cms_WV
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126 rows where "filedate" is on date 2016-05-01
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8507 | 8507 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-05-31 | 280 | E | 1 | 0 | WD3X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy review, and staff interview, the facility failed to revise residents' care plans to include the infection control precautions required by the facility's recognized Infection Control Plan for four (4) of twenty-two (22) sampled residents who were been determined by their physicians to be colonized with a [MEDICAL CONDITION] (MDRO) and/or a ,[MEDICAL CONDITION].-difficile ([MEDICAL CONDITION]) infection. Resident identifiers: #24, #104, #107, and #53. Facility census 120. Findings include: a) Resident #24 A review of the medical record of Resident #24, at 11:10 a.m. on 05/30/13, revealed a 17 page care plan initiated on 02/28/13, with a revision date of 03/09/13 and a target date of 06/20/13. The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. A rectal culture obtained on 03/20/13, revealed the presence of [DIAGNOSES REDACTED] pneumoniae + ESBL (Extended spectrum B-lactamase producing [MEDICATION NAME]), although a notation on the bottom of the culture report stated the resident was symptom-free. Neither the initial care plan, nor the care plan revised on 03/09/13 included the establishment of a measurable goal for preventing the transmission of the known colonized infection through the interventions associated with isolation precautions as required by the facility's infection control plan. During an interview with Employees #80 and #30 (MDS nurses) at 9:00 a.m. on 05/31/13, Employee #80 stated it was the nurses' responsibility to initiate the care plan after the admission process. She stated that only if the admission minimum data set (MDS) assessment triggered an area not included in the care plan, did the MDS nurse make an addition. At the time of the admission MDS, on 03/06/13, the laboratory screening for a multidrug resistant organism (MDRO) had not been done. At 9:15 a.m. on 05/31/13, the DON presented pages 10, 11, and 12 of a 26 page care plan with the revision date of 05/30/1… | 2016-05-01 |
| 8508 | 8508 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-05-31 | 441 | D | 1 | 0 | WD3X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility record review, and staff interview, the facility failed to maintain and appropriately track one (1) of four (4) residents with an active physician's orders [REDACTED]. Resident identifier: #29. Facility census: 120. Findings include: a) Resident #29 A general tour of the facility was made at 3:45 p.m. on 05/29/13, accompanied by the Administrator and the Director of Nurses (DON). They provided a copy of the HOM Bed Board, and explained that it was a list of all residents, generated daily, and was color-coded to allow for easy identification of the source of their infections. The report indicated the following numbers of residents positive for: -- VRE ([MEDICATION NAME]-Resistant [MEDICATION NAME]) - 5 -- CRKP (Carbapenem-Resistant [DIAGNOSES REDACTED] Pneumonia) - 23 -- MRSA (Methicillin-Resistant Staphylococcus aureus) - 19 -- ESBL (Extended spectrum B-lactamase-producing organisms) - 14 --[DIAGNOSES REDACTED] (Clostridium Difficile) - 2 They pointed out the signage on the rooms occupied by the residents affected. When asked if the residents had active infections or were colonized, they stated that all were colonized except three (3). When asked which residents were active, the DON stated that Residents #27, #78, and #83 were the only residents presently in active isolation. The remaining residents were under precautionary measures only, due to colonization. When asked if the Bed Board report indicated which were in active isolation, they replied that it did not. The DON stated that if the resident was active there would be an isolation cart outside the door. This was confirmed by Employee #2 (Registered Nurse) who was interviewed while administering medications at 4:10 p.m. on 05/29/13. Employee #2 stated that identification of who was on active isolation was by the isolation cart outside the room, information on the 24-hour report at the nurses' schedule, or by viewing an isolation sticker on the in… | 2016-05-01 |
| 8509 | 8509 | ST. JOSEPH'S HOSPITAL, D/P | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2013-01-10 | 225 | E | 0 | 1 | IYJG11 | Based on review of personnel records and staff interview, the facility failed to ensure reasonable efforts were made to verify there were no past criminal prosecutions of potential employees. Prior to hiring, the facility's investigations of past histories for potential employees did not include a West Virginia (WV) statewide investigation for five (5) of five (5) employees reviewed. Employee identifiers: #3, #13, #22, #29, and #10. This practice had the potential to affect more than a limited number of residents. Facility census: 13. Findings include: a) A review of personnel records, at 1:00 p.m. on 01/08/13, failed to find evidence of a WV statewide criminal background check for the following employees: Employee: Hire Date: -- #3 Registered Nurse 09/24/12 -- #13 Nurses Aide 12/19/11 -- #22 Dietary Aide 09/20/10 -- #29 Certified Dietary Manager 09/17/12 -- #10 Nurses Aide 11/11/10 These findings were reviewed with the Nurse Manager (Employee #1) at 3:00 p.m. on 01/08/13. She stated she would contact Human Resources for an answer. During an interview with Employee #33 (Human Resources Representative) and Employee #1, at 1:45 p.m. on 01/09/13, they acknowledged the facility had ceased doing fingerprinting which had been sent to the WV State Police for a criminal background check. They described the facility had contracted to a security company whom they assumed was providing the facility with the required information. After reviewing the files, they agreed that only a check of counties of residency, provided by the potential employee, was being done. | 2016-05-01 |
| 8510 | 8510 | ST. JOSEPH'S HOSPITAL, D/P | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2013-01-10 | 226 | C | 0 | 1 | IYJG11 | Based on a review of employee personnel files, policy review, and staff interview, the facility failed to develop policies which required the screening of all potential employees to include a West Virginia (WV) statewide criminal background investigation as directed by the WV State survey agency. Five (5) of five (5) employees reviewed for this requirement did not have this screening. This practice had the potential to affect more than a limited number of residents. Employee identifiers: #3, #13, #22, #29, and #10. Facility census: 13. Findings include: a) A review of employees' personnel files, on 01/08/13, revealed the files for Employees #3 (a professional nurse); #13 and #10 (nurses aides); #22 (dietary aide) and #29 (a dietary manager) had no evidence of a statewide criminal background check for WV. During an interview with Employee #33 (Human Resources Representative) and Employee #1 (Nurse Manager for Long Term Care), at 1:45 p.m. on 01/09/13, they acknowledged the facility had ceased doing fingerprinting which had been sent to the WV State Police for a criminal background check. They stated the facility had contracted to a security company whom they assumed was providing the facility with the required information. After reviewing the files, they agreed that only a check of counties of residency, provided by the potential employee, was being done. b) A copy of the facility's Pre - Employment Investigation policy was provided. It had a requirement for a Criminal Background Check, but did not identify the check was to be a WV statewide check. After verifying the requirements with the Office of Health Facility Licensure and Certification, it was explained that a criminal background investigation through the WV State Police was required. This information was provided in a newsletter, which was distributed to all WV licensed nursing homes and Medicare/Medicaid certified nursing facilities in November 2004. | 2016-05-01 |
| 8511 | 8511 | ST. JOSEPH'S HOSPITAL, D/P | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2013-01-10 | 272 | D | 0 | 1 | IYJG11 | Based on medical record review, resident interview, and staff interview, the facility failed to ensure the accuracy of the minimum data set (MDS) assessment related to a resident's oral/dental status. This was found for one (1) of three (3) Stage II sample residents reviewed for oral/dental care. Resident identifier: #8. Facility census: 13. Findings include: a) Resident #8 Review of the medical record, on 01/08/13, revealed the resident had a missing filling/or decayed tooth. The Nurses' Summary: Seven Day Look Back form, dated 11/16/12, verified the resident had loose or broken natural teeth, under the section labeled oral/dental status. The resident's last dental visit, on 10/17/12, identified the resident had a missing filling or decayed tooth. When the resident was asked, on 01/08/13 at 12:50 p.m., she acknowledged the last time the dentist evaluated her teeth there was a problem with one of her teeth. She stated she chose not to do anything because it was not bothering her other than causing some sensitivity. Review of the annual Minimum Data Set (MDS) assessment, with an assessment reference date of 11/18/12, under section L0200, found an entry code of Z indicating None of the above were present. This should have been coded as D indicating obvious or likely cavity or broken natural teeth. An interview with Employee #4, the Patient Care Coordinator, on 01/08/13 at 1:40 p.m., confirmed the MDS assessment had been coded incorrectly. | 2016-05-01 |
| 8512 | 8512 | ST. JOSEPH'S HOSPITAL, D/P | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2013-01-10 | 279 | D | 0 | 1 | IYJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview, the facility failed to develop a comprehensive care plan which described the care and services necessary to meet the medical, mental, and/or psychosocial needs for three (3) of sixteen (16) Stage II sampled residents. There was a failure to accurately develop a care plan for oral/dental care for one (1) of the residents and a failure to accurately develop a care plan for anticoagulant therapy for two (2) residents. Resident identifiers: #8, #10, and #3. Facility census: 13. Findings include: a) Resident #8 Review of the medical record, on 01/08/13, revealed the resident had a missing filling/or decayed tooth and a history of inflamed gums. A review of the current care plan for Resident #8 (last reviewed by the facility staff on 11/21/12) found no evidence of goals or interventions for oral/dental care. The resident's last dental visit identified the resident had a missing filling or decayed tooth. The resident commented, on 01/08/13 at 12:50 p.m., the last time the dentist had evaluated her teeth there was a problem with one of her teeth. She said she chose not to do anything because it was not bothering her. The resident stated she had problems with sensitivity at times, and had sensitive tooth paste to use. An interview with Employee #4, the Patient Care Coordinator, on 01/08/13 at 1:40 p.m., confirmed the resident's care plan lacked goals and interventions for oral/dental care. b) Resident #10 Review of the medical record, on 01/09/13, revealed the resident was receiving [MEDICATION NAME] for anticoagulant therapy. A review of the current care plan for Resident #10 (last reviewed by the facility staff on 12/04/12) found no goals and interventions regarding anticoagulant therapy. An interview with Employee #4, the Patient Care Coordinator, on 01/09/13 at 11:45 a.m., confirmed the care plan lacked goals and interventions related to the resident's anticoagulant therapy. … | 2016-05-01 |
| 8513 | 8513 | ST. JOSEPH'S HOSPITAL, D/P | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2013-01-10 | 280 | D | 0 | 1 | IYJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to review and revise the care plan to include changes in the health care status for two (2) of sixteen (16) sample residents. The care plans did not denote the changes in stages of pressure ulcers and/or fall status, or the changes in nursing interventions related to these problems. Resident identifiers: #6 and #16. Facility census 13. Findings include: a) Resident #6 A review of the medical record for Resident # 6 revealed she fell on [DATE], while self-propelling her wheelchair in the hall. The nurse's note stated she was found . lying on her right side in the hallway in front of her wc (wheelchair). The initial nursing assessment, on 11/01/12, stated, Upon examination, she was noted to have a large hematoma on the back of her head and a reddened area on her right hip. The same note stated, Medicated with Tylenol per order for perceived discomfort. On 11/06/12, the nurse's notes indicated, Staff reports that resident voiced c/o (complaints of) discomfort during t/r (turning/repositioning) this shift. On 11/07/12 a large bruise was found on the resident's right elbow. These complaints of discomfort continued. On 11/15/12, the physician increased the resident's pain medication and the family was notified. The care plan was reviewed by the facility on 12/11/12. Falls and pain were noted as problems; however, no revisions were made to reflect the resident's current status regarding falls and pain. The entry under falls was based on a history of falls. It did not acknowledge the actual fall on 11/01/12, even though the fall occurred prior to the care plan review date. The goal was not revised, and continued to state: Resident will continue to be free of falls through next evaluation. There were no new interventions. The entry under the problem of pain addressed only . pain r/t (related/to) [MEDICAL CONDITION]. It did not address the newer complaints of p… | 2016-05-01 |
| 8514 | 8514 | ST. JOSEPH'S HOSPITAL, D/P | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2013-01-10 | 309 | D | 0 | 1 | IYJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of incident reports, and staff interview, the facility failed to adequately assess pain for one (1) of three (3) residents sampled due to a history of falls. The resident continually expressed pain after a fall. The was no evidence the facility assessed the resident for causal factors for the pain to ensure appropriate interventions were initiated to relieve the pain. Resident identifier: #6. Facility census: 13. Findings include: a) Resident #6 Review of incident reports and nurses' notes revealed Resident #6 fell at 10:50 a.m. on 11/01/12, while self-propelling her wheelchair in the hall. The nurse's note stated she was found . lying on her right side in the hallway in front of her wc (wheelchair). The initial nursing assessment, on 11/01/12, stated, Upon examination, she was noted to have a large hematoma on the back of her head and a reddened area on her right hip. The same note stated, Medicated with Tylenol per order for perceived discomfort. She was determined to be able to move all extremities and was moved with a lift to a wheelchair, and transferred to bed. The Fall Event summary indicated the level of injury was minor with a harm score of D. The definition of D was: An event occurred that req'd (required) monitoring to confirm that it resulted in no harm and/or required intervention to prevent harm. Her assessment was: Resident is alert and capable of moving all extremities without difficulty. The following information was gathered from the nurses notes: - 11/02/12: She was verbally loud when being turned as s/s (signs/symptoms) pain/distress. - 11/03/12: The notes indicate that the resident propelled herself in her wheelchair in the hall and had no complaints. - 110/4/12: Confused and sometimes agitated and combative with staff. Bruise noted to right elbow. - 11/06/12: The nurses' notes indicated, Staff reports that resident voiced c/o (complaints of) discomfort during t/r (turning/reposition… | 2016-05-01 |
| 8515 | 8515 | ST. JOSEPH'S HOSPITAL, D/P | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2013-01-10 | 314 | D | 0 | 1 | IYJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to promote healing of a pressure ulcer to the maximum extent possible and failed to prevent further deterioration of a pressure ulcer for one (1) of two (2) residents reviewed who had pressure ulcers. The facility did not ensure this incontinent resident was kept clean and dry to promote healing of pressure ulcers and/or to prevent the worsening of pressure ulcers. Resident identifier: #6. Facility census 13. Findings include: a) Resident #6 A review of the medical record for Resident #6 revealed a significant change minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/09/12. The MDS indicated the resident had a decline in health status since the MDS on 09/11/12. One of he declines was in toilet use. The resident went from extensive assist to total dependence. This would indicate a decline in her ability to be taken to the toilet, which would be reflective of her mobility. In September 2012, Resident #6 was treated for [REDACTED]. A nurse's note, dated 10/09/12, stated the area was no longer pink. The medical record revealed monitoring continued on the Weekly Skin Assessments until 11/21/12. No deterioration was noted on the assessments. On 10/10/12, the Weekly Skin Assessment indicated the presence of a pressure ulcer measuring 3.5 X 0.5 cm to the coccyx. It was assessed as a Stage II pressure ulcer. The monitoring reflected a decrease in size to 1 cm in diameter on 11/27/12. The assessment indicated it also had some slough necrotic tissue and serosanguineous drainage with macerated skin surrounding the area. The assessment, on 12/12/12, indicated deterioration of the area. The size of the pressure ulcer had increased to 5 X 1 cm with black eschar, and the area had progressed to a Stage III pressure ulcer. The weekly assessments thereafter indicated there was no reduction in the size of the area, and no healing of surrounding tis… | 2016-05-01 |
| 8516 | 8516 | ST. JOSEPH'S HOSPITAL, D/P | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2013-01-10 | 371 | F | 0 | 1 | IYJG11 | Based on observation and staff interview, the facility failed to store, prepare, and serve food under conditions which prevented, to the extent possible, the contamination of foods. Employees' hair was not effectively restrained and a food item was stored opened and undated in the freezer. This practice had the potential to affect all residents who received nourishment from the facility's kitchen. Facility census: 13 Findings include: a) On 01/07/13 at 11:30 a.m., six (6) dietary employees, Employees #32, #33, #34, #37, #38 and #39, were observed working in the kitchen. Their hair was not effectively restrained to prevent it from falling onto food preparation surfaces and/or onto food items. Wisps of hair were observed around faces and/or necks, strands of hair were observed around ears, and bangs were observed flowing freely without any type of restraint. These employees were observed preparing food in the various stations of the kitchen. They were also observed serving food in the dining area. b) At 8:40 a.m. on 01/08/13, an opened bag containing four (4) pieces of fish was observed on a shelf in the walk-in freezer. It was not tightly closed to prevent potential contamination, and it was undated. This observation was verified by Employee #29, the Certified Dietary Manager (CDM). The CDM secured the contents and dated the bag of fish at that time. c) During an interview with the CDM, on 01/08/13 at 9:00 a.m., when discussing the unrestrained hair and its potential to contaminate food and food preparation areas, the CDM agreed it was an unsanitary situation. At that time, the CDM stated the bag of fish in the freezer had just been opened, and should have been secured and dated before staff left the freezer. | 2016-05-01 |
| 8517 | 8517 | ST. JOSEPH'S HOSPITAL, D/P | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2013-01-10 | 502 | D | 0 | 1 | IYJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, policy review, and physician interview, the facility failed to obtain timely laboratory (lab) services to monitor medication levels, as ordered by the attending physician. This was found for one (1) of ten (10) residents reviewed for unnecessary medication. A potassium level for this resident was not obtained as ordered. Resident identifier: #9. Facility census: 13. Findings include: a) Resident #9 At 2:00 p.m. on 01/09/13, this resident's medical record was reviewed. The review revealed the resident was prescribed the medication potassium, due to use of diuretics for the [DIAGNOSES REDACTED]. On 05/12/12, a serum potassium level was drawn on this resident. The lab report indicated the resident s potassium level was 3.1 (normal range 3.5 to 5.1). Further record review revealed the resident had a serum potassium level drawn on 07/05/12, with a potassium level of 3.4 (normal range 3.5 to 5.1). A pharmacy recommendation form, dated 07/12/12, was reviewed. The pharmacist had recommended a potassium level be done in October 2012. This recommendation was signed by the attending physician. According to facility policy, once a recommendation was signed by the physician, it was a physician's orders [REDACTED].>On 01/09/13 at 3:00 p.m., an interview was conducted with Employee #4, a licensed practical nurse (LPN), regarding the pharmacy recommendation dated 07/12/12. During the interview, a copy of the October 2012 potassium level was requested, as it was not found in the resident's medical record. Upon further inquiry, Employee #4 stated, There was not a laboratory level done in October. When Employee #4 was questioned regarding whether a physician's orders [REDACTED]. Employee #4 verified a potassium level was not obtained in October 2012. She agreed the physician's orders [REDACTED]. An interview was conducted with the attending physician on 01/10/13 at 8:30 a.m. He confirmed he agreed with the pharma… | 2016-05-01 |
| 8518 | 8518 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2013-05-31 | 241 | D | 1 | 0 | 2FP811 | Based on observations, staffing review, and staff interview, the facility failed to ensure each resident was treated with dignity and respect. Residents who could not feed themselves had to sit for a prolonged period while others nearby were being fed. Six (6) residents were observed in the solarium watching and waiting for their evening meal while one (1) resident was being fed by staff and two (2) residents were being fed by family members. One (1) resident was not fed her meal at the same time as her roommate. Another resident was sitting at the nurses' station surrounded by empty trays prior to being assisted with her meal. Resident identifiers: #1, #4, #14, #16, #22, #26, #27, and #34. Facility census: 39. Findings include: a) On 05/28/13 at 5:40 p.m., a random observation in the solarium, revealed the evening meal was being served. At 6:00 p.m., one (1) resident, Resident #15 was being fed by staff. Residents #4, #14, #16, #22, #34 and #26 were watching Resident #15 being fed. At 6:05 p.m., staff started feeding Resident #34 while Residents #4, #14, #16, #22, and #26 were watching. Residents #9 and #36 were being fed by family members during this time period. At 6:12 p.m., three (3) residents, Residents #4, #14, and #16 were served their trays and staff began feeding them. Residents #22 and #26 were still waiting to be fed. At 6:18 p.m., in the solarium, the final two (2) residents, Residents #22 and #26 were served their trays and staff began feeding them. At 6:24 p.m., the last tray was served to Resident #1, in her room. This resident's roommate (Resident #2) had finished the evening meal with Resident #1 not served her meal at the same time. Additionally, at 6:22 p.m., Resident #27 was observed at the nurses' station without a tray while empty trays were on over-bed tables surrounding her. The staff began feeding this resident at this time. | 2016-05-01 |
| 8519 | 8519 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2013-05-31 | 280 | D | 1 | 0 | 2FP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and care plan review, the facility failed to revise the care plan when one (1) of six (6) sample residents experienced a change in condition. Resident #25's care plan was not revised when the resident was no longer able to brush her teeth and required staff to provide oral care. Further, the care plan did not reflect a change in bowel incontinence when the resident had a [MEDICAL CONDITION]. Resident identifier: #25. Facility census: 39. Findings include: a) Resident #25 A review of the medical record, on 05/29/13 at 2:18 p.m., revealed Resident #25 had experienced a decline in her abilities to participate in the activities of daily living (ADLs) due to a deterioration in her medical condition. A review of the care plan, dated April 2013, revealed an intervention dated 03/02/11, Resident is able to brush her own teeth. Staff gets the supplies she needs and sets them up on the over bed table, to perform the task. Another intervention stated . She can apply her own makeup, the staff just gets the materials set up for her on the over bed table. An intervention, dated 03/05/13 stated, Cleanse after each incontinent episode of BM (bowel movement) with warm water and soap. Resident . Resident 25's care plan reflected, on 04/25/13, Needs ostomy ([MEDICAL CONDITION]) care. In an interview with Resident #25, on 05/30/13 at 10:15 a.m., she stated she could no longer brush her teeth or apply make up or comb her hair because of a deterioration in her medical condition. On 05/29/13 at 3:00 p.m., an interview was conducted with the minimum data set (MDS)/Care Plan Coordinator. A review of the care plan for Resident #25 was conducted. She agreed she had not revised the care plan upon readmission to reflect the resident was no longer incontinent of bowel as the resident now had a [MEDICAL CONDITION]. Also the care plan interventions describing this resident could brush her own teeth, apply make up, or comb her hair… | 2016-05-01 |
| 8520 | 8520 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2013-05-31 | 314 | G | 1 | 0 | 2FP811 | Based on minimum data set (MDS) assessment review, medical record review, resident interview, and staff interview, the facility failed to ensure a resident did not develop an avoidable pressure ulcer. A resident developed an avoidable pressure ulcer to the coccyx when a new electric wheelchair was purchase and a pressure relieving cushion was not applied to the wheelchair seat. This affected one (1) of six (6) sample residents. Resident identifier: Resident #25. Facility census: 39. Findings include: a) Resident #25 On 05/29/13 at 1:00 p.m., a review of Resident #25's MDS, with an assessment reference date (ARD) of 11/04/12, revealed the resident was assessed as having no pressure ulcers. The MDS, with an ARD of 02/03/13, revealed an in-house acquired Stage III pressure ulcer was coded for item M0300C. In item M0610, the measurements were recorded as having a length of 1.5 cm, width of 1.0 cm and depth of 0.5 cm, and slough present. A review of the MDS, with an ARD of 04/21/13, revealed a Stage IV pressure ulcer was coded in M0300D. In item M0610m, the measurements were recorded as length 1.5 cm, width .7 cm and depth of 1.8 cm with granulation tissue present. In Section S, item S5005 was coded to indicate none to answer the question In what setting did the pressure ulcers in S5000 develop? This MDS was completed as a readmission from an acute care facility. This resident also returned with a wound vac in place and treatment was being provided by a local wound care clinic. On 05/30/13 at 10:15 a.m., an interviewed was conducted with Resident #25 in private in the resident's room. Resident #25 stated, I am supposed to be turned every two (2) hours and that does not happen all the time. The resident was asked if she was not turned on one (1) shift or all shifts. Resident #25 stated, All shifts. I have a sore above my tailbone and need to be turned. On 05/29/13 at 9:00 a.m., an interview was conducted with the director of nursing (DON) regarding the development of Resident #25's pressure ulcer. The DON replied, I wi… | 2016-05-01 |
| 8521 | 8521 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2013-05-31 | 353 | E | 1 | 0 | 2FP811 | Based on observations, staffing review, and staff interview, the facility failed to deploy staff in a manner to meet the needs of eight (8) residents who could not feed themselves. Six (6) residents were observed in the solarium watching and waiting for their evening meal while one (1) resident was being fed by staff and two (2) residents were being fed by family members. One (1) resident was not fed her meal at the same time as her roommate. Another resident was sitting at the nurses' station surrounded by empty trays prior to being assisted with her meal. Also, it was verified there was not sufficient staff to ensure residents received showers as scheduled and/or desired and a resident with a pressure ulcer denied being repositioned timely. Resident identifiers: #1, #4, #14, #16, #22, #25, #26, #27, and #34. Facility census: 39. Findings include: a) Meal Service On 05/28/13 at 5:40 p.m., a random observation in the solarium, revealed the evening meal was being served. At 6:00 p.m., one (1) resident, Resident #15 was being fed by staff. Residents #4, #14, #16, #22, #34 and #26 were watching Resident #15 being fed. At 6:05 p.m., staff started feeding Resident #34 while Residents #4, #14, #16, #22, and #26 were watching. Residents #9 and #36 were being fed by family members during this time period. At 6:12 p.m., three (3) residents, Residents #4, #14, and #16 were served their trays and staff began feeding them. Residents #22 and #26 were still waiting to be fed. At 6:18 p.m., in the solarium, the final two (2) residents, Residents #22 and #26 were served their trays and staff began feeding them. At 6:24 p.m., the last tray was served to Resident #1, in her room. This resident's roommate (Resident #2) had finished the evening meal with Resident #1 not served her meal at the same time. Additionally, at 6:22 p.m., Resident #27 was observed at the nurses' station without a tray while empty trays were on over-bed tables surrounding her. The staff began feeding this resident at this time. Staffing for this shift includ… | 2016-05-01 |
| 8522 | 8522 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2013-05-30 | 156 | D | 1 | 0 | 6GZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide information upon admission to a resident to ensure the resident had knowledge of his/her rights, and information related to the responsibilities of the facility. During a random review of the medical record for Resident #67, it was discovered the resident was admitted to the facility on [DATE], but did not receive or sign information in the admission packet until ten (10) days after her admission to the facility. Resident identifiers: #67. Facility census: 137. Findings include: a) Resident #67 During a review of the medical record for Resident #67, on 05/29/13 at 12:45 p.m., it was discovered the resident was admitted to the facility on [DATE]. Further review identified the resident did not receive information provided in the facility's admission packet until 05/24/13 - two (2) weeks after admission. The facility's admission packet included the following information provided to each resident upon admission to the facility. I. Rights and Responsibilities of the patient. 1.01 Room and Board Rate 1.02 Ancillary Charges 1.02 a. Transportation 1.03 Collection/Late payments 1.04 Independent Providers 1.05 Governmental Programs 1.06 Third party payors and managed care organizations 1.07 Private pay patient 1.08 Admission information 1.09 Application for Benefits 1.10 Primary Reasonability for Payment 1.11 Personal Physician 1.12 Pharmacy II. Rights and Responsibility of the Responsible party. 2.01 Legal Authority 2.02 Agreement to make payments on behalf of patient 2.03 Exhaustion of Patient's Funds 2.04 Cooperation for Financial Assistance 2.05 Actions Upon Discharge 2.06 Additional Responsibilities III. Rights and Responsibility of the Center 3.01 Room and Standard Services 3.02 Other services 3.30 Deposit 3.04 Refunds IV. General Provisions 4.01 Consent to Release Information 4.02 Consent to Treat (signed on 05/10/13) 4.03 Consent to Photographs 4.04 Notice of Services, P… | 2016-05-01 |
| 8523 | 8523 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2013-05-30 | 253 | D | 1 | 0 | 6GZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, policy review, and record review, the facility failed to prepare a clean and sanitary isolation room for one (1) of six (6) residents reviewed for infection control during the complaint investigation. Resident #67 was placed in an isolation room that was not cleaned after the last occupant was discharged and prior to her occupancy. Resident identifier: #67. Facility census: 137. Findings include: a) Resident #67 During a review of the resident's medical record, on 05/28/13 at 1:50 p.m., it was identified Resident #67 was admitted to the facility on [DATE], after 9:00 p.m. According to Employee #73 (director of nursing - DON), on 05/28/13 at 1:15 p.m., when the hospital called to give report to the nurse, the nurse was told this resident had [DIAGNOSES REDACTED] Enterococcus (VRE) in her urine. Employee #73 further stated, the resident was placed in an isolation room for contact isolation. Prior to Resident #67, being admitted to room ASC, Resident #137 was in the room. Review of the facility's Monthly infection surveillance log, on 05/28/13 at 12:45 p.m., identified Resident #137 had a [DIAGNOSES REDACTED]. On 05/10/13, Resident #137 was moved to a different room at 9:00 p.m. According to the nursing note found in the medical record, Resident #67 was admitted to the same room (ASC) on 05/10/13 at 10:22 p.m. On 05/29/13 at 8:26 a.m., interview with Employee #45 (registered nurse-RN) identified she came in for her shift at 10:30 p.m. She stated, I can't remember if Resident #67 was in the room or in route. I did not see anyone or hear anyone say they cleaned that room. I have not been trained to clean an isolation room when a resident is discharged . Resident #137 was already in the new room. I assisted the nurses with Resident #67's admission paper work. 05/29/13 at 09:29 a.m., in an interview with Employee #46 (licensed practical nurse-LPN), she stated, I don't know who cleaned the room. I know the nurses thought she… | 2016-05-01 |
| 8524 | 8524 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2013-05-30 | 441 | D | 1 | 0 | 6GZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and record review, the facility failed to maintain an infection control program to prevent the spread of disease and infection and failed to track all residents on the monthly surveillance log. This affected two (2) of six (6) residents reviewed for infection control. Resident #67 was placed in an isolation room that was not cleaned prior to her occupancy and Resident #55 was not placed on the monthly surveillance log. Facility census: 137. Resident identifiers: #67 and #55. Findings include: a) Resident #67 During a review of the resident's medical record, it was identified Resident #67 was admitted to the facility on [DATE] after 9:00 p.m. According to Employee #73 (director of nursing - DON) on 05/28/13 at 1:15 p.m., when the hospital called to give report to the nurse, they were told this resident had [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE) in her urine. Employee #73 further stated the resident was placed in an isolation room for contact isolation. On 05/11/13, the facility contacted the hospital to clarify whether or not the resident had active VRE. When the facility found out it was only a history of VRE, on 05/11/13, the resident was moved out of the isolation into another room. The hospital records, sent with the resident on 05/10/13, at the time of her admission, stated the resident had a history of [REDACTED]. On 05/29/13 at 9:45 a.m., Employee #73 (DON) was asked if the nurses review the information from the hospital. She stated, Yes, they are supposed to. When shown the admission information sent from the hospital where it was written the resident only had a history of [REDACTED]. Prior to Resident #67, being admitted to room A Special Care (ASC), Resident #137 had resided in the room. Review of the facility's Monthly infection surveillance log, on 05/28/13 at 12:45 p.m., identified Resident #137 had a [DIAGNOSES REDACTED]. Review of Resident #137's medical record, … | 2016-05-01 |
| 8525 | 8525 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2013-05-30 | 465 | D | 1 | 0 | 6GZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, policy review, and record review, the facility failed to maintain a safe and sanitary environment for a resident. This practice affected one (1) of ten (10) sampled resident during the complaint investigation. Resident #67 was placed in an isolation room which had not been cleaned prior to her admission. Resident identifier: #67. Facility census: 137. Findings include: a) Resident #67 During a review of the medical record it was identified Resident #67 was admitted to the facility on [DATE], after 9:00 p.m. According to Employee #73 (director of nursing - DON) on 05/28/13 at 1:15 p.m., when the hospital called to give report to the nurse they were told this resident had [MEDICATION NAME] resistant [MEDICATION NAME] (VRE) in her urine. Employee #73 further stated, the resident was placed in an isolation room for contact isolation. On 05/11/13, the facility contacted the hospital to clarify whether or not the resident had active VRE. When the facility found out it was only a history of VRE on 05/11/13, the resident was then moved out of isolation into another room. Review of the hospital records sent went the resident on 05/10/13, at the time of her admission stated the resident had a history of [REDACTED].#73 (DON) was asked if the nurses review the information from the hospital. She stated, Yes, they are supposed to. I then showed her in the admission information sent from the hospital it was written the resident only had a history of [REDACTED].#73 (DON) stated, The hospital stated when they called the report the resident had active VRE, so we prepared an isolation room. Prior to Resident #67, being admitted to room ASC, Resident #137 was in the room. Review of the facility's Monthly infection surveillance log, on 05/28/13, at 12:45 p.m., identified Resident #137 had a [DIAGNOSES REDACTED]. On 05/10/13, Resident #137 was moved to a different room, at 9:00 p.m. He was moved to room G1A. On 05/08/13 at 4:33 p.m., the … | 2016-05-01 |
| 8526 | 8526 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2013-05-30 | 502 | D | 1 | 0 | 6GZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain two (2) labs as ordered by a physician. One resident's physician ordered a lab test for [MEDICAL CONDITION] (which causes severe diarrhea), but the test was not completed, and a lab test for urinary tract infection was not collected in a timely manner. This practice affected one (1) of six (6) residents whose medical records were reviewed. Resident identifier: #37. Facility census: 136. a) Resident #37 Review of this resident's medical record, on 05/28/13 at 2:57 p.m., revealed on 04/11/13 the physician ordered a stool culture and [MEDICAL CONDITION] test to be collected due to [DIAGNOSES REDACTED].Review of the physician's orders [REDACTED]. Review on the nurses' progress notes, on 05/28/13 at 3:05 p.m., found no evidence the physician was notified the lab tests had not been obtained. The facility's lab tracking sheet was reviewed on 05/28/13 at 3:15 p.m. This revealed the lab test had been placed on the lab tracking document on 04/12/13, but was marked out and noted Did Not Obtain. In an interview with Employee #222, a registered nurse (RN), on 05/28/13 at 3:37 p.m., she was asked where Resident #37's lab results were for the stool culture and [MEDICAL CONDITION] which were ordered on [DATE]. After reviewing the lab tracking worksheet, she confirmed the tests were not collected. She stated she did not know why the tests were not collected. In an interview with Employee #73, the director of nursing (DON), on 05/28/13 at 3:10 p.m., she stated she would have to look at Resident #37's chart. At 3:15 p.m., the DON confirmed staff did not do the test, nor did staff notify the physician the lab tests were not obtained. b) Resident #37 Review of the resident's medical record, on 05/28/13 at 3:30 p.m., found the physician had ordered a urinalysis and urine culture for dysuria (painful urination) on Thursday, 04/18/13 at 10:30 p.m. Further review of the record revealed … | 2016-05-01 |
| 8527 | 8527 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 156 | E | 0 | 1 | JZJM11 | Based on observation and interview, the facility failed to post the names, addresses and telephone numbers of all pertinent client advocacy groups in a manner in which Residents can view them. The facility also failed to post contact numbers for the State Survey and Certification agency with a statement that a Resident may file a complaint in a manner that Residents can read them. This had the potential to affect any resident dependent on a wheel chair for ambulation. Findings include: a) Observations of the facility on 04/26/12, revealed a bulletin board located across from the social service office on the south side of the building. There was small poster board located on the top left hand side of the bulletin board. The poster board contained information concerning the State Survey and Certification agency and Medicaid and Medicare. The contact information for the agencies was small and difficult to read from a seated wheelchair position. Observations of the facility on 04/26/12, revealed a bulletin board located across from the south nurses' station. At the top right hand corner of the bulletin board was a small poster board which contained information about the Ombudsman including a contact number. The information was not easily accessible for residents. A nurse's treatment cart was located in front of the bulletin board preventing residents, staff and visitors from easily viewing the information. Observations of the facility on 04/26/12, revealed a bulletin board located across from the north nurses' station. There were no posted names, addresses and telephone numbers for pertinent client advocacy groups or contact numbers for the State Survey and Certification agency. During an interview with the facility Administrator, on 04/26/12 at 12:35 p.m., it was verified the required information of all State client advocacy groups was not easily accessible to all residents, staff, and visitors. | 2016-05-01 |
| 8528 | 8528 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 159 | E | 0 | 1 | JZJM11 | Based on resident interview and staff interviews, the facility failed to make resident funds available on an on-going basis. This had the potential to affect more than an isolated number of residents. Resident identifiers: #98, #90, #97, #112. Findings include: a) During interviews with residents, on 4/23/12, residents were asked whether the monies in their personal funds accounts were available to them when they wanted, including weekends. Four (4) residents had negative responses to the question: During an interview with Resident #98, on 04/23/12 at 01:48 p.m., he stated, Have to follow their hours. During an interview with Resident #90, on 04/23/12 at 12:01 p.m., he stated, Only when someone is in the office they have certain hours to give out money. Two (2) other residents, #97 and #112, were interviewed at 12:07 p.m. They just stated, No, without elaboration. During an interview with the Nursing Home Administrator (NHA), on 04/25/12 at 2:00 p.m., he stated the residents had access to their funds, 7 days a week, 7 a.m. - 7:30 p.m. Monday thru Friday and 8 a.m. - 4:30 p.m. on weekends. He continued that all the residents were aware of the times. He elaborated further that the facility once had a petty cash fund because they did not have a receptionist. Now we have a receptionist that works until 7:30 M-F and 8 - 4:30 Sat and Sun. It is a better safe-guard for the money and the nurses can attend to their nursing responsibilities without having to safeguard the cash box too. The NHA was asked how the younger residents living in the building could get a pizza on Saturday if they wanted one. He responded, If there was some pre-planning, they could get a pizza at 9 p.m. on Sat night. They also have a lock-box in their room where they can keep money if they want to. The NHA stated that when he saw how this evolved, I thought I evolved with it. I thought I was accommodating the weekend and evening hours. The NHA concluded, After hours I felt better that nursing didn't have a cash box in medication room. When I made t… | 2016-05-01 |
| 8529 | 8529 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 164 | E | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to provide privacy curtains that ensured full visual privacy for residents in 23 rooms. Room #s 6, 7, 9, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 48, 49, 53, 54, 56, 57, 59, 61, 62, and 64. Findings include: a) During tour of the South Unit of the facility, the following rooms were observed to have a privacy curtain hanging for bed A of each room that did not provide full visual privacy for the residents residing in rooms 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 48, 49, 53, 54, 56, 57, 59, 61, 62, 64. These observations were verified by the maintenance director at 12:30 p.m. on 04/26/12. b) Observation of room [ROOM NUMBER] bed A, on 04/23/12 at 2:50 p.m., and on 04/26/12 at 1:24 p.m., revealed the privacy curtain was not long enough to go entirely around the resident's bed to provide full visual privacy. c) Observation of room [ROOM NUMBER] bed A, on 04/23/2102 at 10:53 a.m., and on 4/26/12 at 1:24 p.m., and also room # 9 bed A, observed on 04/23/12 at 3:53 p.m. and 4/26/12 at 1:25 p.m., revealed these privacy curtains were also not long enough to go entirely around the resident's bed to provide full visual privacy. This was verified by maintenance director on 04/26/12 at 11:30 a.m | 2016-05-01 |
| 8530 | 8530 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 166 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interviews, and staff interviews, the facility failed to replace reported missing property after the resident was told the property would be replaced. This affected 1 of 3 sample residents reviewed out of the 6 residents who had reported missing property. (Sample resident #97) Findings include: a) Resident #97 Review of a Resident Missing Item Request form, dated 12/12/11, for Resident #97 noted Resident #97 had reported a box of 64 [MEDICATION NAME] and a box of 50 [MEDICATION NAME] pencils were missing. It was noted the Social Worker (SW) had completed the report portion of the form. Under Follow Up Required, the Housekeeping Supervisor (HS) wrote, Replace the [MEDICATION NAME] and pencil. The HS dated this part of the form 12/14/11. On 04/23/12 at 03:13 p.m., an interview was conducted with Resident #97. Resident #97 stated, Someone stole my new [MEDICATION NAME] and colored pencils about a month ago. She added she had reported the missing property to the staff. An interview was conducted with the SW at 2:44 p.m. on 04/23/12. The SW stated, if something is reported missing, they would come tell me or send an e-mail or leave me a note. I would fill out a missing item form. I would give it to laundry if it was for them. They would look, then give the form back indicating whether the item had been found. Around Christmas (the resident) was missing some [MEDICATION NAME]. We looked for them but couldn't find them. The HS wrote that we would replace them. Activities (staff) probably did that. An interview was conducted on 04/23/12 at 3:13 p.m. with the the HS. The HS said that reports of missing items were turned in to her; then, she and her staff would look for the item. We usually find everything within 2 weeks. If we can't find it, we will replace it. (Resident #97) has lost other stuff, but we found it. After reviewing the Missing Item form, HS said, I wrote on there we would replace the pencils, but I haven… | 2016-05-01 |
| 8531 | 8531 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 241 | E | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to maintain the dignity of residents who were dependent on staff for assistance in performing activities of daily living. This involved 1 (Resident #172) of 3 residents observed related to activities of daily living out of 41 residents sampled. The facility also failed to maintain the dignity of residents during meal services for 4 residents not served timely. (Residents #61, #131, #135 and #173.) Findings include: a) Review of the medical record for Resident #172 revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the most recent comprehensive assessment, dated 03/27/12, revealed Resident #172 was assessed to be totally dependent on staff for bed mobility, transfers, personal hygiene and bathing. The comprehensive assessment also revealed Resident #172 was assessed to sometimes understand others and as able to respond adequately to simple direct communication. Further review of the medical record revealed a care plan, dated 04/06/12, related to Resident #172's activities of daily living (ADL). The care plan identified the Resident required total care and assistance with grooming. A care plan developed by the facility for Resident #172 related to mouth care revealed interventions that direct nursing staff to brush the Resident's teeth and gums daily and to monitor Resident #172 for discomfort. On 04/25/12 at 10:22 a.m., Nurse Aide (NA) #3, was observed providing personal care to Resident #172. At 10:29 a.m., NA #3 was observed to adjust the resident's pillow with both hands. With her face close to that of Resident #172 the NA stated, We need to do mouth care 'cause your mouth smells like a potty. At 10:40 a.m., when NA #3 left the resident's room, mouth care had not been provided. During an interview, on 04/26/12, the Director of Nursing verified NA #3 had addressed Resident #172 in a manner that did not maintain the resident's dignity an… | 2016-05-01 |
| 8532 | 8532 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 242 | D | 0 | 1 | JZJM11 | Based on resident interviews, staff interviews and record review, the facility failed to allow 1 of 3 sampled residents reviewed, out of 5 residents who reported not having choices, to determine her shower schedule. Resident identifier: #97 Findings include: a) Resident #97 Review of Resident #97's care plan, dated 03/20/12, noted a concern as Distressed mood-persistent anger and anxiety regarding care such as meds, meals, toileting, cleanliness, and bathing. Interventions included: allow to verbalize anger, attempt to resolve, encourage activities of choice, explore perception. During an interview on 04/23/12 at 02:56 p.m., Resident #97 stated that Unit Manager #1 (UM #1) changed her shower day from Friday to Saturday without involving the resident. Resident #97 stated that she did not like that change and the change had been made without asking her. A follow up interview was completed with Resident #97 at 9:15 a.m. on 04/24/12. Resident #97 said, UM #1 told me she changed me from Friday to Saturday recently. I don't know why. No one asked me first. On 04/24/12 at 4:16 p.m., an interview was conducted with UM #1. UM #1 said that when Resident #97 started going to a recurring out-of-facility appointment, the shower was moved from Tuesday morning to Tuesday evening. (Resident #97) was OK with that move. (The resident) may have been a Friday before but we changed the schedule at his/her request. UM #1 said that there wouldn't be any documentation of a request by Resident #97, or notification of Resident #97 for a change in the shower schedule. UM #1 reported that when the facility added Sunday to the schedule for resident showers, many of the residents' schedules had been moved. An interview was conducted with Nursing Assistant #1 (NA#1) at 9:35 a.m. on 04/25/12. NA # 1 stated that Resident #97's shower schedule had changed. (Resident #97) gets a shower on evenings (evening shift) one day a week and the day time on Saturday. The schedule was changed from Tuesday and Friday on the day shift to Tuesday evenings, and … | 2016-05-01 |
| 8533 | 8533 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 248 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide an activity programing for residents based on their comprehensive assessment. This involved 2 of 3 sampled residents. (Residents #22 and #172) Findings include: a) Resident #22 Review of Resident #22's Recreation Assessment, dated 10/11/11, revealed that Resident #22 cannot read due to [MEDICAL CONDITION]. The assessment also noted that Resident #22 liked blue grass and country music and reported that being around pets was very important, especially cats. The assessment also noted that her favorite activities were very important to Resident #22. The Activities Director (AD) noted on the assessment that Resident #22 states she is unable to do anything due to being bedfast. The assessment also indicated the resident was, Encouraged and invited to attend activities of her choice. Resident #22's care plan, dated 04/11/12, was reviewed. The focus was for Resident #22 to attend activities of her choice. Interventions included assist resident in attending and leaving activities, and introduce her to others. The intervention was dated 01/04/12. A form, supplied by the AD, contained daily activity participation from 01/15/12 through 05/05/12. The AD showed the form to the surveyor on 04/25/12. Every day, 7 days a week, the form showed that Resident #22 engaged in conversation and television. The form was filled out through 05/02/12. An interview was completed with Resident #22 at 8:51 a.m. on 04/23/12. Resident #22 reported the activities in the facility did not meet her interests. She stated she liked music, but did not have a way to listen to it. She stated she would like to have a radio or music compact discs (CDs). On 04/24/12 at 9:56 a.m., an interview was conducted with Nursing Assistant #2 (NA #2). NA #2 stated she was familiar with Resident #22 and that Resident #22 did not participate in activities. (Resident #22) used to participate. Now she never gets out of … | 2016-05-01 |
| 8534 | 8534 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 250 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure an ordered follow-up appointment was made and received for 1 of 1 sampled residents. (Resident #22) Findings include: Resident #22 was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of a Report of Consultation form for Resident #22 noted that she was evaluated by the psychologist on 10/12/11. The consultation recorded that Resident #22 was to have a follow up appointment in 2 weeks. There were no other consultation notes by the psychologist located for Resident #22. On 04/26/2012 at 9:00 a.m., an interview was completed with Unit Manager #1 (UM #1). UM #1 stated that Resident #22 was seen by the psychologist in October (2011) and that Social Worker (SW) would have scheduled the two week follow up appointment. After reviewing the record, UM #1 noted that Resident #22 had not been seen for the two week follow up. An interview was completed with the SW at 9:10 a.m. on 04/26/12. The SW stated, I write up the consults (consultations). All of the new and follow ups. Back then (October 2011) he (psychologist) was doing his own follow up scheduling and he missed some, so I took that over. When we found that he was missing them, we started doing them for him from that point. The SW said that no one went back to search for ones that the psychologist missed. When the SW took over the scheduling, it was only from that point forward. I started doing that after the first of the year. | 2016-05-01 |
| 8535 | 8535 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 253 | E | 0 | 1 | JZJM11 | Based on observation and staff interview, it was determined the facility failed to provide maintenance services necessary to maintain an orderly and comfortable interior environment for the residents residing on the North and South Units of the facility. Findings include: a) Observation during the environmental tour, on 4/26/12 at 10:40 a.m., revealed the toilet paper holder in room #3 on the North hall had become dislodged from the wall. No toilet paper could be placed on this holder for 4 residents who used this bathroom. On this date, at 10:47 a.m., the caulking around the sink in Room #4 was noted be be cracked and peeling away from the sink and the vanity. The wall around the air conditioner in Room 12 B was noted to be in need of painting. The bathroom doors in Room 23 and 26 were noted to have large gouges in them and required painting. These findings were verified with the maintained director at 11:02 a.m. on 04/26/12. b) During tour of the South Unit of the facility there were several gouges and scratches noted in the dry wall, door jams and interior doors leading to resident bathrooms. The following rooms were affected: 39, 48, 49, 54, 59, 61, 62, and 64. These observations were verified by the Maintenance Director at 12:10 p.m. on 04/26/12. | 2016-05-01 |
| 8536 | 8536 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 279 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interviews, and resident interviews, the facility failed to develop a care plan to address dental needs for 1 of 1 sampled resident who had dental problems. (Resident #112) Findings include: Resident #112 stated in interview that he did not have any teeth and wanted dentures, but there was no evidence that a dental care plan had been created. Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #112 was coded with a BIMS (Brief Interview for Mental Status) score of 15, indicating he was cognitively independent with decision-making. His dental status was coded as not having dentures or natural teeth. The MDS also marked the resident as having no difficulty with chewing. He was coded as a being totally dependent on staff to carry out ADL functions, including personal hygiene. Observation of Resident #112 on 04/22/12, 04/23/12, 04/24/12, 04/25/12, and 04/26/12 revealed he did not have any teeth. During an interview, on 04/23/12 at 12:08 p.m., Resident #112 stated he did not have any teeth or dentures, but wanted dentures. The resident continued, They tell me I need $350 to pay for them. The resident added that he was trying to save up money from a personal needs account to pay for them. Resident #112 also stated there were many foods he could not eat because he could not chew them - especially meat which he was unable to chew. Resident #112 stated again on 04/25/12 at noon, as he was served corn with the noon meal, I love corn but I can't chew it because I don't have any teeth! Review of the care plans (CP), dated 01/19/12, did not reveal a CP related to dental needs or services. The resident was identified at that time as a short-stay resident (expected to stay in the facility for less than 90 days). Review of the social service care plan, dated 04/17/12, also did not identify any dental needs or… | 2016-05-01 |
| 8537 | 8537 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 280 | E | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and resident interviews, the facility failed to revise care plans for 4 of 23 sampled residents. (Residents #22, #51, #112, and #187) Findings include: a) Resident #22 This resident was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of Resident #22's Recreation Assessment, dated 10/11/11, revealed Resident #22 cannot read due to [MEDICAL CONDITION]. The assessment also noted that Resident #22 liked blue grass and country music and reported that being around pets was very important, especially cats. The assessment also noted that favorite activities were very important to Resident #22. The Activities Director (AD) noted on the assessment that Resident #22 stated she was unable to do anything due to being bedfast. The resident should be encouraged and invited to attend activities of her choice. Resident #22's care plan, dated 04/11/12, was reviewed. The focus was for Resident #22 to, attend activities of his/ her choice. Interventions included assist him/her in attending and leaving activities, and, introduce him/her to others. The intervention was dated 01/04/12. The only intervention dated after 01/04/12 was dated 04/24/12, noting that in room supplies would be provided to Resident #22. A form supplied by the AD contained daily activity participation from 01/15/12 through 05/05/12. The AD showed the form to the surveyor on 04/25/12. Every day, 7 days a week, the form showed that Resident #22 engaged in conversation and television. The form was filled out through 05/02/12. On 04/24/12 at 9:56 a.m., an interview was completed with Nursing Assistant #2 (NA #2). NA #2 stated that she was familiar with Resident #22 and that Resident #22 did not participate in activities. (Resident #22) used to. Now she doesn't get out of bed. I don't know why. We use the (mechanical) lift on her. She refuses to go to the shower, just gets a bed bath. I don't know if anyone has talked to her. NA … | 2016-05-01 |
| 8538 | 8538 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 282 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to provide care for 2 of 41 sampled residents as directed by the Residents' plan of care. (Residents #172 and #174) Findings include: 1. Review of the medical record for Resident #172 revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the most recent comprehensive assessment dated [DATE] revealed Resident #172 was assessed to be totally dependent on staff for bed mobility, transfers, personal hygiene and bathing. The comprehensive assessment also revealed Resident #172 was assessed to sometimes understand others and is able to respond adequately to simple direct communication. Further review of the medical record revealed a plan of care dated 04/06/12 related to Resident #172's activities of daily living (ADL). The plan of care identified that the Resident required total care and assistance with grooming. A plan of care developed by the facility for Resident #172 related to mouth care revealed interventions that direct nursing staff to brush the Resident's teeth and gums daily and to monitor Resident #172 for discomfort. Review of document titled Visual/Bedside Kardex Report, identified by Unit Manager #2 as being a guide for staff to provide care for Resident #172, revealed the Resident's teeth are to be brushed with a soft tooth brush daily. On 04/25/12 at 10:22 A.M., Certified Nurse Aide (CNA) # 3 was observed providing personal care to Resident #172. At 10:29 A.M., CNA #3 was observed to adjust the Resident's pillow with both hands and with her face close to that of Resident #172 stated, we need to do mouth care cause your mouth smells like a potty. At 10:40 A.M., when CNA #3 left the Resident's room and mouth care had not been provided. The drawers holding Resident #172's personal care items were observed to be absent any items used to provide mouth care such as a tooth brush and tooth paste. There were 2 small, store bought disposable … | 2016-05-01 |
| 8539 | 8539 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 309 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure one (1) resident received the necessary care and services to maintain good body alignment while in bed in accordance with his comprehensive assessment and care plan. (Resident #47) Findings include: a) Resident #47 This resident was admitted to the facility on [DATE] with senile dementia and left sided [MEDICAL CONDITION]. Review of his most recent Minimum (MDS) data set [DATE] found he required the extensive assistance of one staff member for bed mobility. The Activity of Daily Living Plan of Care, dated 11/23/12, identified the resident was dependent on staff for bed mobility and staff should ensure the resident maintained good body alignment while in bed. The physical therapy notes, documented on 11/15/11, noted the resident required maximal assistance from staff for bed mobility. When the resident was discharged from physical therapy on 12/30/11, he was documented to require minimal assistance from staff for bed mobility. Observation of Resident #47, on 04/24/12 at 7:55 a.m., revealed he was in bed with his legs hanging out the right side of the bed and his head was leaning up against the wall to the left. He was also noted to be scooted way down in the bed. At 8:22 a.m. he was in the same position and his breakfast tray was in front of him and was empty. He had eaten his meal while positioned as stated above. On 04/24/12 at 9:42 a.m., the resident remained in the same position. On 04/24/12 at 10:30 a.m., the resident was re-positioned by staff, but there was no attempt to place any support devices beside the resident to assist in maintaining good body alignment. On 4/25/12 at 12:31 p.m., Resident #47 was observed in bed with his lunch tray beside him. The head of his bed was elevated, but he was scooted down in the bed and leaning to the left. During interview with Nurse Aide #7, on 04/25/12, the nurse aide revealed she tries to straighten the residen… | 2016-05-01 |
| 8540 | 8540 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 311 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, the facility failed to provide activities of daily living, specifically personal hygiene, for 1 of 8 residents with observed concerns of the 40 residents who were observed on the sample. (Resident #112) Findings include a) Resident #112 This resident stated in an interview he had not had some care provided related to personal hygiene. Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #112 was coded with a BIMS score of 15, indicating he was independent in his cognitive ability for daily decision-making. He was coded as being totally dependent on staff to carry out ADL functions, including personal hygiene. During an interview, on 04/23/12 at 12:08, Resident #112 stated his fingernails were too long. They (staff) have clipped them once, but they need to be clipped again. The resident was asked if he was growing a beard? He responded, They have not shaved me for a couple of weeks -- I would like to be shaved! The resident was asked why they hadn't shaved him? He responded, They keep forgetting to take razors with them when they shower me. He stated further that he thought he could shave himself if he had an electric razor. Observations of Resident #112 on 04/22, 04/23, 04/24 and 04/25 revealed the resident had a short beard. Observation on 04/26/12 revealed he had been shaved. Observation of Resident #112's nails, on 04/22, 04/23 and 04/24/12, revealed they were long and jagged. During the dressing change observation on 04/24/12 at 9:30 a.m., the LPN informed the resident she would be back later to trim his fingernails. Observation of his nails at 5:00 p.m. revealed his nails had been trimmed. Review of the care plan, dated 01/17/12, revealed: Resident demonstrates capacity and motivation to improve function but exhibits or is at risk for decreasing ability to… | 2016-05-01 |
| 8541 | 8541 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 312 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, family interview, and staff interview, the facility failed to provide mouth care for a resident dependent on staff for activities of daily living. This involved 1 of 3 sampled residents investigated related to concerns in the Care Area of Activities of Daily Living. (Resident #172) Findings include: a) Resident #172 Review of the medical record for Resident #172 revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the most recent comprehensive assessment, dated 03/27/12, revealed Resident #172 was assessed to be totally dependent on staff for bed mobility, transfers, personal hygiene and bathing. The comprehensive assessment also revealed Resident #172 was assessed to sometimes understand others and as able to respond adequately to simple direct communication. Further review of the medical record revealed a care plan, dated 04/06/12, related to Resident #172's activities of daily living (ADLs). The care plan identified the resident required total care and assistance with grooming. A care plan developed by the facility for Resident #172 related to mouth care revealed interventions that direct nursing staff to brush the resident's teeth and gums daily and to monitor Resident #172 for discomfort. Review of document titled Visual/Bedside Kardex Report, identified by Unit Manager #2 as being a guide for staff to provide care for Resident #172, revealed the resident's teeth were to be brushed with a soft toothbrush daily. On 04/25/12 at 10:22 a.m., Nurse Aide (NA) #3 was observed providing personal care to Resident #172. At 10:29 a.m., NA #3 was observed to adjust the resident's pillow with both hands and with her face close to that of the resident. The NA stated, we need to do mouth care 'cause your mouth smells like a potty. At 10:40 a.m., NA #3 left the resident's room and mouth care had not been provided. The drawers holding Resident #172's personal care items were observed to … | 2016-05-01 |
| 8542 | 8542 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 323 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to implement interventions to protect two (2) residents with a history of falls. (Residents #51 and #28) 1. The facility failed in multiple areas, specifically: A. Therapy did not evaluate Resident #51's functional abilities after either the first fall or the second. B. Environmental services had arranged the resident's room for safety, however observations revealed both sides of the bed remained cluttered with equipment, even on the fall mats. C. The care plan had not been updated to include the fall on 03/17/12, thereby preventing the facility from providing interventions which might have prevented the second fall where the resident experienced head and facial injuries. D. Food products were kept on the nightstand, but not within reach of the resident, thereby creating a potential for additional falls should the resident reach for a food product that was out of reach. The findings were: a) Resident #51 This resident was re-admitted to the facility on [DATE]. Review of the 11/07/11 MDS revealed sample Resident #51 was [AGE] years old and had [DIAGNOSES REDACTED]. Resident #51's functional status was coded as requiring extensive assistance for ADLs and total assistance required for toileting, hygiene and bathing. She was coded as unsteady with transfers, had range of motion impairments, and was incontinent of bladder and bowel. Resident #51 was 66 inches tall and weighed 155 pounds. Further review of the MDS identified that the resident had experienced no falls since readmission to the facility on [DATE]. The most current MDS, dated [DATE], identified no falls since admission. During the staff interview, on 04/23/2012 at 10:32 a.m., staff identified that Resident #51 had experienced a fall on 04/16/12. The nurse being interviewed identified that the resident had fallen out of bed on the evening of 04/17/12 with resulting bruising to the face. The nursing note indi… | 2016-05-01 |
| 8543 | 8543 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 325 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and resident observations, it was determined the facility failed to maintain acceptable parameters of nutrition for 1 of 3 residents reviewed in Stage 2 for the care area of nutrition. Sample Resident #174 experienced a significant weight loss. Findings include: a) Resident #174 This resident was admitted to the facility 12/30/11. Resident #174 was noted to have a [DIAGNOSES REDACTED]. The resident received speech and occupational therapy from 01/04/12 through 03/22/12 related to dysphagia and inability to feed himself. The most recent dietary assessment, dated 04/05/12, revealed documentation of the diet order for a mechanically altered diet with nectar thick liquids. The resident also received enteral feedings of [MEDICATION NAME] 200 cc three times a day due to [MEDICAL CONDITION]. The dietary notes documented inconsistent oral intake and the resident's weight was down 6 pounds during this review. The most recent Minimum Data Set, dated dated [DATE], documented that Resident #174 required the extensive assist of one staff member for eating and the resident consumed 26-50% of his meals. The care plan, dated 01/10/12 documented the resident required extensive assist of one with eating, would consume 75% of meals, and staff were to monitor the resident's intake and weight changes. Review of Resident #174's weight history revealed the following: Date: 12/30/2011; Weight: 253 Date: 01/16/2012; Weight: 251 Date: 02/03/2012; Weight: 248 Date: 02/24/2012; Weight: 240 Date: 03/22/2012; Weight: 240 Date: 04/20/2012; Weight: 233 These weights reflect a 20 pound weight loss in 4 months. On 04/05/12, the dietitian made a note in the record of no concerns noted. Her notes state the resident has inconsistent oral intake and must be encouraged by staff to eat and feed himself. The notes speak to the resident's weight loss, but documented the resident's weight fluctuated and no further interventions were needed at … | 2016-05-01 |
| 8544 | 8544 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 329 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure 1 of 10 residents reviewed did not receive unnecessary medication. (Resident #22) Findings include: a) Resident #22 This resident was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of Resident #22's Medication Administration Record [REDACTED]. Review of Resident #22's medical record noted a [DIAGNOSES REDACTED]. A review of the monthly pharmacy consultant notes from 10/2011 through 04/2012 found no mention of Resident #22 being on [MEDICATION NAME]. An interview was completed with Resident #22's physician (Physician #1) on 04/25/12 at 2:20 p.m. (Physician #1) said, I noticed today that (Resident #22) was on [MEDICATION NAME]. The reason on the record mentions [MEDICAL CONDITION]. If she isn't compromised and she has genital [MEDICAL CONDITION], we would make that a daily dose. I am having (Unit Manager #1) check on that. The physician noted that if Resident #22 did not have a history of genital [MEDICAL CONDITION], then the use of [MEDICATION NAME] would be time limited. On 4/25/12 at 3:30 p.m., an interview was completed with the facility pharmacy consultant (PC). PC reported that she visits the facility every month and looks at every chart. I thought I asked about the [MEDICATION NAME], but I don't see where I wrote anything. I think I looked up the drug to verify the dose. If I was concerned about it, I would have sent it to the physician. If there is a [MEDICAL CONDITION] infection that is chronic the dose would continue if it was active. It would be up to the doctor to continue (the drug treatment) if it (infection) isn't active. When we go in and review a resident we make sure doses and indications are appropriate. We make sure they (residents) aren't allergic (to any of the medications), make sure lab (laboratory) work is done. We look at physician's orders [REDACTED]. I don't do a 100% MAR indicated [REDACTED]. Sometimes I do look at… | 2016-05-01 |
| 8545 | 8545 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 371 | D | 0 | 1 | JZJM11 | Based on observation, record reviews, and staff interview, it was determined the facility failed to monitor temperatures of the refrigerator on the North hall. Failing to monitor food storage temperatures where resident food is stored creates the potential for foodborne illness for the residents on this Unit. Findings include: a) Observation of the clean utility area, on 04/26/12 at 10:30 a.m., revealed a refrigerator with several small bowls of applesauce, white milk, chocolate milk, and 2 take-out food bags containing resident food items. The temperature log on the door of the refrigerator documented temperatures logged for only two days in April, 04/24/12 and 04/25/12. All other dates for the month of April were blank. An interview with the charge nurse indicated this refrigerator was used for resident food items brought in from outside the facility. There was a sign on the outside of the door that documented that temperatures were to be taken and logged by housekeeping staff, but the charge nurse indicated the monitoring was supposed to be completed by the dietary staff. During an interview with the dietary manager, on 04/26/12 at 11:00 a.m., she indicated her staff were responsible for taking and logging the temperatures in this refrigerator. She stated the staff were very nervous when the survey team entered the building and they had removed the log from the door of the refrigerator. She stated they had replaced the old one with a new one on 04/24/12, so that was why there were only 2 dates logged on the new form. The dietary manager then supplied a log that she stated had been taken down right after the survey team entered the building. This form contained all the dates and temperatures logged since April 1, 2012. The temperature log had been observed by the surveyor doing the initial tour of the facility on 04/22/12 at 4:20 p.m., and the log on the refrigerator door for April had been completely blank. The log on the door during this observation for March was also only sporadically completed with a date a… | 2016-05-01 |
| 8546 | 8546 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 373 | E | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure its paid feeding assistants did not feed residents with complicated feeding problems. This affected 1 resident (Resident #127) and the potential to affect 8 additional residents identified by the facility as having swallowing problems. Findings include: a) Resident #127 Review of the clinical record for Resident #127 revealed a [DIAGNOSES REDACTED]. The diet order was last revised on 12/05/11. Review of the Speech Therapy discharge summary, dated 09/30/11, revealed Resident #127 was seen for 9 days from 09/18/11- 09/30/11. The discharge notes confirmed the resident's [DIAGNOSES REDACTED].#127 had demonstrated the ability to safely tolerate pureed food with thin liquids as the least restrictive diet and that the resident would continue to require assistance with all meals. During an interview with the Unit Manager, on 04/23/12 at 5:03 p.m., the Unit Manager stated Resident #127 was changed to thickened liquids at the request of the family because the resident had been coughing when drinking thin liquids. There was no speech evaluation done at that time and the resident's trouble with coughing had stopped since the physician ordered thickened liquids. During observations, on 04/24/12, of the noon meal being served in the dining room (identified by the facility as the cafe), six (6) residents were being fed by different staff members. Paid Feeding Assistant #9 was observed to be feeding Resident #127. The Feeding Assistant was observed placing a cup of thickened fluids to the resident's mouth so that she might drink. There was a sippy cup observed next to the resident's plate. During an interview with Feeding Assistant #9, at the time of the observation, it was stated she did not know why Resident #127 had a sippy cup, but she did fine without it. The Feeding Assistant was observed feeding Resident #127 her noon meal which was pureed pizza and vegetables. Feeding A… | 2016-05-01 |
| 8547 | 8547 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 412 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interviews, the facility failed to provide dental care and a dental evaluation for a resident with no teeth who wanted dentures. (Resident #112) Findings include: a) Resident #112 This resident stated in interview that he did not have any teeth and wanted dentures. Resident # 112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed resident #112 was coded with a BIMS score of 15. His dental status was assessed as not having dentures or natural teeth. The MDS also marked the resident as having no difficulty with chewing. He was coded as a being totally dependent on staff to carry out ADL functions, including personal hygiene. During an interview, on 4/23/12 at 12:08 p.m., Resident #112 stated he did not have any teeth or dentures, but wanted dentures. He continued, They tell me I need $315 or $350 to pay for them. The resident stated that he was trying to save up money from his personal needs account to pay for them. Resident #112 also stated there were many foods he could not eat because he could not chew them, specifically, meat. Resident #112 stated again, on 04/25/12 at noon, as he was served corn with his noon meal, I love corn but I can't chew it because I don't have any teeth! Review of the care plan, dated 1/19/12 did not reveal a care plan related to dental needs or services. Resident was identified in January 2012 as a short-stay resident, i.e. expected to be in the facility for a short period of time, less than 90 days. Review of the Social Service Care Plan, dated 04/17/12, also did not reveal any dental needs or services. The Social Services Care Plan again identified the resident as short term stay less than 90 days, even though the resident had been admitted on [DATE] and had already exceeded the 90 day mark. Social Services (SS) was interviewed at 11:20 a.m. on 04/25/12. She stated residents g… | 2016-05-01 |
| 8548 | 8548 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 428 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure that medication potentially being used for an excessive period of time was reported to the physician by the consultant pharmacist for 1 of 10 sampled residents. (Resident #22) Finding include: a) Resident #22 This resident was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of Resident #22's Medication Administration Record [REDACTED]. Review of Resident #22's medical record noted a [DIAGNOSES REDACTED]. A review of the monthly pharmacy consultant notes from 10/2011 through 04/2012 found no mention of Resident #22 being on Valtrex. An interview was conducted with Resident #22's physician (Physician #1) on 04/25/12 at 2:20 p.m (Physician #1) said, I noticed today that (Resident #22) was on Valtrex. The reason on the record mentions dermatitis. If she isn't compromised and she has genital herpes, we would make that a daily dose. I am having (Unit Manager #1) check on that. The physician noted that if Resident #22 did not have a history of genital herpes, then the use of Valtrex would be time limited. On 4/25/12 at 3:30 p.m., an interview was completed with the facility pharmacy consultant (PC). The PC reported that she visits the facility every month and looks at every chart. I thought I asked about the Valtrex, but I don't see where I wrote anything. I think I looked up the drug to verify the dose. If I was concerned about it, I would have sent it to the physician. If there is a herpes infection that is chronic, the dose would continue if it was active. It would be up to the doctor to continue (the drug treatment) if it (infection) isn't active. When we go in and review a resident we make sure doses and indications are appropriate. We make sure they (residents) aren't allergic (to any of the medications), make sure lab (laboratory) work is done. We look at physician's orders [REDACTED]. I don't do a 100% MAR indicated [REDACTED]. Sometimes I d… | 2016-05-01 |
| 8549 | 8549 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 514 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to maintain accurate Medication Administration Records for 3 of 10 sampled residents. (Residents #180, #22, and #187) Findings include: a) Resident #180 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of Resident #180's Medication Administration Record [REDACTED]. An observation of Resident #180's medication stock noted [MEDICATION NAME] 250 mcg (micrograms) in single dose packs. On 4/25/2012 at 3:30 p.m., an interview was completed with the Pharmacy Consultant (PC). The PC stated, When we go in and review a resident, we make sure doses and indications are appropriate. We look at physician's orders [REDACTED]. I don't do a 100% MAR indicated [REDACTED]. Sometimes I do look at MARs, but not routinely. I have caught errors on the MARs, but if the order was correct, I might not see it on the MARs. On 04/26/12 at 9:45 AM, an interview was completed with Nurse #2. Nurse #2 acknowledged that the MAR indicated [REDACTED]. She said that she would get a clarification order and change the MAR. 2. Resident #22 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of Resident #22's Medication Administration Record [REDACTED]. An interview was completed with Nurse #1 on 4/25/2012 at 2:50 PM. Nurse #1 said that the K-dur should be 20 mEq instead of 20 mg and the [MEDICATION NAME] is 2 sprays in each nostril. The packages are correct. I will write a clarification order. Resident #22's medication was observed in the mediation cart on 4/25/2012 at 3:00 PM. The Kdur is packaged at 20 mEq and the [MEDICATION NAME] box label reads 2 sprays in each nostril. On 4/25/2012 at 3:30 PM, an interview was completed with the Pharmacy Consultant (PC). When we go in and review a resident, we make sure doses and indications are appropriate. We look at physician's orders [REDACTED]. I don't do a 100% MAR indicated [REDACTED]. Sometimes I do look at MARs, … | 2016-05-01 |
| 8550 | 8550 | ROSEWOOD CENTER | 515105 | 8 ROSE STREET | GRAFTON | WV | 26354 | 2012-03-15 | 167 | B | 0 | 1 | 17TQ11 | Based on the resident council president interview, observation, and staff interview, it was found the facility failed to post their survey results in a place readily accessible to residents, and failed to post a notice of their availability. The survey results were in a bookcase in the lobby, blending in with several books. This practice had the potential to affect any resident or family member wishing to examine the survey results without asking a staff member where they were located. Facility census: 66. Findings include: a) An interview conducted with the resident council president, on 03/13/12 at 9:30 a.m., revealed the resident council president did not know the location of the state survey results. The survey results were not found during an observation of the front lobby, on 03/13/12, at approximately 2:00 p.m., after the interview with the council president. During an interview with the interim Nursing Home Administrator (NHA), Employee #97, on 03/14/12 at 12:00 p.m., the location of the survey results was requested. The NHA located the survey results in the front lobby in a bookcase that contained many books and survey results book blended in with other books. There was also no notice posted of their availability. The NHA agreed the survey results were not posted in an area that was readily available to residents and families without asking staff for their location. | 2016-05-01 |
| 8551 | 8551 | ROSEWOOD CENTER | 515105 | 8 ROSE STREET | GRAFTON | WV | 26354 | 2012-03-15 | 272 | D | 0 | 1 | 17TQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain accurate comprehensive assessments for two (2) of thirty-two (32) stage II sample residents. One (1) resident's minimum data set (MDS) was incorrect relative to assistance required in bathing. The other resident's MDS indicated the resident had not received antipsychotic medications in the last seven (7) days; however, the resident had received antipsychotic medications in the last seven (7) days. Resident identifiers: #6 and #9. Facility census: 66. Findings include: a) Resident #6 Review of this resident's MDS, on 03/14/12 at 12:30 p.m., found her Quarterly MDS, of 11/01/11, section G0110G, dressing, was coded 2, indicating limited assistance was required to help her perform this activity. In her next quarterly MDS, dated [DATE], the section G0110G, dressing, was coded 4, indicating total dependence on staff for the activity. This change in coding from 2 to 4 indicated she had experienced a significant decline in her ability to dress herself from 11/01/11 to 01/31/12. A subsequent review of the progress notes, for the 02/01/12 care plan, revealed documentation the facility had reviewed the problems, goals, and interventions with no significant changes made. The note further stated there were no significant changes in the resident's activities of daily living (ADLs), even though the MDS of 01/31/12 indicated the resident had a significant decline in her ability to dress herself since the MDS dated [DATE]. An interview was conducted with the clinical records coordinator, Employee #1, at 2:05 p.m. on 03/14/12. She confirmed the section of the MDS of 01/31/12 for dressing, had been coded incorrectly. She said it should have been coded as a 2, indicating Resident #6 continued to require limited assistance with dressing. b) Resident #9 Review of the medical record revealed this resident was ordered an antipsychotic medication, [MEDICATION NAME] 0.5 milligrams, to … | 2016-05-01 |
| 8552 | 8552 | ROSEWOOD CENTER | 515105 | 8 ROSE STREET | GRAFTON | WV | 26354 | 2012-03-15 | 371 | F | 0 | 1 | 17TQ11 | Based on observation and staff interview, the facility failed to ensure food was stored, prepared, and/or served under sanitary conditions. Environmental observations in the kitchen and dry storage area revealed a failure to perform routine cleaning of the areas. Equipment, sanitizing stations, and serving items were soiled and/or in disrepair in a manner which had the potential to harbor bacteria or otherwise contaminate food and food preparation areas. Cold food items were not held for service at the required 41 degrees Fahrenheit (F) or below. Dietary employees did not follow safe food handling practices. These sanitation infractions had the potential to affect all residents who received nourishment from the dietary department. Facility census: 66. Findings include: a) The following observations were made during the initial tour of the kitchen and the adjoining dry storage room, at 11:50 a.m. on 03/12/12. The same sanitation infractions were observed again during a follow-up observation, at 11:00 a.m. on 03/14/12. On 03/14/12, the sanitation infractions were also observed by the life-safety surveyor who was present in the kitchen. 1) The pipes running along the wall behind the stove and extending beyond the stove were black with grime. There also was was approximately 1/8 inch of greasy debris on the top surface of the pipes. 2) Anything mounted on the wall was sticky with grime. 3) A rack located on the wall near the office, which was used for hanging utensils, was soiled. 4) The entire wall behind the stove, ice machine, and other items was soiled with brownish stains running down the wall. 5) The floor of the kitchen and the dry storage room had brownish build-up around the entire periphery. In addition, this same build-up was seen around the lower edges and legs of any equipment sitting on the floor. 6) In the area of the ice machine, there were missing and loose floor tiles, rendering the area unable to be properly cleansed and sanitized. 7) The ice machine was encrusted with thick white corroded material… | 2016-05-01 |
| 8553 | 8553 | ROSEWOOD CENTER | 515105 | 8 ROSE STREET | GRAFTON | WV | 26354 | 2012-03-15 | 425 | D | 0 | 1 | 17TQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, drug handbook review, and pharmacist interview, the facility failed to ensure medications were administered according to acceptable methods for one (1) of eleven (11) residents observed during medication pass. Cymbalta, a delayed-released antidepressant medication, was opened and the contents were mixed into applesauce before administering the medication to the resident. Review of the facility's drug handbook revealed this medication should not be opened or crushed. Resident identifier: #76. Facility census: 66. Findings include: a) Resident #76 Medication pass observation with a licensed nurse, Employee #71, on 03/13/12 at 9:08 a.m., revealed the nurse opened a capsule of Cymbalta 60 (sixty) milligrams, then poured and mixed the contents of the capsule with applesauce prior to administering the medication to Resident #76. A 2011 nursing drug handbook, found at the nurse's desk, was reviewed during reconciliation of the medication pass. According to this handbook, Cymbalta is a delayed-release medication and should be administered whole. The handbook specifically noted Cymbalta was not a medication which should be opened or crushed. During an interview with Employee #71, on 03/13/12, at approximately 3:00 p.m., she said she found no directions in the physician's orders [REDACTED]. She said she spoke with someone in the pharmacy used by the facility, who said it was alright to open the capsules, as long as one did not crush the beads of the medicine inside. A pharmacist (at the pharmacy used by the facility) was interviewed, on 03/14/12, at approximately 9:00 a.m. She stated Cymbalta capsules were not to be opened prior to administration. During an interview with the director of nursing, on 03/14/12, at approximately 9:00 a.m., she said she was aware of the incident, and was in the process of researching Cymbalta on the computer. No further evidence was produced by the facility prior to exit. | 2016-05-01 |
| 8554 | 8554 | ROSEWOOD CENTER | 515105 | 8 ROSE STREET | GRAFTON | WV | 26354 | 2012-03-15 | 431 | E | 0 | 1 | 17TQ11 | Based on observation, staff interview, and the pharmacy storage recommendations, the facility failed to dispose of outdated insulin vials for three (3) of seven (7) residents who had insulin vials stored in the medication room refrigerator. The facility also failed to discard two (2) pre-filled syringes of medication (Avenox) for a former resident. Resident identifiers: #57, #90, #12, and #96. Facility census 66. Findings include: a) Observation of the medication storage refrigerator, on 03/12/12 at 1:30 p.m., revealed the presence of three (3) partially used vials of insulin that either had no date of when the vial was opened, or had an opened date inscribed on the vial that was beyond the acceptable parameters for storing or using it. The director of nursing (DON) was present during this observation. She agreed the insulin vials should have been destroyed according to their facility policy to discard after 28 days of opening. The DON produced the facility's pharmacy's storage recommendations which stated all insulin's must be discarded after 28 days from opening, except for Levemir, Novolin R, Novolin N, and Novolin 70/30 all of which can be used for up to 42 days after opening. 1) Resident #57 This resident had a partially used vial of Levemir, with an inscribed opened date of 01/26/12, stored in the medication room refrigerator. This was 46 days from the date it was first opened. 2) Resident #90 This resident had a partially used vial of Lantus insulin, with an inscribed opened date of 02/08/12, stored in the medication room refrigerator. This was 33 days from the date it was first opened. 3) Resident #12 This resident had a partially used vial of Humalog-R, with no date inscribed as to when it had been opened, stored in the medication room refrigerator. 4) Resident #96 This was a former resident at the facility who had two (2) pre-filled syringes for 30 micrograms of Avon. One of the two syringes was inscribed to be given on 09/14/11. During an interview with the DON, on 03/12/12 at 1:30 p.m., she agreed the… | 2016-05-01 |
| 8555 | 8555 | MANSFIELD PLACE | 515129 | PO BOX 930 | PHILIPPI | WV | 26416 | 2012-04-19 | 279 | D | 0 | 1 | SQE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interview, it was determined the facility failed to develop a care plan which described the care and services necessary to meet the medical, mental, and/or psychosocial needs for one (1) of twenty-one (21) stage II sample residents. The resident was noted as anxious, had crying episodes, made attempts to climb out of bed and out of her wheelchair. There was no care plan for non-pharmacological interventions prior to the use of medications, and no care plan which directed staff in the use of a medication ordered for anxiety on as needed (PRN) basis. Resident identifier: #5. Facility census: 57. Findings include: a) Resident #5 Review of physician orders [REDACTED]. In addition, on 02/28/12, the resident was ordered [MEDICATION NAME] 0.25 mg two (2) times daily (BID) for anxiety. During observations of the resident, on 04/17/12 and on 04/18/12, he was observed in a wheelchair with a lap buddy applied. It was also discovered, during the observations, the resident was unable to verbally communicate her wants and needs to staff due to advanced stages of [MEDICAL CONDITION]. Review of the Medication Administration Record [REDACTED]restlessness/trying to get OOB (out of bed) or trying to get OOC (out of chair). Nursing notes for the days the resident was given the PRN doses of [MEDICATION NAME] were reviewed. There was no documentation entered (either in nursing notes or on the MAR) of non-pharmacological interventions such as toileting, taking the resident out of the bed or the chair, provision of food/water, or other measures attempted before giving the [MEDICATION NAME], a sedating medication. There was no evidence staff made attempts to determine the resident's wants and needs prior to the decision to use medication to address the restlessness/trying to get OOB (out of bed) or trying to get OOC (out of chair). During a review of the resident's comprehensive care plan, provided by the direct… | 2016-05-01 |
| 8556 | 8556 | MANSFIELD PLACE | 515129 | PO BOX 930 | PHILIPPI | WV | 26416 | 2012-04-19 | 329 | D | 0 | 1 | SQE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, it was determined the facility failed to ensure the drug regimen for one (1) of twenty-one (21) stage II sample residents was free of unnecessary drugs. The resident was ordered, and received, as needed (PRN) doses of [MEDICATION NAME], a sedating medication, without evidence of non-pharmacological interventions prior to the use of the medication. Resident identifier: #5. Facility census: 57. Findings include: a) Resident #5 Review of physician orders [REDACTED]. During observations of the resident, on 04/17/12 and on 04/18/12, he was observed in a wheelchair with a lap buddy applied. It was also discovered, during the observations, the resident was unable to verbally communicate her wants and needs to staff due to advanced stages of [MEDICAL CONDITION]. Review of the Medication Administration Record [REDACTED]restlessness/trying to get OOB (out of bed) or trying to get OOC (out of chair). Nursing notes for the days the resident was given the PRN doses of [MEDICATION NAME] were reviewed. There was no documentation entered (either in nursing notes or on the MAR) of non-pharmacological interventions such as toileting, taking the resident out of the bed or the chair, provision of food/water, or other measures attempted before giving the [MEDICATION NAME], a sedating medication. There was no evidence staff made attempts to determine the resident's wants and needs prior to the decision to use medication to address the restlessness/trying to get OOB (out of bed) or trying to get OOC (out of chair). During a review of the resident's comprehensive care plan, provided by the director of nursing (DON) on 04/18/12, it was found the problems of anxiety, shaking, crying, and trying to climb out of bed or a chair were not included in the care plan. In addition, the care plan contained no information relative to the resident's use of the PRN [MEDICATION NAME]. The care plan contained no direc… | 2016-05-01 |
| 8557 | 8557 | MANSFIELD PLACE | 515129 | PO BOX 930 | PHILIPPI | WV | 26416 | 2012-04-19 | 371 | F | 0 | 1 | SQE911 | Based on observation, review of Centers for Disease Control (CDC) guidelines for effective handwashing, and staff interviews, the facility failed to serve food under sanitary conditions. Dietary and/or nursing staff members contaminated food, food surfaces, and food preparation, and serving items. There was also a failure to cleanse hands as needed and/or in a manner to prevent contamination. The handwashing station in the kitchen was not maintained in a manner to prevent contamination, and contaminated products were left within close proximity to residents while they were eating their meals. These practices had the potential to affect all residents in the facility who received an oral diet. Facility census: 57. Findings include: a) During observations of the noon meal service in the dietary department, on 04/18/12 at 11:30 a.m., the following unsanitary practices were observed: 1) The cook, Employee #28, donned food handlers' gloves, then touched cabinet handles, the oven handle, and a small cart prior to picking up fish sticks with the contaminated gloves. 2) Employee #28 touched the inside surface of a small plate with her bare thumb prior to placing a slice of cheese on the plate. 3) Dietary staff member, Employee #30, removed a knife from a container of utensils maintained in standing water. She sliced an orange with the knife then placed it back into the container of standing water. When asked what solution was utilized to store the various utensils, she stated it was only hot water. She stated she had scooped cottage cheese earlier, rinsed off the scoop and placed it back into the container of hot water from which she retrieved the knife to cut the orange. The dietary manager, Employee #44, agreed this was not a sanitary practice and was unaware the employee was using these utensils to prepare food. 4) Observation revealed dietary staff members, Employees #28, and #32, washed their hands, then used paper towels to wipe from their elbows, down their forearms, and onto their wet hands. This practice allowed … | 2016-05-01 |
| 8558 | 8558 | MANSFIELD PLACE | 515129 | PO BOX 930 | PHILIPPI | WV | 26416 | 2012-04-19 | 431 | E | 0 | 1 | SQE911 | Based on observation and staff interview, the facility failed to provide a secure locked compartment for controlled drugs. The facility did not have Ativan stored in a locked compartment. This practice had the potential to affect more than an isolated number of residents. Facility census: 57. Findings include: a) Observation of the medication storage room on 04/18/12, at approximately 3:20 p.m., found the door open to the medication storage room. Inspection of the refrigerator inside the medication storage area found five (5) vials of Ativan lying inside the refrigerator. The refrigerator contained a locked box for controlled drugs, but the Ativan was not in the locked box. During an interview with Employee #101 (registered nurse manager) on 04/18/12 at 3:20 p.m., it was confirmed the Ativan should have been secured in the locked box. | 2016-05-01 |
| 8559 | 8559 | MANSFIELD PLACE | 515129 | PO BOX 930 | PHILIPPI | WV | 26416 | 2012-04-19 | 441 | F | 0 | 1 | SQE911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's infection control data, infection control policy and procedures, and staff interview, the facility failed to establish an effective infection control program that included a method of monitoring, investigating, controlling, and preventing further infections in the facility. The facility did not have a system to enable them to analyze clusters or increases in the rate of infections in a timely manner. The facility did not maintained logs or organize data in a manner to include all residents who were receiving antibiotic therapy to ensure these residents had adequate monitoring and treatment of [REDACTED]. The lack of an infection control program to analyze and control the facility's spread of infections had the potential to affect all residents in the facility. Facility Census: 57. Findings Include: a) Infection Control Program. A registered nurse (Employee #101) was the contact person for the infection control data. She was asked, at 10:00 a.m. on 04/18/12, for the infection control logs regarding infections which had been present in the facility. Employee #101 provided a diagram with the facility layout. It had room numbers that were circled. There was a facility layout with each month of 2011 written on the diagram. Attached to each one, was a print out from the hospital laboratory that specified the resident's name, the physician, the source of culture, and the organisms isolated. There was no data recorded for 2012. On 04/17/12, Employee #101 verified she was not able to locate any data for 2012. She stated the facility had the results from the laboratory for these months, but the results had not been put on the facility layout or analyzed. The Director of Inpatient Services (Employee #45) was interviewed on 04/18/12 at 4:00 p.m It was identified she shared the role of monitoring infection control with Employee #101. Employee #45 stated the facility monitored the culture reports from the laboratory data, … | 2016-05-01 |
| 8560 | 8560 | MANSFIELD PLACE | 515129 | PO BOX 930 | PHILIPPI | WV | 26416 | 2012-04-19 | 520 | F | 0 | 1 | SQE911 | Based on a review of the facility's infection control data, policy review, and staff interview, the facility failed to identify, develop, and implement appropriate plans of action to correct inadequate monitoring, tracking, and reporting of the facility's infections. The data used for review at the quality assurance meetings was not adequate to identify the type and actual number of infections the residents of the facility experienced. Additionally, there was no plan developed and implemented to address the number of urinary tract infections the residents experienced during several months in 2011. This practice had the potential to affect all of the residents in the facility. Facility Census: 57. Findings Include: a) Infection Control During review of the facility's infection control program, the facility was unable to provide evidence they identified, monitored, prevented, reduced incidence, or initiated measures to address infection control issues. Information was provided each month during the quality assurance meetings; however, the committee did not analyze this information and did not adequately monitor or track infections to ensure appropriate infection control measures were implemented. Employee #101, the registered nurse responsible for infection control, provided the data the facility used for tracking infections. She verified this was the only data she had. This data included a list of cultures from the laboratory and a facility layout for each month which indicated the location of residents who had positive cultures. She was questioned about further interventions after these reports were completed and was asked for information regarding other infections. Employee #101 verified this was all she had. Even though it was the fourth month of 2012, Employee #101 verified she had not yet analyzed the data for 2012. Additionally, this data had not been recorded on the facility layout for the purpose of tracking and trending. On 04/19/12 at 8:30 a.m., the Director of Inpatient Services (Employee #45) was inter… | 2016-05-01 |
| 8561 | 8561 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 157 | D | 0 | 1 | ZPPW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and medical record review, the facility failed to ensure changes in medications and treatments were discussed with a resident who had capacity to make medical decisions. This was true for one (1) of thirty-seven (37) sampled residents. Resident identifier: #31. Facility census: 54. Findings include: a) Resident #31 During an interview with Resident #31, in stage I of the quality indicator survey (QIS), on 05/14/12, at approximately 4:45 p.m., the resident stated he never made any decisions about his care and changes in treatments and medications were never discussed with him by anyone at the facility. Medical record review found the resident was admitted to the facility on [DATE]. Information accompanying the resident upon admission found a physician from the referring hospital had determined the resident had capacity to make decisions. On 02/24/12 the facility physician also determined the resident had capacity to make medical decisions. Further review of the physician's orders [REDACTED]. 02/28/12-New order to cleanse the thumbnail to the right hand. 03/07/12-New order to change the diet order to a mechanical soft diet, ground meats and nectar thickened liquids. 03/11/12-New order to treat a stage II pressure area to the gluteal crease. 03/16/12-New order to discontinue the resident's Glucerna and add Ensure plus. 03/22/12-New order to discontinue the PRN (as needed) [MEDICATION NAME] and schedule [MEDICATION NAME] 0.5 mg (milligrams) to TID (three times a day). 03/25/12-New order to change the current treatment to the stage II pressure area to the gluteal crease. 03/30/12-New order to provide treatment to a skin tear. 04/02/12-New order for [MEDICATION NAME] and [MEDICATION NAME] for treatment of [REDACTED]. 04/10/12 New order to treat a Stage II pressure ulcer to the right anterior leg. 04/10/12-New order to discontinue the Ensure and add a Magic Cup. 04/20/12-New order to add a bed and chair … | 2016-05-01 |
| 8562 | 8562 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 225 | E | 0 | 1 | ZPPW11 | Based upon review of facility personnel records and staff interview, the facility failed to complete a thorough investigation of past histories for two (2) of five (5) agency staff prior to allowing them to work at the facility. A state wide criminal background check, as required by State law, was not completed for these agency personnel. Employee identifiers: #71 and #72. This practice had the potential to affect more than an isolated number of residents. Facility census: 54. Findings include: a) Personnel records were reviewed on 05/17/12 at 11:30 a.m. Five (5) records of employees hired within the past four (4) months and five (5) records of staff supplied under contract from an outside staffing agency were reviewed. The review included verifying that required criminal background checks and nurse aide registry checks had been completed prior to staff working with residents in the facility. There was no evidence of statewide criminal background checks for two (2) agency personnel. One was licensed practical nurse (LPN), Employee #72, the other was nursing assistant (NA), Employee #71. These individuals' files had checks done by a commercial online vendor, but no statewide West Virginia State Police check was found. During an interview on 05/21/12 at 11:00 am, the administrator, Employee #42, concurred that although the two (2) individuals had been providing care to residents, the required checks were not available. | 2016-05-01 |
| 8563 | 8563 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 241 | D | 0 | 1 | ZPPW11 | Based on observation and staff interview, the facility failed to provide care in an environment at meal time that provided and maintained a resident's dignity. The facility also failed to ensure a resident maintained dignity while being transported to a shower room. This was true for two (2) of thirty-seven (37) residents sampled. Resident identifiers: #45 and #31. Facility census: 54. Findings include: a) Resident #45 Observation of the noon meal on 05/14/12, at approximately 1:10 p.m., found Resident #45 seated at a table in a low wheelchair. She was unable to comfortably reach her bowls of food which were sitting on the table. The resident was observed placing the bowl of food on her lap as the table was too high to accommodate her height. Employee #36, who identified herself as a hospitality aide, agreed the table was to high for the resident. On 05/17/12, at approximately 12:30 p.m., the resident was again observed in the dining room eating her noon meal. At this time, the resident was seated at the table in a regular chair and her feet were placed on a footstool. She was able to reach the food items on the table. Employee #36 commented the resident was really eating much better since being placed in a regular chair. b) Resident #31 Random observation, on 05/16/12 at 10:30 a.m., found Resident #31 being pushed in a shower chair in the hallway by a nursing assistant, Employee #24. His bare feet were visible, and his left foot could be seen and heard scraping along the floor as he approached the central shower room door. Covered with only a white bed sheet, his upper buttocks and lower back were visible through the opening in the back of the shower chair. When asked, Employee #24 agreed that his backside was not covered. During interview with the director of nursing on 05/16/12, at approximately 1:30 p.m., she said this is not an acceptable practice, and the resident should have been covered. | 2016-05-01 |
| 8564 | 8564 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 247 | D | 0 | 1 | ZPPW11 | Based on medical record review, resident interview and staff interview, the facility failed to notify one (1) of thirty-seven (37) Stage 2 sampled residents about receiving a new roommate. During an interview, the resident said she was not made aware she was going to receive a new roommate prior to their arrival. Interview with the social worker confirmed the resident was not given notification she was going to have a new roommate. Resident identifier #17. Facility census 54. Findings include: a) Resident # 17 During an interview with Resident # 17, on 05/16/12 at 9:30 a.m., it was discovered this resident had recently acquired a new roommate. When the resident was asked if she had been informed by the facility of the new roommate prior to their arrival in the room, Resident # 17 stated she was not informed of their arrival before the resident showed up in her room. Review of social service notes revealed no indication the resident was informed she was going to get a new roommate. An interview was conducted with the social worker (Employee #18) on 05/16/12 at 4:13 p.m. At that time, it was confirmed Resident # 17 had not been notified, as required, that she was getting a new roommate prior to their arrival in her room. | 2016-05-01 |
| 8565 | 8565 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 272 | D | 0 | 1 | ZPPW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to ensure the accuracy of the minimum data set (MDS) assessment related to a resident's ability to move herself in her wheelchair. This was found for one (1) of thirty-seven (37) Stage 2 residents reviewed. Resident identifier: #26. Facility census: 54. Findings include: a) Resident #26 This resident's medical record was reviewed on 5/16/12 at 11:30 a.m. Her quarterly MDS, dated [DATE], assessed her locomotion on the unit as: self performance = 0, or independent and support provided = 0, or no help needed. The next quarterly MDS, dated [DATE], assessed her locomotion on the unit as: self performance = 3, or extensive assistance needed and support provided = 2, or 1 person assist. These coding changes from one quarter to the next suggested a decline in her ability to independently move herself about the facility in her wheelchair. An interview was conducted with a registered nurse (RN), Employee #64, on 05/16/12 at 12:25 p.m. She stated there had been no major change in the resident between the evaluation periods, except perhaps a gradual overall decline. The facility uses a computer program for nursing assistants (NA) to enter their individual observations and care provided. The NA records were used for the seven (7) day look back period to code the resident's MDS. A printout of this data for the 12/22/11 and 3/22/12 MDS was requested on 5/16/12 at 1:30 p.m. The information recorded by the NAs, and used for the 12/22/11 MDS for locomotion was: -On the unit: self performance = 3, or extensive assistance needed, support provided = 2, or 1 person assist. -Off the unit: self performance = 1, or supervision needed, support provided = 2, or 1 person assist. The information recorded by the NAs, and used for the 03/22/12 MDS for locomotion was: -On the unit: self performance = 3, or extensive assistance needed, support provided = 2, or 1 person assist. -Off the unit: self performance =… | 2016-05-01 |
| 8566 | 8566 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 279 | D | 0 | 1 | ZPPW11 | Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan for a resident that included measurable objectives and timetables to meet the resident's medical needs related to contractures. The contractures were identified in the resident's comprehensive assessment. In addition, occupational therapy (OT) identified, assessed, and recommended a plan for contracture management which was not reflected in the care plan. This was found for one (1) of thirty-seven (37) Stage 2 residents reviewed. Resident #58. Facility census: 54. Findings include: a) Resident #58 This resident's medical record was reviewed on 05/16/12 at 8:00 a.m. Her comprehensive assessment of 02/16/12 noted she had contractures of her left hand, and contractures of both elbows. Medical record review revealed the resident received occupational therapy from 06/09/11 to 07/11/11 related to a decline in function, contracture management, and splint/orthosis. The recommendation made upon her discharge from occupational therapy, on 07/11/11 was (typed as written): Pt (patient) at this time reaching all goals for splint wear tolerance and staff training. Discontinue OT services at this time. Splint wear schedule and photo of proper placement of splint in Pt's closet. Pt to wear L (left) resting hand splint, 8 hours daily, to increase skin integrity and promote digit extension. There was a therapy in-service record that indicated the use and care of the splint was taught to three (3) nursing assistants on 07/08/11. Medical record review revealed no evidence the splint had ever been ordered or used. During an interview on 05/16/12 at 3:00 p.m., a registered nurse (RN), Employee #64, stated Resident #58 had a contracture to her left hand. She stated the resident did not receive range of motion or have any splint devices in place. The resident's current care plan included a problem statement for a self-care deficit due to cognitive and physical impairments. The goal associated with this problem was that range of m… | 2016-05-01 |
| 8567 | 8567 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 280 | D | 0 | 1 | ZPPW11 | Based on resident interview, medical record review, and staff interview, the facility failed to ensure one (1) of thirty-seven (37) Stage 2 sample residents was given the opportunity to participate in the care planning process. The resident was not invited to his care plan meetings. Resident identifier: #31. Facility census: 54. Findings include: a) Resident #31 During Stage I of the quality indicator survey (QIS), this resident stated he had never been invited to attend a care plan conference and stated the facility just made decisions for him. Review of the resident's current plan of care found the care plan had been reviewed/updated on 02/23/12, 03/07/12, 03/30/12, 04/25/12 and 05/15/12. According to an interview conducted with Employee #11, the minimum data set (MDS) coordinator, at approximately 10:00 a.m. on 05/19/12, the social worker was responsible for inviting residents and/or responsible family members to the care planning conference. An interview with Employee #18, the social service director, at approximately 10:15 a.m. on 5/19/12, found she was unable to provide verification the resident had been invited to care plan conferences. Additionally there was no evidence the resident was made aware of the facility's plan of care addressing his problems, goals and interventions. Employee #18 was unable to verify the resident had any input into his plan of care. She stated she had invited the resident's medical power of attorney to attend the care plan meeting. | 2016-05-01 |
| 8568 | 8568 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 282 | D | 0 | 1 | ZPPW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide care and services in accordance with the care plan for one (1) of thirty-seven (37) Stage 2 sample residents. The resident was assessed with [REDACTED]. Her care plan for the provision of range of motion during care was not implemented. Resident identifier: #58. Facility census: 54. Findings include: a) Resident #58 This resident's medical record was reviewed on 05/16/12 at 8:00 a.m. Her comprehensive assessment of 02/16/12 noted she had contractures of her left hand, and contractures of both elbows. During an interview on 05/16/12 at 3:00 p.m., a registered nurse (RN), Employee #64, stated Resident #58 had a contracture to her left hand. She stated the resident did not receive range of motion. The resident's current care plan included a problem statement for a self-care deficit due to cognitive and physical impairments. The goal associated with this problem was that range of motion would be maintained as evidenced by (AEB) restorative nursing services (RNS) assessments through the next review. Included in the list of interventions, designed to meet this goal, was an intervention for nursing assistants to provide gentle range of motion during care. The quality care director, a registered nurse (RN), Employee #38 was interviewed on 05/16/12 at 9:35 a.m. She was asked to provide evidence to support that range of motion was being provided by the nursing assistants with Resident #58's care. Employee #38 stated there was no specific documentation related to the provision of range of motion exercise during routine daily care. Employee #38 was asked about the goal in the care plan which stated restorative nursing assessments would be the measurement tool to determine whether range of motion was being maintained for this resident. She confirmed there was no evidence of any restorative nursing assessments in the medical record. Therefore, there was no measurement tool, … | 2016-05-01 |
| 8569 | 8569 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 309 | D | 0 | 1 | ZPPW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide care and services to ensure one (1) of thirty-seven (37) Stage 2 sample residents attained or maintained the highest practicable well-being. physician's orders [REDACTED]. Resident identifier: #59. Facility census: 54. a) Resident #59 On 05/17/12 at 1:00 p.m. this resident's medical record was reviewed. The record contained a physician's orders [REDACTED]. A review of Resident #59's medication administration record (MAR) failed to show these medications were being given. This information was provided to the director of nursing (DON), Employee #9. The DON, on 05/17/12 at 1:30 p.m., presented copies of the physician's orders [REDACTED]. She confirmed the order had not been transcribed to the MAR and the resident had not received the medications which were ordered on [DATE]. | 2016-05-01 |
| 8570 | 8570 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 318 | D | 0 | 1 | ZPPW11 | Based on observation, medical record review, and staff interview, the facility failed to ensure one (1) of thirty-seven (37) residents received care and services to reach and maintain her highest level of range of motion. Additionally, the facility failed to implement services to prevent further decline in range of motion. There was no evidence preventive care was provided as recommended by an occupational therapist, and no evidence a care plan for the provision of range of motion during care was implemented. Resident identifier: #58. Facility census: 54. Findings include: a) Resident #58 This resident's medical record was reviewed on 05/16/12 at 8:00 a.m. Her comprehensive assessment of 02/16/12 noted she had contractures of her left hand, and contractures of both elbows. Medical record review revealed the resident received occupational therapy (OT)from 06/09/11 to 07/11/11 related to a decline in function, contracture management, and splint/orthosis. The recommendation made upon her discharge from OT on 07/11/11 was (typed as written): Pt (patient) at this time reaching all goals for splint wear tolerance and staff training. Discontinue OT services at this time. Splint wear schedule and photo of proper placement of splint in Pt's closet. Pt to wear L (left) resting hand splint, 8 hours daily, to increase skin integrity and promote digit extension. There was a therapy in-service record that indicated the use and care of the splint was taught to three (3) nursing assistants on 07/08/11. Medical record review revealed no evidence the splint had ever been ordered or used. The resident's current care plan included a problem statement for a self-care deficit due to cognitive and physical impairments. The goal associated with this problem was that range of motion would be maintained through the provision of gentle range of motion by nursing assistants during care. This care plan contained nothing specific to the identified contractures of the resident's left hand and elbows. Additionally, the care plan contained nothi… | 2016-05-01 |
| 8571 | 8571 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 323 | E | 0 | 1 | ZPPW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observation, and policy and procedure review, the facility failed to ensure resident equipment and the environment was as free of accident hazards as possible. Additionally, the facility failed to evaluate injuries of unknown origin to identify potential environmental hazards and/or individual residents at risk for accidents. There was no evidence of a systematic process which effectively identified, assessed, and addressed potentially avoidable accident hazards. Identified concerns included: two (2) of sixty (60) beds had mattresses which did not fit the bed frames; the facility did not attempt to determine causes of bruising and/or skin tears for two (2) of thirty-seven (37) residents; and cleaning chemicals were not safely stored in the central bath. Resident identifiers #31, #41, and #82. The chemical storage had the potential to affect more than an isolated number of residents. Facility census: 54. Findings include: a) Resident #31 Medical record review found a physician's orders [REDACTED]. The director of nursing (DON) was interviewed on 05/16/12 at 5:00 p.m. She was unable to provide verification the resident's injuries were investigated to determine the cause of the injury to rule out any neglect/abuse, faulty equipment, or other avoidable accident hazards. On 05/17/12, at approximately 9:30 a.m., the DON stated she thought the order was a mistake and it was the resident's roommate who actually had an injury. Review of the treatment administration record (TAR) found the facility had provided a daily treatment to Resident #31's third digit on the left hand from 03/30/12 to 04/05/12. Review of the nurses notes for 04/05/12 found, .Steri-strips remain dry and intact to left third digit, no odor, no drainage, light bruising noted, no symptoms of infection . The TAR and nurse's notes were indicative Resident #31 had an injury. Review of the resident's care plan dated 03/26/12 found the resi… | 2016-05-01 |
| 8572 | 8572 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 325 | D | 0 | 1 | ZPPW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to ensure one (1) of thirty-seven (37) Stage 2 sample residents was provided nutritional supplementation as recommended by the consultant registered dietitian (RD). This resident was identified at nutritional risk. The RD assessed her nutritional needs and recommended increased protein for wound healing. The facility failed to ensure the additional protein was provided. Resident identifier: #58. Facility census: 54. Findings include: a) Resident #58 This resident was assessed at nutritional risk due to Alzheimer's dementia and dysphagia. She required a pureed diet, thickened liquids, and feeding by staff for all meals. Dietary progress notes were reviewed on 05/16/12 at 2:30 p.m. There was an RD note, dated 11/17/11, which stated in part (typed as written): Receiving vitamin C and zinc supplements and Prosource started on 11/15/11 r/t (related to) wound healing. Another RD note, dated 02/29/12, stated in part (typed as written): Recommend d/c (discontinue) vitamin C and zinc supplements. However, will continue with Prosource for extra protein as Resident may not be meeting protein needs consistently through diet. During an interview on 05/16/12 at 3:10 p.m., a registered nurse (RN), Employee #64, stated Resident #58 was not receiving any nutritional supplements. Review of the resident's physician's orders [REDACTED]. There was no reference to stopping the Prosource supplement. The last order found for the Prosource, was dated 02/6/12 - 03/7/12. On 05/16/11 at 9:35 a.m., Employee #38, an RN who was the director of quality care, confirmed the Prosource had been discontinued on 03/7/12, although the RD had recommended that it should be continued. | 2016-05-01 |
| 8573 | 8573 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 329 | D | 0 | 1 | ZPPW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy and procedure review, the facility failed to ensure one (1) of thirty-seven (37) Stage 2 residents was free from unnecessary medications. The resident had received [MEDICATION NAME] 0.5 mg. TID (three times a day) since 10/28/10 without any attempt at a dose reduction, without evidence of the risks versus the benefits of the continued use of the medication, without consistent monitoring of behaviors, and without consistent documentation of non-pharmacological approaches tried to relieve the residen'ts distressed behaviors. Resident identifier: #61. Facility census: 54. Findings include: a) Resident #61 Medical record review found the resident had been receiving [MEDICATION NAME] 0.5 mg. three (3) times daily for a [DIAGNOSES REDACTED]. Further review found the consultant pharmacist reviewed the resident's medications and recommended a dose reduction of [MEDICATION NAME] on 04/19/12 and again on 06/24/11. On both occasions the pharmacist recommended, This resident has been receiving the anti-anxiety agent [MEDICATION NAME] ([MEDICATION NAME]) since 10/28/10. Please consider an attempted dose reduction or trial discontinuation as you deem appropriate. If this cannot be accomplished, please document risk vs. benefit of continued therapy with current regimen On 04/20/12 the physician's response to the pharmacist's recommendation was, Resident continues to be anxious, yells out frequently and is comfort measures only per family request. On 06/24/11 the physician's response to the recommendation was CMO (unknown abbreviation)-yells out at times. Review of the facility's behavior monitoring sheets for the past five (5) months (January 2012 through May 2012) found the facility was monitoring the resident for continuous crying out, screaming and or yelling, and impaired functional capacity. Documentation on the psychoactive drug monthly flow record found the resident had not exhibite… | 2016-05-01 |
| 8574 | 8574 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 356 | B | 0 | 1 | ZPPW11 | Based on observation and staff interview, it was determined the facility failed to post the required nurse staffing data in a prominent place in the facility that was readily accessible to residents and visitors. This information was posted on an inside wall at the entrance to the nurse's station, and not on a wall which would be easily viewed by visitors and residents. This practice had the potential to affect all residents and visitors who were interested in viewing the daily staffing in the facility. Facility census: 54. Findings include: a) An attempt to locate the required nurse staffing data posting, on 05/15/12, revealed it was not posted with the other required postings or in a prominent location convenient for viewing by visitors and residents. During an interview with a random staff member, on 05/15/12 at 11:15 a.m., it was revealed the nurse staffing was located at the nurse's station. Observations found the posting was located just inside the nurse's station on a side wall. The posting was not readily accessible or visible to visitors and residents who was interested in the daily nurse staffing information. On 05/17/12 at 11:45 a.m., an interview was conduced with the administrator (NHA), Employee # 42. The NHA was informed the posting was not located in an area that was easily viewed by visitors and residents. The NHA stated the nurse staff posting was located at the nurse's station so nursing staff could easily update the posting at each shift. This regulation requires the nurse staff posting be in a prominent place which is readily accessible to visitors and residents, not posted in an area for staff convenience. | 2016-05-01 |
| 8575 | 8575 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 371 | F | 0 | 1 | ZPPW11 | Based on observations and staff interview, the facility failed to store and serve food under sanitary conditions. Contaminated gloves were worn to serve a meal and touch food items. Foods were not dated to ensure they were used by an appropriate use-by date. These practices had the potential to affect all residents who received nourishment from the dietary department. Facility census: 54 Findings include: a) On 05/14/12 at 10:35 a.m., a bag of leftover rolls was observed in the kitchen. The rolls did not contain a date describing when they were placed in the bag and/or by what date they should be discarded. This was reported to a dietary aide, Employee #8, who confirmed the bag was not labeled. The dietary manager (DM), Employee #7, agreed the bag should be labeled, and discarded the rolls. b) On 05/17/12 at 11:40 a.m., observation in the kitchen revealed a cook, Employee #69, opened two (2) oven doors with gloved hands. The cook returned to the tray line and meal service without changing the contaminated gloves. During the service of the meal, the cook repositioned meat on a plate with a gloved finger, and placed an orange slice garnish on each plate while wearing the same contaminated gloves. During an Interview with the dietary manager (DM), Employee #7, on 05/17/12 at 2:00 p.m., the DM agreed Employee #69 should have removed the contaminated gloves before continuing to prepare plates or touch the garnishes. | 2016-05-01 |
| 8576 | 8576 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 425 | D | 0 | 1 | ZPPW11 | Based on observation, staff interview, review of the facility's Nursing 2012 drug handbook, and the facility's Clinical Practice Guideline, the facility failed to ensure two (2) of ten (10) sampled residents received inhalant medications according to manufacturer's recommendations. The residents' inhaled respiratory medications were administered in a manner which had the potential to place the residents at higher risk of acquiring oral thrush. Resident identifiers: #65 and #55. Facility census: 54. Findings include: a) Resident #65 Observation, on 05/15/12 at 7:44 a.m., found Resident #65 was directed by a licensed nurse, Employee #37, to take one (1) inhalation of Advair Diskus 250/50, a corticosteroid inhalant medication. Further observation revealed this resident was not asked by the nurse to rinse her mouth and spit after the medication was administered; therefore, the resident did not rinse her mouth and spit after inhaling the prescribed respiratory medication. When asked, Employee #37 stated there was nothing on the Medication Administration Record [REDACTED]. b) Resident #55 Observation on 05/16/12 at 8:10 a.m. found Resident #55 was directed by a licensed nurse, Employee #34, to take one (1) inhalation of Advair Diskus 250/50, a corticosteroid inhalant medication. Shortly afterward, Employee #34 gave the resident a cup of water to rinse her mouth, but did not direct her to spit, or give her anything to spit in; therefore, the resident sipped the water and swallowed, but neither rinsed her mouth or spit. Review of the facility's Nursing 2012 Drug Handbook, the 32nd. Edition, page 617, gave directives to instruct the resident to rinse the mouth without swallowing after inhalation, to prevent oral candidiasis. During interview with the nurse educator, Employee #38 on 05/16/12, at approximately 6:00 p.m., she said it is generally understood that the mouth is to be rinsed after the use of inhaled corticosteroid medication. On 05/17/12 at 12:30 p.m., Employee #38 produced page 20 (twenty) of the facility's Cli… | 2016-05-01 |
| 8577 | 8577 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 431 | E | 0 | 1 | ZPPW11 | Based on observation, staff interview, and policy review, the facility failed to ensure all outdated or expired medications were removed from the medication carts and medication storage refrigerator. This practice had the potential to affect more than an isolated number of residents. Facility census: 54. Findings include: a) B Hall medication cart Observation of the B Hall medication cart, on 05/15/12 at 4:15 p.m., revealed two (2) partially used bottles of multivitamins stored beyond their expiration dates. A partially used container of a 110 count Centrum Silver multivitamin bottle had an expiration date of 03/20/12. Also, a partially used container of a 100 count generic multivitamin bottle had an expiration date of 09/20/10. A licensed nurse Employee #34, who was present at this time, said these two (2) bottles should have been discarded, but were not. b) Medication storage refrigerator Observation of the medication storage refrigerator on 05/15/12, at approximately 4:30 p.m., revealed a partially used vial of Novolin-N insulin, with the date of opening inscribed as 04/12/12. A licensed nurse, Employee #37, was present at this time, and said opened vials of insulin were to be discarded after 30 (thirty) days of opening. Employee #37 stated the insulin should have been discarded and was not. During an interview with the nurse educator, Employee #38, on 05/17/12 at 8:40 a.m., she produced a policy from Millennium Pharmacy Systems which directed staff to always date the insulin vial when opened, and discard after 28 (twenty-eight) days of opening. | 2016-05-01 |
| 8578 | 8578 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 463 | D | 0 | 1 | ZPPW11 | Based on observation during Stage 1 and staff interview, the facility failed to ensure a functioning communication system was available in each resident's room. One (1) of forty (40) resident rooms did not have a functioning call light to allow the resident to contact caregivers. Resident identifier: #43. Facility census: 54. Findings include: a) Resident #43 During Stage I of the quality indicator survey (QIS), Resident #43's call light was tested at 2:45 p.m. on 05/14/12. When tested , both the audio and visual signals failed to work. Employee #19, a licensed nurse manager for the unit, also tested the call light and found it was not working. Employee #19 contacted Employee #16, a maintenance worker, who tested the call light and stated he would fix the problem. | 2016-05-01 |
| 8579 | 8579 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2013-05-22 | 428 | E | 1 | 0 | ZBDS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review. the licensed pharmacist failed to identify irregularities in the reconciliation of the inventory during the monthly medication regimen review and/or report those irregularities. This had the potential to affect more than a minimal number of residents. Facility census 93. Findings include: a) Pharmacy agreement Exhibit C of the Pharmacy agreement with the facility included: A. 2. Required Consultant Services. (f) Consultant shall identify any irregularities as defined in the State Operations Manual. (j) Consultant shall assist Facility in reviewing the safe and secure storage of medications in locked compartments under proper temperature controls in accordance with manufacturers specifications. (k) Consultant shall assist Facility in developing and implementing safeguards and systems to control, account for, and periodically reconcile controlled medications. A review of the monthly summary reports generated after the pharmacist's medication regimen reviews revealed: 1. Each month (January - April 2013): Discontinued medications were available for administration. 2. January and February 2013: Controlled substances were NOT properly and securely stored. 3. Each month (January - April 2013): Controlled substance inventory was NOT reconciled. In February 2013 the facility identified and reported the diversion of controlled medications by nursing staff members. These findings were addressed in the previous Complaint Investigation (Reference #8029 / and #8030 / ) by this office on 04/29/13. A review of those investigations completed by the facility revealed that although the pharmacy review consistently recognized the lack of reconciliation being performed by nursing staff, both before and after the diversions, no further action had been taken by the pharmacist to ensure that further diversions did not occur and/or that there was prompt recognition of new incidents. During an interview with… | 2016-05-01 |
| 8580 | 8580 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2013-05-22 | 431 | D | 1 | 0 | ZBDS12 | Based on observation, staff interview, and review of the facility's narcotic book and shift narcotic count sheet, the facility failed to maintain and implement an accurate system of reconciliation for controlled medications. The narcotic (controlled medication) count was not accurate on the 330 hall medication cart for for one (1) resident. Resident identifier: #35. Facility census: 93 Findings include: a) Resident #35 On 07/01/13 at 11:55 a.m. the narcotic count was reviewed with Employee #129, a Licensed Practical Nurse (LPN), for the medication cart on the 330 hall. During the observation, at 12:05 p.m., the documentation in the narcotic book showed fourteen (14) tablets of Ambien 10 mg were available for Resident #35. Review of the end of the shift count sheet indicated Employee #129 and Employee #18, also an LPN, counted the narcotics on the 330 hall cart at 7:00 a.m. They documented verification that the number of narcotics on the cart coincided with the number documented in the narcotics book. Upon counting the blister package for the Ambien for Resident #35, it contained only thirteen (13) tablets, not fourteen (14) as indicated on the reconciliation performed by the two (2) nurses at 7:00 a.m. Employee #129 agreed the narcotic count was not accurate for the Ambien. On 07/01/13 at 12:15 p.m., Employee #129 informed Employee #146, the Manager of Clinical Operations (MCO)/acting Director of Nursing (DON), of the inaccurate narcotic count for the Ambien for Resident #35. An interview was conducted with Employee #41, the administrator, and Employee #146 at 12:30 p.m. on 07/01/13. They agreed the discrepancy should have been caught during the end of the shift count, and the nurses were in error by verifying that the narcotic count was correct. | 2016-05-01 |
| 8581 | 8581 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2013-05-22 | 490 | E | 1 | 0 | ZBDS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, staff interview, and facility document review, the administration failed to ensure the implementation of policies/procedures and/or staff compliance with the practices intended to identify the potential diversion of controlled substances. This had the potential to affect more than a minimal number of residents by increasing the potential for diversion of controlled drugs. Facility census: 93. Findings include: In a complaint survey completed on 04/29/13, (Reference #8029 / and #8030 / ) it was established the facility had instances of controlled drug diversions and the discovery of the diversions had been prolonged due to the failure of the nursing staff to either complete the end-of-shift count of controlled drugs and/or to report their inability to reconcile the counts as required by facility policy. a) A review of the monthly summary reports generated after the pharmacist's medication regimen reviews revealed: 1. Each month (January - April 2013): Discontinued medications were available for administration. 2. January and February 2013: Controlled substances were NOT properly and securely stored. The monthly narrative notes read: -- 01/07/13: Narcotics are being replaced to the omnicell but then logged into the blue books and not placed in the omnicell. They should NEVER be logged into a blue book but DIRECTLY into the omnicell. -- 02/07/13: [MEDICATION NAME] Concentrate for omnicell logged into blue book and used for resident instead of being replaced to omnicell. Resident has 2 bottles opened and both are being used. 226a AP. Could not locate current order for med on February MAR-. -- 3. Each month (January - April 2013): Controlled substance inventory was NOT reconciled. The monthly narrative notes read: 01/07/13: NUMEROUS holes in shift to shift counts in back of blue books. 02/01/13: same as above 03/01/13: Shift to shift count blanks continue to be present in ALL Blue Books - ALL… | 2016-05-01 |
| 8582 | 8582 | WILLOW TREE MANOR | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2013-05-02 | 253 | E | 1 | 0 | SKGC11 | Based on observation and staff interviews, the facility failed to provide effective housekeeping and/or maintenance services to ensure the cleanliness of two (2) of the shower rooms located on the first floor. This had the potential to affect any of the residents on this floor who showered in these rooms, as well as certain residents from the other two (2) floors who were routinely brought to the shower room on the 200 hall of first floor due to the larger size of this shower room. Facility census: 97. Findings include: a) 100 hall During the general tour of the environment at 3:30 p.m. on 05/01/13, an observation was made of the shower room located on the 100 hall of the first floor adjacent to the beauty shop. The shower area was tiled with ceramic tile which was dirty and grimy on the floor area and the lower 6 - 12 inches of the walls. The grout was dark with grime and resembled mold growth. There were several broken or missing tiles in areas where effective cleaning could not be ensured. A housekeeper (Employee #4) had been seen exiting the shower room with her cleaning supplies and when asked if she were done, answered she was. The findings in this area were reported to the Administrator at 4:30 p.m. on 05/01/13. He returned after viewing the room and produced a copy of a purchase order that had been placed for replacement tiles for the repair of this and other shower areas. He had no explanation for the lack of cleanliness of the tile and grout, stating he would have it cleaned at once. b) An observation on 05/01/13 at 3:45 p.m., found the bath/shower room on Station 2 had grime/mold on the floor of the shower. The shower had dark brown and dark green grime/mold around the back of the shower floor and half way around the floor tile on either side of the shower floor. The shower area on Station 2 was shown to the Administrator on 05/01/13 at 4:15 p.m. The Administrator confirmed the observation and stated it is dirty. He further stated that housekeeping had not cleaned in here yet. Upon questioning if the s… | 2016-05-01 |
| 8583 | 8583 | WILLOW TREE MANOR | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2013-05-02 | 514 | B | 1 | 0 | SKGC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, nursing staff failed to document a time on the Physician/Prescriber order sheets when a verbal or telephone order was written. One (1) of eight (8) records reviewed was found to have orders without the time the order had been obtained noted. Resident identifier: #98. Census: 97. Findings include: a) Resident #98 On 05/02/13 at 12:30 p.m., record review for Resident #98 found five (5) of the Physician/Prescriber order sheets were not timed when the verbal or telephone order had been written. On 05/02/13 at 12:55 p.m., Employee #2, the director of nursign, was interviewed. She said she had conducted mandatory inservices with the staff regarding telephone and verbal orders on 04/12/13 and 04/26/13. She provided copies of the inservice records, but the timing of orders was not listed on the agenda or inservice sheets. The DON stated orders were timed when they were put in the computer, but sometimes the nurses did not time the physician orders [REDACTED]. Upon further questioning of timing the orders when written, Employee #2, the DON again stated they are timed when the nurse enters them in the computer. | 2016-05-01 |
| 8584 | 8584 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2012-04-19 | 225 | D | 0 | 1 | KWL711 | Based of review grievance/concern documents and staff interview, the facility failed to ensure all allegations involving neglect were reported immediately to officials in accordance with State law through established procedures. Review of grievance/concern reports for the past six (6) months revealed allegations of neglect for two (2) of thirty-three (33) Stage II sample residents which were not reported to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Service (APS), or the Ombudsman as indicated by the nature of the occurrence. Resident identifiers: #43 and #99. Facility census: 60. Findings include: a) Resident #99 Review of a grievance/concerns form, dated 01/27/12, revealed Resident #99 had complained she was left unattended to bathe in the bathroom. According to the complaint, the call bell was not placed within her reach. The resident reported that as a result of not being able to call for staff, she became cold and upset. During an interview with the social worker and the administrator, on 04/19/12, at approximately 12:30 p.m., they said they did not report this to state agencies because they did view this as an allegation of neglect. b) Resident #43 Review of a customer and family concerns form, with the date of contact 04/02/12, revealed the sister of Resident #43 had left a letter in the social services office with multiple concerns. In one instance, the sister made an allegation the resident's teeth do not appear to be cleaned regularly. Another concern was noted as family reports that hair has looked unclean past couple visits. During an interview with the social worker and the administrator, on 04/19/12, at approximately 12:30 p.m., they said they did not report this to state agencies because they did not view this as an allegation of neglect. | 2016-05-01 |
| 8585 | 8585 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2012-04-19 | 249 | C | 0 | 1 | KWL711 | Based on review of requested documentation and staff interview, the facility failed to ensure the activities program was directed by a qualified professional. The facility did not have an activities director to plan, direct, or oversee an ongoing program of activities designed in accordance with the comprehensive assessments, the interests of the residents, and the physical, mental, and psychosocial well-being of the residents. The facility failed to employ a qualified professional to oversee the activities program for a period of approximately seven (7) months. This had the potential to affect all residents. Facility census: 60. Findings include: a) On the day of entry to the facility, on 04/16/12, the administrator (Employee #45) provided the requested the Key Personnel form which indicated the position of activities director was vacant. This was verified during an interview with a recreation aide (Employee #80) at 9:15 a.m. on 04/18/12. Employee #80 stated the previous activities director had gone on disability leave in either July or August 2011 and returned in March 2012, but had resigned shortly after her return. She stated the facility had acquired an interim director who had left at the first of 2012. She stated she had no knowledge of the credentials of the interim director. Employee #80 also stated she had been assembling the monthly activity calendars and presenting them to the administrator for approval. She stated Employee #68 (another recreation aide) completed the new admission assessment forms and gave them to the Clinical Reimbursement Coordinator (Employee #43). Employee #80 stated the recreation aides continued their daily duties based on previous practices. She knew of no plans for hiring an activity director. A third recreation aide, Employee #24, as well as Employee #80, had been in their positions for five (5) years each, but neither possessed the qualifications to serve as the activities director. During an interview with the administrator, at 10:30 a.m. on 04/19/12, she stated the former … | 2016-05-01 |
| 8586 | 8586 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2012-04-19 | 279 | D | 0 | 1 | KWL711 | Based on medical record review and staff interview, the facility failed to develop a care plan with interventions for the prevention of skin breakdown for a resident identified as being at high risk for developing pressure ulcers and who had a recent history of healed pressure ulcers. This was true for one (1) of thirty-three (33) sampled residents in stage II of the Quality Indicator Survey (QIS). Resident identifier: #53. Facility census: 90. Findings include: a) Resident #53 At the time of the resident's admission to the facility, on 12/30/11, the facility identified two (2) stage II pressure areas to the coccyx. A care plan was established addressing the pressure areas. On 02/02/12, both areas were noted to have healed and the care plan was discontinued. The resident's minimum data set (MDS) assessments, with assessment reference dates (ARD) of 02/17/12 and 04/03/12 were reviewed. These assessments were completed after the pressure areas present on admission had healed. According to these assessments, the resident was still at risk of developing pressure ulcers. Review of the Braden scale for predicting pressure ulcers, completed on 04/03/12, found the resident was assessed as being at high risk for developing pressure ulcers. Review of the resident's skin integrity report, completed on 04/15/12, found the resident had developed a deep tissue injury to the left outer heel. This was measured as being 2.5 cm (centimeters) in length by 1.8 cm. in width. The surrounding tissue was identified as inflamed with healthy wound edges. Review of the current care plan found the facility had failed to address the resident's risk for developing pressure ulcers/skin breakdown, from 02/02/12 until 04/15/12, when the new area of breakdown to the left outer heel was discovered. On 04/18/12 at 10:10 a.m., the care plan was reviewed with Employee #43, the registered nurse clinical reimbursement coordinator. She verified the care plan failed to address the potential for the development of pressure areas from 02/02/12 until 04/15/… | 2016-05-01 |
| 8587 | 8587 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2012-04-19 | 312 | D | 0 | 1 | KWL711 | Based on medical record review, observation, and staff interview, the facility failed to ensure a dependant resident received staff assistance to maintain good person hygiene as evidenced by a malodorous smell emanating from the resident's feet. This was true for one (1) of thirty-three (33) residents reviewed in Stage II of the Quality Indicator Survey. Resident identifier: #53. Facility census: 60. Findings include: a) Resident #53 On 04/18/12 at 2:00 p.m., a dressing change to the left outer heel was observed with Employee #32, a licensed practical nurse. The resident was in bed with her socks off and Employee #32 stated, I need to clean her feet before I do the dressing, I didn't know they smelled so bad. Observation revealed the resident's toes on both feet were pressed tightly against each other. The toes were deformed and curled under. Employee #32 verified the odor was not from the deep tissue injury on the resident left outer foot, but was coming from the areas between the resident's toes. Review of the skin integrity report, completed on 04/15/12, identified the deep tissue injury on the left outer heel as having no odor. The resident's care plan included a problem identified as, I am dependent for bathing and all ADL's (activities of daily living) due to cognitive loss/dementia. There are times I am resistant to care yelling, scratching and spitting on staff when care is attempted. The goal associated with this problem was, My care needs will be anticipated and met every day as evidence by my care flow sheet and me presenting well groomed every day. Review of the shower scheduled, on 04/18/12, found no documentation the resident had refused showers. Interview with the director of nursing (DON), on 04/19/12 at 10:00 a.m., found the DON could not explain the reason for the odor emanating from the resident's feet. She verified the resident had showers or bed baths as needed, but no further information regarding the cause of the odor was provided. | 2016-05-01 |
| 8588 | 8588 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2012-04-19 | 314 | D | 0 | 1 | KWL711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and observation, the facility failed to ensure interventions were in place to prevent the development of additional pressure areas for a resident who had a history of [REDACTED]. This was true for one (1) of thirty-three (33) residents reviewed in Stage II of the Quality Indicator Survey (QIS). Resident identifier: #53. Facility census: 90. Findings include: a) Resident #53 This resident was admitted to the facility from the hospital on [DATE]. She had a surgical wound secondary to repair of a [MEDICAL CONDITION], and two (2) Stage II pressure ulcers on her coccyx. The resident's admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/06/12, identified the resident as being totally dependent on staff for bed mobility, she did not walk, and she had limitations in the range of motion in one of her lower extremities. A care plan had been developed upon admission addressing the pressure areas that were present at that time. This care plan was discontinued on 02/02/12, when both areas had healed. A new care plan was not developed at that time to address the prevention of recurrence of the healed pressure ulcers or prevention of new pressure areas. Review of the resident's skin integrity report found the resident had developed a deep tissue injury to the left outer heel on 04/15/12. The area measured 2.5 cm (centimeters) in length and 1.8 cm in width. The surrounding tissue was documented as being inflamed with healthy wound edges. Employee #32, a licensed practical nurse, was observed performing a dressing change to the resident's heel at 2:00 p.m. on 04/18/12. The area was noted to have intact skin, was purple in color, and slightly reddened around the edges. stated she felt the area could have occurred when the resident's heel rubbed against a molded foot rest on the resident's wheelchair. She stated the footrest was hard and rounded around the resident's outer f… | 2016-05-01 |
| 8589 | 8589 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2012-04-19 | 329 | D | 0 | 1 | KWL711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to: (1) identify the targeted behaviors for use of a PRN (as needed) medication, [MEDICATION NAME]; (2) implement non-pharmacological interventions before administration; (3) monitor for potential adverse side effects; and (4) monitor the residents' response to the medication. This was true for two (2) of thirty-three (33) residents sampled in Stage II of the Quality Indicator Survey who received PRN doses of the benzodiazepine, [MEDICATION NAME]. Resident identifiers: #30 and #53. Facility census: 60. Findings include: a) Resident #30 Medical record review found the resident was receiving [MEDICATION NAME] 0.5 mg by mouth, PRN three (3) times a day, since 08/17/11 for nervousness and anxiety. Review of the Medication Administration Record [REDACTED]. These included 03/06/12, 03/09/12, 03/10/12, 03/13/12, 03/14/12, 03/17/12, 03/18/12, 03/20/12, 03/22/12, 03/23/12, 03/25/12, 03/27/12, 03/28/12, 03/29/12 and 03/20/12. Review of the monthly behavior monitoring flow sheet for March 2012 found the resident was receiving [MEDICATION NAME] for multiple medical complaints. The entire flow sheet was blank for each of the fifteen (15) days the medication was administered. The directions on the flow sheet required nursing staff to indicate the day the medication was used, identify the non-pharmacological interventions implemented before administration, and to document the outcome and any possible side effects associated with the medication. During an interview with the director of nursing (DON), Employee #72, on 04/18/12 at 4:30 p.m., she reviewed the behavior monitoring flow sheet, nurses' notes and nursing assessments. The DON was unable to locate any information to verify the behaviors exhibited by the resident warranted the medication. In addition, she was unable to provide evidence of attempts at non-pharmacological interventions, descriptions of the outcome of the medications,… | 2016-05-01 |
| 8590 | 8590 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2012-04-19 | 371 | E | 0 | 1 | KWL711 | Based on observation and staff interview, the facility failed to ensure food was prepared under sanitary conditions. Two (2) peanut butter and jelly sandwiches were being prepared beside a wet dish cloth. Both the cloth and the cleaning solution on the cloth created a potential for food contamination. This had the potential to affect more than a limited number of residents who received nourishment from the dietary department. Facility census: 60. Findings include: a) On 04/17/12 at 11:24 a.m., four (4) slices of white bread, two (2) of which had peanut butter on them, were observed on the preparation table in the kitchen. A cleaning cloth was lying beside the four (4) slices of bread. This was brought to the attention of the food service director (Employee #14) and the cook (Employee #67). Employee #67 stated the cloth was on the preparation table in order to clean the table after the sandwiches were made. Employee #67 confirmed the cloth should have been in the sanitizing solution. Furthermore, Employee #14 agreed the cloth was not to be on the preparation table when food was being prepared, and should have been stored in the sanitizing solution until needed. | 2016-05-01 |
| 8591 | 8591 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2012-04-19 | 425 | C | 0 | 1 | KWL711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, pharmacist interview, and record review, the facility failed to properly dispose of medications after discharging residents and/or after expiration of the medication. The facility's pharmacy policy contained directives for medication disposal which were not implemented by the facility. This had the potential to affect all residents, as there was only one (1) medication preparation/storage area. Facility census 60. Findings include: a) During observation of medication storage, in the sole medication storage and preparation room, accompanied by the director of nurses (Employee #72) at 3:00 p.m. on 04/18/12, the following medications were found in the refrigerator in the shelf of the door: - One (1) opened and resealed bottle labeled Ativan intensol 2mg/ml with a name handwritten across the label. There was no date to indicate when it was opened. The previous name on the label was blackened out with a marker. Employee #72 confirmed the medication belonged to Resident #1001, who was discharged on [DATE]. - One (1) bottle of Novolin R insulin and one (1) bottle of Novolin N insulin whose labels indicated they were opened on 03/15/12. According to facility policy, these should have been disposed of on 04/11/12. They were labeled for Resident #1002 who was discharged on [DATE]. - One (1) opened bottle of Lantus insulin labeled as opened on 03/24/12. It belonged to Resident #1003, who was discharged on [DATE]. - One (1) opened bottle of Novolog insulin labeled as opened on 03/16/12. It belonged to Resident #69, a current resident. According to facility policy, this medication should have been discarded on 04/12/12. Observation revealed a sign, posted above the refrigerator in the medication storage/preparation room, which stated, OPENED VIALS TO BE DISCARDED AFTER 28 DAYS. The director of nursing (DON) was present, and verified this was facility policy. She acknowledged all these medications should have been dis… | 2016-05-01 |
| 8592 | 8592 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2012-04-19 | 428 | D | 0 | 1 | KWL711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, consultant pharmacist interview, and staff interview, the consultant pharmacist failed to identify medication irregularities for two (2) of thirty-three (33) Stage II sample residents. The residents each received Xanax PRN (as needed) without: (1) identification of targeted behaviors for use; (2) implementation of non-pharmacological interventions before deciding to use the medication; (3) monitoring for potential adverse side effects; and (4) monitoring each resident's response to the medication. Resident identifiers: #30 and #53. Facility census: 60. Findings include: a) Resident #30 Medical record review found the resident was receiving Xanax 0.5 mg by mouth three (3) times daily as needed. This order was written 08/17/11 for nervousness and anxiety. Review of the Medication Administration Record [REDACTED]. These included 03/06/12, 03/09/12, 03/10/12, 03/13/12, 03/14/12, 03/17/12, 03/18/12, 03/20/12, 03/22/12, 03/23/12, 03/25/12, 03/27/12, 03/28/12, 03/29/12 and 03/20/12. Review of the monthly behavior monitoring flow sheet for March 2012 found the resident received the Xanax for multiple medical complaints. The entire flow sheet was blank. The directions on the flow sheet required nursing staff to indicate the day the medication was used, identify the non-pharmacological interventions implemented before administration, and to document the outcome and any possible side effects associated with the medication. During an interview with director of nursing (DON), Employee #72, on 04/18/12 at 4:30 p.m., she reviewed the behavior monitoring flow sheet, nurses notes, and nursing assessments. She was unable to locate any information which indicated the resident exhibited any behaviors which warranted the medication and was unable to verify non-pharmacological interventions were attempted prior to medication use. Additionally, the DON was unable to locate monitoring for the outcome of the medications or monitoring o… | 2016-05-01 |
| 8593 | 8593 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2012-04-19 | 431 | C | 0 | 1 | KWL711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, consultant pharmacist interview, and record review, the facility failed to reconcile controlled medications and/or ensure that a controlled medication was appropriately labeled in accordance with currently accepted professional principles and facility policy. This had the potential to affect more than an isolated number of residents, as there was only one (1) medication storage room. Facility census: 60. Findings include: a) During observation of medication storage, in the sole medication storage and preparation room, accompanied by the director of nurses (Employee #72) at 3:00 p.m. on 04/18/12, an opened and resealed bottle of Ativan intensol 2 mg/ml was found in the the refrigerator on a shelf in the door. A resident's name was handwritten across the label. There was no date to indicate when the medication was opened. The previous name on the label had been blackened out with a marker. Employee #72 confirmed the medication belonged to Resident #1001, who was discharged on [DATE]. A second bottle of the same medication, unopened, and labeled by the pharmacy for Resident #1001, was also found on a shelf of the refrigerator. The DON stated the facility's practice was to mark out the resident's name on a label if the resident was discharged , and keep it a locked container inside the refrigerator, until it was needed by a resident with a new order. According to the DON, this ensured a resident with a new order had immediate access to the medication. The process eliminated waiting for a written signed order to be delivered to the pharmacy and the medication then delivered to the facility. When asked, the DON acknowledged this was not in accordance with state pharmacy guidelines. Observation revealed she discarded the opened bottle, marked out the resident's name on the unopened bottle, and placed it in the locked container in the refrigerator. During a telephone interview with the facility's consultant phar… | 2016-05-01 |
| 8594 | 8594 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2012-04-19 | 441 | E | 0 | 1 | KWL711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure an infection control program which helped prevent the development and transmission of disease. Clean linens and hydroculator covers were not stored in a manner to prevent contamination. Additionally, nursing personnel failed to practice effective hand hygiene. These practices had the potential to affect more than an isolated number of residents. Facility census: 60 Findings include: a) Linens On 04/17/12 at 9:00 a.m., clean linen was found on the sink countertops in rooms 301 through 308. The linens included towels, wash cloths, sheets and reusable pads. The linens were placed on both sides of the sinks. An additional tour of the 300 Hall, on 04/17/12 at 11:15 a.m., revealed additional clean linens had been placed on the countertops. The items included fitted and flat sheets. Employee #72, the director of nursing (DON), was informed of these findings at 11:30 a.m. She was taken to room [ROOM NUMBER] to see the manner in which the linen was stored. Upon seeing the clean linen on the countertop, she stated staff knew the clean linen should not be stored on the sink and she would take care of this. b) Hydroculator covers Observation, on 04/16/12 at 1:00 p.m., revealed the soiled linen hamper and the uncovered cart containing clean hydroculator covers were side by side in the rehabilitation room. An additional observation, on 04/17/12 at 2:00 p.m., found the carts in the same location. Another observation, on 04/19/12 at 9:30 a.m., found the same situation. An interview, on 04/19/12 at 1:15 p.m., with the certified occupational therapist (Employee #87) revealed staff were not aware of the need to separate the clean covers from the soiled linen hamper. Employee #87 stated this would be corrected immediately. c) Handwashing - Observation during the lunch meal, on 04/17/12 at 12:14 p.m., found a nursing assistant (Employee #23) washed her hands and dried her hands with paper tow… | 2016-05-01 |
| 8595 | 8595 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2012-04-19 | 492 | C | 0 | 1 | KWL711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each dietary employee had a valid food handlers permit as required by county regulations. Two (2) dietary employees did not have a current food handlers card. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 60 Findings include: a) Upon entrance, facility personnel were asked to provide evidence of food handlers permits, if the county in which the facility was located required them. On [DATE] at 11:40 a.m., a review of the food handlers permits, with the food service director (Employee #14), revealed the cooks (Employees #67 and #8) did not have valid food handlers permits. Inspection of the food handlers permits for these two (2) revealed each had expired in [DATE]. Employee #14 stated both employees had renewed their food handlers permits, but had not provided their cards. At the time of the survey, the facility had no evidence these employees had fulfilled the requirements to renew their food handlers permits. . | 2016-05-01 |
| 8596 | 8596 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2013-05-30 | 157 | D | 1 | 0 | BVS711 | Based on medical record review and staff interview the facility failed to notify the physician of changes in condition for two (2) of eight (8) residents in the sample. Resident #16 had a psychiatric evaluation and the physician was not made aware of the recommendations. In addition, the physician was not notified of Resident #60's change in condition related to abnormal vital signs. Resident identifiers: #16 and #60 Facility census: 78 Findings include: a) Resident #16 A medical record review, conducted on 05/30/13 at 2:00 p.m., revealed the resident had a consultation with a mental health professional on 01/04/13. The consultation sheet was in the resident's paper copy chart. It contained recommendations from the psychologist. There was no evidence the physician was notified of the recommendations. Nursing notes did not indicate the physician was notified, and the consultation sheet was not signed by the physician. An interview was conducted, on 05/30/13 at 3:00 p.m., with Employee #33, a registered nurse (RN) unit manager. When asked if the resident's consultation from 01/04/13 was followed up by the physician, the RN stated if there had been a follow up, there would be a nursing note or a signature on the consultation sheet. Employee #33 was unable to locate a note which described the physician was notified of the recommendations by the mental health professional. The facility's medical director was interviewed on 05/31/13 at 2:15 p.m. When asked how he was informed of information from a consultation, he stated nursing staff called him or placed the recommendations in his folder for him to review. When asked if he signed off on consultation sheets, he said he did, or the nurse marked he was notified. When he was shown the consultation sheet for Resident #16 from 01/04/13, he stated he had never seen the consultation, and was unaware of any recommendations prior to the resident's last admission to the hospital. b) Resident # 60 A nursing note, dated 05/02/13 at 4:59 p.m. stated, Called to hall outside resident… | 2016-05-01 |
| 8597 | 8597 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2013-05-30 | 201 | D | 1 | 0 | BVS711 | The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; The safety of individuals in the facility is endangered; The health of individuals in the facility would otherwise be endangered; If transfer is due to a significant change in the resident's condition, but not an emergency requiring an immediate transfer, then prior to any action, the facility must conduct the appropriate assessment to determine if a new care plan would allow the facility to meet the resident's needs. (See ?483.20(b)(4)(iv), F274, for information concerning assessment upon significant change.) Refusal of treatment would not constitute grounds for transfer, unless the facility is unable to meet the needs of the resident or protect the health and safety of others. Documentation of the transfer/discharge may be completed by a physician extender unless prohibited by State law or facility policy. Procedures: During closed record review, determine the reasons for transfer/discharge. o Do records document accurate assessments and attempts through care planning to address resident's needs through multi-disciplinary interventions, accommodation of individual needs and attention to the resident's customary routines? o Did a physician document the record if residents were transferred because the health of individuals in the facility is endangered? o Do the records of residents transferred/discharged due to safety reasons reflect the process by which the facility concluded that in each instance transfer or discharge was necessary? Did the survey team observe residents with similar safety concerns in the facility? If so, determine differences between these residents and those who were transfer… | 2016-05-01 |
| 8598 | 8598 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2013-05-30 | 221 | D | 1 | 0 | BVS711 | Based on medical record review and staff interview, the facility failed to ensure one (1) of eight (8) sampled residents had the right to be free from a physical restraint which was not required to treat a medical symptom. Resident #16's care plan contained an intervention for a physical restraint. This restraint was for staff convenience, in that the restraint was an action to control the resident's behavior with a lesser amount of effort by the facility. Resident identifier: #16 Facility census: 78 Findings include: a) Resident #16 A medical record review was conducted 05/30/13 at 2:00 p.m. The resident's care plan revealed an intervention related to the resident's wandering that stated, If unable to redirect Resident #16 and it is not safe for him to be wandering (for example if he is going into other resident's room) Use a sheet to wrap him up in to administer IM medications when needed. Medical record review revealed no evaluation for the need of a restraint.Assessment and Care Planning for Restraint Use There are instances where, after assessment and care planning, a least restrictive restraint may be deemed appropriate for an individual resident to attain or maintain his or her highest practicable physical and psychosocial well-being. This does not alter the facility's responsibility to assess and care plan restraint use on an ongoing basis. Before using a device for mobility or transfer, assessment should include a review or the resident's: o Bed mobility (e.g., would the use of the bed rail assist the resident to turn from side to side? Or, is the resident totally immobile and cannot shift without assistance?); and o Ability to transfer between positions, to and from bed or chair, to stand and toilet (e.g., does the raised bed rail add risk to the resident's ability to transfer?). The facility must design its interventions not only to minimize or eliminate the medical symptom, but also to identify and address any underlying problems causing the medical symptom. The interventions that the facility might i… | 2016-05-01 |
| 8599 | 8599 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2013-05-30 | 250 | D | 1 | 0 | BVS711 | Based on medical record review and staff interview the facility failed to provide medically necessary social services for a resident with behavior problems. The facility failed to care plan for a resident's involuntary discharge from the facility. Behavioral interventions and additional education with staff on providing care to residents with dementia was not provided. This was found for one (1) of eight (8) sample residents. Resident identifier: #16 Facility census: 78 Findings include: a) Resident #16 A medical record review was conducted 05/30/13 at 2:00 p.m. the resident had a care plan which did not have his involuntary thirty (30) day notice of discharge planned. The resident had multiple interventions listed for behaviors and dementia issues the resident may have. An interview was conducted with Employee #13, the social worker, on 05/31/13 during the afternoon regarding the residents discharge planning and staff training. The social worker stated she did not know that she needed to care plan the resident's discharge. When asked about staff training and inservicing for dementia residents she stated she did not do the inservicing or training. When she was asked about the interventions for Resident #16 relating to his behaviors and dementia she stated this is not a psychiatric hospital we are not River Park. An interview was conducted with Employee #2 on 05/31/13 at 10:30 a.m. she stated the corporation had dementia training that staff had to attend. When asked if they did specialized training to deal with behaviors such as Resident #16 has she stated no they had not done anything, but could get that arranged. | 2016-05-01 |
| 8600 | 8600 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2013-05-30 | 280 | D | 1 | 0 | BVS711 | Based on medical record review, a review of the facility's incident and accident reports, and staff interview, the facility failed to ensure the care plans were revised for two (2) of eight (8)sampled residents when they experienced changes which required a care plan revision. Resident #60 had multiple falls. A new care plan was initiated and dated after each fall; however, the care plans did not reflect any changes or new interventions to address the prevention of falls. In addition, the facility presented a 30-day discharge notice to the responsible party of Resident #16. His plan of care was not revised to reflect this change in the resident's discharge plans. Resident identifiers: #60 and #16. Facility Census: 78. Findings include: a) Resident #60 Review of incident and accident reports revealed this resident had multiple falls. His care plan, initially established on 08/17/12, identified this resident at high risk for falls due to a past history of falls, decreased functioning, and cognitive status. His goal stated he would not have a fall with injury requiring hospitalization through the next review period. This care plan had been continued, without revision, since it was initially established on 08/17/12. The facility initiated a new care plan with each fall, but did not develop interventions to prevent falls for any of the care plans. As of 05/28/13, fourteen (14) care plans for falls had been initiated since March 2013. Review of these care plans revealed they all said the same thing. No changes were made as the resident continued to experience falls. There was no evidence the facility made any attempts to determine the causes of each fall so effective individualized interventions could be put into place to prevent the falls from reoccurring. At 3:00 p.m. on 05/31/13, Employee #2, a licensed practical nurse, was interviewed about the fall care plans for this resident. When asked about the facility's protocol for falls, she stated they initiated these new care plans after each fall. She was asked if there… | 2016-05-01 |
| 8601 | 8601 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2013-05-30 | 281 | E | 1 | 0 | BVS711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications were administered in accordance with the facility's administration guidelines. The guidelines for administration, Policy IIA2, stated medications are administered as prescribed in accordance with good nursing principles and practices. The guidelines and procedures set forth in this policy were not followed. Medications were not administered according to the orders given by the physician. This was true for four (4) of eight (8) sampled residents. Resident identifiers: #42, #19, #59, and #60. Facility Census: #78. Findings include: a) Resident #42 This resident was observed during medication pass on 05/28/13. At 1:12 p.m., Employee #25 verified this resident had medications due at 9:00 a.m. which had not yet been administered at 1:12 p.m. On 05/28/13 at 3:00, review of computerized medical records, which indicated the time medications were actually administered, verified morning medications for Resident #42 were not administered until 2:20 p.m. The medications that were scheduled at 9:00 a.m., but not administered until 2:20 p.m., included [MEDICATION NAME] 750 mg which was scheduled twice a day (bid) for [MEDICAL CONDITION], [MEDICATION NAME] 15 mg twice a day for pain control, [MEDICATION NAME] Inhaler one puff four times a day, [MEDICATION NAME] 2.5 mg tablet, [MEDICATION NAME] 40 mg every morning, Senna 8.6 mg tablet every morning, [MEDICATION NAME] sulfate 325 mg tablet daily, [MEDICATION NAME] 20 mg tablet once each morning, KCL 10 meq tablet each day. b) Resident #19 During a medication pass observation on 05/28/13 at 1:15 p.m., the nurse (Employee #25) was observed pulling up the medications for Resident #19. The electronic Medication Administration Record [REDACTED]. During an interview with the nurse at 1:15 p.m., 05/28/13 she verified she had not yet given these medications. Employee #25 stated the times for admi… | 2016-05-01 |
| 8602 | 8602 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2013-05-30 | 329 | D | 1 | 0 | BVS711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure residents were free from unnecessary medications. Two (2) of eight (8) residents received medications for which there was no evidence of necessity to treat their assessed conditions. Resident #60 received a medication for [MEDICAL CONDITION] without adequate indications for use, without adequate monitoring, and administered contrary to physician's orders. Resident #59 received a sedating medication early in the morning, contrary to physician's orders. It was ordered as needed (PRN) for anxiety at bedtime. Resident identifiers: #60 and #59. Facility Census: 78. Findings include: a) Resident #60 During a review of the medical record, it was identified this resident had a physician's order, written on 04/17/13, for [MEDICATION NAME] 50 mg one tablet by mouth at HS (hour of sleep) PRN (as needed) due to [MEDICAL CONDITION]. This medication was on the Medication Administration Record [REDACTED]. It was noted this medication was not administered for the entire month it was ordered. In addition, there was no indication the resident needed this medication. On 05/13/13, [MEDICATION NAME] 50 mg tablet one by mouth at hour of sleep due to [MEDICAL CONDITION] was scheduled, instead of only as needed (PRN), on the MAR for each night at 9:00 p.m. The resident began receiving this medication each night. There was no written physician's order found for this change from PRN to every night. During an interview with the nurse, Employee #12, on 05/30/13 at 3:28 p.m., she was asked to find a physician's order for the [MEDICATION NAME] to be given each night, instead of PRN. She was unable to find such an order. At that time, it was verified with the nurse, that the medical record contained no evidence the resident had [MEDICAL CONDITION] which required this medication every night. This nurse also stated this resident was usually re-directed after calling his family. She stated she w… | 2016-05-01 |
| 8603 | 8603 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2013-05-30 | 332 | D | 1 | 0 | BVS711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure the medication error rate was five percent (5%) or less. Two (2) errors were identified in twenty-five (25) opportunities for medication errors, resulting in a medication error rate of eight percent (8%). The medication [MEDICATION NAME], which is for [MEDICAL CONDITION], and the diuretic medication [MEDICATION NAME] ordered for hypertension, were each ordered by the physician to be given twice daily. These medications were administered in a time span that was too close together, resulting in timing errors. Resident identifiers: #42 and #19. Facility Census: 78. Findings include: a) Resident # 42 During a medication administration observation, on 05/28/13 at 1:15 p.m., Resident #42 was observed receiving his medication. The nurse, Employee #25, was asked why this resident's medications were highlighted in Red in the computer. She stated they were Red because they were past due. The nurse stated she came to administer the resident's medications earlier, but he was asleep. The nurse was observed administering Resident #42's medications. She only gave him two (2) medications. She stated she gave him his pain medication and inhaler, but did not administer the rest of his medications that were highlighted in Red. She said she would not be able to administer those medications because they were so late. During a review of the Medication Administration Record [REDACTED]. This made these medications five (5) hours and twenty (20) minutes past the scheduled administration time. These medications were administered outside the allowable 60 minute time frame as required by facility policy. The medication [MEDICATION NAME] 750 mg one tablet by mouth twice a day was ordered due to [MEDICAL CONDITION]. This medication was scheduled at 9:00 a.m., but was not administered until 2:20 p.m. on 05/28/13. This was more than five (5) hours past the scheduled time for this… | 2016-05-01 |
| 8604 | 8604 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2013-05-30 | 514 | F | 1 | 0 | BVS711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain complete and accurate medical records for eight (8) of eight (8) sampled residents. In addition, the facility failed to ensure the computerized medical records were readily accessible to staff members and other authorized persons, such as the State certification agency surveyors. Also, pertinent information which was supposed to be computerized was not always available in the computer. Hand written medical records were also incomplete. The information provided to indicate when baths were given did not always contain resident names and no months were written on behavior logs. Resident #16 had been given a thirty (30) day discharge notice by the facility. This resident's medical record did not contain a copy of the discharge notice. Resident identifiers: #58, #60, #61, #59, #65, #42, #19, and #16. Facility Census: 78. Findings include: a) Residents #58, #60, #61, #59, #65, #42, #19, #16 The computerized medical records were reviewed for these residents from 05/28/13 to 05/31/13. The computerized records were not always able to be accessed by surveyors. Access was denied (locked out) after a few minutes of not touching the computer. At the point access was locked out, a facility staff member had to come to log the surveyor back into the system. On more than one occasion, the computer was not even able to be accessed by facility personnel, and information technology employees had to be called for assistance. This process of obtaining access to the medical record extended the length of time required to complete the investigations and obtain the needed information from the records. b) Residents #58, #60, #61, #59, #65, #42, #19, #16 The information for activities of daily living were requested for the above named residents. Employee #2 provided skin sheets that she stated the employees completed each time they did a bath or shower. Review of these skin sheets reveal… | 2016-05-01 |
| 8605 | 8605 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2013-05-31 | 157 | D | 1 | 0 | 5M3K11 | Based on medical record review and staff interview the facility failed to notify the physician of changes in condition for two (2) of eight (8) residents in the sample. Resident #16 had a psychiatric evaluation and the physician was not made aware of the recommendations. In addition, the physician was not notified of Resident #60's change in condition related to abnormal vital signs. Resident identifiers: #16 and #60 Facility census: 78 Findings include: a) Resident #16 A medical record review, conducted on 05/30/13 at 2:00 p.m., revealed the resident had a consultation with a mental health professional on 01/04/13. The consultation sheet was in the resident's paper copy chart. It contained recommendations from the psychologist. There was no evidence the physician was notified of the recommendations. Nursing notes did not indicate the physician was notified, and the consultation sheet was not signed by the physician. An interview was conducted, on 05/30/13 at 3:00 p.m., with Employee #33, a registered nurse (RN) unit manager. When asked if the resident's consultation from 01/04/13 was followed up by the physician, the RN stated if there had been a follow up, there would be a nursing note or a signature on the consultation sheet. Employee #33 was unable to locate a note which described the physician was notified of the recommendations by the mental health professional. The facility's medical director was interviewed on 05/31/13 at 2:15 p.m. When asked how he was informed of information from a consultation, he stated nursing staff called him or placed the recommendations in his folder for him to review. When asked if he signed off on consultation sheets, he said he did, or the nurse marked he was notified. When he was shown the consultation sheet for Resident #16 from 01/04/13, he stated he had never seen the consultation, and was unaware of any recommendations prior to the resident's last admission to the hospital. b) Resident # 60 A nursing note, dated 05/02/13 at 4:59 p.m. stated, Called to hall outside resident… | 2016-05-01 |
| 8606 | 8606 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2013-05-31 | 166 | D | 1 | 0 | 5M3K11 | Based on complaint file review, staff interview, and complaint policy review, it was determined the facility failed to thoroughly investigate concerns expressed by family members for two (2) of eight (8) sampled residents. The facility had specific procedures regarding the receipt, documentation, investigation, and follow-up for concerns/complaints. This policy was not implemented for the concerns/complaints lodged by these residents' family members. Resident identifiers: #59 and #61. Census: 78. Findings include: a) Resident #59 Review of the complaint/concern forms, on 05/30/13, revealed a complaint, dated 05/22/13, lodged by the resident's family. The family was concerned the resident was not receiving necessary care and services, such as assistance with oral care and toileting. The complaint included a statement indicating it appeared nothing had been done to correct these issues, which the family member had complained about two (2) weeks prior to the complaint dated 05/22/13. As of 05/30/13, the 05/22/13 complaint had not been addressed or resolved. In addition, there was no documentation regarding the issues which were reported two (2) weeks prior. A discussion regarding the concerns was held with Employee #13, the social worker (SW) and Employee #2, nurse/staff development coordinator, on 05/31/13 at 12:10 p.m. At that time, the SW and Employee #2 were unable to locate any information regarding the original complaint. The family's concerns were not addressed and/or resolved until intervention during the survey on 05/31/13. b) Resident #61 Review of complaint/concern forms revealed this resident's family member felt Employee #50, a nursing assistant (NA), was excessively rude. The family member stated he was offended and insulted by the NA's response to his request for help for the resident. This was reported on 04/30/13. The facility's forms contained a section for the investigating staff member to complete regarding what was found, the final determination, and action taken. Employee #13, the social servic… | 2016-05-01 |
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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 );