zippers of duffel bags were secured by the use of a luggage-type tab which was merely threaded through the rubber loops to hold the bags closed. This tab was easily removed. An inspection of the contents of all three (3) duffel bags found numerous medications intended for return to the pharmacy. Employee #27 confirmed the three (3) duffel bags containing medications had been present at the nursing station as of the afternoon of 06/07/11. The unit manager placed the duffel bags in her office until pick up by the pharmacy. | 2016-01-01 |
| 9242 | 9242 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 246 | D | 0 | 1 | UNLT11 | Based on resident interview, observation and staff interview, the facility failed to ensure a resident's right to receive services with reasonable accommodation of individual needs. One (1) of twelve (12) Stage II sample residents did not have access to her call bell when she needed to be assisted to the bathroom. Resident identifier: #121. Facility census: 61. Findings include: a) Resident #121 On 05/11/11 at 9:07 a.m., during a conversation with the resident, she said she needed to go to the bathroom. She was seated in her wheelchair approximately two and one-half (2 -1/2) feet to the right of her bed. Her call bell was on the floor under her bed. It was also noted the resident had a cast on her right lower arm. While retrieving the resident's call bell for her, this surveyor inadvertently set off the resident's bed alarm. A nursing assistant (Employee #53) responded to the sound of the alarm in approximately two (2) minutes; at that time, he was informed of the resident's request to be taken to the bathroom. After assisting the resident out of the bathroom, Employee #53 asked whether the resident had used her call bell. He said they had been working with her to use her call bell when she needed to go to the bathroom. It was explained to him the call bell had been under the bed and the resident had been unable to reach the call bell. | 2016-01-01 |
| 9243 | 9243 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 274 | D | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a significant change assessment when indicated. One (1) of twelve (12) Stage II sample residents had experienced declines and improvements during the three (3) months between her admission assessment and the following quarterly assessment. These changes had the potential to affect her care needs. A comprehensive assessment was needed to determine possible causal factors for the declines and to determine what interventions might be implemented to reverse, or prevent further, declines. Resident identifier: #90. Facility census: 61. Findings include: a) Resident #90 Review of the resident's admission assessment with an assessment reference date (ARD) of 12/22/10, and her quarterly assessment with an ARD of 03/22/11, found she had experienced declines and improvements in a number of areas. The following changes were noted: 1. Her ability to understand and to be understood declined from usually to sometimes. 2. The score on her Brief Interview of Mental Status (BIMS) score declined from 11 to 3 (with a maximum score of 15). 3. In the section for signs and symptoms of [MEDICAL CONDITION], she had been coded as having none on the admission assessment, while the quarterly assessment indicated she had inattention and disorganized thinking. 4. Her quarterly assessment was coded as her having problems sleeping and feeling tired or having low energy, which had not been present on the admission assessment. 5. She did not have problems concentrating according to her admission assessment. Her quarterly assessment indicated she had problems in this area nearly every day. 6. Her admission assessment indicated she did not have physical behaviors or reject care, but the quarterly assessment indicated both of these were present one (1) to three (3) days a week. 7. She had wandered one (1) to three (3) days according to the admission assessment, but the quarterly assessment indica… | 2016-01-01 |
| 9244 | 9244 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 279 | D | 0 | 1 | UNLT11 | Based on medical record review, staff interview, and observation, the facility failed to develop care plans for two (2) of twelve (12) Stage II sampled residents to address care and services required to meet each resident's medical and nursing needs. Resident identifiers: #90 and #121. Facility census: 61. Findings include: a) Resident #90 Review of the resident's admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/22/10, and her quarterly assessment with an ARD of 03/22/11, found she had experienced declines in continence. Her admission assessment indicated she was frequently incontinent of urine. The quarterly assessment was coded as always incontinent. She was also assessed as having declined from being always continent of bowel on her admission assessment to being frequently incontinent on her quarterly assessment. No care plan had been developed to address the declines in bowel and bladder continence in an attempt to restore her to prior levels of continence or to prevent further decline in these areas. -- c) Resident #121 Review of this resident's care plan found it was identified the resident had a cast on her right arm. However, it was not identified the resident's right side was her dominant side. The care plan did not identify what accommodations / adaptations needed to be implemented to assist the resident in maintaining as much independence as possible. For example, her call bell was on the floor to her right on 05/11/11. If the call bell had been on the bed, it still would have been difficult for the resident to access with her right hand. At lunch time on 05/18/11, observation found the cast on her right arm had been replaced with a splint. She continued to eat with her left hand. She was able to eat, but an adaptive device (such as a scoop plate, a plate guard, or a plate with a raised edge) would have been of benefit in making it easier for her to get food on her fork. | 2016-01-01 |
| 9245 | 9245 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 280 | D | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, and staff interview, the facility failed to review / revise the care plans of two (2) of twelve (12) Stage II sample residents when changes were indicated in their care and treatment. Resident identifiers: #14 and #30. Facility census: 61. Findings include: a) Resident #14 While standing in the corridor outside of Resident #14's room on 05/11/11 at 9:15 a.m., this nurse surveyor observed Resident #14 in his bed slumped toward the right with his head on the siderail. After entering his room, observation found an overbed table placed across his abdominal area with his breakfast tray on top. His head, right arm, and right shoulder were pressed against the siderail of his bed, two (2) pillows were noted on the left side of the resident, and the call bell was wedged under his right side between the air mattress and siderail. The resident had a lift pad beneath him, which did not offer resistance to sliding when in contact with the surface of the air mattress. The resident was noted to have partially masticated eggs on his chin and on the front of his shirt. He complained of having choked on his eggs. The resident was unable to reposition himself away from the siderail when cued. A nursing assistant (NA - Employee #70) responded to a request for assistance. She assisted the resident to move away from the siderail and retrieved the call bell from between the siderail and the air mattress. After repositioning Resident #14, Employee #70 brushed back his hair with her hand, revealing a rectangular reddened area in the shape of the top of the siderail above the resident's right ear. When asked, Employee #70 stated she would report this reddened area to his nurse. She stated the resident chokes easily but had refused to get up that morning. -- An interview with the licensed practical nurse (LPN) responsible for the resident (Employee #27) was conducted at 9:22 a.m. on 05/11/11. She stated the resid… | 2016-01-01 |
| 9246 | 9246 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 309 | E | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility's bowel protocol, the facility failed to institute the bowel protocol for five (5) of ten (10) residents experiencing constipation. Review of the residents' activities of daily living (ADL) flow sheets, medication administration records (MARs), and the facility's standing orders revealed these residents experienced constipation for more than three (3) days before the facility intervened. Resident identifiers: #44, #12, #54, #90, and #27. Facility census: 61. Findings include: a) Residents #44, #12, #54, #90, and #27 1. Resident #44 Review of the resident's April 2011 MAR, on 05/17/11, revealed Resident #44 had no bowel movement (BM) for four (4) days, for which the facility failed to initiate the bowel protocol. On 04/06/11, Resident #44 was given a [MEDICATION NAME] suppository after not having a bowel movement for four (4) days. On 04/07/11, Resident #44 was given a fleets enema. Further review of the MAR found, on 04/20/11 Resident #44, was again given a [MEDICATION NAME] rectal suppository for no bowel movement after four (4) days. According to the bowel protocol (which is described below), staff should have administered a 30 cc dose of milk of magnesia (MOM) for a resident who had no BM after three (3) days. -- 2. Resident #12 Review, on 05/17/11, of Resident #12's April 2011 ADL flow sheet identified this resident had no BM from 04/03/11 through 04/06/11 (four (4) days). On 04/06/11, a [MEDICATION NAME] rectal suppository was given. Further review revealed Resident #12 also went from 04/15/11 through 04/20/11 without a BM. The MAR indicated [REDACTED]. According to the May 2011 ADL flow sheet, on 05/12/11, Resident #12 did not have a BM from 05/12/11 through 05/15/11 (four (4) days). A dose of MOM was given on 05/15/11. -- 3. Resident #54 Review, on 05/17/11, of Resident #54's April 2011 ADL flow sheet revealed this resident had no BM for eight (8) days, from 04/10/11 t… | 2016-01-01 |
| 9247 | 9247 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 323 | J | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to assure that one (1) of twelve (12) Stage II sample residents received the necessary supervision and positioning to prevent choking / aspiration during oral consumption. Resident #14, a [AGE] year old male with [DIAGNOSES REDACTED]. The resident was discovered slumped sideways in his bed at 9:15 a.m. on 05/11/11, with his breakfast tray on an overbed table above his abdomen. His head, right arm, and right shoulder were pressed against the siderail of his bed, with the call bell wedged under his right side between the mattress and siderail. The resident was noted to have partially masticated eggs on his chin and on the front of his shirt. He complained of having choked on his eggs. The resident was unable to reposition himself away from the siderail when cued. Interviews with staff members revealed the resident had experienced an episode of choking earlier the same morning, with staff intervening and repositioning him in the bed. The resident was left unsupervised to continue to eat until discovered by this nurse surveyor. review of the resident's medical record revealed [REDACTED]. Staff was aware he would frequently refuse to get out of bed for meals, and he was evaluated by a speech language pathologist (SLP) to see what could be done to promote safe eating and drinking while in bed. A recommendation was made to have him sitting in an upright position in bed with pillow positioning under his right side to assist him in maintaining this upright position, but this recommendation was not incorporated into the resident's care plan. In fact, his care plan was not revised at all to address his frequent refusals to get out of bed for meals. With regard to the amount of supervision Resident #14 was to receive during meals, the SLP's recommendation for distant supervision was made based on the need to consider the availability of nursing staff… | 2016-01-01 |
| 9248 | 9248 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 328 | D | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and pulse oximeter reading, the facility failed to assure one (1) of twelve (12) Stage II sampled residents received continuous oxygen as ordered by the attending physician. Resident identifier: #30. Facility census: 61. Findings include: a) Resident #30 During random observations of the resident environment on 05/19/11 at 10:15 a.m., Resident #30 was seated in her wheelchair in the middle of the 100 hallway. The resident was noted to have her head tilted back and appeared to be sleeping. Closer observation found the resident displayed an indentation extending from her nares, across her cheek, to her right ear. This type of mark is frequently observed with residents who utilize oxygen via a nasal cannula. No oxygen tank was observed on the back of her wheelchair, nor was any oxygen tubing observed. Review of the resident's medical record found the attending physician ordered the resident to receive oxygen at a rate of 2 liters / minute via nasal cannula continuously for a [DIAGNOSES REDACTED]. This active order was dated 09/13/10. A request was made of the director of nursing (DON - Employee #40 to check the resident's oxygen saturation at 10:18 a.m. on 05/19/11. The DON then asked a licensed practical nurse (LPN - Employee #67) to check the resident's oxygen saturation. Employee #67 obtained a pulse oximeter and checked the resident's oxygen level while the resident was in the dining room. The initial reading on the pulse oximeter was 89%. As the resident was stimulated with conversation, her reading increased to 92%. | 2016-01-01 |
| 9249 | 9249 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 360 | E | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to assure seven (7) of sixty (60) residents receiving an oral diet containing an adequate amount of protein for the evening meal; the dietary staff failed to prepare pureed turkey in a manner to assure residents on a pureed diet received 2 ounces of turkey as required by the planned menu. Additionally, the facility failed to assure one (1) of twelve (12) Stage II sample residents was provided the ordered amount of nutritional supplement. Resident identifiers: #29, #44, #46, #55, #63, #66, #83, #90, and #7. Facility census: 61. Findings include: a) Residents #29, #44, #46, #55, #63, #66, #83, and #90 During observations of the evening meal service on 05/16/11, the cook (Employee #61) was observed portioning pureed turkey with a 2 ounce scoop. Review of the menu found residents were to receive a turkey sandwich for dinner. Employee #61 was not observed to serve pureed bread with the pureed diets. When asked why residents did not receive pureed bread, Employee #61 stated he had pureed the turkey and bread together. The dietary manager (Employee #5) was asked, at 4:50 p.m., how much protein residents on pureed diets were to receive. She stated the residents on pureed diets were to receive 2 ounces of pureed turkey. When asked how Employee #61 was providing 2 ounces of turkey when he had pureed turkey and bread together and was utilizing a 2 ounce scoop to serve the combined food items, she agreed the residents were not receiving 2 ounces of turkey and gave Employee #61 a 3 ounce scoop to utilize for service of the pureed turkey / bread mixture to residents on a pureed diet. -- b) Resident #7 During morning medication pass on 05/17/11, the nurse said the resident was to receive 4 ounces of Hi-Cal (a nutritional supplement) as she poured the liquid into a small plastic cup. She poured up to the lowest decorative line on the cup. The same type of cup used during the medication pass was la… | 2016-01-01 |
| 9250 | 9250 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 371 | F | 0 | 1 | UNLT11 | Based on observation and staff interview, the facility failed to assure dietary personnel prepared and distributed food in a sanitary manner. This deficient practice had the potential to affect sixty (60) of sixty-one (61) residents who consumed an oral diet. Facility census: 61. Findings include: a) During the evening meal service on 05/16/11 at 4:20 p.m., observation found a small food bar set-up in the resident dining room. Residents and staff referred to this arrangement as the cafe. Staff members obtained individual plates of food and bowls of soup from the cook for delivery to the residents seated in the dining room. This created a restaurant-like atmosphere. Observation further noted that dietary slips were arranged on a table in front of the food bar. Numerous staff members in the dining room handled the dietary slips with their bare hands. During the service, staff members handed the cook the dietary slips, who would place them on top of the eating surface of a clean plate. The cook would then place food on these contaminated plates for service to the residents in the dining room. Prior to beginning the food service, the cook was observed at 4:20 p.m. on 05/16/11 to enter the cafe area from the resident hallway. Without washing his hands, the cook donned gloves in preparation to begin assembling turkey sandwiches. When asked where he had come from, the cook (Employee #61) stated he had been fixing the handrail in the resident hallway. After this prompting, Employee #61 removed the gloves and washed his hands. Observations of the meal service noted Employee #61 would repeatedly use his gloved hands to pull up the back of his pants and touch other parts of his clothing. He would then use the contaminated gloves to touch white bread, tomato, lettuce, and slices of turkey to assemble the turkey sandwiches being served for the regular consistency diets. When this practice was brought to the attention of the dietary manager (Employee #5), she stated Employee #61 tended to fidget when nervous. -- b) Initial din… | 2016-01-01 |
| 9251 | 9251 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 425 | D | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain medications in a timely manner for administration to two (2) of twelve (12) Stage II sample residents. The facility failed to assure Resident #67 received Ativan 2 mg as prescribed by the attending physician, for treatment of [REDACTED].#7 in a timely manner. Resident identifiers: #67 and #7. Facility census: 61. Findings include: a) Resident #67 Review of Resident #67's medical record found an order by the attending physician written on 05/01/11 for Ativan 2 mg at bedtime for treatment of [REDACTED]. During an interview with a registered nurse (Employee #84) on 05/17/11 at 1:22 p.m., she was asked why the resident missed two (2) doses of Ativan 2 mg after it was ordered by the physician. Employee #84 relayed they did not have a prescription to send to the pharmacy. When asked why the medication was not obtained from the emergency drug box, she stated nursing staff should have contacted the physician and requested they call the pharmacy to provide an access code which would allow the nursing staff to remove this controlled medication from the emergency drug box. -- b) Resident #7 On 05/17/11 at 8:30 a.m., a licensed practical nurse (LPN - Employee #27) was observed administering medications to this resident. During reconciliation of medication pass to this resident on 05/17/11 at approximately 10:50 a.m., it was noted the resident had not received the medication Prilosec that morning. The MAR, when checked to ascertain the time it was scheduled to be given, indicated the medication should have been given during the morning medication pass. At 11:18 a.m., Employee #27 was asked about the Prilosec. She said the resident was out of the medication. She was asked to verify this by checking the medication cart. There was an empty box in the drawer of the medication cart for this resident. Review of the medications available in the emergency medication box found Prilos… | 2016-01-01 |
| 9252 | 9252 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 431 | F | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on inspection of medication storage rooms, the facility had failed to ensure medications and supplies were stored in a safe and orderly manner. Expired medications, improperly stored medications, expired ancillary items, and expired non-medication items were found stored in a disarrayed fashion. This had the potential to affect all residents receiving medications. Facility census: 61. Findings include: a) Medication storage rooms On 05/19/11 at approximately 4:00 p.m., inspection of the medication storage rooms found the following (this list is not all inclusive): -- A gastrostomy tube that was labeled as having been sterile stamped by the manufacturer as Use by [DATE] -- 2 ml Monoject safety syringes that expired 02/2011 -- An open 10 ml vial of bacteriostatic sodium chloride with less than half of the solution remaining was not labeled to indicate when it had been opened -- Two (2) tabs of Lipitor 40 mg were found loose in a drawer -- One (1) bag of mixed meds including Amoxicillin, Cephalexin,Warfarin of various strengths, Cipro 500, Lisinopril 40, Coreg, Bactrim, Lasix- various strengths , Levaquin, Nexium, Chlorpromazine, Clindamycin, etc. There were over fifty (50) pills in the bag. -- A book of Bible Puzzles for Kids -- Four (4) Vacutainers for urine that had an expiration date of 04/2007 -- An IV connecter that expired 11/2009 -- A Micro-tainer that had expired December 1999 -- Seven (7) Vacutainers (purple top) that had passed their expiration dates -- Applicators that had expired 10/10 , 10/08, 12/06 -- An IV start kit that had expired 10/10 -- A contaminated Foley catheter -- IV supplies and urinary catheters were found stored in drawers in a haphazard manner -- Three (3) vials of Influenza Virus Vaccine that were open, with no date to indicate when they were opened. Additionally they were stamped by the manufacturer as expiring 03/31/11 -- One (1) vial of Influenza Virus Vaccine that was opened and dated 11/14/10, that had e… | 2016-01-01 |
| 9253 | 9253 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 441 | F | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of facility surveillance data, review of hand hygiene guidelines from the Centers for Disease Control and Prevention (CDC), and review of facility policies and procedures, the facility failed develop and implement an infection control program to prevent the development and spread of disease. Surveillance data was not analyzed to determined whether there were trends and / or patterns of infection, employees did not perform handwashing using accepted guidelines, clean gloves were not handled in a manner to prevent contamination before use, the scoop for [MEDICATION NAME] was not stored to prevent contamination of the product, and the tip of the dropper bottle for eye drops was contaminated during medication administration. All residents had the potential to be affected by these practices. Facility census: 61. Findings include: a) Initial dining observation In the main dining room during the evening meal on 05/09/11, two (2) dietary staff (Employees #61 and #72) were observed preparing the meals for the residents at a table in the dining room. Two (2) skillets were being used to prepare grilled cheese sandwiches. Employee #61 was observed handling the grilled cheese with gloved hands. At one point, Resident #58 said she wanted chicken soup, not the tomato soup that was being served. This was communicated to a staff member when she served. The staff member informed Employees #61 and #72 of Resident #58's request. Employee #72 reached under the table with his gloved hand and removed a can of chicken noodle soup. He then handled a grilled cheese sandwich before opening the can of soup. After putting the soup in a bowl and putting it into the microwave behind the table, he returned to the table. He proceeded to handle another grilled cheese sandwich and added Tater Tots to a plate. Both items were handled with the same gloves worn when the soup was opened and microwaved. A few minutes later, Employee #61… | 2016-01-01 |
| 9254 | 9254 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 492 | D | 0 | 1 | UNLT12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and a review of the West Virginia Board of Pharmacy, West Virginia Code of State Rules, the facility failed to comply with the rules set forth by the board of pharmacy related to labeling of medication for one (1) of eight (8) sampled residents. Resident identifier: #21. Facility census: 58. Findings include: a) Resident #21 On 07/21/11 at approximately 2:00 p.m., the medical record for Resident #21 revealed a physician's orders [REDACTED].) The order, written at 10:00 p.m. on 07/15/11, stated: (symbol for 'change') [MEDICATION NAME] to 66 ml BID (twice per day). The Medication Administration Record [REDACTED]. On 07/22/11 at approximately 3:00 p.m., Employee #76 (registered nurse / nurse practice educator) and Employee #77 (a corporate registered nurse) provided a copy of the label attached to the bottle of [MEDICATION NAME]. The label contained the resident's name as well as the date 07/14/11. The label indicated the following dosage instructions: 22.5 ml by mouth every eight (8) hours. The bottle also identified the contents of the medication as [MEDICATION NAME] 10 gm/15 ml solution. The West Virginia Board of Pharmacy, West Virginia Code of State Rules, states: 19.13.2. To dispense, deliver, or distribute a prescription drug order accurately as prescribed. For the purposes of this paragraph 'accurately as prescribed' means a. To the correct patient (or agent of the patient) for whom the drug or devise was prescribed; b. with the correct drug in the correct strength, quantity, and dosage from ordered by the practitioner; a pharmacist may substitute a generic drug pursuant to W.Va. Code? 30-5-12b; and c. With correct labeling (including directions for use) as ordered by the practitioner. On 07/22/11 at approximately 3:30 p.m., Employees #76 and #77 confirmed the label on the bottle of [MEDICATION NAME] did not accurately reflect the current order by the prescribing practitioner. | 2016-01-01 |
| 9255 | 9255 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 502 | D | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure an ordered laboratory test was completed timely. One (1) of twelve (12) Stage II sample residents did not have a metabolic panel completed as ordered after she was found to have a critically low serum potassium level. Resident identifier: #27. Facility census: 61. Findings include: a) Resident #27 A basic metabolic panel (BMP) was ordered on [DATE] to be done in three (3) days. The results of the complete metabolic panel (CMP), completed on 04/18/11, showed the resident had a potassium of 2.4, which was noted to be a critical level (normal 3.5 - 5.2 according to the lab printout). The physician ordered the resident's [MEDICATION NAME] be reduced from 80 mg TID (three (3) times a day) to 80 mg BID (two (2) times a day) and her potassium chloride be increased from 20 mEq in the morning and 40 mEq at night to 40 mEq BID. Review of the medical record, on the mid-afternoon of 05/18/11, did not find the results of the BMP that should have been completed on 04/22/11. Employees #25 (the ward clerk) and #83 (a registered nurse) looked in the physicians' notebooks, reports that needed to be filed, the resident's medical record, and elsewhere. The results could not be located. Employee #83 found the treatment book, where it was indicated the day the BMP was scheduled and the nurse had written REF. The nurse said this meant the resident had refused the test. The nursing entries were reviewed, but there was no mention of the resident's refusal of the lab study. There was no indication the physician had been made aware of the resident's refusal. There was no evidence further attempts were made to collect the needed specimen. | 2016-01-01 |
| 9256 | 9256 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 508 | D | 0 | 1 | UNLT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain an ordered chest x-ray for one (1) of twelve (12) Stage II sample residents in a timely manner when ordered by the attending physician. An x-ray that was ordered by the physician to be obtained on 03/25/11 was not obtained until 03/29/11. Resident identifier: #14. Facility census: 61. Findings include: a) Resident #14 Review of the medical record found that, on 03/24/11, the attending physician ordered the facility to obtain a chest x-ray on 03/25/11. The physician also ordered, on 03/24/11, the antibiotic medication [MEDICATION NAME] 500 mg every day for seven (7) days. Review of the Medication Administration Record [REDACTED]. The medical record did not contain evidence of the chest x-ray results which was ordered to be obtained on 03/25/11. On the morning of 05/19/11, the director of nursing (DON) was asked for the results from the chest x-ray ordered by the attending physician (which was to have been obtained on 03/25/11). She provided a report which evidenced that the facility did not obtain the chest x-ray until 03/29/11, six (6) days after the resident began receiving antibiotics. An interview was conducted on 05/19/11 at 10:40 a.m. with the ward clerk, Employee #25. She stated she was responsible for scheduling the tests ordered by physicians. When asked why Resident #14 did not receive the ordered chest x-ray until 03/29/11, she relayed that she works Monday through Friday. She stated that she called their contracted mobile x-ray company on 03/25/11 to request the chest x-ray. She then returned on Monday, 03/28/11 and noted that the x-ray had not been done. She stated that she called them again and they did not come until 03/29/11. The DON, who was present in the nursing station during the interview with Employee #25, stated the facility can obtain ordered x-rays 24/7 (twenty-four hours a day / seven days a week). She relayed that, if needed, residents … | 2016-01-01 |
| 9257 | 9257 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2011-05-19 | 514 | E | 0 | 1 | UNLT11 | Based on medical record review and staff interview, the facility failed to maintain clinical records in accordance with accepted professional standards and practices. Review of activities of daily living (ADL) flow sheets for nine (9) of twelve (12) Stage II sample residents found staff failed to follow accepted practices for correcting errors in entries. The section of each ADL flow sheet related to frequency of bowel movements contained entries that had been written over. Resident identifiers: #44, #110, #121, #67, #12, #82, #54, #39, and #27. Facility census: 61. Findings include: a) Residents #44, #110, #121, #67, #12, #82, #54, #39, and #27 Review, on 05/17/11, of the facility's records of ADL flow sheets found the record of Residents #44, #110, #121, #67, #12, #82, #54, #39, and #27 to have incorrect documentation of bowel movements. Resident records for 04/01/11 through 05/17/11 were reviewed. The nursing assistants document the frequency of bowel movements for each of these residents on the ADL flow sheets. Review of these records identified inaccurate correction of errors. The nursing assistants had written in zeros (0), identifying the residents to not having a bowel movement. These zeros (0) were written over identifying entries indicating the residents did have bowel movements. Interview with the director of nursing (DON - Employee #40), at 2:50 p.m. on 05/17/11, identified the facility had inserviced staff on proper correction of documentation errors in August 2010. She further stated, They know not to do this. Review, on 05/17/11, of the ADL flow sheets identified a designated area for errors to be corrected. During an interview with the MDS nurse (Employee #52) on 05/18/11 at 2:00 p.m., she reported having inserviced the nursing staff on this in August 2010. | 2016-01-01 |
| 9258 | 9258 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2013-01-30 | 309 | G | 1 | 0 | 7W2211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being for one (1) of seven (7) sampled residents. The facility failed to assess, monitor, and provide interventions to potentially prevent hospitalization of a resident with a urinary tract infection, [MEDICAL CONDITIONS], and mental status changes. Resident identifier: #63. Facility census: 61. Findings include: a) Resident #63 Review of the medical record, on 01/28/13 at 2:30 p.m., revealed an interdisciplinary note completed on 12/24/12 at 10:00 p.m. It noted the resident's temperature was 101.3 degrees Fahrenheit. Tylenol was administered for the fever. On 12/25/12 at 6:35 a.m., according to a nursing entry, the resident's temperature was 101.8 and his apical heart rate was 109. He was suctioned for copious amount of sputum . MD (physician) faxed. On 12/25/12 at 7:10 a.m., a nurse noted rales scattered throughout bilateral lungs, oxygen saturation was 77-82%. His oxygen was applied at 4 lpm (liters per minute) and his sat (oxygen saturation) increased to 86%. The physician was notified at 7:20 a.m., and the resident was transferred to the hospital. A physician's orders [REDACTED]. Another order, dated 12/22/12, indicated a urinalysis with culture and sensitivity (U/A C&S) was to be obtained on 12/23/12 Further review of the medical record, revealed a hospital discharge summary, dated 01/10/13. It verified Resident #63 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Additionally, a hospital progress note, dated 12/26/12, noted altered mental status due to infection, dehydration, underlying dementia, and [MEDICAL CONDITION]. A hospital history and physical visit note, dated 12/27/12, noted the chief complaint on admission was altered mental status and shortness of breath . while at the nursing home the resident was found to have alter… | 2016-01-01 |
| 9259 | 9259 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2013-01-30 | 327 | G | 1 | 0 | 7W2211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to ensure a resident received sufficient fluid intake to maintain proper hydration and health. One of seven (7) sample residents was transferred to the hospital and admitted with the [DIAGNOSES REDACTED].#63. Facility census: 61. Findings include: a) Resident #63 Review of the medical record, on 01/28/13 at 2:30 p.m., included a review of a hospital discharge summary. It verified Resident #63 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Lab results included a blood urea nitrogen (BUN) of 36, Serum Creatinine (Cr) of 1.5, and Serum Sodium (Na) of 161 on the date of admission. On 01/08/13, the hospital lab report indicated the resident ' s BUN was 13, Cr was 1.00 and Na was 147. Upon admission to the hospital the urine was noted as, turbid in clarity. A hospital history and physical visit note, dated 12/27/12, described the chief complaint on admission was altered mental status and shortness of breath. . while at the nursing home the resident was found to have altered mental status compared to his baseline as well as a low oxygen saturation and low grade fevers . On arrival to the emergency department, the patient was significantly obtunded (mentally dulled) as well as being significantly tachypneic (rapid respirations) with gurgling respiration . was significantly hyperglycemic (high blood sugar) . The patient had a corrected sodium value 168 with estimated free water deficit of 7.4 liters. The patient appeared to be severely dehydrated, and per patient's family had significantly decreased p.o. (oral) intake over the past several weeks . The patient was volume resuscitated with two liters of [MEDICATION NAME] ringers with some improvement in blood pressure. The patient remained significantly obtunded. On 12/28/12, an interdisciplinary note, completed by the licensed social worker, noted . Fluid intake reviewed for month of December with adequate inta… | 2016-01-01 |
| 9260 | 9260 | CAMERON NURSING AND REHABILITATION CENTER, LLC | 515125 | ROUTE 4, BOX 20 | CAMERON | WV | 26033 | 2011-10-05 | 159 | D | 0 | 1 | JZU011 | Based on record review and staff interview, the facility failed to obtain written authorization for the management of personal funds from the legal representative of one (1) of five (5) sampled residents. Resident identifier: #40. Facility census: 55. Findings include: a) Resident #40 Review of the financial records of five (5) sampled residents for whom the facility managed personal funds found an account was being managed by the facility for Resident #40. Further review found no evidence the resident or a legal representative with the authority to make financial decisions on the resident's behalf had provided written authorization permitting the facility to manage the resident's personal funds. This was verified by Employee #47 ( who was assisting with the review) at 2:00 p.m. on 10/04/11, and acknowledged by the director of nurses and the administrator at 2:30 p.m. on 10/04/11, after they had reviewed the records. | 2016-01-01 |
| 9261 | 9261 | CAMERON NURSING AND REHABILITATION CENTER, LLC | 515125 | ROUTE 4, BOX 20 | CAMERON | WV | 26033 | 2011-10-05 | 225 | D | 0 | 1 | JZU011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility record review, policy review, and staff interview, the facility failed to immediately report an incident involving possible neglect to the appropriate State officials and/or to investigate the incident which involved a fall resulting in a resident sustaining a fracture. This affected one (1) of thirty-two (32) Stage II sample residents. Resident identifier: #42. Facility census: 55. Findings include: a) Resident #55 Medical record review revealed Resident #42 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This resident had been determined to lack capacity to form her own medical decisions and had a court-appointed guardian for several years. A review of the physician's orders [REDACTED]. The following was added on 12/28/10: Transfer order: transfer with two assist and gait belt, wheelchair for mobility w/i (within) facility. A new order was written on 07/26/11, stating: Transfer order: transfer with two assist and sit to stand lift. The ambulation order was discontinued except for physical therapy, and she was to be turned every two (2) hours. The resident's physical status had deteriorated, and the physical therapy record stated that, during the treatment period from 07/25/11 through 08/11/11, the resident had poor balance and was unable to stand at all on several occasions during this treatment period. The notes attributed this to weakness caused by a recent bout of pneumonia. At the time of her fall on 08/11/11, she had met none of her therapy goals. A review of the quarterly minimum data set assessment (MDS) with an assessment reference date of 07/21/11 found the assessor indicated the resident required physical assistance from 2 + persons for transfers, she was not steady getting on and off the toilet, and she could only stabilize with assistance. The resident sustained [REDACTED]. The incident report completed by the licensed practical nurse (LPN - Employee #7)… | 2016-01-01 |
| 9262 | 9262 | CAMERON NURSING AND REHABILITATION CENTER, LLC | 515125 | ROUTE 4, BOX 20 | CAMERON | WV | 26033 | 2011-10-05 | 226 | D | 0 | 1 | JZU011 | Based on record review and staff interview, staff did not follow the Reporting / Response section of the facility's policy for reporting allegations of abuse or neglect by not indicating in their Five Day Follow-Up - Nursing Home Program either the outcome of the investigation or the complete corrective action taken by the facility for one (1) of three (3) reports reviewed. Resident identifier: #29. Facility census: 55. Findings include: a) Resident #29 Review of the facility's self-reported allegations of abuse / neglect found that, on 05/17/11, the daughter of Resident #29 reported the following, which was recorded on a grievance / concern report form (quoted as written): daughter stated that while resident was out to appointment 'that girl lifted my mom into the seat of the van without a gait belt. I don't think she knows how bad my mom's arms are. If she whines tonight that her arms hurt that is why.' On 05/18/11, the facility submitted the following allegation to the State survey agency on a form titled Immediate Fax Reporting of Allegations - Nursing Home Program: While transferring patient from wheelchair to facility van sent nurse did not use gait belt as ordered by physician. Patient complained of Left arm pain on 5/18/11. On 05/18/11, the facility submitted a form titled Five Day Follow-Up - Nursing Home Program stating the following under the heading Outcome / Results of Investigation (quoted as written): X-rays of Left arm were negative for any fracture or dislocation. Heat wrap applied to left shoulder. Under the heading titled Corrective Action By Facility was written: Nurse reeducated to use of gait belt and following physician orders. In an incident summary, the reporter noted the alleged perpetrator stated (quoted as typed) . she wrapped she did not pull or move patient's arms during the transfer . she wrapped her arms around patient's waist and with patient's help completed the transfer. She stated that during transport resident was complaining of seatbelt strap was hurting her arm. The facility… | 2016-01-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );