cms_WV
Data source: Big Local News · About: big-local-datasette
201 rows where "filedate" is on date 2016-07-01
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8181 | 8181 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-08-01 | 279 | D | 1 | 0 | HEN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan reflective of an accurate assessment of the resident. The resident had a deep tissue injury (DTI) to his buttocks. According to the care plan, a contributing factor related to the development of the DTI was incontinence; however, the resident had a suprapubic catheter and a [MEDICAL CONDITION]. This was true for one (1) of four (4) residents whose care plan was reviewed during the complaint investigation. Resident identifier: #82. Facility census: 111. Findings include: a) Resident #82 Medical record review, on 07/30/13, found a care plan for the DTI, initiated on 07/29/13. The care plan addressed a problem of DTI to left buttocks surrounded by incontinence associated [MEDICAL CONDITION] (IAD) related to immobility and incontinence. Further review of the medical record found the resident had a suprapubic catheter and a [MEDICAL CONDITION] before the development of the DTI. At 5:00 p.m. on 07/30/13, the director of nursing verified the care plan was not correct. She stated incontinence was not a contributing factor in the development of the DTI as the resident had a suprapubic catheter and a [MEDICAL CONDITION] before the development of the DTI. | 2016-07-01 |
| 8182 | 8182 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-08-01 | 282 | D | 1 | 0 | HEN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure licensed nursing staff followed the facility's written care plan for Resident #116 related to the maintenance of a Foley catheter. This was true for one (1) of seven (7) residents whose care plans were reviewed during the complaint survey. Resident identifier: #116. Facility census: 111. Findings include: a) Resident #116 Resident #116 was noted to have an indwelling Foley catheter due to [MEDICAL CONDITION] and hypertrophy of the prostate with urinary obstruction. Review of care plan, on 07/30/13 at 11:00 a.m., found an intervention for the nursing staff to Empty catheter drainage bag every shift and record. Review of medical records, on 07/30/13 at 12:00 p.m., found the staff did not consistently record the amount emptied from the catheter bag as directed by the written care plan. In interviews with Employee #56, a licensed practical nurse (LPN), and Employee #47, a registered nurse (RN), on 07/30/13 at 12:30 p.m., both confirmed the catheter bags were emptied every shift and the urine outputs were not recorded routinely. Occasionally the licensed nurse did record the output in the nurses' notes. In an interview conducted on 07/30/13 at 1:30 p.m., Employee #1, the director of nursing, (DON) confirmed the staff did empty catheter bags every shift, but did not record the resident's output every shift as directed in the resident's written care plan. | 2016-07-01 |
| 8183 | 8183 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-08-01 | 309 | D | 1 | 0 | HEN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure consistent assessment, monitoring, and evaluation of a resident who had an indwelling Foley catheter. This practice affected one (1) of five (5) residents reviewed during the complaint survey who had an indwelling Foley catheter. Resident identifier: #116. Facility census: 111. Findings include: a) Resident #116 Review of medical records, on 08/01/13 at 11:30 a.m., noted this resident had been admitted to the facility on [DATE]. The resident had an indwelling Foley catheter due to [MEDICAL CONDITION] and hypertrophy of the prostate with urinary obstruction. Review of nurses' notes found a note written by Employee #66, a licensed practical nurse (LPN), on 07/15/13 at 2:45 p.m. The nurse noted (typed as written), Foley cath changed due to leaking. 24 french 30 cc balloon placed without difficulty. Redness to right and left groin area noted, treatment ordered. The next nurse's note concerning the Foley catheter was written on 07/20/13 at 12:00 p.m. The nurse noted Foley cath to BSD (bedside drainage) intact, no leaking, sediment urine noted. The next nurse's note concerning the Foley was dated 07/25/13 at 10:30 p.m. The nurse documented Foley patent to BSD (bedside drainage) with approx. 300 cc of urine, dark yellow. During an interview with Employee #1, the director of nursing (DON), on 08/01/13 at 1:00 p.m., it was confirmed from review of nurses' notes, the licensed staff had not consistently assessed, monitored, and evaluated the Foley catheter and the nature and amount of the resident's urinary output. | 2016-07-01 |
| 8184 | 8184 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-08-01 | 441 | D | 1 | 0 | HEN111 | Based on observation, medical record review, and staff interview, the facility failed to maintain proper care of a resident's catheter to prevent the spread of infection. Observation found the resident's catheter drainage bag was lying on the floor. This was true for one (1) of four (4) observations of residents with catheters. Resident identifier: #82. Facility census: 111. Findings include: a) Resident #82 During the initial tour of the facility, on 07/30/13, the resident was in bed at 9:45 a.m. on 07/30/13. His catheter drainage bag was lying on the floor beside the bed. Employee #46, the assistant director of nursing (ADON) was in the hallway outside the resident's room at 9:45 a.m. on 07/30/13. She was asked to witness the observation. She entered the room and stated, I will get a new bag and change it because of infection control issues. She verified the catheter bag should not be lying on the floor. At 5:00 p.m. on 07/30/13, the director of nursing (DON) was made aware of the above situation. She stated the resident could have knocked the catheter onto the floor by moving around in bed. Further review of the resident's care plan found a problem, initiated on 07/29/13, related to the resident's deep tissue injury, which stated the resident was immobile. Review of the resident's most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/27/13, found Item G0110, (activities of daily living assistance - bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture,) reflected the resident required the extensive assistance of two (2) staff persons to complete the activity of moving while in bed. . | 2016-07-01 |
| 8185 | 8185 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-08-01 | 514 | D | 1 | 0 | HEN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of facility policy and procedure, the facility failed to ensure a permanent entry in the resident's medical record was not changed after being recorded. This was true for one (1) of seven (7) medical records reviewed during the complaint survey. Resident identifier: #82. Facility census: 111. Findings include: a) Resident #82 Review of the resident's current care plan, located on the medical record, on 07/30/13 at 10:15 a.m. found a handwritten entry to the care plan, Deep tissue injury (DTI) to left buttocks surrounded by IAD (incontinence related [MEDICAL CONDITION]) related to immobility and incontinence, this entry was dated 07/29/13. On 07/30/13 at 10:30 a.m. the unit manager, Employee #47, was asked to make a copy of the resident's care plan. When she returned with the care plan, the original problem was no longer on the care plan. A new care plan problem had been written and dated 07/29/13, Deep tissue injury to left buttocks surrounded by MASD (moisture associated [MEDICAL CONDITION]) related to immobility. The surveyor found Employee #47 and Employee #34, a registered nurse, at the nurses station at 10:35 a.m. on 07/30/13. The surveyor spoke to both employees and asked who had changed the original care plan. Employee #34 stated she had re-written the care plan because it was incorrect. Employee #34 stated she saw the resident's DTI could not be due to incontinence because the resident had a catheter and a [MEDICAL CONDITION]. During the discussion with Employees #47 and #34, the director of nursing (DON) came to the nurses' station. The DON told Employee #34 she should have, yellowed out the problem and corrected it on the original copy. Employee #34 was asked for the original copy of the care plan and she said she could not find it. The DON found the original copy of the care plan in the trash can, torn into pieces. The DON stated she would tape the care plan t… | 2016-07-01 |
| 8186 | 8186 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2012-05-18 | 156 | B | 0 | 1 | 6XWO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate liability notices to one (resident #277) out of four sampled residents reviewed for liability notices and beneficiary appeal rights. Findings Include: Resident #277 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident was notified by the facility that skilled nursing services would end on May 12, 2012. Notice of Medicare Non-Coverage (CMS Form ) was signed by the resident on May 10, 2012. Resident remained in the facility and was not discharged following the end of covered services. However, the resident was not issued the Skilled Nursing Facility Advance Beneficiary Notice (CMS Form ). An interview with employee #76 was conducted on May 16, 2012. Employee #76 stated that she issued the CMS Form and not the CMS Form . A subsequent interview was conducted with employee #76 on May 17, 2012. Employee #76 stated that she misunderstood the training she received regarding the requirements for issuing liability notices. | 2016-07-01 |
| 8187 | 8187 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2012-05-18 | 157 | D | 0 | 1 | 6XWO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the responsible party of an administration of intravenous antibiotics for treatment of [REDACTED].#248) out of three sampled for urinary incontinence out of a eight residents identified as having a decline in urinary continence. Findings include: Resident #248 had [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed the resident was always continent. The MDS dated [DATE] revealed the resident had a decline and was occasionally incontinent. The plan of care for incontinence dated 4/3/12 revealed the resident will have incontinence episodes managed without signs and symptoms of urinary tract infection and will have dignity maintained with incontinence care. The plan of care revealed to observe for signs and symptoms of urinary tract infection, monitor labs, and provide perineal care daily and as needed. Observations were made on 5/15/12 at 12:36 p.m. of the resident lying in bed and on 5/16/12 at 6:00 p.m. the resident was ambulating in the halls talking to staff. An interview was done with the resident and she stated she didn't feel well today, but she is a lot better than she used to be. She stated she walks and takes herself to the bathroom and doesn't need any help. During an interview on 5/15/12 with CNA #64 at 12:40 p.m., the CNA stated the resident will ask for help if needed, but very seldom, she stated, she can take herself to the bathroom and doesn't need help from the staff. The CNA stated the resident has been incontinent at times and had been ill awhile back. An interview with RN #32 at 1:45 p.m. was done. The RN stated the resident had a urinary tract infection in March and was started on antibiotic ([MEDICATION NAME]) intravenously (IV) for 10 days on 3/23/12. The RN stated she talks to the daughter all the time, but could not be certain that she notified her when the IV antibiotics was started. She verified there was no documentati… | 2016-07-01 |
| 8188 | 8188 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2012-05-18 | 166 | D | 0 | 1 | 6XWO11 | Based on record review and interview, the facility failed to resolve a grievance related to missing personal property for one (resident #85) of three sampled residents out of eight residents who complained of having missing personal property during resident interviews. Findings include: During interview with Resident # 85 on 05/14/12 at 3:20 p.m., it was stated he had missing shirts and a pair of jeans missing from his room. Resident #85 also stated during the interview he told someone in the laundry department. Review of the medical record for Resident #85 revealed a form titled Inventory of Personal Effects dated 01/13/12. There are 4 slacks listed and 8 shirts. Review of an undated form titled, Process for Missing Items revealed if an item is identified as missing the resident would need to inform the nurse or staff member regarding the missing items with date and time the item was missing, the staff will check the inventory sheet for the description of the item, the staff will complete a concern form with the item identified and complete an in-house communication slip to notify all departments of missing item and the staff will make every effort to locate or find the missing item. During interview with Social Worker (SW) #43 on 05/15/12 at 1:38 p.m. it was stated she doesn't know much about missing property and the Social Worker Manager would know more. SW #43 then phoned the Laundry Department at the time of the interview and asked if any missing items had been reported by Resident #85. They stated there were none at that time. Licensed Practical Nurse (LPN) #50, identified as the Unit Manager, was made aware of the missing personal property by SW #43. LPN #50 stated she would fill out a form and follow up. LPN #50 also verified laundry personnel had taken the report from Resident #85 and stated nursing staff should also have received notice of the missing items. During interview on 05/17/12 with LPN #47, identified as the Social Worker Manager, it was verified there were no missing items reported for Reside… | 2016-07-01 |
| 8189 | 8189 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2012-05-18 | 224 | G | 0 | 1 | 6XWO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures to prohibit neglect for one resident (resident #28) of 3 residents sampled from 8 residents identified by the facility to have had a fall and/or fracture in the last 30 days. Findings Include: Resident #28 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was totally dependent on two or more staff for physical assistance with transfers. Review of the care plan for Transfers dated August 3, 2011 revealed the resident has a potential for injury and impaired ability to self-transfer. The resident requires use of full body mechanical lift and 2 person assistance with transfers to/from bed and chair. The care plan goal was for the resident to be transferred with identified transfer devices/assistance through next review on July 10, 2012. Review of the Resident Care Cardex which outlines relevant resident care needs revealed the resident requires use of a LBGC (Lean Back Geri-Chair). A change of condition form was completed on April 29, 2012 due to increased pain and decreased range of motion. A physician's orders [REDACTED]. Nurse's Notes on April 29, 2012 also document the change of condition. The radiological report, dated April 29, 2012, could not exclude a fracture/dislocation. Recommended were repeat images or a CT (computed tomography). Documented on the report was notification to the physician and his instructions to continue to monitor. A change of condition form was completed on May 2, 2012 due to redness and warmth of the right leg. Physician orders [REDACTED]. [MEDICAL CONDITION] was ruled out. Physician orders [REDACTED]. Nurse's notes on May 3, 2012 documented increased pain to right hip and decreased range of motion. A physician's orders [REDACTED]. The CT report, dated May 4, 2012, revealed the presence of a spiral type fracture involving… | 2016-07-01 |
| 8190 | 8190 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2012-05-18 | 248 | D | 0 | 1 | 6XWO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide activities for two residents (residents #281 and #120) of three sampled residents out of eight cognitively impaired residents observed not participating in activities. Findings include: 1. Review of the medical record for Resident #281 revealed an admission date of [DATE] and pertinent [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), a comprehensive assessment dated [DATE] revealed Resident #281 has no difficulty hearing, does not speak words, is never or rarely able to make herself understood, rarely or never understands others, has impaired vision and does not have corrective lenses. The MDS also revealed Resident #281 has both long and short term memory problems, is not able to recall the current season, location of her room, staff names or faces and that she is in a nursing home. Resident #281 was also assessed to have moderately impaired decision making skills. The MDS revealed the resident's family members stated it was important for Resident #281 to be around animals such as pets, to keep up with the news, to go outside to get fresh air when the weather is good and to do her favorite activities. Further review of the MDS revealed Resident #281 was assessed by the facility to require extensive physical assistance with bed mobility, transfers, dressing and personal hygiene. Review of an undated activities assessment located in the resident's medical record revealed Resident #281 likes to watch the news everyday and has current interest in watching TV, watching movies, listening to country music, talking and conversing, coloring and enjoys cats. Review of the care plans for Resident #281 revealed a plan of care dated 04/17/12 which identified the resident as being at risk for social isolation due to depression and [MEDICAL CONDITION]. The plan of care also states Resident #281 is aphasic and does not like to be around people she does n… | 2016-07-01 |
| 8191 | 8191 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2012-05-18 | 250 | D | 0 | 1 | 6XWO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide medically-related social services in the area of discharge planning for one resident (resident #177) of three residents sampled for community discharge. Findings include: Review of the medical record for Resident #177 revealed an admission date of [DATE] and pertinent [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), a comprehensive assessment dated [DATE], revealed the resident has adequate hearing and vision, is able to make himself understood and able to understand others. Resident #177 was also assessed to score a 12 out of 15 on the Brief Interview for Mental Status (BIMS). Section Q of the MDS revealed Resident #177 wishes to return to the community. Review of the care plans for Resident #177 revealed a plan of care dated 01/13/12 which states the resident chooses to be highly involved in daily care decisions regarding suggested or recommended interventions and has specific preferences related to discharge planning. The goal for this plan of care is stated to be Resident #177 will have preferences honored with individual education related to benefits, risks and potential outcomes of choices and preferences. The interventions for this plan of care include to invite the individual to review and discuss suggested or recommended treatments or interventions to allow individual preferences and choices, provide individual education related to individual choices and exercise of preferences relating to standard interventions or treatments, document education provided using Resident Education Record, review potential alternative choices to individual, notify MD of individual's choices and preferences, honor individual choices and preferences as able within parameters of facility and other individual's safety and choices or preferences and observe individual for changes in cognitive and decision making abilities with review of pr… | 2016-07-01 |
| 8192 | 8192 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2012-05-18 | 279 | D | 0 | 1 | 6XWO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to develop three care plans in the areas of community discharge, [MEDICAL TREATMENT], and pain for three residents (residents 177, 59, 16) of 36 care plans reviewed. Findings include: 1. Review of the medical record for Resident #177 revealed an admission date of [DATE] and pertinent [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), a comprehensive assessment dated [DATE] revealed the resident has adequate hearing and vision, is able to make himself understood and able to understand others. Resident #177 was also assessed to score a 12 out of 15 on the Brief Interview for Mental Status (BIMS). Section Q of the MDS revealed Resident #177 wishes to return to the community. Review of the care plans for Resident #177 revealed a Plan of Care dated 01/13/12 which states the resident chooses to be highly involved in daily care decisions regarding suggested or recommended interventions and has specific preferences related to discharge planning. The goal for this Plan of Care is stated to be Resident #177 will have preferences honored with individual education related to benefits, risks and potential outcomes of choices and preferences. The interventions for this Plan of Care include, to invite the individual to review and discuss suggested or recommended treatments or interventions to allow individual preferences and choices, provide individual education related to individual choices and exercise of preferences relating to standard interventions or treatments, document education provided using Resident Education Record, review potential alternative choices to individual, notify MD of individual's choices and preferences, honor individual choices and preferences as able within parameters of facility and other individual's safety and choices or preferences, and observe individual for changes in cognitive and decision making abilities with review… | 2016-07-01 |
| 8193 | 8193 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2012-05-18 | 282 | D | 0 | 1 | 6XWO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement four care plans in the areas of accidents and activities for three residents (resident #'s 28, 120, 281) out of 36 care plans reviewed. Findings include: 1. Resident #28 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was totally dependent on two or more staff for physical assistance with transfers. Review of the care plan for Transfers dated August 3, 2011, revealed the resident has a potential for injury and impaired ability to self-transfer. The resident requires use of mechanical lift and 2 person assist. The care plan goal was the resident be transferred with identified transfer devices/assistance through next review on July 10, 2012. An interview with Certified Nursing Assistant (CNA) employee #110 was conducted on May 17, 2012. Employee #110 stated on April 27, 2012, he failed to transfer the resident per her plan of care. Specifically, he failed to use a mechanical lift during transfers. Employee #110 stated he had not verified resident #28's care requirements on her care plan nor on the resident care cardex prior to the transfer. 2. Resident #120 had [DIAGNOSES REDACTED]. The most recent Activity assessment dated [DATE] indicated the resident's most current interests in activities included: Watching television adventures, listening to country music, talking and conversing, spiritual and religious events, specifically catholic religion, and dogs. The most recent Minimum (MDS) data set [DATE] was documented as a zero on section F for activities. The resident's most recent plan of care for activities dated 4/27/11 was reviewed. The care plan revealed the resident was at risk for social isolation with [DIAGNOSES REDACTED]. The goals on the activity plan of care were to maintain the level of activity attendance and participation, engage the resident in independent, self di… | 2016-07-01 |
| 8194 | 8194 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2012-05-18 | 309 | D | 0 | 1 | 6XWO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and resident interview, the facility failed to provide the necessary care and services for the highest practicable well-being in the form of medications for one resident (resident #59) of five residents receiving [MEDICAL TREATMENT] services. Resident #59 has [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The plan of care for [MEDICAL TREATMENT] did not indicate anything about the administration of the resident's medications. The Plan of Care did not state on days of [MEDICAL TREATMENT] whether the resident's medications would be given to the resident at the facility or sent with the resident to the [MEDICAL TREATMENT] center. The resident was interviewed on 5/17/12 at 2:20 p.m The resident stated she does not have any medication sent with her on [MEDICAL TREATMENT] days. A review of the medical record Medication Administration Records (MAR's) for the months of February, March, April and May 2012 was conducted. The MARs had several days of different medications listed with Out of Facility (OOF). During an interview on 5/17/12 at 1:40 p.m. with RN #51, she stated the medications were documented as (OOF) because the resident was out of the facility and did not receive her medications at those times of day because she was out for [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. The RN verified there was no instruction on the Plan of Care about how the resident would receive medications on the days the resident went to [MEDICAL TREATMENT]. The RN verified the medications were not given to the resident at 9:00 A.M. on the days of [MEDICAL TREATMENT] by the nurses as ordered by the physician. The RN stated some type of change needed to be made because the resident did not receive the medication as ordered by the physician and there were many times the resident had not received her medications while out of the facility for [MEDICAL TREATMENT]. The medications ordered at 9:00 a.m. included: [MED… | 2016-07-01 |
| 8195 | 8195 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2012-05-18 | 315 | D | 0 | 1 | 6XWO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure two (residents #71 and #248) of three residents identified with a decline in urinary continence received care and services to maintain bladder function. Findings include: 1. Review of the medical record for Resident #71 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE], a comprehensive assessment for Resident #71, revealed the resident required limited assistance of one staff member for bed mobility, dressing and walking in the room. Resident #71 was also assessed to require supervision during eating and locomotion on the unit and assessed to require extensive assist from one staff member with transfers, personal hygiene and toilet use. The resident was also assessed to be incontinent of urine occasionally. The comprehensive assessment revealed Resident #71 had both long and short term memory problems, is unable to recall the current season, location of her room, staff names and faces and that she is in a nursing home. Resident #71 was also assessed to have moderately impaired decision making skills. Review of the MDS quarterly assessment dated [DATE] revealed Resident #71 is assessed to now require limited assistance with locomotion on the unit, extensive assist of one staff member for dressing. All other pertinent activities of daily living remained unchanged. Resident #71 was assessed to have declined in the area of urinary incontinence from occasionally to frequently incontinent of urine on this quarterly assessment. Review of the care plans for Resident #71 revealed a plan of care dated 12/30/11 for incontinence related to functional factors and pain. The goal for the plan of care states Resident #71 will have incontinence episodes managed without signs and symptoms of potential complications, including skin breakdown and urinary tract infection [MEDICAL CONDITION] and will have dignit… | 2016-07-01 |
| 8196 | 8196 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2012-05-18 | 323 | G | 0 | 1 | 6XWO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review and review of a preliminary investigative report, the facility failed to prevent a fracture and multiple falls for two residents (residents #28 and #120) out of three residents sampled of eight residents identified by the facility for falls/and or fractures in the last 30 days. Findings include: 1. Resident #28 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was totally dependent on two or more staff for physical assistance with transfers. Review of the care plan for Transfers dated August 3, 2011, revealed that the resident has a potential for injury and impaired ability to self-transfer. The resident requires use of full body mechanical lift and 2 person assistance with transfers to/from bed and chair. The care plan goal was that the resident be transferred with identified transfer devices/assistance through next review on July 10, 2012. Review of the Resident Care Cardex which outlines relevant resident care needs revealed that the resident requires use of a LBGC (Lean Back Geri-Chair). A change of condition form was completed on April 29, 2012, due to increased pain and decreased range of motion. A physician's orders [REDACTED]. Nurse's Notes on April 29, 2012 also document the change of condition. The radiological report, dated April 29, 2012, could not exclude a fracture/dislocation. Recommended were repeat images or a CT (computed tomography). Documented on the report was notification to the physician and his instructions to continue to monitor. A change of condition form was completed on May 2, 2012, due to redness and warmth of the right leg. Physician orders [REDACTED]. Deep vein thrombosis was ruled out. Physician orders [REDACTED]. Nurse's notes on May 3, 2012, documented increased pain to right hip and decreased range of motion. A physician's orders [REDACTED]. The CT report, dated May 4, 2012, re… | 2016-07-01 |
| 8197 | 8197 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2012-05-18 | 431 | E | 0 | 1 | 6XWO11 | Based on observation and interview, the facility failed to ensure that expired medications were not available for resident use in two out of three medication storage rooms. Findings include: 1. On 05/14, the medication storage room was observed on the unit identified by the facility as being OB (old building). There was one opened 1000 count bottle of Acetaminophen 325 mg tablets with an expiration date of 03/12 located in the medication storage cabinet. The observation was verified by Licensed Practical Nurse (LPN) #50, identified as the Unit Manager. 2. Observations were made on 5/14/12 at 4:45 p.m. on Unit 3 in the New Building. The Medication Storage room was observed to have a 16 ounce container of fiber powder that had an expiration date of April, 2012. Observations were made in the same Medication Storage room of two 1000 count bottles of Acetaminophen 325 mg tablets with an expiration date of March, 2012 on both bottles. The observations of the expired medications were verified by RN staff #151. The Policy and Procedure for the facility's storage of medications was reviewed. The policy stated the facility should ensure medications and biologicals that have an expired date on the label should be stored separate, away from use from other medications until destroyed or returned to the supplier. | 2016-07-01 |
| 8198 | 8198 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 156 | E | 0 | 1 | JXHC11 | Based on medical record review, staff interview, resident interview, and observation, the facility did not ensure written information was prominently displayed about how to apply for and use Medicaid benefits. The facility also failed to ensure one (1) of forty- six (46) residents had received information regarding how to contact the physician responsible for her care. In addition, the facility failed to ensure two (2) of five (5) residents received the appropriate liability notice after they were discharged from a Medicare Part A service. Resident identifiers: #45, #58, and #114. Facility census: 115. Findings include: a) On 05/15/12, at approximately 9:00 a.m., an observation of the facility revealed they had not posted the necessary information regarding how to apply for and use Medicaid benefits. On 05/16/12, at approximately 9:00 a.m., the administrator (Employee #43) agreed the facility had not posted this information. She indicated the facility had previously posted the information, but people kept taking it down. b) Resident #114 On 05/15/12, at approximately 4:00 p.m., the director of admissions (Employee #68) indicated she gave the residents the consent for treatment and release of information form at the time of admission. Review of Resident #114's medical record, conducted on 05/15/12, at approximately 4:30 p.m., found the consent for treatment and release of information form. The form did list the resident's physician; however, the form did not have contact information listed for the physician. The form had a place to list the physician's telephone number and physician's address, but this information had not been provided on the form. In an interview on 05/22/12, at approximately 8:45 a.m., Resident #114 indicated she did not know how to contact her physician. On 05/22/12, at approximately 5:00 p.m., the director of nursing (Employee #2) asked what type of contact information the facility needed to give the residents regarding how to contact their physician. The director of nursing agreed that the re… | 2016-07-01 |
| 8199 | 8199 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 241 | E | 0 | 1 | JXHC11 | Based on observations and staff interviews, the facility failed to promote care for residents in a manner that maintained each resident's dignity. During the dining room observations, seven (7) of twenty-two (22) residents were not treated in a dignified manner during the lunch meal. Six (6) of the seven (7) residents were not served their meals although others at the same table were already eating. One (1) of seven (7) residents was not given silverware with which to eat her meal. Facility census: 115. Resident identifiers: #10, #8, #90, #81, #13, #60, and #101. Findings include: a) Resident #10, #8, #90, #13, #60 and #81 During observation of the lunch time meal, on 05/14/12 at 12:00 p.m., these six (6) residents were observed sitting at tables with other residents who had been served and were already eating their meals. Resident #8's was not served until 12:15 p.m. She was seated at a table with two (2) residents who were being fed by staff. When Resident #8 received her meal, she stated her soup was cold. Resident #81 also received her meal at 12:15 p.m., after the other two (2) residents at her table were already eating. Resident #60 did not receive her meal at all during the observation. Resident #60 became very upset and threw her clothing protector across the table. She stated, she had ordered a special lunch while she was in Bingo earlier that morning, but did not receive it. She left the dining room without eating. Resident #13 did not receive her meal. She was seated at a table with two (2) other residents who had already consumed most of their food. Observation of the meal ticket for one (1) of the residents seated at Resident #13's table found Resident #13's meal had been given to the wrong resident. Resident #13 did not receive her meal until 12:25 p.m. Resident #90 received her meal ten (10) minutes after the other resident's at her table obtained their meal trays. Resident #10 was seated at a table with two other residents who were eating. She received her meal fifteen (15) minutes after the other… | 2016-07-01 |
| 8200 | 8200 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 250 | D | 0 | 1 | JXHC11 | Based on medical record review, staff interview, and resident interview, the facility did not provide medically-related social services for two (2) of forty-six (46) residents. By not providing these essential services, the facility did not ensure the two (2) residents attained/maintained their highest practicable physical, mental, and psychosocial well-being. Resident #114 had disclosed information to nursing staff related to a personal history of abuse by a former spouse. The facility did not provide any social service related interventions to the resident after she disclosed how troubling these past issues were to her. Resident #17 had voiced to nursing staff members both suicidal and homicidal ideations. The facility did not intervene with social service interventions for this resident. Resident identifiers: #114 and #17. Facility census: 115. Findings include: a) Resident #114 On 05/14/12, at approximately 1:00 p.m., Resident #114 indicated she felt sad due to thoughts she had related to the abuse she had endured from her former spouse. She said she struggled with the memories of the abuse she and her children endured. She said she felt she neglected her children and had not protected them as she should have. A nursing note, dated 05/12/12, revealed the resident had expressed to nursing staff her distress over memories associated with spousal abuse and abuse she encountered as a child. The note stated the resident was difficult to redirect. The note also stated the nurse had contacted social services. The medical record review, conducted on 05/17/12 at 9:30 a.m. with Employee #17 (social worker), revealed she knew the resident had talked with nursing staff about the issues of being abused by a former spouse. She said the resident would not open up to her about the issues. She had no progress notes related to her attempts to speak with the resident regarding the issue. She also denied having requested the assistance of nursing or the other social worker regarding the issue. On 05/21/12 at 12:00 p.m., Employee… | 2016-07-01 |
| 8201 | 8201 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 253 | E | 0 | 1 | JXHC11 | Based on observations and staff interview, the facility failed to ensure all essential resident care equipment was maintained in a safe operating condition. Observations were made of unsteady arms on toilet safety frames, inappropriate and cracked toilet tank covers were observed, as well as issues were identified with the surfaces on doors and doorframes. These problems were noted on three (3) of the facility's four (4) hallways. The 100, 300, and 400 hallways had deficits in maintenance identified. Facility census: 115. Findings include: a) Room 114 On 05/15/12, at approximately 6:15 p.m., observations were made of a leaking wax ring around the toilet in Room #114. Resident #55 utilized this toilet. Employee #105 (nurse aide) commented this toilet had leaked for an extended period. On 05/16/12, Employee #97 (maintenance supervisor) indicated he had replaced the wax ring on the toilet in Room #114. b) Rooms #405, #406, #407, and the 100 hall central bath area On 05/16/12, at approximately 11:00 a.m., observations were made of the arms on the toilet safety frames in Room #405, #406, #407 and in the central bath area on the 100 hallway. The arms of the safety frames, which were to assist residents in getting on and off of the toilet, were shaky and unsteady. Employee #97 indicated he knew these safety frames had issues with unsteadiness of the arms and had tried to replace as many as possible. He indicated he wanted to replace them all with a grab-bars/handrails that attached to the wall. c) Rooms #405 and #407 On 05/22/12, at approximately 10:00 a.m., an observation revealed an inappropriate toilet tank covering in Room #405. The facility had utilized a plastic tray to cover the back of the toilet tank. In Room #407, the toilet tank cover was cracked. Employee #97 indicated he would replace these tank coverings and agreed these were not safe. d) Walls, doors, door frames On 05/15/12 at 4:11 p.m., an observation of the door frame going into the bathroom of Room #411 revealed scratched and marred areas. On 05/14/12… | 2016-07-01 |
| 8202 | 8202 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 272 | E | 0 | 1 | JXHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, family interview, and staff interview, the facility failed to ensure that conditions residents were experiencing were thoroughly and accurately assessed for issues requiring further interventions. There was no evidence Resident #179 and Resident #132 had an accurate assessment completed to reflect their dental status. Residents #184 and #185 did not have their pain thoroughly assessed in order to evaluate the site and severity of the pain, and Resident #73 did not have a thorough range of motion assessment. Failure to properly assess these conditions had the potential to result in the conditions not being properly treated. This practice was true for five (5) of forty-six (46) Stage 2 sampled residents. Resident identifiers: #179, #132, #184, #185, and #73. Facility Census: 115. Findings include: a) Resident # 179 During a resident interview, conducted on 05/14/12 at 1:00 p.m., it was identified this resident was alert and oriented. She was questioned about her oral status and was asked whether she had any pain in her mouth or problems with her dentures. She said she does have pain related to her dentures because they rub her guns and needs new ones. She stated she can hardly eat anything, as her dentures have rubbed her gums sore on the bottom because they are too big. According to the resident, she has lost a lot of weight over the past several months. During a review of the medical record for Resident #179, it was noted her oral assessment was conducted on 04/23/12. This assessment indicated she did not have anything wrong with her teeth at that time. Her Minimum Data Set, dated dated [DATE], also indicated there were no oral or dental problems present. Her nursing notes were reviewed and there were no problems identified with oral status in the nursing notes since her admitted . There was no evidence there had been any complaints of mouth pain The resident was interviewed again on 05/17/12 at 2:0… | 2016-07-01 |
| 8203 | 8203 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 274 | D | 0 | 1 | JXHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a comprehensive assessment after a significant change for one (1) of forty-six (46) sampled residents. The resident's health status changed, all medications were discontinued, [MEDICATION NAME] was added for pain, and the resident was put on comfort care only. Facility census: 115. Resident identifier: #104. Findings include: a) Resident #104 Review of the medical record for Resident #104 found the resident had been placed on comfort measures only on 04/26/12. Employee #39 (registered nurse) and Employee #16 (social worker) met with the resident's son and discussed his wishes for comfort care. The medical record identified Employee #39 updated the post form to reflect the changes in care. On 05/01/12 the physician discontinued all medications and added [MEDICATION NAME] related to pain. During an interview with Employee #17, on 05/16/12 at 10:15 a.m., it was confirmed she and Employee #39 had discussed with the son his wishes. On 05/17/12, an interview was conducted with Employee #44 related to the comfort measures put in place for Resident #104, the discontinuation of her medications, and the addition of [MEDICATION NAME]. When Employee #44 (MDS nurse) was asked, on 05/17/12 a 1:45 p.m., if a significant change had been completed for Resident #104, she stated, I guess we missed that. | 2016-07-01 |
| 8204 | 8204 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 279 | E | 0 | 1 | JXHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interviews, staff interview, and observations, the facility failed to ensure care plans reflected the care a resident was assessed to need, and the care that was being provided to the residents. The care plans were not accurate and did not reflect the care being provided to the residents. This was found to be true for nine (9) of forty-six (46) sampled residents. Resident identifiers: #145, #179, #132, #73, #35, #104, #7, #3, and #117. Facility Census: 115. Findings include: a) Resident #145 1) This resident was observed on 05/14/12 at 1:00 p.m. in a bed in the high position. She had her bedside table beside her and appeared comfortable. She was interviewed and was alert and oriented answering all of the questions correctly as verified in her record. She was observed in bed multiple times and always had her head elevated in a high position and not in a low bed. During a review of the physician's orders [REDACTED]. It was verified in the medical record this resident had not fallen since she had been at this facility. She had fallen at home and broken her leg. She had been admitted to the facility for therapy. A nursing assistant (Employee # 46) was interviewed, on 05/17/12 at 12:15 p.m., regarding this resident's bed. She stated she had never seen this resident in a low bed and that she did not know she needed one. She also said she had never seen this resident try to get up and did not know of any falls since the resident had been there. The resident's care plan,dated 04/30/12,was reviewed. The care plan identified this resident as a falls risk. The intervention listed in her care plan was utilize low bed. 2) The resident's care plan was further reviewed for the amount of transfer assistance she required. Her care plan addressed that she needed extensive/total assistance for ADL (activity of daily living) care in bathing, grooming, dressing, bed mobility, transfers, locomotion, toileting, due to left distal fe… | 2016-07-01 |
| 8205 | 8205 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 280 | E | 0 | 1 | JXHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to revise the care plans for four (4) of forty-six (46) sampled residents. Residents' care plans were not revised when they were receiving comfort care, [MEDICAL TREATMENT] interventions were not incorporated into the care plan, [MEDICAL CONDITION] were not addressed, interventions for the use of psychoactive medications were not established, and no interventions were put in place for a resident experiencing episodes of pain. Facility census: 115. Resident identifiers: #104, #17, #55, and #185. Findings include: a) Resident #104 Review of the medical record for Resident #104 found, on 04/26/12, the resident was placed on comfort measures only. Employee #39 (registered nurse) and Employee #16 (social worker) met with the resident's son and discussed his wishes for comfort care. The medical record identified Employee #39 as the person who updated the POST (physician's orders [REDACTED]. On 05/01/12, the physician discontinued all medications and added [MEDICATION NAME] related to pain. During an interview with Employee #17, on 05/16/12 at 10:15 a.m., it was confirmed that she and Employee #39 had discussed with the son his wishes and the care plan was not updated to reflect the changes in care. b) Resident #17 1) Suicidal ideation Review of the medical record found Resident #17 had stated to the facility on [DATE], I wish I had a gun, I'd shoot them both then shoot myself. On 05/21/12 at 1:48 p.m., Employee #2 (director of nursing) stated, She has said she was going to kill herself before. Back on 01/31/12, she was sent to the hospital then for psychiatric services. Review of the medical record found further documentation the resident had suicidal ideation on other occasions. On 02/10/12, Resident #17 told the nurse I don't care if I die. On 01/31/12, the resident told her roommate and daughter, with a nursing assistant present, she was going to kill herself. The care… | 2016-07-01 |
| 8206 | 8206 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 309 | D | 0 | 1 | JXHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure Resident #185 was provided services to attain her highest practicable level of comfort from pain. She did not receive her medication as ordered by the physician to treat her chest discomfort. The resident had a [DIAGNOSES REDACTED]. A medication was ordered by the physician for treatment of [REDACTED]. Additionally, a pain medication given this resident was noted effective on the Medication Administration Record [REDACTED]. Resident identifier: #185. Facility Census: 115 Findings Include: a) Resident #185 During an interview with this resident, on 05/22/12 at 8:15 a.m., she stated her left chest was hurting. She said that they had just given her some medication, but it was still hurting. Her Medication Administration Record [REDACTED]. This was just fifteen (15) minutes prior to the resident expressing she was having pain. It was also recorded, on the MAR, that this medication was effective. This was fifteen (15) minutes after it was administered. In addition, the MAR indicated [REDACTED]. The resident's medical record was reviewed. It was noted this medication had been ordered at 1:40 p.m. on 05/21/12. The medication was scheduled on the MAR indicated [REDACTED] The dose for 05/21/12 at 9:00 p.m. was circled, meaning it was not given. At 8:15 a.m. on 05/22/12, the dose to be given at 9:00 a.m. on 05/22/12 was circled. The nurse (Employee #67) was interviewed on 05/22/12 at 8:45 a.m. She was questioned about the record stating the resident's pain medication was effective. She stated she must have circled that by accident. Employee #67 was then asked why the medication [MEDICATION NAME] 150 mg, that was ordered the day prior to this observation, had been circled as unavailable two (2) times. She stated that it had not yet come in from the pharmacy. The nurse was questioned about the availability of medications in the facility. She stated, They have m… | 2016-07-01 |
| 8207 | 8207 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 323 | D | 0 | 1 | JXHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and resident interview, the facility failed to ensure safety interventions ordered by the physician were implemented in an attempt to lessen the risk of injury. The residents had physician's orders [REDACTED]. Observations found these measures were not being employed. Two (2) of forty-six (46) sampled residents were affected. Facility census: 115. Resident identifiers: #17 and #145. Findings include: a) Resident #17 During the resident interview, on 05/15/12 at 10:30 a.m., Resident #17 was observed in bed. The bed was not in a low position and no floor mats were present. Review of the medical record revealed the resident had an order in place for floor mats and a low bed related to accidents. During an interview with Employee #2 (director of nursing), on 05/16/12 at 4:46 p.m., it was learned the mats should be in position except when the resident was eating or being bathed. At 4:48 p.m. on 05/16/12, the resident was again observed while in bed. There were no mats in place and the bed was not in the low position as ordered. This information was immediately conveyed to Employee #2. The facility discontinued the mats and low bed on 05/16/12 at 6:15 p.m.; however, at the time of the observations, the orders for the mats and low bed were in effect. b) Resident #145 This resident was observed on 05/14/12 at 1:00 p.m. in a bed in the high position. She had her bedside table beside her and appeared comfortable. She was interviewed and found to be alert and oriented. She answered all of the questions correctly as verified by review of her medical record. She was observed in bed multiple times. Her head was always elevated and the bed was in a high position. During a review of the physician's orders [REDACTED]. It was verified in the medical record this resident had not fallen since she had been at this facility. She had fallen at home, broken her leg, and had come to the facility for therapy. A nursing assistant … | 2016-07-01 |
| 8208 | 8208 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 329 | D | 0 | 1 | JXHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the medication regimen for one (1) of forty-six (46) Stage 2 sample residents was not free from unnecessary medications. The facility failed to provide non-pharmacological interventions for a resident expressing [MEDICAL CONDITION], and failed to review the resident for falls related to the use of [MEDICAL CONDITION] medications for one (1) of forty-six (46) sampled residents. Facility census: 115. Resident identifier: #17. Findings include: a) Resident #17 1) Review of the medical record found Resident #17 had stated to the staff, on 04/02/12, I wish I had a gun, I'd shoot them both then shoot myself. On 05/21/12 at 1:48 p.m., Employee #2 (director of nursing) stated, She has said she was going to kill herself before back on 01/31/12. She was sent to the hospital then for psychiatric services. Review of the medical record found further documentation the resident had [MEDICAL CONDITION] on other occasions. On 02/10/12, Resident #17 told the nurse I don't care if I die. On 01/31/12, the resident told her roommate and daughter with a nursing assistant present, she was going to kill herself. On 04/03/12, the attending physician ordered [MEDICATION NAME] 20 mg now and then BID (twice a day). On 05/01/12, the [MEDICATION NAME] was increased to 40 mg twice a day. During an interview with Employee #2 (director of nursing), on 05/21/12 at 12:45 p.m., she was asked why the [MEDICATION NAME] had been started on 04/03/12. She stated, The [MEDICATION NAME] was ordered related to the suicidal ideation on the day before. Review of the care plan for Resident #17 found no interventions put in place for staff to follow for the use of [MEDICATION NAME]. The use of [MEDICATION NAME] could not be found listed on the care plan. During an interview with Employee 17 (Social Worker) on 05/21/12 at 12:53 p.m., she stated, She was unaware Resident #17 had suicidal ideation, she said no one had ever told her. Employee #17 was… | 2016-07-01 |
| 8209 | 8209 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 364 | D | 0 | 1 | JXHC11 | Based on resident interview, observation, measurement of food temperatures, and staff interview, the facility failed to serve hot food for two (2) of one hundred fifteen (115) residents. These residents were served cold lentil soup during the lunch meal. Resident identifiers: #8 and #81. Facility census: 115 Findings include: a) Resident #8 During observation of the lunch meal on 05/14/12, Resident #8 received her lunch meal fifteen (15) minutes after other residents seated at her table received theirs. When her tray arrived, she stated her soup was cold. b) Resident #81 During observation of the lunch meal on 05/14/12, Resident #81 received her lunch meal after other residents seated at the same table had already been served. The facility provided a thermometer to Employee #87. When Employee #87 checked the temperature of the soup, the thermometer showed the soup was 100 degrees Fahrenheit (F). To ensure palatability, the professionally accepted temperature for hot foods at the point of service is a minimum of 120 degrees F. | 2016-07-01 |
| 8210 | 8210 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 367 | D | 0 | 1 | JXHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure the therapeutic diet for one (1) of forty-six (46) Stage 2 sampled residents was prescribed by the attending physician. The resident was ordered a regular diet, but was provided a mechanical soft diet. Resident identifier: #7. Facility census: 115. Findings include: a) Resident #7 Review of the medical record found a discrepancy between the diet ordered by the physician and the diet the resident was receiving. According to the current physician's orders [REDACTED]. Observation of the noon meal, on 05/21/12, noted the resident received a mechanical soft diet. An interview with a dietary staff member, on 05/21/12 at 2:30 p.m., revealed the resident's diet was changed from a regular diet to a mechanical soft diet on 05/09/12. The dietary staff member provided a copy of a diet order and communication form, dated 05/09/12, which changed the resident's diet texture from regular to mechanical soft. The form was signed by a licensed practical nurse (LPN), Employee #67. Review of the medical record found no order by the attending physician changing the resident's diet. An interview with an LPN, Employee #67, on 05/21/12 at 3:20 p.m., revealed the nurse was feeding the resident breakfast on 05/09/12 when she noted the resident was having difficulty eating a piece of sausage. Employee #67 stated she filled out a form to change the resident's diet texture to mechanical soft and sent it to the dietary department. The nurse could provide no evidence the attending physician was consulted prior to making this change to the resident's diet. The nurse stated it was her understanding they did not require an order to downgrade a resident's diet, only to upgrade one. An interview with a corporate nursing consultant, on 05/21/12 at 4:30 p.m., elicited the facility had no standing orders or facility policy which would allow an LPN to change a resident's diet without a ph… | 2016-07-01 |
| 8211 | 8211 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 371 | F | 0 | 1 | JXHC11 | Based on observation, facility policy review, and staff interview, the facility failed to ensure foods were served and stored under sanitary conditions. Observations were made in the cafe area of staff members touching nonfood items, then food items without changing gloves. In addition, observations were also made of undated/unlabeled food, and expired/out dated food items, stored in the nourishment pantry refrigerators at both nursing stations. This practice had the potential to affect more than an isolated number of residents. Facility census: 115. Findings include: a) 100/200 hall On 05/16/12, at approximately 6:00 p.m., observations on the 100/200 hall nourishment pantry revealed: -- Peanut butter sandwiches with a date of 05/11/12. Employee #101 (registered nurse) indicated she would throw away these sandwiches. b) 300/400 hall On 05/16/12, at approximately 6:15 p.m., Employee #28 (licensed practical nurse) assisted with the observations of the refrigerator on the 300/400 hall. The following were noted: -- A carton of Activia yogurt did not have a date or any resident's name on the package. -- A carton of Yoplait yogurt in the freezer did not have a date or resident's name labeled on the package. The LPN stated a family had probably brought these items in for a resident. -- A carton of eggs had a manufacturer's date of 2010. The egg carton had eggs in it and contained no one's name. -- There were several sandwiches with no date or label in the refrigerator. -- A plastic container of fruit had spoiled. The fruit had no date or label and appeared to be container brought in from a resident or family, not a container provided by the facility. -- A Subway salad had no date or label and when the LPN opened the salad the contents were spoiled. The dietary manager (Employee #130) provided a copy of the facility's Use By dating guideline. The guideline stated Foods that have been mixed with other ingredients, prepared in any way, or portioned out include but are not limited to: Juices, thickened beverages, canned fru… | 2016-07-01 |
| 8212 | 8212 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 425 | D | 0 | 1 | JXHC11 | Based on record review, resident interview, and staff interview, the facility failed to administer a medication to one (1) of forty-six (46) Stage 2 sample residents in a timely manner. Resident #185 did not receive the medication Zantac, as ordered by the physician to treat her chest discomfort related to gastroesophageal reflux disease (GERD), for eighteen (18) hours after it was ordered. Resident identifier: #185. Facility Census: 115 Findings Include: a) Resident #185 During an interview with this resident, on 05/22/12 at 8:15 a.m., she stated her left chest was hurting. She said that they had just given her some medication, but it was still hurting. Her Medication Administration Record [REDACTED]. It was also noted, on the MAR, that the resident had a new medication order dated 05/21/12 for Zantac 150 mg twice a day (BID). Further review of the medical record found this medication had been ordered at 1:40 p.m. on 5/21/12. It was scheduled on the MAR indicated [REDACTED] The dose for 05/21/12 at 9:00 p.m. was circled, meaning it was not given. At 8:15 a.m. on 05/22/12, observation revealed the dose to be given at 9:00 a.m. on 05/22/12 was circled. The nurse (Employee #67) was interviewed on 05/22/12 at 8:45 a.m. When asked why the medication Zantac 150 mg, that was ordered the day prior to this observation, had been circled unavailable two (2) times, she stated it had not yet come in from the pharmacy. She was questioned about the availability of medications in the facility and she stated, They have meds in the Pyxis but I would have to go up and check if that is in there. (It was verified that when she referred to the Pyxis she was actually referring to the facility's in house medication system which was the Omni-Cell. Employee #67 reported, at 8:55 a.m., that she looked in the facility's Pyxis and the Zantac was available there, so she went ahead and gave it. The resident was interviewed again, at 9:15 a.m. on 05/22/12. She confirmed her pain was better after she took her medicine (Zantac). This medication … | 2016-07-01 |
| 8213 | 8213 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 428 | D | 0 | 1 | JXHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, pharmacist interview, and staff interview, the facility failed to report, and the pharmacist did not identify, repeated falls for one (1) of forty-six (46) sampled residents. The resident had repeated falls and was on psychotropic medications. Facility census: 115. Resident identifier: #17. Findings include: Resident #17 Review of the falls investigation forms found Resident #17 had nine (9) falls between 02/14/12 and 04/12/12. During an interview with Employee #2 (director of nursing) on 05/21/12 at 12:45 p.m., she was asked whether the facility had the pharmacist review the psychotropic medications related to falls. She stated, We discussed it in IDT (interdisciplinary team). Review of the medical record found on 02/21/12, the facility held a meeting and discussed the resident for falls. The note included, Discussed with IDT r/t (related to)fall on 02/20/12: cont (continue) with current POC (plan of care) treatment for [REDACTED]. During an interview, on 05/21/12 at 4:10 p.m., with Employee #43 (administrator), Employee #30 (assistant director of nursing), and Employee #130 (pharmacist/via telephone conference), the pharmacist was asked whether the facility had asked her to review Resident #17's psychotropic medications related to falls. Employee #130 stated, No. No evidence could be found of the facility having followed up on notifying the pharmacist on the falls Resident #17 was experiencing. Additionally, the pharmacist had not identified this potential adverse consequence of the psychotropic medication. | 2016-07-01 |
| 8214 | 8214 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 431 | F | 0 | 1 | JXHC11 | Based on observations and staff interview, the facility failed to ensure medications were properly stored and safely label. The facility's front medication room did not provide a sanitary environment to store medications. The sink was dirty and sink and walls had dried spills on them. There were medications stored in the refrigerator that were not properly labeled and were in a package with different medications. The package stated Pneumovax and there was a vial of the medication Acetylcysteine mixed in with the Pneumovax vials. There were vials of vitamin B12 (cobalamin) injectable laying in the bottom of the refrigerator that had no box or label. The back medication room also had containers of Tobramycin for inhalation laying in the refrigerator with no name or label. There was an opened half empty bottle of orange soda on the medication cart with no name or date. The practice of not providing safe labeling and safe storage of medications had the potential to affect more than a limited number of residents. Facility Census: 115. Findings include: a) Front Medication Room 1) The front medication room was observed with Employee #39 (a nurse), at 11:45 a.m. on 05/16/12. The sink was soiled with dried spills and the walls also had dried spills on them creating an unclean environment for the storage of medications. 2) Observations of the storage of the medications found a plastic bag with a label from the pharmacy that read Pneumovax. Inside the plastic bag were several vials of Pneumovax for injection and there was one vial that was not the same This vial was labeled 4 ml of Acetylcysteine 10% 100 mg per ml. (Pneumovax in a pneumonia vaccine. Acetylcysteine is for inhalation treatments.) The Acetylcysteine vial instructed the medication was not for injection, yet it was stored in the same plastic bag with the Pneumovax vials for injection. 3) There were two (2) vials of B 12 (cobalamin) injection in the bottom of the refrigerator. These vials did not have a label or box and it could not be determined for which resid… | 2016-07-01 |
| 8215 | 8215 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 441 | E | 0 | 1 | JXHC11 | Based on observation and staff interview, the facility failed to maintain a safe, sanitary environment to help prevent the development and transmission of disease and infection. It was the facility's practice to leave opened carts of partially consumed foods, soiled plates, soiled bowls, soiled glasses, and soiled cups in the resident hallway outside the dietary department for extended periods of time. This deficient practice affected one (1) of forty-six (46) Stage 2 sampled residents, and provided access to contaminated food-related items by any resident present in the hallway. Resident identifier: #109. Facility census: 115. Findings include: a) Resident #109 Observation throughout this survey event found open three-shelf metal carts left in the resident hallway outside the dietary department for extended periods of time. It was noted the carts contained partially eaten food items, soiled plates, cups, bowls and glasses. This practice was observed following the morning snack pass, following the noon meal service, following the afternoon snack pass, and following the evening meal service. On 05/21/12 at 2:30 p.m., Resident #109 was observed in his wheelchair adjacent to the dietary department door. It was noted he was looking at the cart parked outside the dietary department which contained partially consumed food items from the afternoon snack pass. Resident #109 approached the cart and removed a Styrofoam cup of an ice cream-like substance from the top of the cart. He removed the paper covering from the cup exposing the contents. It was noted the rim of the cup was broken, and spoon marks were trailing along the top. The resident stuck his tongue into the cup and began licking and sucking at the contents. The facility placed Resident #109 and other residents at risk of disease and/or infection by this unsafe and unsanitary practice. | 2016-07-01 |
| 8216 | 8216 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2012-05-22 | 514 | D | 0 | 1 | JXHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, and staff interview, the facility failed to document the correct area of injury and treatment and failed to document the correct medication ordered by the physician. Two (2) of forty-six (46) sampled residents were affected. Facility census: 115. Resident identifiers: #17 and #22. Findings include: a) Resident #17 Observation of Resident #17, on 05/15/12, found a dressing to the left knee. The resident stated she had a fall in the bathroom and had hurt her knee. Review of the incident and accident form, dated 04/04/12, identified the resident had an injury to the right knee from her fall in the bathroom. The physician's orders [REDACTED]. During an interview with Employee #2, on 05/16/12 at 12:45 p.m., it was confirmed the injury was to the left knee. b) During an observation of the medication administration for Resident #22, on 05/16/12 at 10:00 a.m., Employee #36 was observed to administer a medication from a bottle that read [MEDICATION NAME] Sodium 100 mg . A review of Resident #22's Medication Administration Record [REDACTED]. The nurse was interviewed about this medication and it was noted that the [MEDICATION NAME] in the medication cart was 10 mg. She stated that had to be wrong because it would take 10 (ten) of the [MEDICATION NAME] to made 100 mg. She stated they had always given the resident [MEDICATION NAME] and that this must be a transcription error. The nurse called the physician and had the order clarified. She stated they had been giving the correct medication, but it had been transcribed incorrectly. | 2016-07-01 |
| 8217 | 8217 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-07-25 | 154 | D | 1 | 0 | 1LKT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to accurately inform the family and resident of the total health status related to antibiotic use for one (1) of three (3) residents reviewed for the use of antibiotics. The facility notified the resident and family member the resident was receiving the antibiotic [MEDICATION NAME] for a urinary tract infection. The resident was actually receiving the antibiotic for another diagnosis. He did not have a urinary tract infection at the time this antibiotic was ordered. Resident identifier: #114. Facility census: 112. Findings include: a) Resident #114 Review of the medical record, on 07/24/13, identified a physician's orders [REDACTED].#90 (licensed practical nurse - LPN) dated 06/29/13. The physician's orders [REDACTED]. Further review of the medical record found a general note written by Employee #90 (LPN), on 06/29/13 at 19:12, stating the family was notified this resident was ordered [MEDICATION NAME] for a urinary tract infection. During an interview conducted on 07/24/13 at 3:11 p.m., Employee #137 (family nurse practitioner), revealed she did not order [MEDICATION NAME] for a urinary tract infection. She stated, The [MEDICATION NAME] was ordered for results of a chest-x-ray called to me on 06/29/13, by the facility. Employee #137 also stated, I wouldn't have ordered [MEDICATION NAME] for a urinary tract infection. Review of the medical record identified a chest x-ray, dated 06/29/13, with the following impression: Under ventilated lungs, mild cardiomegaly, ill-defined densities left lung base could represent atelectasis or mild consolidation, recommend follow up. | 2016-07-01 |
| 8218 | 8218 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-07-25 | 160 | D | 1 | 0 | 1LKT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of discharged residents' financial account balances, medical record review, and staff interview, the facility failed to provide a final accounting and a refund of the balance of a resident's personal funds to the individual or probate administering the individual's estate within thirty (30) days of death. This was true for one (1) of three (3) discharged records reviewed for personal funds. Resident identifier: #122. Facility census: 112. Findings include: a) Resident #122 Medical record review found the resident expired at the facility on [DATE]. The resident's financial account was reviewed with Employee #59, the business office assistant, at 3:35 p.m. on [DATE]. Employee #59 verified a check was not issued for the balance of the resident's funds ($1,065.13) until [DATE]. At 5:00 p.m. on [DATE], the administrator stated the facility had to wait until the account was settled before issuing the funds and this was not always possible to refund a residents money within 30 days of death. | 2016-07-01 |
| 8219 | 8219 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-07-25 | 205 | E | 1 | 0 | 1LKT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to provide a discharge/transfer bed-hold policy notice that included the contact names and information should the resident wish to appeal the discharge/transfer from the facility. This was found for three (3) of three (3) residents reviewed for notice of the bed-hold policy at the time of transfer. This had the potential to affect all residents discharged /transferred from the facility. Resident identifiers: #116, #44, and #123. Facility census: 112. Findings include: a) Resident #116 Medical record review, on 07/23/13 at 11:00 a.m., revealed the resident was originally admitted to the facility on [DATE]. The resident was transferred to an acute care facility on 06/27/13. The resident was readmitted to the facility on [DATE], then transferred again on 07/04/13. No evidence was found in the resident's medical records that the resident or family was given a transfer/discharge bed-hold policy at the time of either transfer from the facility. During an interview on 07/24/13 at 3:00 p.m., with Employee #123, the director of nursing (DON), she was unable to provide evidence the bed-hold policy, either verbal or written notice, was provided to the resident/family. In addition, a copy of the written notice of transfer was not included in the resident's medical record as required by facility policy. b) Resident #44 Medical record review on 07/23/13 at 1:00 p.m., found the resident was originally admitted to the facility on [DATE]. The resident was transferred to an acute care facility on 07/18/13. No evidence was found in the resident's medical records that the resident/family was given a transfer/discharge bed-hold policy upon transfer from the facility. During an interview, on 07/24/13 at 3:00 p.m., with the DON, she was unable to provide evidence the bed-hold policy notice, either verbal or written, was provided to the resident/family. In addition, a copy of t… | 2016-07-01 |
| 8220 | 8220 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-07-25 | 225 | D | 1 | 0 | 1LKT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of information reported by the facility, review of medical records, resident interview, and staff interview, the facility failed to conduct a thorough investigation to determine whether or not an injury of unknown origin was the result of abuse or neglect for one (1) of twenty-seven (27) reportable allegations/incidents reviewed. The resident was found with an avulsion [MEDICAL CONDITION] shoulder. The source of the injury was unknown, There was no evidence the facility conducted a thorough investigation to rule out abuse or neglect. Resident identifier: #62. Facility census: 112. Findings include: a) Resident #62 Review of the facility documentation of reportable allegations of abuse/neglect on 07/23/13 at 2:15 p.m., revealed a reported injury of unknown origin regarding this resident. An incident report was written by Employee #32, a licensed practical nurse (LPN) on 06/05/13 at 2:00 p.m. The report noted the incident was not witnessed and the resident's activity prior to the incident was unknown. The resident's mental status prior to the incident was documented as alert and disoriented. The mobility status prior to the incident indicated the resident required assistance, as she had paralysis on the right side. According to the report, the resident complained of shoulder pain to someone and this was reported to the nurse practitioner (NP). An x-ray was ordered. The x-ray of the right shoulder showed an avulsion fracture of the right shoulder. The physician and the responsible party were both notified of the results of the x-ray on 06/05/13. This injury of unknown origin was faxed to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Ombudsman on 06/05/13. Review of the nurses' notes revealed nothing regarding an investigation regarding the [MEDICAL CONDITION] shoulder. The facility's investigation contained a statement by the social worker dated 06/05/13 and one by th… | 2016-07-01 |
| 8221 | 8221 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-07-25 | 250 | D | 1 | 0 | 1LKT11 | Based on medical record review and staff interview the facility failed to ensure a resident received medically-related social services when the resident became visibly upset after being taunted and verbally abused by another resident. This was a random finding for one (1) resident. Resident identifier: #52. Facility census: 112. Findings include: a) Resident #52 While reviewing the medical record of Resident #91 a nurses' note, written on 06/27/13 at 15:02, was discovered. The note was, Resident pulling foods off another elderly residents table, intentionally doing it, moved her drinks from her then poured her drink on the other resident, laughing, called her retard, this other resident was visible upset and crying pointing at (name of Resident #91.) This other resident has a hx (history) of being quiet, smiles a lot and not known to bother other residents. 2 residents on this hall and 1 staff member told me what (Resident #91) was doing, one resident said she was just being mean to her picking at her. I did intervene at that time and asked (Resident #91) to remove herself from the area, (Resident #91) denied it but was laughing and did not move. The resident who was upset did agree to move, as being transferred from area, (Resident #91) told her bye retard An interview was conducted with Employee #35, the social service director, at 12:58 p.m. on 07/24/13. Employee #35 identified the resident who was verbally abused and taunted, as Resident #52. She verified Resident #52 was the resident referred to in the note as being quiet and was not know to bother others. Employee #35 stated Resident #91 was sent to the hospital for her behaviors. Employee #35 agreed she should have spoken to Resident #52 when the incident occurred. Employee #35 further verified Resident #52 was alert and oriented and even though the resident was unable to speak after her stroke, she would have know and understood what Resident #91 had said to her. At approximately 2:00 p.m. Employee #35 returned to the surveyor and stated she was unable to… | 2016-07-01 |
| 8222 | 8222 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-07-25 | 279 | D | 1 | 0 | 1LKT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to to develop a care plan for one (1) of seven (7) residents related to multiple health conditions and psychosocial needs for the resident. The care plan did not include information related to the care and use of a PICC line, Foley catheter, [MEDICAL CONDITION], and the use of pain medications. The care plan was also incomplete, as it did not address the identified distressed mood symptoms of this resident. Resident identifier: #114. Facility census: 112. Findings include: a) Resident #114 During a review of the medical record for Resident #114 on 07/23/13, it was found the resident entered the facility on 06/10/13. Further review identified this resident had a [MEDICAL CONDITION] in place, a peripheral inserted central catheter (PICC), a Foley catheter, and was also receiving Oxy-fast liquid and Oxy IR for pain. Review of the care plan found nothing relative to the Foley catheter, PICC line, [MEDICAL CONDITION], or the use of pain medication. This review of the care plan revealed the facility identified the resident exhibited distressed mood systems; however, the facility did not develop goals and interventions for the identified distressed mood symptoms. On 07/23/13 at 2:12 p.m. Employee #123 (director of nursing) confirmed the care plan did not identify the use of a Foley catheter, pain medications, [MEDICAL CONDITION] and PICC line. Employee #123 also confirmed the care plan for distressed mood symptoms was incomplete, in that it had no goals and interventions for the identified problem. | 2016-07-01 |
| 8223 | 8223 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-07-25 | 280 | D | 1 | 0 | 1LKT11 | Based on medical record review, observation of the resident's meal tray, and staff interview, the facility failed to update a resident's care plan to reflect a requested food item for one (1) of seven (7) residents reviewed. Yogurt was to be served with all meals, for this resident identified by the facility with significant weight loss. Resident identifier: #27. Facility census: 112. Findings include: a) Resident #27 Observation of the resident's breakfast tray, served in her room on 07/22/13 at 10:00 a.m., found a meal ticket which listed plain yogurt for a meal preference. The yogurt was not served to the resident. The resident's husband was at her bedside during the observation. He stated his wife had not been eating well and had lost some weight since her arrival at the facility. He said he requested plain yogurt be served with all her meals because, she will eat that when she doesn't eat anything else. He further added she ate yogurt prior to admission to the facility, and they made several special dishes at home which included yogurt as an ingredient. He said he was not sure why the facility could not comply with his request for yogurt. He stated sometimes it's there and sometimes it's not there. Employee #62, a licensed practice nurse, entered the resident's room for medication pass during the interview. This employee was asked why the yogurt was not on the resident's tray. She stated she thought the yogurt was served as a snack at 10:00 a.m., 2:00 p.m. and 8:00 p.m. but she was not sure. Further review of the resident's medical record found the resident's weight was recorded as 144.4 pounds on the date of her admission, 10/30/12. The resident's most current weight, recorded on 07/17/13 was 112.6 pounds. An interview conducted with the dietary manager, Employee #6, on 07/23/13 at 10:05 confirmed the yogurt should have been served with the resident's meal, as she received a dietary supplement (a magic cup) twice a day at 10:00 a.m. and 2:00 p.m. Observation of the kitchen refrigerator revealed the facility… | 2016-07-01 |
| 8224 | 8224 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-07-25 | 309 | D | 1 | 0 | 1LKT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure three (3) of five (5) residents, in a facility sample of thirty-one (31), received care and services necessary to promote their highest level of well-being. The facility failed to provide antibiotic medication and total parental nutrition (TPN) via Resident #116's peripherally inserted central catheter (PICC). Resident #44 had no follow-up after a laxative was administered. The facility failed to assess and treat Resident #114's complaints of stomach upset/abdominal pain. Resident identifiers: #116, #44, and #114. Facility census:112. Findings include: a) Resident # 116 1) Medical record review on 07/24/13 at 10 a.m., found the resident was originally admitted to the facility on [DATE]. Review of the admission orders [REDACTED]. All three (3) were to be given via a PICC line. According to the Medication Administration Record [REDACTED]. It was also not administered on 06/27/13 during the 11:00 p.m. through 7:00 a.m. shift. [MEDICATION NAME] was not administered at 6:00 p.m. on 06/26/13 or at 6:00 a.m. on 06/27/13. [MEDICATION NAME] was not administered on 06/26/13 and 06/27/13 at 9:00 p.m. An interview was held with Employee #123, the director of nursing (DON), on 07/24/13 at 3:00 p.m. She verified the MAR indicated [REDACTED]. No further evidence this medication was administered was provided prior to exit. 2) Further medical record review, on 07/24/13 at 11:00 a.m., found the resident was discharged on [DATE] at 22:45 (10:45 p.m.) and re-admitted to the facility on [DATE] 19:08 (7:00 p.m.) and was discharged again on 07/04/13 at 2:00 p.m. Review of the 07/01/13 admission orders [REDACTED]., 6 a.m., 12 p.m., and 6 p.m.) and Meropenem 500 milligrams (mg) every twelve (12) hours (9 a.m. and 9 p.m.) Both medications were to be given via the PICC line for the treatment of [REDACTED]. Review of the MAR for the resident's stay at the facility from 07/01/13 through 07/… | 2016-07-01 |
| 8225 | 8225 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-07-25 | 314 | D | 1 | 0 | 1LKT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and medical record review, the facility failed to provide care and services to promote the healing of pressure ulcers for one (1) of four (4) residents reviewed for pressure ulcers. Resident #41 had three (3) pressure ulcers for which treatments were not provided as ordered. Resident Identifier: #41. Facility census: 112. Findings include: a) Resident #41 During a review of the medical record for Resident #41, it was found this resident had three (3) pressure ulcers. Further review of this resident's treatment administration record (TAR)identified the facility was not providing treatments as ordered. The TAR indicated numerous times for which there was no evidence the dressing was changed as ordered. The facility provided no evidence the physician's orders [REDACTED]. On 07/23/13 at 3:36 p.m., Employee #123 (director of nursing), provided copies of the TARs for Resident #41 for the months of June 2013 and July 2013. At this time, Employee #123 confirmed the facility was not changing the dressing as ordered by the physician. During an interview with Resident #41 on 07/25/13, at 8:24 a.m., he also confirmed the facility was not changing the dressings as ordered by the physician. . | 2016-07-01 |
| 8226 | 8226 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-07-25 | 363 | F | 1 | 0 | 1LKT11 | Based on observation of meals served, preparation of food items, recipes, resident interview, and staff interview, the facility failed to ensure menus were followed. Daily planned menus were posted throughout the facility for resident observation. These menus were not followed. The facility also failed to ensure recipes were followed during food preparation. This practice had the potential to affect all residents who received food from the facility's kitchen. Facility census: 112. Findings include: a) Confidential interviews were conducted with nine (9) residents who complained about the food served at the facility, including the taste. b) Observation of the posted planned menu for the noon meal on 07/22/13 found the facility's main kitchen, was serving, Italian sub sandwich with ham, salami, and American cheese, accompanied by tomatoes, lettuce and onion on a steak roll. Residents were also were to be served a cucumber and tomato salad. Numerous observations of the noon meal received by the residents, who were eating in their rooms, found not all sandwiches included ham, salami and bologna. The sandwiches served varied from bologna and cheese to salami, bologna, and cheese. Tomatoes, lettuce and onions were not served on these resident's trays. At 1:30 p.m. on 07/22/13, Employee #136, the regional food services director, was interviewed regarding the variety of sandwiches served. Employee #136 also accompanied the surveyor to view the various sandwiches served to residents and the cucumber salad. Employee #136 asked the cook, Employee #134, if she had made the sandwiches according to the posted menu. She stated she ran out of ham. On 07/23/13 at 2:00 p.m. Employee #136 was asked for a copy of the recipe for the cucumber salad that was served for lunch on 07/22/13. The recipe required the cucumbers be peeled and the salad was to be made with white vinegar. Employee #136 acknowledged the salad was not made with white vinegar because the facility did not have this ingredient available and the cucumbers were not pee… | 2016-07-01 |
| 8227 | 8227 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-07-25 | 364 | F | 1 | 0 | 1LKT11 | Based on observation, temperature measurement, resident interview, and staff interview, the facility failed to ensure food items were served to residents at acceptable temperatures. This practice had the potential to affect all residents who received meals from the kitchen. Facility census: 112. Findings include: a) Confidential interviews with five (5) residents, who received meals in their rooms. found complaints of cold food. b) At 9:30 a.m. on 07/25/13, Employee #6, the dietary manager was asked to obtain temperatures of the last tray served for breakfast on the Unit 3 tray cart. Employee #6, verified the temperatures of the following items served for breakfast: -eggs - 93.9 degrees -oatmeal 107.4 degrees The dietary manager stated the items were too cold and were not served at the proper temperatures. | 2016-07-01 |
| 8228 | 8228 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-07-25 | 366 | D | 1 | 0 | 1LKT11 | Based on observation of the resident's meal tray, medical record review, family interview and staff interview, the facility failed to ensure a resident, with a known weight loss, was provided a requested food item to be served with each meal. This was true for one (1) of three (3) dependent residents observed during meal times. Resident identifier #27. Facility census: 112. Findings include: a) Resident #27 Observation of the resident's breakfast tray, served in her room, on 07/22/13 at 10:00 a.m., found a meal ticket which listed plain yogurt for a meal preference. The yogurt was not served to the resident. The resident's husband was at her bedside during the observation. He stated his wife had not been eating well and had lost some weight since her arrival at the facility. He had requested plain yogurt be served with all her meals because, she will eat that when she doesn't eat anything else. He further added she ate the yogurt prior to admission to the facility and they made several special dishes at home which included yogurt as an ingredient. He was not sure why the facility could not comply with his request for yogurt. He stated sometimes it's there and sometimes it's not there. Employee #62, a licensed practice nurse, entered the resident's room for medication pass during the interview. This employee was asked why the yogurt was not on the resident's tray. She stated she thought the yogurt was served as a snack at 10:00 a.m., 2:00 p.m. and 8:00 p.m. but she was not sure. Further review of the resident's medical record found the resident's weight was recorded as 144.4 pounds on the date of her admission, 10/30/12. The resident's most current weight, recorded on 07/17/13 was 112.6 pounds. An interview conducted with the dietary manager, Employee #6, on 07/24/13 at 9:30 a.m. confirmed the yogurt should have been served with the resident's meal, as she receives a dietary supplement (a magic cup) at 10:00 a.m., 2:00 p.m. and 8:00 p.m. Observation of the kitchen refrigerator revealed the facility did have the pl… | 2016-07-01 |
| 8229 | 8229 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-07-25 | 371 | F | 1 | 0 | 1LKT11 | Based on staff interview, review of the facility's temperature logs, and review of facility policy and procedure, the facility failed to ensure food items were cooked to the the proper temperatures to prevent the rapid and progressive growth of infectious organisms resulting in the potential of foodborne illnesses. This practice had the potential to affect all residents receiving meals from the kitchen. Facility census: 112. Findings include: a) Confidential interviews with eight (8) residents who receive meals in their rooms found complaints of receiving cold food. b) On 07/23/13 at 2:00 p.m., Employee #136, the regional food service director and Employee #6 the dietary manager were asked to provide evidence of food temperatures taken prior to meal service for the past three (3) days. The facility served food from the kitchen and also served meals in the cafe. Temperatures of foods prior to service were requested for items served in the kitchen as well as temperatures from items served in the cafe. Employees #136 and #6 verified the following information: -On 07/20/13 tuna salad sandwiches were served in the cafe. The temperature of the tuna was recorded as 42 degrees before service. Employee #6 verified the temperature should not have exceeded 40 degrees. -The breakfast meal on 07/21/13 consisted of orange juice, oatmeal, scrambled eggs, muffin, milk and coffee. There was no evidence temperatures were obtained. -The hot meal served for lunch on 07/21/13 which consisted of a fish fillet on a roll, rissole potatoes and vegetable or minestrone soup had no record of temperatures being obtained. -The breakfast meal served on 07/22/13, which consisted of orange juice, cream of wheat french toast milk and coffee had no record of temperatures being recorded before service. -The noon meal served from the kitchen on 07/22/13, consisted of an Italian sub sandwich, cucumber salad, cheddar cheese soup, milk and coffee. The facility had no evidence temperatures taken before service. -Employee #6 stated at 2:00 p.m. on 07/23/… | 2016-07-01 |
| 8230 | 8230 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-07-25 | 514 | E | 1 | 0 | 1LKT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, resident interview, and staff interview, the facility failed to ensure medical records were complete and accurate for six (6) of ten (10) residents reviewed. Resident #49's treatment administration records for pressure ulcers could not be found by the facility. Resident #114's respiratory assessment was completed on 07/01/13 while the resident was not in the facility. In addition, documentation was incorrect regarding the reason an antibiotic was ordered for Resident #114. The allergies [REDACTED]. Residents #116, #123, and #44's medical records did not contain a transfer form. Resident identifiers: #49, #114, #115, #123, #116, and #44. Facility census: 112 Resident findings: a) Resident #49 Resident #49 was admitted to the facility with pressure ulcers. During an interview held with this resident on 07/22/13 at 1:00 p.m., he stated, I had to have surgery on my wounds because they were not changing my dressings. On 0723/13 the treatment administration record was requested for Resident #49. On 07/25/13, Employee #123 (director of nursing) confirmed the treatment administration records for Resident #49 could not be located. On 07/22/13 at 1:00 p.m., Resident #49 alleged the facility did not take care of his wounds and he had to undergo debridement of his wounds. The treatment administration records since admission were requested from the facility on 07/24/13. On 07/25/13 at 8:25 a.m., Employee #123 (director of nursing) with Employee #68 (administrator) present confirmed the treatment administration records from 06/13/13 thru 06/26/13 could not be located. Further review of the medical record for Resident #49 confirmed this resident was sent to the hospital for wound care on 06/26/13. On 07/25/13 at 8:25 a.m., Employee #123 confirmed the facility could not locate the treatment administration records for 06/13/13 thru 06/26/13. b) Resident #114 1) Resident #114 was discharged from the facility on 06… | 2016-07-01 |
| 8231 | 8231 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2012-05-03 | 241 | D | 0 | 1 | 9YCU11 | Based on observations and interview, the facility failed to maintain dignity for 2 residents during the service of the morning meal on 05/02/12. This affected 2 of 27 residents eating breakfast in their rooms on Unit 2. (Resident #22 and Resident #51) Findings include: a) Resident #22 During observation on 05/02/12, of the morning meal service on the B hall of Unit 2, trays were observed being passed by staff. At 8:03 a.m., on 05/02/12 Resident #22, was observed to be seated in her wheelchair next to her bed. Resident #99, who resides in the same room, was observed to be seated in a stationary chair next to her bed. Resident #99 was eating from a breakfast tray that had been delivered by Nurse Aide (NA) #120. Resident #22 did not receive her breakfast tray until 8:24 a.m. b) Resident #51 Resident #148 was observed to be seated on the edge of the bed facing Resident #51 in Bed B of the room. Resident #148 stated at the time of the observation that she was finished eating her meal. Resident #51 did not yet have a meal tray. During interview on 05/02/12 at 9:00 a.m., Resident #51 stated she was waiting for her breakfast. At 9:04 a.m., NA #99 had brought Resident #51's breakfast tray into the room and assisted her to eat. c) During interview, on 05/02/12 at 9:25 a.m., with NA #120, it was stated the meal carts are not filled with trays in any particular order and sometimes the residents eating in their rooms do not receive a tray at the same time. On 05/02/12 at 9:30 a.m., the Director of Nursing (DON) stated during interview, Residents #22 and # 51 should not have to wait on their food while their roommates eat their meal. Staff delivering the meal trays should ensure they provide both residents with their food near or at the same time. The DON also verified the trays should be ordered in the meal delivery cart in a manner that would help prevent this undignified situation when possible. | 2016-07-01 |
| 8232 | 8232 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2012-05-03 | 242 | D | 0 | 1 | 9YCU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interview, the facility failed to assess a resident's food preferences. This affected 1 of 2 sampled residents of 14 residents interviewed. (Resident #53) Findings include: a) Resident #53 During an interview with Resident #53, on 04/30/12 at 11:29 a.m., he revealed he does not get to participate in the choice of foods he receives. He stated they just give him whatever they want to bring him. Review of the medical record revealed no evidence of a dietary assessment indicating what foods Resident #53 likes and dislikes. Interview with Resident #53, on 05/01/12 at 1:04 p.m., revealed he has never been asked what kind of foods he likes and does not like. He said they always bring him Rice Crispies in the morning and he has told them he wants Cheerios. He said, how hard can it be for an [AGE] year old man to just get some Cheerios? He says if he complains enough about it, sometimes the staff will go get him Cheerios, but most of the time he just eats what he is delivered. Further interview with Resident #53 was conducted at 9:12 a.m. on 05/02/12. The resident stated he would like to have some involvement in the food he receives at the facility. He stated he is not satisfied with the fact he does not get Cheerios in the morning for breakfast. His breakfast tray was still in front of him and he pointed to his cereal bowl. He said as you can see they gave me Rice Crispies again this morning. He said he ate them only because he loves cereal, but they are not really what he likes. He stated at home he always had a bowl of Cheerios in the morning and he does not understand why he can not have them here. He again said if he keeps asking the staff to get him Cheerios, sometimes they will take the time and go get him some, but this does not happen often. He stated he does not remember any staff ever coming in and asking him about what kind of food he likes and does not like. He said he will usually just eat what h… | 2016-07-01 |
| 8233 | 8233 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2012-05-03 | 279 | E | 0 | 1 | 9YCU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to develop a comprehensive care plan reflective of the resident's condition for 5 residents reviewed in stage 2. Forty-seven (47) care plans were reviewed for the areas of pressure ulcer prevention, range of motion services, physical restraints and discharge planning. (Residents #2, #58, #29, #32, and #135) Findings include: a) Resident #58 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set, dated dated [DATE], documented the resident was at risk for the development of a pressure ulcer and required the extensive assistance of 2 staff members for bed mobility. This MDS also documented Resident #58 had a deep tissue injury wound and necrotic skin tissue and had pressure reduction to her bed. The care plan for skin, dated 12/13/11, documented impaired skin integrity and impaired mobility. Staff were to do weekly skin assessments, encourage fluids, pressure reducing mattress, assist with repositioning and minimize pressure on bony prominences and use pillows for support. Staff were to observe skin during care and report changes to the nurse. On 01/17/12, the care plan indicated a new entry of a pressure ulcer to the right heel. On 02/03/12, the care plan was updated to reflect a heel riser when in bed, as tolerated. Review of the current physician orders [REDACTED]. The nursing weekly skin assessments, documented on 12/17/11, indicated the resident continued to have a Stage 2 open ulcer to right heel. On 03/10/12, this area was noted to be documented as a dry scabbed area. Observation of Resident #58, on 05/01/12 at 10:05 a.m., revealed she was in bed on her back with her feet elevated off the bed with the heel elevator in place. On this date, at 12:26 p.m., the resident was observed in her wheelchair in the hall with no pressure relieving device noted in her chair. She was noted to have non-skid socks on… | 2016-07-01 |
| 8234 | 8234 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2012-05-03 | 280 | D | 0 | 1 | 9YCU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to revise the care plan to reflect the resident's current condition. This affected 2 of 3 residents reviewed out of 8 residents identified for significant weight loss (Residents #53 and #71), and 1 of 10 residents reviewed for unnecessary medications (Resident #53). Findings include: a) Resident #53 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum (MDS) data set [DATE] documented Resident #53 required minimal assistance of one staff for eating. Review of the dietary assessment, dated 02/21/12, documented Resident #53 weighed 156 pounds and was 72 inches tall. This note also documented a weight of 167 on admission and revealed he had experienced a 6.6% weight loss since admission. The resident's current diet order was a low concentrated sweets diet with mechanical ground meat and super foods with all three meals. A dietary note, dated 04/11/12, identified the addition of super foods to Resident #53's diet related to weight loss. The nutritional care plan documented the resident was at nutritional risk due to inadequate food intake, nausea, and presence of a pressure ulcer. Review of the nutritional care plan revealed interventions to maintain weight at 181 pounds, plus or minus 7 pounds, encourage intake, offer fluids at every care encounter, offer substitutes as needed, and encourage frequent intake. The nutrition care plan did not include the intervention of super foods that had been ordered by the physician. According to an interview with the the dietary manager, on 05/02/12 at 1:30 p.m., she verified that she had not updated the nutrition care plan to include the new intervention of super foods. b) Resident #53 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A new order, dated 03/28/12, had been written for [MEDICATION NAME], a benzodiazepine, 0.5 mg 1 by mouth every eight … | 2016-07-01 |
| 8235 | 8235 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2012-05-03 | 282 | D | 0 | 1 | 9YCU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interview, the facility failed to implement the care plan for 1 of 3 residents reviewed with pressure ulcers; and 1 of 3 residents reviewed, out of 4 residents identified for investigation in the Care Area of Activities of Daily Living, as being inappropriately dressed for the time of day.(Resident #58 and Resident #13) Findings include: a) Resident #58 This resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set, dated dated [DATE], found the resident was at risk for the development of a pressure ulcer and required the extensive assistance of 2 staff members for bed mobility. This MDS also documented Resident #58 had a deep tissue injury wound and necrotic skin tissue and was to have pressure reduction to her bed. The care plan, dated 12/13/11, documented impaired skin integrity and impaired mobility. Staff were to conduct weekly skin assessments, encourage fluids, provide a pressure reducing mattress, assist with repositioning, minimize pressure on bony prominences and use pillows for support. Staff were to observe skin during care and report changes to the nurse. On 01/17/12, the care plan indicated a new entry of a pressure ulcer to the right heel. On 02/03/12, the care plan was updated to reflect heel riser when in bed, as tolerated. Review of the current physician orders [REDACTED]. Review of the nursing weekly skin assessments, on 12/17/11, found the resident continued to have a Stage 2 open ulcer to right heel. On 03/10/12, this area was documented as a dry scabbed area. The skin care plan remained in place indicating the staff should minimize pressure on the resident's bony prominences Observation of Resident #58, on 05/1/12 at 10:05 a.m., revealed she was in bed on her back with her feet elevated off the bed with the heel elevator in place. Also on this date, at 12:26 p.m., the resident was observed in her wheelchair in the hal… | 2016-07-01 |
| 8236 | 8236 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2012-05-03 | 309 | D | 0 | 1 | 9YCU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interivew, the facility failed to provide care and services to prevent skin tears for 1 of 3 residents reviewed who were identified to have skin conditions other than pressure ulcers. (Resident #57) Findings include: a) Resident #57 This resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The most recent Minimum Data Set, dated dated [DATE], documented Resident #57 had no impairment to her upper extremities and was documented to have skin tears. Review of the skin care plan, dated 02/15/12, revealed the resident was at risk for impaired skin integrity due to impaired circulation, diabetes, and she was prone to skin tears. The physician orders [REDACTED]. The care plan documented staff were to assist her with positioning. The skin care plan did not address how staff should be careful when providing care to the resident due to her high risk for skin tears. Review of the physician orders [REDACTED].#57 had experienced on 04/15/12 to the upper left wrist and 04/19/12 to the left forearm. The nursing notes revealed documentation on 03/28/12 of a skin tear to the resident's right outer forearm and on 04/06/12 these notes revealed nursing documentation stating the resident's skin was fragile and was prone to bruising easily. Resident #57 was observed on 05/01/12 to be in bed with bilateral half bed rails in the raised position on her bed. The resident was observed to have multiple bruises on both arms and hands. She had a dressing on the left wrist and a second dressing observed on her left upper arm. She also had a bruise on her mid chest area. A sign was noted hanging on the inside of her bathroom door directing staff should place long sleeves on the resident. She was observed to be in a sleeveless gown in bed with no covering or blankets to her upper body. Observation, on 05/01/12 at 12:18 p.m., revealed Resident #57 was in the dining room for lunch. She was dressed in a short slee… | 2016-07-01 |
| 8237 | 8237 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2012-05-03 | 312 | D | 0 | 1 | 9YCU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide the care and services needed for a resident comprehensively assessed as dependent on staff for activities of daily living. This affected 1 of 5 residents reviewed for the care area of Activities of Daily Living. (Resident # 13) Findings include: a) Resident #13 Review of the medical record for Resident #13 revealed a most recent admission date of [DATE]. Pertinent [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) a comprehensive assessment, dated 02/27/12, revealed Resident #13 had both short and long term memory problems. The MDS also revealed the resident had moderately impaired decision-making skills and required cues and supervision. Resident #13 was also assessed to be dependent on staff for bed mobility, transfers, dressing, eating and personal hygiene. Review of the care plans for Resident #13 revealed a care plan dated 03/14/12 related to the resident's self-care deficit due to her chronic illness, [MEDICAL CONDITION], weakness and decreased ability for understanding. The interventions for the care plan included: to provide the resident with a wet wash cloth and give simple instructions and cues to wash her own face and hands, to provide assistance with oral hygiene and grooming daily, to provide extensive to total assistance during shower and daily bathing, and to provide simple choices of clothing daily. The same interventions were noted to be listed on a document titled, CNA Care Card, found in a binder at the nurses station. Resident #13 was observed in bed wearing a pink night gown on 04/30/12 at 2:40 p.m., on 05/01/12 at 10:02 a.m., 11:11 a.m., 12:45 p.m., 1:59 p.m., and 3:14 p.m. Resident #13 was also observed in bed wearing the same pink night gown on 05/02/12 at 7:06 a.m. and 11:15 a.m. On 05/02/12 at 11:15 a.m., Nurse Aide (NA) #83, identified as one of the NAs caring for Resident #13, stated the resident gets up to the chair once a… | 2016-07-01 |
| 8238 | 8238 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2012-05-03 | 314 | D | 0 | 1 | 9YCU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide care and services to prevent the development of a pressure ulcer for 1 of 3 residents reviewed for the Care Area of Pressure Ulcers. (Resident #58) Findings include: a) Resident #58 This resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set, dated dated [DATE], found the resident was assessed at risk for the development of a pressure ulcer. The resident required the extensive assistance of 2 staff members for bed mobility. This MDS also documented Resident #58 had a deep tissue injury wound and necrotic skin tissue and was to have pressure reduction to her bed. Review of the skin care plan, dated 12/13/11, documented impaired skin integrity and impaired mobility. Staff were to do weekly skin assessments, encourage fluids, provide pressure reducing mattress, assist with repositioning and minimize pressure on bony prominences and use pillows for support. Staff were to observe skin during care and report changes to the nurse. On 01/17/12, the care plan indicated a new entry of a pressure ulcer to the right heel. On 02/3/12, the care plan was updated to reflect heel risers to be used when in bed to reduce the pressure to the resident's heels. Review of the current physician orders [REDACTED]. Review of the nursing weekly skin assessments documented on 12/17/11 indicated the resident continued to have a Stage 2 open ulcer to right heel. On 3/10/12 this area was documented as a dry scabby area. Observation of Resident #58, on 05/01/12 at 10:05 a.m., revealed she was in bed on her back with her feet elevated off the bed with the heel elevator in place. On this, date at 12:26 p.m., the resident was observed in her wheelchair in the hall with no pressure relief device noted in her chair. She was noted to have non-skid socks on her feet and her heels were resting on the cement tile floor. No pressure reduc… | 2016-07-01 |
| 8239 | 8239 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2012-05-03 | 318 | D | 0 | 1 | 9YCU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide treatment and services to maintain and prevent further decrease in range of motion. This affected 2 of 3 residents reviewed for the care area of Range of Motion. (Resident #2 and Resident #32) Findings include: a) Resident #2 Review of the medical record for Resident #2 revealed [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), a comprehensive assessment dated [DATE], revealed Resident #2 has functional limitations in range of motion (ROM) with impairment on both the upper and lower extremities of one side of the body. The MDS did not include documentation of the resident receiving restorative range of motion services. Further review of the MDS revealed Resident #2 is dependent on staff for bed mobility, transfer, locomotion on and off the unit and dressing. The MDS also indicated Resident #2 does not stand or walk. Review of the care plans for Resident #2 revealed no plan of care related to the Resident's limited ROM. Review of a document titled, Rehab Screening, dated 05/02/12 revealed the physical therapist assessed Resident #2 to have a contracture of the right knee at 100 degrees flexion. Resident #2 was observed in bed with both legs bent at the knee on 05/01/12 at 10:09 a.m., 12:42 p.m., 1:54 p.m., and 3:12 p.m. Resident #2 was also observed in bed with both knees bent at 7:00 a.m. and 12:40 p.m. on 05/02/12. During an interview, on 05/02/12 at 12:40 p.m., with nurse aide (NA) #109, she stated that she provides ROM daily for Resident #2 with morning care. NA #109 also stated the resident's right leg draws up underneath her and they have to pull it down routinely. During interview with Registered Nurse #47, the Unit Manager, she stated the facility performs ROM assessments for residents upon admission and quarterly. During interview on 05/02/12 with the Director of Nursing (DON), rehabilitation department manager and RN #42, the MDS … | 2016-07-01 |
| 8240 | 8240 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2012-05-03 | 323 | D | 0 | 1 | 9YCU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure an environment free of accident hazards for 1 of 3 sampled residents reviewed for the care area of accidents related to the use of bed rails. (Resident # 83) Findings include: a) Resident #83 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set, dated dated [DATE], documented the resident required extensive assistance of 2 staff for bed mobility. The resident was identified as cognitively intact on the MDS. Review of the side rail assessment, dated 02/19/12, revealed the resident was not able to ambulate on her own, had no problem with trunk control, needed assistance with bed mobility, and stated the resident wanted the side rails to hold on to when she was being turned and changed. Review of the current physician orders [REDACTED]. Review of the care plan for ADL function revealed that on 04/30/11, the care plan was updated to include the use of half rails on both sides of the bed to assist the resident with bed mobility. This care plan also revealed documentation that the resident had decreased participation in her ADL's. She also has a plan of care for Cognitive loss due to Alzheimer's dementia, decline in memory. Observation of Resident #83, on 04/30/12 at 9:07 a.m., revealed she was in bed with bilateral half rails on her bed in the raised position. The rails were observed to be very loose on the bed. When the rails were touched they moved back and forth easily and were not firmly attached to the bed. This was verified with another surveyor at this time. This was also shared with the DON at the same time and she verified the rails should not be loose and that she would notify maintenance. Interview with the resident at this time revealed that she does use the rails to assist in turning herself. These loose rails could present an accident hazard for the resident if she attempted to turn… | 2016-07-01 |
| 8241 | 8241 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2012-05-03 | 325 | D | 0 | 1 | 9YCU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to implement interventions to prevent significant weight loss for 2 of 3 sampled residents of 8 residents identified with weight loss. (Resident # 53 and Resident #71) Findings include: a) Resident #53 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set, dated dated [DATE], documented Resident #53 required minimal assistance of one staff for eating. Review of the physician orders [REDACTED].#53 had a diet order of, Low concentrated sweets/diabetic/no added salt. On 04/11/12, a new order was received for super foods three times a day with meals. Review of the dietary assessment, dated 02/21/12, found Resident #53 weighed 156 pounds and was 72 inches tall. This note stated he weighed 167 pounds on admission and had experienced a 6.6% weight loss since admission. His ideal body weight was 161-195 pounds and the current BMI was 21.5. The dietary assessment documented the resident had good dietary intake and staff were to monitor his daily intake. This dietary assessment noted the resident was at high risk for weight loss. The resident's usual meal intake was 76-100%, and he had a good appetite. Review of a dietary note, dated 03/06/12, documented the resident's weight was now 170 pounds. He was noted to be receiving a supplement, Ensure, three times a day. His meal intake was 50-70%. Dietary recommendations documented that the resident was upset with the need to have further therapy and did not want to discus his dietary concerns. Review of a dietary note, dated 04/02/12, revealed Resident #53's weight had dropped to 166 pounds. The assessment documented staff were to monitor him closely for adequate intake due to his complaints of stomach pain. A dietary note, dated 04/11/12, identified a change in the diet order to also include super foods related to weight loss. He was to receive super foods at all th… | 2016-07-01 |
| 8242 | 8242 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2012-05-03 | 329 | D | 0 | 1 | 9YCU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure each resident's medication regime was free of unnecessary medications. This affected 2 of 10 residents whose medication regimen was reviewed for unnecessary medications and 1 of 3 residents reviewed for the appropriate use of benzodiazepines. (Resident #53 and Resident #71) Findings include: a. Resident #53 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was hospitalized and re-admitted on [DATE]. A new [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED] -- 04/02/12 at 1:48 p.m. per resident request; -- 04/03/12 at 9:57 a.m. per resident request / no visible signs of anxiety; -- 04/04/12 at 8:19 a.m. and 3:24 p.m. per resident request; -- 04/05/12 at 9:35 a.m. and 4:40 p.m. per resident request; -- 04/07/12 at 10:44 a.m. per resident request; -- 04/09/12 at 11:54 a.m. per resident request; -- 04/10/12 at 10:26 a.m. per resident request; -- 04/14/12 at 11:38 p.m. given for agitation documentation revealed the resident was upset because his medication was late; -- 04/16/12 at 9:49 a.m. per resident request; -- 04/17/12 at 9:42 a.m. per resident request; -- 04/18/12 at 9:25 a.m. per resident request; -- 04/19/12 at 10:54 a.m. for anxiety, restless agitation; -- 04/20/12 at 8:37 a.m. given for restlessness. Documentation revealed the nurse attempted other interventions prior to giving the medication; -- 04/23/12 at 11:36 p.m. and 8:24 a.m. given for anxiety no other interventions attempted prior to giving the medication; -- 04/24/12 at 8:25 a.m. for anxiety / other intervention attempted prior to giving the medication; -- 04/25/12 at 9:12 a.m. no other interventions attempted prior to administering this medication; -- 04/28/12 at 8:56 a.m. for anxiety with no other interventions attempted prior to administering this medication; -- 04/30/12 at 12:36 a.m. for anxiety / no other interventions attempted pr… | 2016-07-01 |
| 8243 | 8243 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2012-05-03 | 364 | F | 0 | 1 | 9YCU11 | Based on observation and interview, the facility failed to serve food to residents that was palatable and served at the proper temperatures. This had the potential to affect 105 of 107 residents residing in the facility. Findings include: a) During observation in the main dining room, on 04/29/12 at 12:20 p.m., both Resident #113 and Resident #117 stated the meat was too tough to eat. Several residents in the main dining room at this time were observed attempting to cut their meat and were unable to cut it. These residents were observed to pick up the piece of meat and bite it to tear it apart. The meat was observed to be a very thinly cut piece of beef and very dry around the edges. b) Observation of lunch being served on C Wing, on 04/29/12 at 12:30 p.m., revealed there was one staff on the unit serving trays. Continued observations at 1:05 p.m. revealed there were still 6 trays on the meal cart left to be served to the residents. At 1:25 p.m., another nurse aide came to the unit to assist with passing trays. She passed one of the 6 remaining trays to a resident; the food on the tray was observed to be pureed. Nurse aide #106 sat down to feed the residents. She was asked if it normally took over an hour to pass the meal trays on this hall. She stated yes it takes 1-1.5 hours to pass trays and feed the residents on the C Wing. When asked if she ever re-heated the food after it had sat in the non-heated cart for an hour, she said if it was not still hot she would, but she felt the pureed food she was feeding the resident was still hot and continued to feed the resident. This food had been on the cart for 55 minutes before it was served to the resident. The resident was not able to be interviewed. c) A second dining observation was conducted on the C wing on 05/02/12 for concerns regarding food temperature and palatability. The main dining room was served at 7:05 a.m. There were 8 residents observed in the dining room. The residents were served bacon and eggs. They ordered their egg the way they wanted it cooked a… | 2016-07-01 |
| 8244 | 8244 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2012-05-03 | 371 | F | 0 | 1 | 9YCU11 | Based on observation and interview, the facility failed to maintain and distribute food under sanitary conditions. This had the potential to affect 105 of 107 residents residing in the facility. Findings include: a) Observation of the food being plated in the kitchen was conducted at 12:15 p.m. on 04/30/12. Dietary staff #17 was observed to pick up plates and bowls with gloved hands and touch the portion of the plate on which the food was placed. She was then observed to touch her hair, glasses, and clothing, and continue with the same practice of touching the portion of the plates she would be placing the food items on. She was observed serving roast beef with a spatula and it was difficult for her to pick up the pieces of meat with this utensil. Wearing the same gloves, she was observed to place the meat on the plate and then used the potentially contaminated gloved hands to hold onto the meat while she cut the meat into pieces. There were times she had difficulty picking the pieces of meat up out of the serving container so she was observed to use the potentially contaminated gloved hands to pick the meat up by sticking her fingers into the container to pick up the meat. At times she was unable to cut the meat with the knife and stated, it is so hard to cut this stuff, so then she would just pull the meat apart with her fingers. This surveyor shared with the dietary staff during this observation the need to change gloves before serving any additional food items due to the potential for cross-contamination. An interview was conducted with the dietary manager and the dietitian at 10:15 a.m. on 05/02/2012. The observations of staff #17 serving food in an unsanitary manner during the first day of the survey were shared at this time. The dietary manager stated this staff member should know better. The dietitian stated it seems once the staff put on gloves they think they can touch anything and then come back to serving food and touching items with the same gloved hands. This allowed for a potential of food borne il… | 2016-07-01 |
| 8245 | 8245 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2013-07-30 | 166 | D | 1 | 0 | YIJO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and grievance record review, the facility failed to resolve a grievance for one (1) of twelve (12) sampled residents in a timely manner. A resident who allegedly lost her glasses in early March, had no grievance report made until nearly four (4) months later. There was no resolution of the grievance prior to her discharge from the facility. Resident identifier: #122. Facility census: 119. Findings include: a) Resident #122 Review of the medical record, on 07/29/13 at 2:00 p.m., revealed Resident #122 was a [AGE] year old resident with dementia. She was admitted to the facility on [DATE] for rehabilitation following a [MEDICAL CONDITION]. Review of the inventory list, dated 03/05/13, found she had one (1) pair of glasses at the time of admission to the facility. An interview was conducted with the Licensed Social Worker (LSW), Employee #20, on 07/29/13 at 4:00 p.m. She said the Medical Power of Attorney (MPOA) called after the resident's discharge to home on 06/12/13, and asked about the resident's missing glasses. The LSW said an eye exam was done on this resident on 04/03/13 at the facility, and on 05/15/13 she was again seen by the eye doctor at the facility. The LSW said the thought there was some kind of issue at the doctor's office, and a delay with the laboratory (lab) that makes the glasses. She gave this as the reasons the resident did not receive the glasses before going home. Review of the medical record, on 07/29/13 at 4:30 p.m., confirmed a visual analysis was completed by an eye doctor on 05/15/13. The written treatment plan indicated a new prescription was medically necessary to improve distance and near vision in both eyes. On 07/30/13 at 9:00 a.m., review of the grievance reports revealed a grievance dated 06/27/13. The heading was Customer First Concern/Grievance Report. Attached to the grievance was a typed letter from the MPOA of Resident #122, dated 06/24/13, with an allegation that stated, Her gla… | 2016-07-01 |
| 8246 | 8246 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2013-07-30 | 225 | E | 1 | 0 | YIJO11 | Based on resident interviews, staff interviews, review of grievance reports and reportable allegations, and policy reviews, the facility failed ensure misappropriation of property was thoroughly investigated and/or reported to the appropriate State agencies. Three (3) of twelve (12) residents reviewed for personal property issues had a total of five (5) instances of missing money which were not reported and/or investigated. Resident identifiers: #46, #27, and #81. Facility census: 119 Findings include: a) Resident #46 On 07/24/13 at 2:30 p.m., grievance and concern forms were reviewed for the months of May, June, and July 2013. It was noted Resident #46 had filed a concern/grievance report on two (2) different occasions regarding money taken from his room. A concern form dated 05/19/13, indicated the resident placed $20.00 in his Bible, and placed the Bible under the sheets. When he returned from bingo, his Bible had been moved and the money was gone. No evidence was present to indicate the incident was investigated. Another grievance form, dated 07/16/13, indicated the resident had hidden $5.00 in quarters in his Santa Claus, and it was missing. Review of reportable allegations for May, June, and July 2013 provided no evidence the incidents were reported to the State agencies. An interview with Resident #46, on 07/25/13 at 8:30 a.m., revealed the resident was alert, coherent, and oriented. He confirmed money was taken from his room on two (2) different occasions. He said on the first occasion, money was taken from a Bible, which was hidden beneath his sheets. On the most recent occasion, quarters were taken from his Santa Claus. He indicated the money had been stolen. He said he did not misplace it. During an interview with Employee #7, a licensed practical nurse (LPN), on 07/30/13 at 11:30 a.m., the LPN said Resident #46 had complained someone had gone through his belongings. b) Resident #27 During a review of the grievance/concern forms, on 07/24/13 at 2:30 p.m., it was noted Resident #27 reported $22.00 was m… | 2016-07-01 |
| 8247 | 8247 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2013-07-30 | 309 | D | 1 | 0 | YIJO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, medical record review, policy review, and incident/accident review, the facility failed to ensure one (1) of ten (10) residents maintained his highest level of well-being. The facility did not accurately and timely assess and monitor an abrasion. Resident identifier: #46. Facility census: 119. Findings include: a) Resident #46 Review of an incident report, dated 07/07/13, indicated Resident #46 received an injury while two (2) nursing assistants were assisting him onto the toilet with a lift on 07/05/13. The report indicated he had an open wound, identified as an abrasion, that was bleeding onto the floor. During an interview with Resident #46, at 8:30 a.m. on 07/25/13, he confirmed the incident and injury. The medical record, reviewed on 07/25/13 at 8:45 a.m., revealed no evidence the wound was treated, or evaluated prior to 07/08/13. An order was entered on 07/08/13, to apply [MEDICATION NAME] to abraded scar tissue. The care plan, dated 07/07/13, indicated the wound was to be assessed frequently to ensure healing. Further review of the medical record revealed no ongoing assessment or monitoring of the wound. The nurses' notes and the treatment administration record were reviewed with the wound/treatment nurse, (Employee #58), a registered nurse. She confirmed a wound evaluation form had not been completed as of 07/25/13, nor was the any evidence of ongoing wound assessments. An interview with Employee #122, a registered nurse (RN), on 07/25/13 at 3:30 p.m., revealed he became aware of the incident on 07/07/13. The nurse said he did not evaluate the wound because he was not caring for the resident. The RN said he initiated an investigation, but was unaware of anything else related to the incident. Review of the facility's 1.40 First Aid Policy, on 07/29/13 at 10:00 a.m., revealed all injured persons were to receive immediate interventions and measures to prevent further injury. Emergency treatme… | 2016-07-01 |
| 8248 | 8248 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2013-07-30 | 425 | D | 1 | 0 | YIJO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, review of incident reports, and medical record review, the facility failed to provide pharmaceutical services for one (1) of ten (10) sample residents. A Duragesic patch (pain medication) was not available in the facility when it was due for administration. The patch was not received from the pharmacy until the following day, and was not applied until twenty-six (26) hours after it was originally due. Resident identifier: #121. Facility Census: 119. Findings include: a) Resident #121 A 07/24/13 review of an incident report, created on 06/30/13, described a situation in which Resident #121 was due a Duragesic patch on 06/29/13. The patch was not available from the pharmacy because a new prescription (Rx) was required from the physician for this medication. The report described repeated conversations by the nurse, Employee #89, and the Administrator, Employee #111, with the pharmacy and physician in attempts to get the Rx faxed to the pharmacy. An interview was conducted with Employee #89, Licensed Practical Nurse (LPN), on 07/29/13 at 3:30 p.m. The interview with the LPN was consistent with the medical record. Both the nursing notes and the Medication Administration Record [REDACTED]. A physician's orders [REDACTED]. The medication was signed into the narcotic drawer as received from the pharmacy on 06/30/13, on the Master controlled medication log for medication cart for RRS Front. It was not until 06/30/13 that both the nurse's note and the MAR indicated [REDACTED]. It was signed off as given at 11:00 a.m. (twenty-six (26) hours after it was originally due) on 06/30/13 by Employee #89, LPN. She verified this in her interview on 07/29/13 at 3:30 p.m. This matter was discussed with the Administrator on 07/29/13 at 3:30 p.m. She agreed the medication was not available. No additional information was provided by the end of the survey. | 2016-07-01 |
| 8249 | 8249 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2013-07-30 | 514 | D | 1 | 0 | YIJO11 | Based on medical record review and staff interview, the facility failed to ensure the medical record for (1) of three (3) residents reviewed for blood sugar monitoring, contained an accurate representation of the resident's medical status. This resident's blood sugar monitoring documentation contained an entry which was illegible. Resident identifier: #98. Facility census: 119. Findings include: a) Resident #98 On 07/30/13 at 4:30 p.m., Resident #98's medical record was reviewed for blood sugar monitoring. Review of the Medication Administration Record [REDACTED]. A nurses' note, dated 07/05/13, indicated the physician was notified the blood sugar was completed late, but did not require coverage. During an interview with Employee #35 (director of nursing) and Employee #111 (administrator), on 07/30/13 at 5:00 p.m., they acknowledged the entry was illegible. They confirmed the results of the blood sugar could not be determined from the documentation on the MAR. | 2016-07-01 |
| 8250 | 8250 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2012-06-08 | 166 | D | 0 | 1 | 26RQ11 | Based on interview and record review, the facility failed to develop an effective grievance program that included follow-up visits to ensure residents' grievances had been resolved to their satisfaction for three (3) residents reviewed. Resident identifiers: #84, #18, and #74. Findings include: 1. Review of the documentation provided by the Social Services Assistant (SSA) on 6/6/12 revealed the following information: a) Resident #84 The SSA was advised on 01/26/12 that R84 had voiced a complaint about noise on his hallway. The SSA visited R84 on 01/27/12 at 11:56am and he stated that he was disturbed in the middle of the night when the residents on either side of him were yelling and screaming. The SSA documented that there was little the facility could do to prevent the residents in question from yelling at night. She informed R84 that the facility had ear plugs which might help him sleep. The SSA reported R84 ' s concern to the nurse on his unit and the nurse stated that she would make an effort to keep the other residents as quiet as possible at night. As of 06/08/12 at 12:00 noon, there was no subsequent documentation relative to R84 ' s grievance. The facility failed to follow up with R84 to ensure that his grievance had been resolved to his satisfaction. There was no documentation relative to the potential intervention (ear plugs), or if the resident continued to be disturbed in the middle of the night by the loud residents on his hallway. An interview with the SSA on 06/06/12 at 4:00pm confirmed that she had failed to follow up with R84 to ensure that he was able to sleep throughout the night without being disturbed. b) Resident #18 The SSD visited R18 on 02/06/12 at 2:54 pm and again on 4:15pm because she was upset over her roommate (R60) and she was expressing fear of her. The SSD spoke with R18 ' s family and they stated that they did not want R18 to change rooms but they wanted the facility to relocate her roommate, R60 instead. They stated that R18 was in the room first, and felt that she had the righ… | 2016-07-01 |
| 8251 | 8251 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2012-06-08 | 241 | D | 0 | 1 | 26RQ11 | Based on observation, interview, and clinical record review the facility required three (3) cognitively impaired residents wear helmets that a reasonable person would not if given the choice. Resident identifiers: #34, #57, and #78. Findings include: a) Resident #78 Observation on 06/06/12 at 3:30 pm, revealed R 78 lying in bed asleep with a beige helmet on his head. The helmet had a hard outer shell and foam inside. Several holes placed about the helmet presumably for ventilation. The helmet was square in shape at the top front and had large loops hanging down from the ears. The helmet was secured with a strap under the chin. R 78 ' s helmet was pushed forward and sideways on his head causing his brow to be wrinkled and covering his right eye. Observation on 06/06/12 at 4:00 pm, revealed R 34 was ambulating in the hallway near the nurse ' s station. Each time she turned her head the helmet obstructed her vision. Each time she would remove the helmet, staff would replace it. When the helmet was off, the resident ' s hair was matted and wet. Review of R 78 ' s clinical record revealed that before his current illness he had been a professional person held in high esteem by his peers and having distinguished himself in his field. b) Resident #57 Observation of R57 on 06/05/12 at 1:30 pm revealed that she was seated in an arm chair across from the 1st floor nursing station. She was wearing eye glasses and a soft helmet that was secured under her chin. She was talking out loud to herself and asking questions. Her questions were not directed at anyone. She appeared cognitively impaired. On 06/05/12 at 1:45pm, R57 began to pull at her helmet. As she twisted the helmet to the left side of her head, her glasses fell off and landed on the floor. She removed her helmet and placed it on the chair beside her. She continued to talk to herself. R57 did not want the helmet on her head. On 06/05/12 at 1:55pm, a staff member who had passed by saw R57 without her helmet and glasses. Staff picked R57 ' s glasses up off the floor and… | 2016-07-01 |
| 8252 | 8252 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2012-06-08 | 279 | D | 0 | 1 | 26RQ11 | Based on observation, interview and record review, the facility failed to develop an individualized dental care plan that included specific requirements for one of 19 sampled residents, R34. Findings include: Observation of R34 during the initial tour on 6/5/12 at 9:30am revealed that she was in bed and her dentures were in her mouth. Upon closer inspection of R34 ' s dentures at that time, revealed that they were visibly soiled. During an interview with R34 ' s family member on 6/7/12 at 10:15am via telephone revealed that they were unhappy because they believed that the facility had not been taking R34 ' s dentures out at night before she went to bed. Observation of R34 on 6/7/12 at 10am revealed that she was in bed, fully dressed, and sleeping. Her dentures were in her mouth and her denture cup was empty. Interview with the Certified Nursing Assistant (CNA #19) who was assigned to R34 on 6/7/12 at 10:25am confirmed that it was the facility ' s policy to take the residents ' dentures out after breakfast and after dinner. She stated that staff was supposed to take R34 ' s dentures out after breakfast, brush them and put them in a denture cup to soak. After dinner, staff was supposed to do the same thing. This practice was to happen every day. She stated that on at least 3 occasions, when she went into R34 ' s room to get her up for the day, her dentures were still in her mouth. She stated that the evening staff had failed to take R34 ' s dentures out before she went to bed. The CNA #19 stated that she had reported this deficient practice to the charge nurse. Interview with the Charge Nurse, LPN #55 on 6/7/12 at 10:40am confirmed that CNA #19 had reported the night shift staff for not removing R34 ' s dentures before putting her to bed. She stated that she had spoken to the night shift staff about this concern, but she did not document that meeting. Review of the facility provided documentation, the ADL Observations which had been completed by the CNAs on a daily occasion, revealed that R34 required assistance wi… | 2016-07-01 |
| 8253 | 8253 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2012-06-08 | 280 | E | 0 | 1 | 26RQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family/staff interviews and clinical record review, the facility failed to ensure that the comprehensive care plans were revised as needed for 4 of 19 sampled residents (R9, R10, R14, and R34). Findings include: 1. Observation of R34 during the initial tour on 06/05/12 at 9:30am revealed that she was in bed and her dentures were in her mouth. Closer inspection of R34 ' s dentures at that time revealed they were visibly soiled. An interview with R34 ' s family member on 06/07/12 at 10:15am via telephone revealed they were unhappy because they believed the facility had not been taking R34 ' s dentures out at night before she went to bed. Observation of R34 on 06/07/12 at 10:00am revealed that she was in bed, fully dressed, and sleeping. Her dentures were in her mouth and her denture cup was empty. Interview with Certified Nursing Assistant (CNA) #19, who was assigned to R34, on 06/07/12 at 10:25am, confirmed that it was the facility ' s policy to take the residents ' dentures out after breakfast and after dinner. She stated that staff was supposed to take R34 ' s dentures out after breakfast, brush them and put them in a denture cup to soak. After dinner, staff was supposed to do the same thing. This practice was to happen every day. She stated that on at least 3 occasions, when she went into R34 ' s room to get her up for the day, her dentures were still in her mouth. She stated that the evening staff had failed to take R34 ' s dentures out before she went to bed. CNA19 stated that she had reported this to the charge nurse. Interview with the Charge Nurse, Licensed Practical Nurse (LPN) #55 on 06/07/12 at 10:40am confirmed that CNA19 had reported the night shift staff for not removing R34 ' s dentures before putting her to bed. She stated that she had spoken to the night shift staff about this concern, but she did not document that meeting. Review of the facility provided documentation, the ADL Observations which had been… | 2016-07-01 |
| 8254 | 8254 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2012-06-08 | 309 | G | 0 | 1 | 26RQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review the facility failed to ensure that timely care and services were provided for two (R10 and R14) of a total of nineteen residents. R14 did not receive timely treatment for [REDACTED]. Findings include: a) Resident #14 R14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facility assessed R14 as being interviewable. A review of the Nurse ' s Notes indicated the following: 04/30/12 at 5:00am: Resident lost balance when CNA (Certified Nursing Assistant) transferring from BSC (bedside commode) to W/C (wheelchair). CNA lowered (resident) to floor. 04/30/12 at 10:30am: Resident insisting on taking her shoes off to use the restroom this am. Tried to explain to resident that her socks alone were too slippery. She took her shoe off herself. As she was transferring herself she tried to sit herself on the floor. 04/30/12 at 3:00pm: Has large swollen area in outer left ankle. She said she bumped it on chair during transfer. Dr. (doctor) ordered x-ray. 04/30/12 at 5:00pm: X-ray at bedside to do x-ray. 04/30/12 (no time documented): X-ray results of left ankle. There is no evidence for fracture; mild lateral soft tissue swelling is identified. 05/01/12 at 3:00am: Swelling noted to left ankle. Resident refused to stand to transfer to BSC and refuses to use bed pan. Several incontinence episodes this shift. 05/01/12 at 12:00pm: Bruising to left foot. Will monitor. 05/02/12 at 2:00am: Mild swelling in left ankle. 05/02/12 at 3:00am: Resident continues to refuse to stand up and refuses to use bed pan. Several incontinence episodes and refuses to be changed. 05/02/12 at 9:00pm: Resident alert with pleasant confusion at times - attention seeking most of shift. Bruising and small amount of swelling to left ankle. Resident c/o (complains of) pain in left ankle upon weight bearing/ambulation. 05/03/12 at 3:00am: Follow-up to fall with injury to left ankle. Area swollen with bruising presen… | 2016-07-01 |
| 8255 | 8255 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2012-06-08 | 323 | E | 0 | 1 | 26RQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and clinical record reviews, review of policies and procedures, and review of accident and incident reports, the facility failed to provide an environment free of hazards The facility failed to ensure adequate supervision and assistive devices needed to prevent accidents for six (6) of nineteen (19) sampled residents. The facility failed to determine possible root causes for multiple falls, and/or provide assistive devices/supervision needed to prevent further accidents. Resident identifiers: #9, #10, #33, #34, #78 and #85. Findings include: a) Resident #9 R9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R9 sustained falls on 02/24/12, 04/15/12, 04/20/12, 05/03/12, 05/09/12, 05/11/12 (twice), and 05/18/12. A review of the Risk Management Accident/Incident (A/I) Report for each of these falls indicated that an investigation form was completed. However, review of the reports revealed that the data gathered during the investigation was not assessed by the Interdisciplinary team (IDT) to determine possible root causes for each fall. There was no evidence the IDT evaluated why identified interventions had not been successful in preventing the multiple accidents, and R9 ' s care plan was not revised with new approaches as needed. (Refer to F280.) b) Resident #10 R10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R10 sustained falls on 04/15/12, 04/17/12, 05/16/12, and 05/18/12. A review of the Risk Management Accident/Incident (A/I) Report for each of these falls indicated that an investigation form was completed. However, review of the reports revealed that the data gathered during the investigation was not assessed by the Interdisciplinary team (IDT) to determine possible root causes for each fall. There was no evidence the IDT evaluated why identified interventions had not been successful in preventing the multiple accidents, and R10 ' s care plan was not revised wit… | 2016-07-01 |
| 8256 | 8256 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2012-06-08 | 364 | F | 0 | 1 | 26RQ11 | Based on observation and staff interview, the facility failed to prepare and serve palliative foods for all of the residents who had a physician ordered pureed diet. This deficient practice affected three (3) of nineteen (19) sample residents as well as the other sixteen (16) residents who were ordered pureed diets. Residents #R62, R77, R79, R5, R7, R19, R21, R22, R35, R94, R93, R92, R91, R90, R83, and R80. Findings include: 1. Observation of the dinner meal that was served in the dining rooms on 06/05/12 at 5:30pm revealed that all of the residents who were ordered a pureed diet received a cold plate that consisted of; lumpy pureed turkey salad, pureed macaroni salad, lumpy pureed tomatoes and a slice of white bread. All of the pureed foods were placed on the same dinner plate and all were floating in cold white milk. The slice of bread was saturated with milk and it was losing its shape on the plate. Observation of the residents who had been served that puree meal in the dining rooms revealed that they were eating less than 25% of their meal on average. 2. Review of the Spring/Summer, Week Three preplanned menu revealed that the residents who were ordered a pureed diet and those residents who were ordered a regular diet were to have the same food except the food would be pureed for those residents who required it. The following foods were prepared for dinner on Tuesday 06/05/12: a. Cold Turkey salad b. Crescent rolls c. Macaroni Salad d. Lettuce and Tomato slices. 3. During an interview with R33, on 06/05/12 at 5:45pm in the 2nd floor dining room, the fine dining room revealed that she was unhappy with the appearance of her puree food and she had refused to eat it. She stated, I don ' t want that stuff. An interview with a Certified Nursing Assistant (CNA) #38 on 05/06/12 at 5:45pm, in the dining room on the 1st floor, confirmed that the residents did not like lumpy, cold puree foods. She stated, the residents don ' t really like cold plates for dinner and the plates don ' t look very appetizing. When interview… | 2016-07-01 |
| 8257 | 8257 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2012-06-08 | 365 | F | 0 | 1 | 26RQ11 | Based on observation, staff interview and record review, the facility failed to prepare and serve food in a form that met the individualized needs of those residents who had physician ordered puree diets. The facility did not serve puree foods that were smooth in texture and holding their shape. This deficient practice affected three (3) of nineteen (19) sample residents as well as the other sixteen (16) residents who were ordered pureed diets. Residents #R62, R77, R79, R5, R7, R19, R21, R22, R35, R94, R93, R92, R91, R90, R83, and R80. Findings include: 1. Observation of the kitchen and the steam table on 06/05/12 at 5:00 pm revealed that the dinner meal was prepared and ready for service. Observation of the ready to eat foods revealed that there were chunks of green particles throughout the puree turkey salad. Upon closer inspection, at that time, revealed that the green chunks were pieces of pickles. The turkey salad was not smooth in texture. Observation of the dinner meal that was served in the dining rooms on 06/05/12 at 5:30pm revealed that all of the residents who were ordered a pureed diet ((R58, R33, R89, R62, R77, R79, R5, R7, R19, R21, R22, R35, R94, R93, R92, R91, R90, R83, R80) received a cold plate that consisted of; lumpy pureed turkey salad, pureed macaroni salad, lumpy pureed tomatoes and a slice of white bread. All of the pureed foods were placed on the same dinner plate and all were floating in cold white milk. The slice of bread was saturated with milk and it was losing its shape on the plate. When the puree food came in contact with the milk on the plate the consistency was changed. It was runny and not holding its shape. When interviewed about why the residents who were on a puree diet received their food floating in milk, the Assistant Dietary Manager (ADM) stated on 06/05/12 at 5:50pm that the facility soaked bread in cold milk rather than preparing pureed bread and that was the reason for the floating milk throughout the plate. Per the Academy of Nutrition and Dietetics Association, a pur… | 2016-07-01 |
| 8258 | 8258 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2012-06-08 | 371 | F | 0 | 1 | 26RQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to utilize sanitary techniques in the food service department when they; did not sanitize the thermometer probe before use, did not clean and sanitize the Robot Coupe (blender) after use, when they did not operate the dish machine in a safe and sanitary fashion, and when they created a potential for cross contamination when taking food temperatures and serving cold foods. This deficient practice had the ability to affect all the residents who received meals from the kitchen. Findings include: 1. Observation of the kitchen and the steam table on 06/06/12 at 7:00am revealed that the breakfast food had been prepared and it was ready for service. At that time, the morning cook (E77) had begun to take the temperatures of the ready to eat foods. She removed the thermometer probe from the protective sleeve and then she laid the probe on an un-sanitized wood counter. Before she sanitized the probe, she inserted it into the center of the ready to eat pancakes which created the potential for cross contamination. During an interview with E77, at that time, she confirmed that she had made a mistake when she placed the contaminated probe into the center of the pancakes before she sanitized it. During observation of the steam table and E77, on 06/06/12 at 7:00am, revealed she had created a potential for cross contamination when she laid the thermometer ' s protective sleeve across the ready to eat pureed sausage patties. Interview with E77, at that time, confirmed that she had not sanitized the protective sleeve and she should not have laid it across the ready to eat pureed sausage. Observation of the Robot Coupe (blender) on 06/06/12 at 7:30am revealed that the inside of the blender contained sitting water and food debris on the blade, the sides of the blender, and under the blender lid. Interview with E77 on 06/06/12 at 7:35am confirmed that she had used the blender to grind sausage p… | 2016-07-01 |
| 8259 | 8259 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2012-06-08 | 441 | E | 0 | 1 | 26RQ11 | Based on observations, staff interviews, and Policy and Procedure review, the facility failed to implement their infection control policy for one of nineteen sampled resident (R88) and one un-sampled resident (R15.) Eye drops were administered with contaminated gloves. Staff was observed tasting medication with a bare finger. Residents ' foods were handled with unwashed or bare hands. Findings include: 1. During medication pass conducted on 06/05/12 at 4:00pm, Licensed Practical Nurse (LPN) #66 donned gloves, poured R15 ' s medications, locked the medication cart, knocked on the door, entered the room, gave R15 her medications, and touched R15 ' s glass. LPN66 then administered eye drops to both of R15 ' s eyes without changing her gloves. 2. Observation on 06/05/12 at 4:10pm revealed LPN68 pouring Prosource (liquid protein supplement) 30ml (milliliters). After pouring the medication, LPN68 stated I wonder how this tastes and proceeded to stick his bare finger into the medicine cup and tasted the medication from his finger. Review of the facility policy titled ' Standard Precautions revealed, Hands are to be washed before and after each resident contact and after removing gloves. During an interview with the Director of Nursing (DON) on 06/06/12 at 3:00pm, the DON acknowledged that LPN66 should have changed her gloves before administering the eye drops to R15 and the DON indicated the observation of LPN68 tasting medication was unacceptable. 3. During observation on 06/06/12 at 7:45am, Certified Nursing Assistant (CNA) #12 placed R88 ' s breakfast tray on the nurses ' desk, removed the cover, picked up a piece of toast with her bare hand and applied jelly. When finished with the first piece of toast, she picked up the second and did the same. She then recovered the plate and took the tray into the resident ' s room. Interview on 06/06/12 at 7:45am, with CNA12 revealed that, when asked if she washed her hands before picking up the resident ' s toast barehanded, she stated, No. 4. Observation of the dining room on … | 2016-07-01 |
| 8260 | 8260 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2012-06-08 | 456 | E | 0 | 1 | 26RQ11 | Based on observation and interview, the facility failed to maintain their essential kitchen equipment, the Robot Coupe (blender) blades, in safe operational condition. This deficient practice had the ability to affect five (R58, R33, R34, R85 and R89) residents in a sample of 19 and 29 (R62, R77, R79, R5, R7, R19, R21, R22, R35, R94, R93, R92, R91, R90, R83, R80, R57,R63, R71, R12, R13, R21, R23,R30, R32, R38, R36, R86, and R82) un-sampled residents all of whom require a mechanically altered diet. Findings include: Observation of the kitchen during the initial tour on 06/05/12 at 9:30am revealed that the metal blades inside the Robot Coupe (blender) were chipped and missing small pieces of metal. Interview with the Assistant Dietary Manager (ADM) on 06/05/12 at 9:35am confirmed that the facility used the Robot Coupe to grind and puree foods for those residents who required a mechanically altered diet. She confirmed that the blades were chipped and missing metal pieces and that the facility had not maintained the blades in a safe operating fashion. When the solid food came into contact with the chipped metal blades, it created the potential for small slivers of metal to dislodge from the blade and enter into the residents mechanically altered foods. If consumed, the small slivers of metal had the potential to contaminate the food and cause internal injury for those residents. | 2016-07-01 |
| 8261 | 8261 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2012-06-08 | 497 | F | 0 | 1 | 26RQ11 | Based on interview and personnel training record review for five Certified Nursing Assistants ( ' s) (12,15, 17, 19, and 21) , the facility failed to ensure CNAs received at least twelve hours of in-service education. The facility also failed to develop a program of in-service education based on areas of weakness identified through annual performance reviews. Findings include: Review of personnel records for CNAs employed for more than one year revealed no documentation for total hours of in-service education received during the year of 2011. During an interview on 06/08/12 at 10:20am, the Assistant Director of Nursing (ADON) confirmed she could not verify if each CNA was provided at least twelve hours of continuing education for 2011. She indicated that all employees were to attend a series of mandatory trainings, as well as education in other areas as needed. Further interview with the ADON confirmed there was no system to track the actual number of hours/minutes each staff attended to assure they received a minimum of 12 hours per 12 months. | 2016-07-01 |
| 8262 | 8262 | RALEIGH CENTER | 515088 | PO BOX 741 | DANIELS | WV | 25832 | 2012-05-03 | 247 | D | 0 | 1 | POUN11 | Based on resident interview, policy and procedure review, and staff interview, the facility failed to notify a resident he would be receiving a new roommate. This was found for one (1) of 36 Stage II sample residents. Resident identifier: #73. Facility census: 64. Findings include: a) Resident #73 On 04/30/12 at 2:24 p.m., Resident #73 answered No when asked if he was given notice before a roommate change. This resident stated, The new roommate was just brought in and no one told me. A review of the facility policy and procedure titled 1.81 Room Changes, on 05/03/12 at 9:00 a.m., revealed, under Process, the following: 6. For a patient who is receiving a new roommate: 6.1 Give the patient as much notice as possible. 6.2 Provide information about the new roommate while maintaining confidentiality regarding medical information. On 05/03/12 at 10:00 a.m., the admission coordinator (Employee #46) and the director of nursing (Employee #76), both agreed Resident #73 had not been informed about a new roommate. They could provide no evidence the notification had been made. | 2016-07-01 |
| 8263 | 8263 | RALEIGH CENTER | 515088 | PO BOX 741 | DANIELS | WV | 25832 | 2012-05-03 | 272 | D | 0 | 1 | POUN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, incident and accident report review, and staff interview, it was determined the facility had not completed a comprehensive assessment for the need for side rails and/or for the use of alternative or less restrictive devices for two (2) of 36 stage II sample residents who were observed with four (4) quarter (1/4th) side rails attached to their beds. Resident identifiers: #60 and #83. Facility census: 64. Findings include: a) Resident #60 Review of accident and incident reports revealed this resident was found lying on her back on the floor on 04/25/12. The resident stated she had no pain any where and she was just trying to get out of bed. No injuries were noted at the time of the fall. The resident was assisted to a geri-chair with the use of a total lift and assistance of three (3) staff members. The quarterly Minimum Data Set (MDS) assessment, dated 03/06/12, noted the resident had no falls prior to admission. The current care plan indicated the resident was at risk for falls. According to the care plan, bilateral upper and lower rails were in use due to the request of the resident's medical power of attorney (MPOA). There was no evidence of an assessment for the need for side rails, and or the least restrictive type of device to prevent falls. This resident was observed on 05/02/12, at approximately 4:10 p.m., with four (4) quarter (1/4th) side rails attached to the bed. Medical record review revealed a physician's orders [REDACTED]. The use of the upper side rails for turning and positioning was understandable; however, the use of the lower side rails for turning and positioning did not seem plausible. Discussion with the director of nursing, Employee #75, and the administrator, Employee #71, immediately following the observation of the resident, verified the facility had not assessed the resident for the use of side rails. This discussion revealed the lower side rails were for safety, not posi… | 2016-07-01 |
| 8264 | 8264 | RALEIGH CENTER | 515088 | PO BOX 741 | DANIELS | WV | 25832 | 2012-05-03 | 279 | E | 0 | 1 | POUN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility's interdisciplinary team failed to develop comprehensive care plans to assist the resident in reaching his or her highest practicable level of well-being. The care plans were not complete, or did not provide instructions to provide care, in the areas of: depression for two (2) residents; the use of side rails; and prevention of falls. This was true for four (4) of thirty-six (36) residents. Resident identifiers: #125, #3, #60, and #48. Facility census: 64. Findings include: a) Resident #125 Medical record review found the resident was admitted to the facility on [DATE]. Hospital discharge records, accompanying the resident upon admission found, . She has tried to hurt herself in the past by taking pills which she was hospitalized for [REDACTED]. Further review of the pre-admission screening (PAS) found a Level II evaluation was completed on 03/20/12. Although the PAS reviewer found the resident did not need specialized services at that time, the following was documented, .She has displayed thoughts of hopelessness, worthlessness, and thoughts that life is not worth living during her stay. .In the event that (name of resident) physical conditions improves in the nursing facility and the thoughts of self-harm continue, a psychiatric consultation may be warranted at this time. Particularly if she voices a specific plan of how she would harm herself and this plan would be feasible for her to complete. Review of the interim care plan, on 05/03/12, found the facility had not addressed the residents [DIAGNOSES REDACTED]. Review of the facility policy entitled: 4.0 Care Plan: Patient, found, An initial care plan is developed within 24 hours of admission. Employee #61, the care plan coordinator, was interviewed on 05/04/12 at 9:00 a.m. She was unable to provide information to demonstrate the facility had addressed the resident's depression in the care plan. b) Resident #3 Review of the p… | 2016-07-01 |
| 8265 | 8265 | RALEIGH CENTER | 515088 | PO BOX 741 | DANIELS | WV | 25832 | 2012-05-03 | 280 | D | 0 | 1 | POUN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise a care plan for a resident who had experienced actual falls in the facility after admission. This resident's current care plan did not include any new interventions related to falls beyond those listed on the initial care plan dated 04/16/12. This was evident for one (1) of thirty-six (36) sampled residents. Resident identifier: #83. Facility census: 64. Findings include: a) Resident #83 Care plan review found Resident #83 was at risk for falls related to impaired mobility, cognitive loss, and lack of safety awareness, and the overall goal was for her to have no falls with injury in the next 90 (ninety) days, beginning 04/16/12. Interventions included a low bed, a total lift with a sling, and quarter rails for turning and repositioning. Review of an incident report, dated 04/20/12, found this resident sustained [REDACTED]. The post-fall evaluation contained new interventions and preventive measures of bilateral mats to the floor. However, review of the care plan found no revision for bilateral mats to the floor by the bed. Review of an incident report, dated 05/01/12, found this resident sustained [REDACTED]. She was again found sitting on the floor by her bed. The post-fall evaluation contained new interventions and preventive measures of bilateral upper and lower rails to the bed. However, review of the care plan found no revision for lower rails to the bed. During an interview with the Director of Nursing, on 05/02/12 at 9:28 a.m., she agreed there were no written revisions on the care plan related to the two (2) falls since admission on 04/03/12, or of new interventions to try to prevent falls beyond those listed on the care plan on 04/16/12. | 2016-07-01 |
| 8266 | 8266 | RALEIGH CENTER | 515088 | PO BOX 741 | DANIELS | WV | 25832 | 2012-05-03 | 425 | D | 0 | 1 | POUN11 | Based on observation and staff interview, the facility failed to ensure the correct dosage of an antidepressant medication was supplied when the dosage was decreased, or the label on the medication was changed to reflect only half of the provided dosage should be administered. This had the potential for a medication error if any nurse failed to realize the dose that was written on the Medication Administration Record [REDACTED]. Resident identifier: #66. Facility census: 64. Findings include: a) Resident #66 During medication pass observation on 05/02/12 at 8:36 a.m., a licensed nurse, Employee #88, removed a 40 milligram (mg.) tablet of Celexa from Resident #66's medication box, and broke the tablet in half with her bare hands. She then discarded half the tablet, and gave the other half to Resident #66. Observation of the Medication Administration Record [REDACTED]. daily, until the dose was decreased to 20 (twenty) mg. daily on 04/25/12. Observation of the box of Celexa in the medication cart for Resident #66 found only Celexa 40 (forty) mg. tablets for dispensing, and the box contained no directives to administer only one-half tablet to achieve the correct dose. During interview with Employee #88 at this time, she said pharmacy will need to be called to obtain the correct dosage of Celexa. During an interview with the Director of Nursing, on 05/02/12, at approximately 10:00 a.m., she said she was made aware of this issue today by the nurse, and the pharmacy would take care of the problem. | 2016-07-01 |
| 8267 | 8267 | RALEIGH CENTER | 515088 | PO BOX 741 | DANIELS | WV | 25832 | 2012-05-03 | 431 | E | 0 | 1 | POUN11 | I. Based on observation and staff interviews, the facility failed to ensure all opened vials of Purified Protein Derivative (PPD), used for tuberculin skin testing, and all opened vials of insulin, were discarded timely after opening. This was evident for one (1) partially used vial of PPD stored in the medication room refrigerator that had no date of opening, and for one (1) partially used vial of regular insulin on the B Hall medication cart that contained no date as to when it had first been opened. This had the potential to affect more than a limited number of residents. Facility census: 64. Findings include: a) Medication storage room Observation of the medication storage room, on 04/30/12 at 12:47 p.m., found there was one (1) partially used vial of Purified Protein Derivative (PPD), that had no date of opening. During an interview with a licensed nurse, Employee #87, at that time, she stated that once opened, the vial of PPD should have been discarded after 30 (thirty) days. She acknowledged there was no date of opening, and it could not be verified how long it had been since the vial had been opened. b) B Hall medication cart Observation of the B Hall medication cart, on 04/30/12, at approximately 1:00 p.m., found one (1) partially used vial of Humulin R insulin with no date of opening. Licensed nurse, Employee #87, said that most insulins are discarded after having been opened for 28 days. She agreed this vial had no date of opening, and it could not be verified how long it had been opened, or which resident it belonged to. During an interview with the Director of Nursing, on 05/03/12 at approximately 10:00 a.m., she said they discard opened vials of injectable medications at 30 (thirty) days after opening, although certain insulins may be stored a short while longer. She further stated that all vials of insulin, and other injectables, were to be dated when opened. II. Based on observation and staff interview, the facility failed to ensure the provision of a medication cart with a functional locking mech… | 2016-07-01 |
| 8268 | 8268 | ROSEWOOD CENTER | 515105 | 8 ROSE STREET | GRAFTON | WV | 26354 | 2013-08-15 | 157 | G | 1 | 0 | RDF011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of hospital records, and policy review, the facility failed to ensure the physician was notified as directed by facility policy when a resident's blood sugars were over 400. The resident's condition declined, she was sent to the hospital, and subsequently expired. One (1) of five (5) sampled residents was affected. Resident identifier: #63. Facility census: 62. Findings include: a) Resident #63 Medical record review on [DATE], noted the resident had a medical history of [REDACTED]. When she was transferred to the long term care facility on [DATE], she was placed on finger sticks twice a day at 7:00 a.m. and 9:00 p.m. upon admission for two (2) weeks and the nurses were instructed to draw a HgbA1c with the next lab draw on [DATE]. According to the Medication Administration Record [REDACTED]. Although the finger stick blood sugar results were elevated, the medical record contained no evidence of notification of the physician. On [DATE] at 9:00 p.m., the resident's blood sugar result was 416. On [DATE] at 9:13 p.m., the resident's blood sugar was 475. On [DATE] at 7:00 a.m., the resident's blood sugar was 408. On [DATE] at 12:30 p.m., (more than five (5) hours after the results of the finger stick was recorded), Employee #32, a registered nurse (RN), notified the physician of the elevated finger stick blood sugars and received an order for [REDACTED].>At 4:05 p.m. (16:05) on [DATE], an order was obtained to send the resident to the emergency room . At 8:26 p.m. (20:26) the resident expired at the acute care facility emergency room . This matter was discussed with the DON at 2:30 p.m. on [DATE]. She said a blood sugar value that was over 400 was considered an urgent value for a finger stick that required immediate notification of the physician. She provided the facility's policy on finger sticks. The Policy Diabetic Care Protocol 15.14, effective [DATE] revised [DATE], in Section 9.1.1 inclu… | 2016-07-01 |
| 8269 | 8269 | ROSEWOOD CENTER | 515105 | 8 ROSE STREET | GRAFTON | WV | 26354 | 2013-08-15 | 309 | G | 1 | 0 | RDF011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of hospital records, and policy review, the facility failed to provide timely care and services for a resident with a [DIAGNOSES REDACTED]. The resident was on scheduled and sliding scale insulin coverage. The physician was not notified, as directed by facility policy, when the resident's blood sugars were over 400 at varying times on three (3) consecutive days. The resident's condition declined, she was sent to the hospital, and subsequently expired. One (1) of five (5) sampled residents was affected. Resident identifier: #63. Facility census: 62. Findings include: a) Resident #63 Medical record review on [DATE], noted the resident had a medical history of [REDACTED]. When she was transferred to the long term care facility on [DATE], she was placed on finger sticks twice a day at 7:00 a.m. and 9:00 p.m. upon admission for two (2) weeks. The the nurses were instructed to draw a HgbA1c with the next lab draw on [DATE]. According to the Medication Administration Record [REDACTED]. Although the finger stick blood sugar results were elevated, the medical record contained no evidence of intervention by nursing, or notification of the physician. On [DATE] at 9:00 p.m., the resident's blood sugar result was 416. On [DATE] at 9:13 p.m., the resident's blood sugar was 475. On [DATE] at 7:00 a.m., the resident's blood sugar was 408. On [DATE] at 12:30 p.m., (more than five (5) hours after the results of the finger stick was recorded), Employee #32, a registered nurse (RN), notified the physician of the elevated finger stick blood sugars and received an order for [REDACTED]. Employee #32, an RN, was interviewed on [DATE] at 3:30 p.m. She said she could not remember the situation, but it was likely the time from the receipt of the order until administration (12:30 p.m. to 3:30 p.m.) of the insulin was how long it took to obtain the medication from the pharmacy, as it was a new order. At 4:05 p.m. (1… | 2016-07-01 |
| 8270 | 8270 | ROSEWOOD CENTER | 515105 | 8 ROSE STREET | GRAFTON | WV | 26354 | 2013-08-15 | 514 | D | 1 | 0 | RDF011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of acute care hospital records, the ambulance transfer report, and the death certificate, the facility failed to provide a clinical record that accurately depicted a resident's transfer from the facility. A nurse repeatedly documented the wrong acute care facility in the medical record when a resident was transferred. This practice affected one (1) five (5) sample residents. Resident identifier #63. Facility census: 62. Findings include: a.) Resident #63 Review of the resident's medical record on [DATE] noted the resident experienced a change in condition on [DATE] at 4:00 p.m. according to the Nursing Progress Notes signed by Employee #32, a registered nurse (RN). There was a physician's orders [REDACTED]. There was a nursing note, dated at 4:15 p.m. (16:15), which stated the resident was transferred to Acute Care Hospital A. An ambulance transfer form provided by the director of nursing (DON) identified the resident was transferred to Acute Care Hospital A. An interview was held with Employee #32, an RN. She she said resident was sent to Acute Care Hospital A specifically at the family's request. A progress note from Acute Care Hospital A stated the resident expired in the emergency room (ER) of Acute Care Hospital A. The resident's death certificate was reviewed. It noted the place of death was in Acute Care Hospital A. A licensed practical nurse (LPN), Employee #46, wrote a nursing note, at 8:00 p.m. (20:00) on [DATE], stating she called Acute Care Hospital B and Nurse states res is being admitted to ICU. This same employee then wrote a physician's orders [REDACTED]. At 8:20 p.m. (20:20) on [DATE], a nursing note was composed by Employee #46, LPN stating Acute Care Hospital B called facility .and stated that res had passed away. The DON was interviewed at 2:30 p.m. on [DATE] regarding this matter. She provided documentation regarding the ambulance transfer which did not support Employee #46's documen… | 2016-07-01 |
| 8271 | 8271 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2013-01-23 | 167 | D | 0 | 1 | C0FX11 | Based on observation and staff interview, the facility failed to ensure it had posted a sign informing residents of where the state and federal survey results were located. This practice had the potential to affect more than an isolated number of the facility's residents. Facility census: 26. Findings include: a) On 01/22/13 at 1:00 p.m., an observation revealed the facility had a folder inside a plastic box mounted on the wall across from the nursing station. Further observation revealed the folder contained the survey results. Without inspecting the folder one would not have known it contained the results of the facility's last inspection. On 01/22/13 at 1:10 p.m., the director of nursing (Employee #10) agreed to put a sign on the plastic box notifying residents the survey results were inside the box. | 2016-07-01 |
| 8272 | 8272 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2013-01-23 | 225 | D | 0 | 1 | C0FX11 | Based on a review of the facility's abuse/neglect policy, reportable allegations of abuse and neglect, and staff interview, the facility failed to ensure implementation of their policy on reporting allegations of abuse, neglect, and misappropriation of resident property. The facility had failed to report one (1) of three (3) reviewed allegations to the appropriate outside agencies required by State law as well as their own policy. Facility census: 26. Findings include: a) On 01/16/13 at 2:10 p.m., a review of the facility's reportable allegations of abuse, neglect, and misappropriation of resident property revealed the facility had failed to report one (1) allegation of misappropriation of property to an outside agency as required by State law. The allegation, which took place in January 2012, involved missing money. A resident had reported that a nurse aide had taken five (5) dollars from her. The investigation revealed the facility did not report this to their local law enforcement agency. The abuse reporting requirements for West Virginia nursing homes, revised in October 2011 requires nursing homes to report any suspicion of a crime against a resident to their local law enforcement. A review of the facility's policy and procedure on abuse and neglect (revision 09/21/11) revealed the following excerpt In instances of visitor to resident abuse, mistreatment or misappropriation of property, the appropriate law enforcement agency will be notified to conduct an investigation as they deem necessary. On 01/16/13 at 5:00 p.m., the administrator (Employee #3) confirmed she did not report this allegation to local law enforcement. | 2016-07-01 |
| 8273 | 8273 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2013-01-23 | 226 | D | 0 | 1 | C0FX11 | Based on a review of the facility's abuse/neglect policy, reportable allegations of abuse and neglect review, and staff interview, the facility failed to ensure they implemented their policy on reporting allegations of abuse, neglect, and misappropriation of resident property. The facility had failed to report one (1) of three (3) reviewed allegations to the appropriate outside agencies required by their policy and state law. Facility census: 26. Findings include: a) On 01/16/13 at 2:10 p.m., a review of the facility's reportable allegations of abuse, neglect, and misappropriation of reside property revealed the facility had failed to report one allegation of misappropriation of property to an outside agency as required by West Virginia state law and their policy on reporting. The allegation, which took place in January 2012, involved missing money. A resident had reported a nurse aide had taken five (5) dollars from her. The investigation revealed the facility did not report this to their local law enforcement agency. The abuse reporting requirements for West Virginia nursing homes, revised in October 2011 requires nursing homes report any suspicion of a crime against a resident to their local law enforcement. A review of the facility's policy and procedure on abuse and neglect (revised 09/21/11) revealed the following excerpt In instances of visitor to resident abuse, mistreatment or misappropriation of property, the appropriate law enforcement agency will be notified to conduct an investigation as they deem necessary. On 01/16/13 at 5:00 p.m., the administrator (Employee #3) confirmed she did not report this allegation to local law enforcement. | 2016-07-01 |
| 8274 | 8274 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2013-01-23 | 241 | D | 0 | 1 | C0FX11 | . Based on observation and staff interview, the facility failed to provide care for residents in a manner and environment that maintained or enhanced each resident's dignity by leaving urinary catheter bags uncovered and visible from the hallway. This was found for two (2) of sixteen (16) Stage II sample residents. Resident identifiers: #102 and #223. Facility census: 26. Findings include: a) Resident #102 The resident's Foley catheter bag was observed to be uncovered, hanging on the right side of the resident's bed and visible from the hall way on 01/15/13 at 2:33 p.m. A follow up observation of Resident #102, on 01/17/13 at 9:23 a.m., again found the Foley catheter bag to be uncovered and visible from the hall way. An interview with a nursing assistant, Employee #36, on 01/17/13 at 10:20 a.m., confirmed the catheter bag was not covered, because the facility no longer stocked the covers. On 01/17/13 at 2:25 p.m., the Director of Nursing (DON), Employee #10, reported the resident's catheter bag was now covered. The DON confirmed the catheter bag needed to be covered to maintain the dignity of the resident. b) Resident #223 During an observation of Resident #223, on 01/14/13 at 3:30 p.m., he was lying in bed, with a Foley catheter bag uncovered at his bedside. The catheter bag, which contained urine, could be seen from the hallway. During another observation, on 01/15/13 at 9:07 a.m., the Foley catheter bag was again observed uncovered. Employee #10, the director of nurses, observed the uncovered Foley catheter bag on 01/15/13 at 9:30 a.m. She confirmed the Foley catheter should have been covered to promote the dignity of the resident. She said she would have staff put a cover on the catheter bag. | 2016-07-01 |
| 8275 | 8275 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2013-01-23 | 242 | D | 0 | 1 | C0FX11 | Based on resident interview, resident observation, record review, and staff interview, the facility failed to ensure (3) three of (6) six stage II residents exercised her right to make choices with bathing and diet preferences. Resident identifier: #220, #225, #223. Facility census: 26. Findings include: a) Resident #220 During a stage I interview, on 01/15/13 at 2:17 p.m., Resident #220 said she was not given a choice of bathing options. She said, You can't get a tub bath, they don't have one. Review of the interim care plan on 01/17/13 at 5:00 p.m. revealed no bathing preference was identified. Employee #4, registered nurse, stated the comprehensive care plan would not be completed until 01/28/13. The director of nurses (DNS), Employee #10 , was interviewed on 01/17/13 at 5:33 p.m. She stated she was employed as DNS in April 2012. She verified a bathtub was available for residents use. She said, No one has used it since I've been here; there is a shower in each room. The nursing assessment was reviewed with the DNS. She stated, There is nothing to ask about bathing preference on nursing assessment. She also stated occupational therapy may make recommendations regarding bathing. In addition, the nursing assistant may ask the resident his/her bathing preference. Employee #36, a nursing assistant, was interviewed on 01/22/13 at 8:25 a.m. She stated she was unsure how to determine a residents preference for taking a tub bath, shower, or bed bath. Additionally, during an interview with Resident #220, on 01/15/13 at 2:27 p.m., she stated she was not pleased with the meals because they serve the same thing over and over. She further added, You don't get what you ask for. b) Resident #225 During an observation at on 01/14/12 at 6:03 p.m., Resident #225, complained they did not send her tomato and lettuce. In addition, she received carrot cake, rather than the angel food cake she had ordered. She added, They never give me what I ask for. Employee #10, director of nursing (DON), spoke with the patient, reviewed the tray … | 2016-07-01 |
| 8276 | 8276 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2013-01-23 | 248 | D | 0 | 1 | C0FX11 | Based on staff interview, record review, family interview, and observation, the facility failed to provide activities of interest, or encourage a resident to attend activities, for (1) one of (3) three Stage II sampled residents. Resident identifier: #102. Facility Census: 26 Findings include: a) Resident #102 During a family interview, on 01/15/13 at 11:39 a.m., Resident #102's daughter stated she had never seen him participate in any activities and did not know of anyone offering him activities. The medical record was reviewed on 01/17/13 at 8:50 a.m. The minimum data set with an assessment reference date of 12/19/12 under section F labeled Interview for Activity Preferences identified the following activities: books, newspapers and magazines; keeping up with the news; doing things with groups of people; and going outside for fresh air in good weather, as being coded as a 2 indicating these activities are somewhat important. Random observations on 01/14/13, 01/15/13, 01/16/13 and 01/21/13 found the resident alone in his room with the television on. No newspapers, books, or magazines were present. No staff interactions were observed except during morning care or meal deliveries. An interview, on 11/17/23 at 4:00 p.m., with the activities director, Employee #2, verified she had completed the resident's activity assessment on 12/18/12, and commented he liked fishing. She said she used to stop in and visit him everyday, but he was usually sleeping, so she had not been visiting. She presented the resident's daily activity record and acknowledged it was blank from 12/20/12 through 01/12/13 because she had not been visiting him. | 2016-07-01 |
| 8277 | 8277 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2013-01-23 | 272 | D | 0 | 1 | C0FX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of the minimum data set (MDS) definitions of pressure ulcers at each stage, and staff interview, the facility failed to ensure pressure ulcers were accurately assessed for two (2) Stage II sample residents. Staff assessed a red blanchable area as a Stage I pressure ulcer for one resident and another resident was noted to have an abrasion which was a Stage II pressure ulcer. Resident identifiers: Resident identifiers: #68 and #217. Facility census: 26 Findings include: a) Resident #68 On 01/21/13 at 1:30 p.m., a review of Resident #68's closed medical record, revealed the resident had Stage I pressure ulcers on the [MEDICATION NAME] spine, elbows, heels, and coccyx. Each of the Stage I pressure ulcers was described as area red blanchable. The facility's Weekly Pressure Ulcer Progress Report defined a Stage I as A persistent area of skin redness (without a break in the skin) that does not disappear when pressure is relieved. The MDS, under Section M Skin Conditions, defines a Stage I pressure ulcer as Intact skin with non-blanchable redness of a localized area usually over a bony prominence. In an interview with the director of nursing (DON), on 01/21/13 at 2:00 p.m., she stated the staff did not appropriately assess this resident (Resident #68), as a redness that is blanchable is not a stage I pressure ulcer. She further agreed the nursing staff needed to be educated on the staging of pressure ulcers. b) Resident #217 01/17/13 at 10:30 a.m., a review Resident #127's medical record revealed the resident was admitted from an acute care unit on 12/31/12 with a Stage II pressure ulcer on the right buttock. The Weekly Skin Condition Report included Wound Type: Abrasion. Measurements of 2.0 cm (centimeter) x (by) 2.0 cm x 0 cm with granulation tissue were noted on admission. On 01/06/13 measurements of 2.0 cm x 2.0 cm x 0.1 cm were noted. On 01/09/13. the weekly skin condition report noted area hea… | 2016-07-01 |
| 8278 | 8278 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2013-01-23 | 279 | D | 0 | 1 | C0FX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, family interview, care plan review, medical record review, and staff interview, the facility failed to ensure care plans were developed to meet the immediate needs for eight (8) of twenty- one (21) residents reviewed in Stage II. Residents had no care plan or care plans did not include measurable goals and interventions to meet those goals for areas such as activities, dental, activities of daily living, pain management and pressure ulcers. Resident identifiers: #207, #102, #224, #123, #226, #223, #220, and #217. Facility census: 26. Findings include: a) Resident #226 On 01/15/13 at 12:05 p.m., an observation of Resident #226 revealed she had a red area on her left arm covered with a clear dressing. The resident stated she had fallen and scratched her arm while at the facility. On 01/21/13 at 12:20 p.m., a review of the incident/accident reports revealed the resident had stood up from her chair and fallen, hitting her arm on the chair. She sustained a skin tear/abrasion to the left forearm and left flank. Further medical record review revealed no evidence of the facility having developed a care plan for this resident who was admitted to the facility on [DATE], over 30 days ago. On 01/21/13 at 12:30 p.m., the director of nursing (Employee #10) confirmed the facility had not developed a care plan. The director of nursing said the admission nurse should have started the development of the resident's interim care plan. However, this did not occur. b) Resident #102 During a family interview on 01/15/13 at 11:26 a.m., the daughter of Resident #102 reported that her father's fingernails needed trimmed. On 01/17/12, review of the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/19/12, verified the resident required extensive assistance with personal hygiene. The care area assessment summary identified the activities of daily living as a triggered care area with the decision to develop a car… | 2016-07-01 |
| 8279 | 8279 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2013-01-23 | 280 | D | 0 | 1 | C0FX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure resident care plans were revised to meet the resident's current needs and to reflect their current status. Two (2) of twenty-one (21) residents whose care plans were reviewed in Stage II of the survey had identified problematic issues related to nutrition, or pressure ulcers. The facility had not updated the care plans to reflect the current care needs of these residents. Resident identifiers: #205 and #68. Facility census: 26. Findings include: a) Resident #205 A review of the care plan for Resident #205, on 01/16/13 at 11:00 a.m., revealed the facility had developed a care plan for with the problem of weight gain. The care plan stated the resident had gained 40 pounds in four (4) days. On 01/16/13 at 1:00 p.m., Employee #73 (registered dietitian) reviewed the resident's care plan. She stated she had assessed the resident upon admission and explained his normal weight was 190 pounds. She said the resident weighed 190 pounds on 12/18/12, 229.5 pounds on 12/22/12, and 191 pounds on 12/29/12. According to the dietitian, the 229.5 pound weight was inaccurate. She agreed the care plan was not updated to accurately reflect the resident's needs, the resident had not experienced a 40-pound weight gain in four (4) days. b) Resident #68 Resident #68 was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS) assessments, with assessment reference dates (ARD) of 11/21/12 and 11/27/12, under item M0210, indicated this resident did not have one or more unhealed pressure ulcer(s) at Stage I or higher. On the MDS with an ARD of 12/08/12, item M0100 indicated the resident having a Stage I or greater pressure ulcer. Item M300 indicated the resident had a stage II pressure ulcer and M0900 was marked as No indicating there were pressure ulcers present on the prior assessment. The facility Weekly Skin Condition Report, dated 11/15/12, revealed the resident had a S… | 2016-07-01 |
| 8280 | 8280 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2013-01-23 | 312 | D | 0 | 1 | C0FX11 | Based on observation, resident interview, family interview, staff interview, and record review, the facility failed to provide three (3) of twenty-six (26) Stage I dependent residents the necessary services to maintain good grooming and personal hygiene. There was a failure to trim and clean fingernails for three (3) residents and failure to groom facial hair for one (1) of the those (3) residents. Resident identifiers: #102, #208, and #224. Facility census: 26. Findings include: a) Resident #102 During a family interview, on 01/15/13 at 11:26 a.m., the daughter of Resident #102 reported her father's fingernails needed trimmed. An observation, on 01/15/13 at 2:33 p.m., found Resident #102 to have dirty untrimmed fingernails with jagged edges. On 01/17/12, review of the Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/19/12, verified the resident required extensive assistance with personal hygiene. An interview with a registered nurse, Employee #9, on 01/17/13, confirmed Resident #102 needed his fingernails cleaned and trimmed. A follow up observation, on 01/21/13 at 11:30 a.m., again found the resident's nails to be dirty and untrimmed with jagged edges. b) Resident #208 On 01/15/13 at 3:14 p.m., during a family interview, the son of Resident #208 indicated he often had to groom the facial hair off his mother's chin. On 01/21/13 at 12:55 p.m., an observation of Resident #208, revealed she had long chin hair. On 01/21/13 at 1:01 p.m. Employee #1 (nurse aide) said the resident could wash her own face, but would not be able to remove the chin hair on her own. She said she had not trimmed the resident's chin hair. On 01/21/13 at 1:28 p.m., the interim care plan for Resident #208 was reviewed and revealed she needed ongoing assistance with maintaining hygiene. c) Resident #224 On 01/21/13 at 4:45 p.m., observation of the hands of Resident #224 revealed dark brown debris beneath her fingernails and her nails were chipped. Her daughter was at the bedside and said the resident's nails were… | 2016-07-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );