cms_WV
Data source: Big Local News · About: big-local-datasette
160 rows where "filedate" is on date 2017-04-01
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7424 | 7424 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2013-07-12 | 160 | D | 0 | 1 | WFVL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, financial record review, and staff interview, the facility failed to convey the personal account funds of a deceased resident to a legally qualified entity for one (1) of five (5) residents who no longer resided in the facility. The facility issued a check for the balance of the personal funds, after the death of a resident, to the funeral director. The resident had no one appointed to legally handle his finances and/or to make the decision for the disbursement of the resident's funds. Resident identifier: #99. Facility census: 141. Findings include: a) Resident #99 During a review of the records of the personal funds belonging to the residents of the facility, at 11:30 a.m. on [DATE], accompanied by Employees #9 (Finance Director) and #72 (Business Office Manager), Employee #9 was asked to explain the dispersal of funds for Resident #99, after his death. She stated the balance of his account ($1572.35) was paid to the funeral home on [DATE], on the verbal instructions of his family. Both employees acknowledged, after reviewing the records, that Resident #99 had a Health Care Surrogate (HCS), but had made no appointment of a Power of Attorney prior to his death. They affirmed the resident's account included monthly deposits from both Social Security and a private pension. They acknowledged that neither the HCS nor the funeral director had presented documentation which allowed legal acceptance of these funds. An interview was conducted with Employee #121 (Social Service Supervisor) at 3:30 p.m. on [DATE]. She verified Resident #99 had been deemed by his physician to be unable to form his own health care decisions and a HCS (his niece) had been appointed. She stated the niece was advised of the rising balance of the resident's personal fund account and the effect it would have on his Medicaid status. Employee #121 said she was unsure of any final decisions made. Employee #121 verified the resident had only a HCS,… | 2017-04-01 |
| 7425 | 7425 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2013-07-12 | 225 | D | 0 | 1 | WFVL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of complaint files, and staff interview, the facility failed to ensure allegations of mistreatment, neglect, and potential abuse were reported immediately to the appropriate State offices in accordance with State law for three (3) of eight (8) sample residents. In addition, the facility failed to ensure these allegations were thoroughly investigated. Resident #187 alleged neglect, mistreatment, and fear; Resident #30 alleged neglect; and the family of Resident #114 alleged neglect. Although these allegations were reported to facility personnel, the facility did not recognize them as allegations of mistreatment, neglect and potential abuse, and did not act upon them as such. Resident identifiers: #187, #30, and #114. Facility census: 141. Findings include: a) Resident #187 Review of a Resident/Patient Concern Form revealed Resident #187, who was alert and oriented, and indicated as interviewable by the facility, had alleged, on 06/04/13, she had not gotten her shower until very late. She also alleged the new nursing assistant had been very unkind and that she (resident) was afraid to ask her to put her lotions on. This concern was received by Employee #132 (Activity Assistant) and communicated to Employee #24 (RN Supervisor). This allegation was not reported to the appropriate State offices as required and there was no evidence a thorough investigation was completed. According to the concern form, the resident was interviewed on 06/04/13 by Employee #121 (Social Worker) and again on 06/06/13, by Employee #24. There was no evidence that any staff or the resident's roommate were interviewed about the incident. The only action recorded was that the resident was interviewed. Employee #24 did state on the form that she would . let the 3-11 CNA's (nursing assistants) aware of her preferences. The above concern was discussed with the Administrator, the Director of Nurses, and the Corporate Consultant at 4:30 p.m… | 2017-04-01 |
| 7426 | 7426 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2013-07-12 | 241 | E | 0 | 1 | WFVL11 | Based on observation and staff interview, the facility failed to promote resident dignity during dining. There were designated dining areas, but they were used for storage of resident equipment. The dining areas were not maintained in a manner which promoted a comfortable and homelike dining experience for residents. In addition, the areas were not conducive to socialization and enjoyable mealtime experiences. This practice had the potential to affect more than a limited number of residents. Facility census 141. Findings include: a) On 07/08/13 at 12:05 p.m., observation of the facility revealed all wings had designated dining rooms at the end of each hall. These dining rooms were away from the nursing station. Neither the dining rooms nor residents in the rooms could be observed without walking to the end of the wings. The entire room could not be observed without actually stepping into the room. Although these rooms were identified by the facility as dining areas, observations revealed the purpose of these rooms was not apparent. The rooms contained tables without chairs, resident equipment, and activity supplies. These rooms looked like storage rooms, not dining areas. On 07/08/13, 07/09/13 and 07/10/13 Wings 1, 2, and 3 were each observed with multiple wheelchairs, geri-chairs, and Hoyer lifts stored in the designated dining rooms. Nursing care staff did not prepare these rooms for dining prior to service of the meal trays. During an interview with the director of nursing (DON) at 1:00 p.m. on 07/09/13, she stated all residents on a unit had the option to eat in the activity room on that unit. The DON explained that these trays all arrived at the same time. She said there were no separate meal times for residents who needed assistance to eat or required feeding. At 5:00 p.m. on 07/10/13, an interview was conducted with the director of nursing, (DON), the administrator, and a corporate consultant, Employee #216. Concerns were expressed relative to the absence of fine dining in the facility, and a lack of a hom… | 2017-04-01 |
| 7427 | 7427 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2013-07-12 | 252 | E | 0 | 1 | WFVL11 | Based on observations and staff interview, the facility failed to create a homelike environment for dining which de-emphasized the institutional character of the facility. The dining areas were used for storage of resident care items. This was not an environment that enhanced residents' quality of life during meals. This practice had the potential to affect more than an isolated number of residents. Facility Census 141. Findings include: a) On 07/08/13 at 12:05 p.m., observation of the facility revealed all wings had designated dining rooms at the end of each hall. Although these rooms were identified by the facility as dining areas, observations revealed the purpose of these rooms was not apparent. The rooms contained tables without chairs, resident equipment, and activity supplies. These rooms looked like storage rooms, not dining areas. On 07/08/13, 07/09/13 and 07/10/13 Wings 1, 2, and 3 were each observed with multiple wheelchairs, geri-chairs, and Hoyer lifts stored in the designated dining rooms. Nursing care staff did not prepare these rooms for dining prior to service of the meal trays. At 5:00 p.m. on 07/10/13, an interview was conducted with the director of nursing, (DON), the administrator, and a corporate consultant, Employee #216. Concerns were expressed relative to the absence of fine dining in the facility, and a lack of a homelike environment in the designated dining areas. The rooms looked like storage areas. They did not have the appearance of designated dining areas for attractive, homelike resident dining. An environmental tour of Wings 5, 6 and 7, on 07/11/13 between 8:40 a.m., and 9:20 a.m., revealed these designated dining areas were also used for storage of resident equipment. There were wheelchairs, geri-chairs, and Hoyer lifts stored in the rooms. Some table chairs were stored against the wall. The Wing 3 dining area also had a bed stored in the room. The Wing 3 observation revealed a male resident sitting in a chair, by the wall and behind a table, with storage all around him. In addit… | 2017-04-01 |
| 7428 | 7428 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2013-07-12 | 280 | D | 0 | 1 | WFVL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to evaluate and revise a care plan after a status change for one (1) of three (3) residents evaluated for nutrition in a Stage 2 sample of thirty-six (36). The care plan for Resident #199 was not revised after the resident experienced significant weight losses. The interdisciplinary team did not identify the need for a revision in the resident's care plan. Resident identifier: #199. Facility census: 141. Findings include: a) Resident #199 On 07/10/13 at 8:20 a.m., a record review was conducted for Resident #199. This revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Each of these [DIAGNOSES REDACTED]. The record review also showed the resident was receiving a diuretic daily for her [MEDICAL CONDITION], as well as an antibiotic for [MEDICAL CONDITION]. A review of the weight chart showed the resident's weight on 02/18/13 was 155 pounds (lbs.). On 03/04/13 her weight was 151 lbs. The resident's weight on 03/15/13 was 145 lbs. This was a severe weight loss of 6.3% in eleven (11) days. The resident's care plan was not revised to reflect the severe weight loss. There was a review, with a date of 03/01/13, prior to the weight taken on 03/15/13. The next review date was 06/07/13. The weight loss was not identified on the care plan on this date. The resident continued to lose weight. On 04/03/13 her weight was 152 lbs. On 05/07/13 her weight was 142 lbs. Med Pass (a dietary supplement) was added three (3) times daily on 05/23/13; however, the care plan did not indicate the reason the supplement was added. The care plan did not indicate the resident was experiencing significant weight losses. The only weight noted on the care plan was 155 lbs. This was what the resident weighed on 02/18/13, which was the resident's first recorded weight after admission on 02/14/13. The resident's care plan contained no goals and interventions specifically related to weight lo… | 2017-04-01 |
| 7429 | 7429 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2013-07-12 | 329 | D | 0 | 1 | WFVL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the medication regimen for two (2) of ten (10) residents reviewed for unnecessary medications were free from unnecessary medications. Residents #66 and #111 each had a physician's orders [REDACTED]. Resident #66 had a PRN order for [MEDICATION NAME]/APAP 5-325 mg every four (4) hours without an indication for administration. Resident #111 had a PRN order for [MEDICATION NAME] 10 mg daily without an indication for administration. Resident identifiers: #66 and #111. Facility census: 141. Findings include: a) Resident #66 Review of the medical record, on 07/10/13 at 3:43 p.m., revealed Resident #66 received forty-two (42) doses of [MEDICATION NAME]/APAP 5-325 mg between 06/01/13 and 07/10/13. The order was for PRN use, but contained no indication for its administration. The Medication Administration Record [REDACTED]. The reason/indication for use of this medication was not given. An interview was conducted with Employee #35, a licensed practical nurse (LPN), on 07/10/03 at 3:51 p.m. She reviewed Resident #66's record and agreed the MAR indicated [REDACTED]. On 07/11/13 at 10:30 a.m., the administrator, Employee #144, presented a hand written order dated 12/05/12 and signed by the physician on 12/08/12. It stated, [MEDICATION NAME] 5/325 by mouth every four hours as needed for pain. Although the [MEDICATION NAME] had an indication for use on 12/05/12, the current order on the MAR indicated [REDACTED]. The administrator confirmed this information was not included on the current MAR for the administration of the PRN [MEDICATION NAME]/APAP. b) Resident #111 Review of the Medication Administration Record [REDACTED]. The order was for PRN use, but contained no indication for its administration. The MAR indicated [REDACTED]. An interview was conducted with Employee #35 on 07/10/03 at 3:51 p.m. She verified the current MAR indicated [REDACTED]. She stated it was for itchi… | 2017-04-01 |
| 7430 | 7430 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2013-07-12 | 371 | F | 0 | 1 | WFVL11 | Based on observation and staff interview, the facility failed to ensure foods were handled and stored using methods which reduced the risk of food contamination and/or foodborne illness. A dietary staff member handled food items with gloves which had been used to handle non-food items, and undated opened foods were stored in the nourishment pantries. These practices had the potential to affect all residents who received foods from the main kitchen area and nourishment pantries. Facility census: 141. Findings include: a) Dietary observations were completed as part of the initial tour, on 07/08/13 at lunch time. A dietary cook was observed using the same gloves to handle both food and non-food items. The staff member handled buns and meats for sandwiches, touched the outside wrapper of wheat bread, then returned to handling food items again. This practice had the potential to lead to cross contamination of the food. At the time of the observation, this was verified with Employee #155, the dietitian. The dietitian was in agreement this was not an acceptable practice. b) During a tour of the nursing home environment at 9:15 a.m. on 07/11/13, the following storage infractions were observed in the snack/nourishment refrigerators: -100 unit: Gallons of milk and quart containers of Thick & Easy were opened and re-sealed with no date indicating when they were opened. -200 unit: Gallons of milk and quart containers of Thick & Easy were opened and re-sealed with no date indicating when they were opened. -300 unit: Gallons of both chocolate and white milk and quart containers of Thick & Easy were opened and re-sealed with no date indicating when they were opened. -700 unit: Gallon containers of both chocolate and white milk and quart containers of Thick & Easy were opened and re-sealed with no date indicating when they were opened. In addition, a container of lemonade was opened and resealed, and the label on the bottle was dated 02/25/13. -800 unit: Three (3) quart containers of Thick & Easy juices and a gallon each of choc… | 2017-04-01 |
| 7431 | 7431 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2013-07-12 | 428 | D | 0 | 1 | WFVL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the consultant pharmacist failed to identify and report medication irregularities for two (2) of ten (10) Stage 2 residents reviewed for unnecessary medications. The current medication administration records (MARs) for these residents did not contain indications for the administration of as needed (PRN) medications. Residents #66 and #111 each had a physician's orders [REDACTED]. Resident #66 had a PRN order for Oxycodone/APAP 5-325 mg every four (4) hours without an indication for administration. Resident #111 had a PRN order for Loratadine 10 mg daily without an indication for administrationResident #66 had an as needed order for Oxycodone/APAP 5-325 mg and is receiving the medication without a documented indication for administration. Resident #111 is receiving Loratadine 10 mg as needed without a documented indication for administration. The consulting pharmacist failed to identify these irregularities and report them as required by this regulation. Resident identifiers: #66 and #111. Census: 141. Findings include: a) Resident #66 Review of the medical record, on 07/10/13 at 3:43 p.m., revealed Resident #66 received forty-two (42) doses of Oxycodone/APAP 5-325 mg between 06/01/13 and 07/10/13. The order was for PRN use, but contained no indication for its administration. The Medication Administration Record [REDACTED]. The reason/indication for use of this medication was not given. An interview was conducted with Employee #35, a licensed practical nurse (LPN), on 07/10/03 at 3:51 p.m. She reviewed Resident #66's record and agreed the MAR indicated [REDACTED]. On 07/11/13 at 10:30 a.m. the administrator, Employee #144, presented a hand written order dated 12/05/12 and signed by the physician on 12/08/12. It stated, Percocet 5/325 by mouth every four hours as needed for pain. Although the Percocet had an indication for use on 12/05/12, the current order on the MAR indicated [REDACTED]. The… | 2017-04-01 |
| 7432 | 7432 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2013-07-12 | 441 | D | 0 | 1 | WFVL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of policies and procedures, and medical record review, the facility failed to maintain an infection control program to control, to the extent possible, the onset and spread of infection in the facility related to one (1) of two (2) sample residents who tested positive for Methicillin Resistant Staphylococcus Aureus (MRSA). Resident #127 had MRSA in a weeping leg wound. The facility failed to place this resident on contact isolation as required by their policies and procedures. The implementation of transmission - based precautions (isolation precautions), when they are indicated, in addition to standard precautions, is a critical component of the infection prevention and control program in order to prevent or control the spread of infections. Resident identifier: #127. Facility Census: 141. Findings include: a) Resident #127 A review of this resident's medical record was conducted throughout the survey. The physician progress notes [REDACTED]. and Ext: (symbol for no) blistering, but dry. On 06/06/13 a treatment was put into place: Cleanse bilateral lower legs with soap and water, apply [MEDICATION NAME] and abd pads and Kling qd (daily) and prn (as needed). Underneath this order on the same line of the treatment sheet was a hand written order for A&D ointment to legs. A History and Physical dated 06/24/13, from an acute care facility stated, The patient does have a history of MRSA of the nares, as noted, in prior HPI . Nursing Progress Notes, dated 06/28/13 at 11:00 a.m. stated, (acute care facility) called to say the residents L leg wound is positive for MRSA. No special precautions needed at this time except keep drainage contained. The wound culture final results, dated 06/28/13, indicated the wound tested positive for MRSA. There was a hand written note in the corner that said, likely colonization with MRSA. OK not to treat. A weekly skin measurement tool dated 07/07/13 described, Bilateral l… | 2017-04-01 |
| 7433 | 7433 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2013-07-12 | 463 | E | 0 | 1 | WFVL11 | Based on observation and staff interview, the facility failed to ensure each resident using the toilet had a means of directly contacting caregivers in four (4) of twenty (20) resident bathrooms reviewed. The call light cords were less then six (6) inches long, making them not easily reachable in these bathrooms. This practice had the potential to affect more than an isolated number of residents. Rooms #102, #103/104, #209, and #602. Facility census: 141. Findings include: a) During the initial tour of the facility, at 11:30 a.m. on 07/08/13, the call light cord in the bathroom serving Rooms #103 and #104 was observed too short to be easily reachable (it was six (6) inches or less), especially by a resident who had fallen to the floor. A subsequent tour, at 10:10 a.m. on 07/11/13, accompanied by the Maintenance Director (Employee #55) revealed three (3) additional bathrooms (for Rooms #102, #209, and #602) with call cords less than six (6) inches long. Employee #55 acknowledged the cords were supposed to reach almost to the floor and these did not. He stated all bathroom call lights would be immediately checked and replaced as needed. | 2017-04-01 |
| 7434 | 7434 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2013-07-12 | 514 | D | 0 | 1 | WFVL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined the facility failed to ensure complete and accurate medical records for two (2) of thirty-six (36) residents reviewed. There was no order for hospice services for Resident #160, and the Health Care Surrogate document for Resident #98 was not complete. Resident identifiers: #160 and #98. Facility census: 141. Findings include: a) Resident #160 This resident was admitted on [DATE] with a physician's orders [REDACTED]. Hospice completed the consultation and provided orders for medications. Those orders were later clarified. There was never an order for [REDACTED]. On 07/10/13 at 10:06 a.m., this was discussed with a registered nurse, Employee #130. The nurse was going to attempt to find an original order permitting hospice to provide care. On 07/12/13 the administrator, Employee #144, provided an order, dated 05/11/12, which contained a clarification of hospice services. At the time of the survey, the resident did not have a physician's orders [REDACTED]. In addition, the facility was unable to provide evidence there was ever a physician's orders [REDACTED]. b) Resident #98 A review of medical records revealed Resident #98 was admitted on [DATE]. There was a Designation of Surrogate Decision Maker form in the medical record indicating the daughter was appointed as the Health Care Surrogate (HCS) for the resident; however, there was no date indicating when this HCS was appointed by the physician. During an interview with Employee #121 (Social Service Supervisor) at 3:30 p.m. on 07/10/13, she stated the daughter had made all care decisions for the resident since admission. This was verified by reviewing entries in the medical record, although a progress note on 05/23/13, by Employee #121, referred to the daughter as MPOA which she was not. Employee #121 could not verify when the HCS appointment was made. On 07/10/13 at 10:30 a.m., during an interview with Employees #144 (Adminis… | 2017-04-01 |
| 7435 | 7435 | GOLDEN LIVING CENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-10 | 225 | D | 0 | 1 | KU9T11 | Based on a review of the abuse/neglect reportable allegations and staff interview, the facility did not ensure allegations of abuse/neglect were reported to licensing boards as required by State law. One (1) of five (5) allegations of abuse/neglect involved the termination of a licensed practical nurse (LPN). The facility did not report this allegation and outcome of the investigation to the LPN board. Resident identifier: #110. Facility census: 92. Findings include: a) Resident #110 On 04/10/13 at 2:04 p.m., the social worker (Employee #56) provided a binder containing the abuse/neglect reportable allegations. After reviewing five (5) allegations it was determined, the facility had not reported one (1) allegation of abuse to the LPN board. According to the reports, on 01/14/13 the facility investigated an allegation of abuse involving alleged victim, Resident #110, and alleged perpetrator, an LPN, Employee #101. The allegation stated, Reported by another employee that this LPN told Resident to go ask an agitated resident what was wrong. The agitated Resident then threw water on (Resident #110). The outcome/results of the investigation included, (Resident #110) did have water thrown on him by co -resident. The corrective action by the facility was, Employee was suspended pending investigation. Employee being terminated related to steps in progressive disciplinary action. During an interview on 04/04/13 at 12:30 p.m., the social worker (Employee #56) confirmed the facility had not reported this issue to the LPN board. The abuse/neglect reporting requirements for West Virginia nursing homes and nursing facilities (revised October 2011) requires allegations of abuse, neglect and/or misappropriation of property where the alleged perpetrator is a licensed professional, be reported to the individual's licensing board. | 2017-04-01 |
| 7436 | 7436 | GOLDEN LIVING CENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-10 | 241 | D | 0 | 1 | KU9T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to promote dignity and respect during the provision of care for one (1) of thirty-six (36) Stage 2 sample residents. A nurse administered this resident's insulin injection in a hallway near the nurses' station. Resident identifier: #89. Facility census: 92. Findings include: a) Resident #89 During a random observation, on 04/02/13 at 8:45 a.m., Employee #81, a nurse, was observed administering an injection of insulin into the right arm of Resident #89. Both were standing in the hallway near the nurses' station on the East wing. Medical record review, on 04/03/13 at 10:00 a.m., revealed this resident had a [DIAGNOSES REDACTED]. During an interview with Resident #89, on 04/04/13 at 10:00 a.m., she was unable to give any information related to her insulin injections. An interview was conducted with the assistant director of nursing, Employee #49, on 04/10/13 at 10:40 a.m. She said nurses were supposed to administer insulin injections in the resident rooms. She said they were not allowed to give injections in such places as the dining room or hallways, as that would be a dignity issue. During an interview with the administrator, director of nursing, and clinical consultant, Employee #102, on 04/10/13 shortly before noon, the latter acknowledged she witnessed Resident #89 receiving the insulin injection in the hallway on 04/03/13, but she was not close enough to intervene. She and the administrator acknowledged it was not company policy to give injections in public. | 2017-04-01 |
| 7437 | 7437 | GOLDEN LIVING CENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-10 | 253 | E | 0 | 1 | KU9T11 | Based on observation, staff interview, and an anonymous complaint, the facility failed to maintain an environment free of persistent lingering offensive odors in the rooms and hallways near rooms 106, 137, and 138. In addition, the facility failed to ensure maintenance and housekeeping services for two (2) shower/tub rooms, each between two (2) resident rooms. These practices had the potential to affect more than a limited number of residents. Facility census: 92. Findings Include: a) Upon initial tour of the facility, on 04/01/13 at 12:30 p.m., the hallways of the facility were noted to have offensive odors. An anonymous complaint was received by the Office of Health Facility and Licensure (OHFLAC) on 04/06/13, in which the complainant stated the facility had an offensive odor. On each day of the survey, persistent offensive odors were noted in the facility, by all five (5) members of the survey team. This odor was specifically noted in the hallways near, and in, rooms 106, 137, and 138. b) During observation of the facility, on 04/08/13 at 3:30 p.m., the bathtub in the shower/tub room for rooms 135 and 137 was rusty, soiled, and had water dripping from the faucet. The bathtub shared by rooms 136 and 138 was also rusty and soiled. The shower/tub rooms were used to store unrelated items. Each room was in need of housekeeping services. A registered nurse, Employee #17, observed these shower/tub rooms on 04/08/13 at 3:45 p.m. and confirmed the identified maintenance and housekeeping issues. | 2017-04-01 |
| 7438 | 7438 | GOLDEN LIVING CENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-10 | 254 | D | 0 | 1 | KU9T11 | Based on observation and staff interview, the facility failed to ensure residents' bed linens were in good condition. The beds for four (4) of ninety two (92) residents had bed linens that were worn and had holes in them. Resident identifiers: #45, #86, #101, and #109. Facility census: 92. Findings include: a) Residents #45, 86, #101, and #109 On 04/10/13 at 11:00 a.m., an observation of these residents' linens revealed the fitted sheets were worn and had holes in them. On 04/10/13 at 11:15 a.m., during an interview with the executive director (Employee #13) and the clinical services consultant (Employee #102) regarding the condition of the residents' bed linens, neither disagreed the sheets were in poor condition. By the time of exit, no further information was provided regarding the condition of the fitted sheets. | 2017-04-01 |
| 7439 | 7439 | GOLDEN LIVING CENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-10 | 272 | D | 0 | 1 | KU9T11 | Based on a review of the medical record, minimum data set assessment (MDS), and staff interview, the facility did not ensure the accuracy of the MDS assessment for one (1) of thirty six (36) Stage II residents. Resident #21's quarterly assessment incorrectly indicated the resident had broken or ill-fitting dentures. The resident did not have dentures. Resident identifier: #21. Facility census: 92. Findings include: a) Resident #21 On 04/08/13 at 2:45 p.m., a review of Resident #21's quarterly MDS assessment, assessment reference date 03/22/13, Section L0200, indicated the resident had loosely or broken fitting full or partial dentures. On 04/08/13 at 3:00 p.m., Employee #75 (registered nurse/assessment coordinator) indicated she looked in the resident's mouth and verified the resident did not wear dentures. She said the MDS assessment, Section L0200, was coded incorrectly. | 2017-04-01 |
| 7440 | 7440 | GOLDEN LIVING CENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-10 | 278 | D | 0 | 1 | KU9T11 | Based on a review of the medical record, minimum data set assessment (MDS), and staff interview, the facility did not ensure the MDS assessment for one (1) of thirty six (36) Stage II residents accurately reflected the resident's status. Resident #21's quarterly assessment incorrectly reflected the resident had broken or ill-fitting dentures. The resident did not have dentures. Resident identifier: #21. Facility census: 92. Findings include: a) Resident #21 On 04/08/13 at 2:45 p.m., a review of Resident #21's quarterly MDS assessment, assessment reference date 03/22/13, Section L0200, indicated the resident had loosely or broken fitting full or partial dentures. On 04/08/13 at 3:00 p.m., Employee #75 (registered nurse/assessment coordinator) indicated she looked in the resident's mouth and verified the resident did not wear dentures. She confirmed the MDS assessment, Section L0200, did not correctly reflect the resident's dental status. | 2017-04-01 |
| 7441 | 7441 | GOLDEN LIVING CENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-10 | 279 | D | 0 | 1 | KU9T11 | Based on medical record review and staff interview, the facility failed to develop an accurate comprehensive care plan for two (2) of thirty-six (36) Stage 2 sample residents. Residents #128 and #125 had bladder incontinence which was not addressed in their care plans. Resident identifiers: Residents #128 and #125. Facility census: 92. Findings include: a) Resident #128 On 04/08/13 at 4:50 p.m., a review of Resident #128's medical record revealed the resident experienced bladder incontinence while at the facility. The minimum data set (MDS) admission assessment, with an assessment reference date (ARD) of 11/28/12, indicated the resident was always incontinent of urine. An MDS 30 day assessment, with an ARD of 12/08/12, indicated the resident was frequently incontinent of urine. An MDS 60 day assessment, with an ARD of 01/28/13, indicated the resident was frequently incontinent of urine. An MDS 90 day assessment, with an ARD of 02/28/13, indicated the resident was always incontinent of urine. The nursing progress notes, dated 02/28/13, indicated the resident was occasionally incontinent of bowel and bladder and sometimes used the bathroom with assistance. The nursing progress notes dated 03/01/13 and 03/05/13 indicated the resident was incontinent of urine and sometimes used the bathroom with assistance. The care area assessment (CAA), completed with the admission assessment on 11/28/12, indicated the facility would care plan the area of urinary incontinence to ensure staff were aware of the resident's toileting/incontinence needs. On 04/08/13 at 5:00 p.m., upon inquiry regarding why Resident #128 had no care plan for incontinence, Employee #75 (registered nurse/assessment coordinator) said the facility had care planned the incontinence/toileting needs for this resident until February 2013, then discontinued this area from the resident's care plan. Employee #75 confirmed the resident remained incontinent and needed assistance with toileting. b) Resident #125 Review of a minimum data set (MDS), with an assessment r… | 2017-04-01 |
| 7442 | 7442 | GOLDEN LIVING CENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-10 | 280 | D | 0 | 1 | KU9T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise the comprehensive care plan for one (1) of thirty-six (36) Stage 2 sample residents who experienced a decline in condition. The care plan in use did not reflect the resident's current status. Resident identifier: Resident #110. Facility census: 92. Findings include: a) Resident #110 Resident #110 had a [DIAGNOSES REDACTED]. Medical record review, on 04/04/13, found nursing notes, dated 03/10/13 and 03/11/13, that described conversations between nursing and the representative of Resident #110 regarding resident condition and possible hospice consult. At that time, it was determined the resident would have a hospice referral for palliative care and pain management if need be. A social services note, dated 03/26/13, included . he has had a significant emotional change. Resident has also had physical decline and is now palliative care. On 04/02/13, another social services note stated Resident needs much encouragement he is depressed and receiving palliative care. Review of current care plan found no indication of any decline in the resident's condition, the provision of palliative care services, or that he was a potential hospice candidate. There was nothing in the care plan addressing a decline in functioning. In fact, one goal regarding physical functioning was I will improve my current level of physical functioning. This concern was discussed with the MDS Coordinator on 04/09/13 at 12:00 p.m. She was unable to provide information the care plan was revised after the resident's change in condition. | 2017-04-01 |
| 7443 | 7443 | GOLDEN LIVING CENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-10 | 312 | D | 0 | 1 | KU9T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and medical record review, the facility failed to provide services to maintain good personal hygiene for one (1) of six (6) sampled residents who required staff assistance. Resident #110 had dried blood on his left cheek and left hand for a prolonged period of time. Resident identifier: Resident #110. Facility census: 92. Findings include: a) Resident #110 Review of the medical record, regarding this resident's departure time from [MEDICAL TREATMENT] on 04/02/13, found Resident #110 completed [MEDICAL TREATMENT] at 15:30 (3:30 p.m.). A nursing note, written on 04/02/13 stated, Transport reports [MEDICAL TREATMENT] center stated that resident had scratched his face while at their facility. Observation of Resident #110, in the dining room at 4:30 p.m. on 04/02/13, found the resident had several small scabs on his left cheek and dried blood covering the cheek. Observation of his left index and middle fingers revealed they were almost entirely covered in dried blood. Resident #110 was interviewed, at 4:45 p.m. on 04/02/13, regarding the blood and he said, I know, the girls told me. He verified facility staff members were aware of the dried blood. He was observed as he continued to sit in the dining room and was served his evening meal. No one provided the resident assistance to remove the blood from his face and hand. According to the most recent Minimum Data Set assessment, of 02/09/13, this resident required extensive assistance of one (1) staff member for personal hygiene. His current care plan also stated he required extensive assistance of one (1). This matter was discussed with Employee #82, who was responsible for infection control on 04/10/13 at 8:45 a.m. | 2017-04-01 |
| 7444 | 7444 | GOLDEN LIVING CENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-10 | 323 | D | 0 | 1 | KU9T11 | Based on observation and staff interview, the facility failed to ensure the residents' environment was as free of accident hazards as possible. A medication was left in a clear plastic cup on a resident's over-the-bed table. Resident identifier: #96. Facility census: 92 Findings include: a) Resident #96 Observation before, during, and after a medication pass with a nurse (Employee #33) on 04/02/13, revealed an unidentified white pill in a clear plastic medication cup on Resident #96's over-the-bed table. This medication was not observed by the nurse prior to surveyor intervention. Employee #33 said it was not a medication she had given the resident. she said it was a medication left from some other medication pass. Employee #33 said she would dispose of the medication, which she believed was a cholesterol lowering drug. This resident resided in a four (4) bed room. In addition, there were ambulatory residents who resided in the facility. During an interview with the administrator, director of nursing, and clinical consultant (Employee #102), on 04/10/13 shortly before noon, no further information was provided. | 2017-04-01 |
| 7445 | 7445 | GOLDEN LIVING CENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-10 | 329 | D | 0 | 1 | KU9T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of unnecessary medications for ten (10) residents, and staff interviews, the facility failed to ensure one (1) of ten (10) residents was free from unnecessary medications. The facility did not monitor the use of a medication for clinically significant side effects or consequences as the result of using the medication. The facility did not obtain blood glucose levels as ordered by the physician, for a resident on a prescribed medication known to increase blood glucose levels. Resident #83. Facility census: 92. Findings Include: a) Resident #83 Review of medical records, on 04/09/13 at 10:20 a.m., revealed a physician order [REDACTED]. [MEDICATION NAME] is a medication known to increase blood glucose levels. Further review of medical records revealed the resident's glucose was checked on 10/01/12 at 6:36 a.m., prior to the physician's orders [REDACTED]. No additional blood glucose levels were found in the medical record review. At 10:40 a.m., a registered nurse, Employee #82, stated she was also unable to find the blood glucose level results, as ordered by the physician. At 10:50 a.m., a registered nurse, Employee #33, also stated the blood glucose level was not documented in the e-mar. No evidence was presented to indicate the blood glucose levels were completed as ordered. | 2017-04-01 |
| 7446 | 7446 | GOLDEN LIVING CENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-10 | 334 | D | 0 | 1 | KU9T11 | Based on medical record review, staff interview, and policy review, the facility failed to ensure one (1) of six (6) residents reviewed received the influenza vaccine in 2012. There was a consent to administer the vaccine; however, there was no documented evidence this vaccine was administered. Resident identifier: #87. Facility census: 92. Findings include: a) Resident #87 Review of the medical record, on 04/10/13 at 10:00 a.m., revealed a consent form signed by the resident's medical power of attorney (MPOA) in September 2012 consenting to the administration of the influenza vaccine. Further record review found no evidence Resident #87 received the influenza vaccine during or after September 2012. During an interview with the infection control nurse, Employee #82, on 04/10/13 at 10:15 a.m., she said she recalled giving Resident #87 an influenza vaccination in October 2012, but could produce no evidence other than by memory. She said she wrote the resident's name down on a worksheet, and knew she must have given the vaccination. An interview was conducted with the administrator on 04/10/13 at 10:30 a.m. She clarified that Employee #82 had written, on her own personal worksheet, that she gave the vaccination, but failed to transfer that data to the computer or to the medical record. The administrator produced a copy of the facility's Influenza/Pneumococcal Immunization Guideline. According to page three (3), The immunization log is to be maintained on the resident's current medical record. Items to be documented included the type of vaccine, the date it was administered, who administered, and the lot number. | 2017-04-01 |
| 7447 | 7447 | GOLDEN LIVING CENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-10 | 371 | E | 0 | 1 | KU9T11 | Based on observation, staff interview, and policy review, the facility failed to store food items in the dietary department in a manner which ensured they were used by a date in which they remained safe to use. The facility's kitchen had opened foods which were not dated to indicate when they were opened. This practice had the potential to affect more than an isolated number of residents who received nourishment from the dietary department. Facility census: 92. Findings include: a) Observations of the kitchen, on 04/01/13, revealed the following: 1) At 12:19 p.m. an undated open container of beef base was observed. During an interview with Employee #97 (cook) and Employee #55 (cook), at 12:20 p.m., they both confirmed the beef base did not have a date. The employees stated the opened food item was supposed to be dated. 2) An observation in the freezer, at 12:21 p.m., revealed a bag of stir-fry and a bag of beef meatballs which did not have dates indicating when they were opened for use. 3) At 12:30 p.m. a bag of opened Hershey chocolate chips was observed. It did not have a date indicating when it was opened for use. 4) On 04/01/13 at 12:35 p.m., a tour of the kitchen was completed with the consultant dietitian (Employee #101). Another tour was completed with the dietary manager on 04/01/13 at 2:00 p.m. They were shown the items of concern, and both confirmed the opened items should have been dated. | 2017-04-01 |
| 7448 | 7448 | GOLDEN LIVING CENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-10 | 441 | E | 0 | 1 | KU9T11 | Based on observation, staff interview, resident interview, and medical record review, the facility failed to maintain an environment free from potential spread of pathogens. Resident #110, with dried blood on his face and hand, went without timely staff intervention. This is true for one (1) of thirty five (35) Stage I residents observed. The facility also failed to store reusable bedpans in a sanitary manner in rooms. This is true for two (2) of thirty eight (38) rooms observed. Resident identifier #110. Room identifiers 106 and 108. Facility census: 92. Findings include: a) Resident #110 Review of the medical record regarding the departure time from dialysis on 04/02/13 found Resident #110 had completed dialysis at 15:30 (3:30 p.m.). A nursing note, written on 04/02/13 stated Transport reports Dialysis center stated that resident had scratched his face while at their facility. Observation of Resident #110 in the dining room at 4:30 p.m. found the resident had several small scabs on his left cheek and dried blood covering the cheek. His left index and middle fingers were almost entirely covered in dried blood. Resident #110 was interviewed at 4:45 p.m. regarding the blood and he said, I know, the girls told me. He verified that he was indicating facility staff members were aware of the dried blood. He was observed as he continued to sit in the dining room and was served his evening meal without receiving assistance to remove the blood from his face and hand. According to the most recent Minimum Data Set assessment of 02/09/13, this resident required the extensive assistance of one (1) staff member for personal hygiene. His current care plan also stated he required the extensive assistance of one (1) for personal hygiene. This matter was discussed and confirmed with Employee #82, who is responsible for infection control, on 4/10/13 at 8:45 a.m. | 2017-04-01 |
| 7449 | 7449 | GOLDEN LIVING CENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-10 | 514 | D | 0 | 1 | KU9T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a complete, accurately documented clinical record for two (2) of thirty-six (36) Stage 2 sample residents. There was no documentation Resident #87 was receiving showers daily. Additionally, there was no documentation Resident #122 was receiving assistance with a bowel and bladder program. Resident identifier: #122 and #87. Facility census: 92. Findings include: a) Resident #122 Medical record review, on 04/08/13 at 2:00 p.m., revealed a physician's orders [REDACTED]. The order also included the resident was to be provided incontinence care every shift and whenever needed. Interview with Employee #54, a nursing supervisor, on 04/08/13 at 5:14 p.m., revealed she placed the resident on the bowel and bladder program on 02/04/13, due to the resident's incontinence. Review of the resident's continence by shift report, on 04/08/13 at 5:30 p.m., revealed the resident was incontinent of urine on a daily basis from 01/15/13 through 04/03/13. The resident's nursing assistant flow sheet, for taking the resident to the toilet, was reviewed on 04/09/13 at 9:00 a.m. There was no documented evidence staff took the resident to the toilet before meals and at bedtime, providing incontinence care every shift and whenever needed. There was also no documentation on the nursing assistant flow sheet, from the start date of 02/04/13 through 03/31/13. The nursing assistant flow sheet had initials of nursing staff only on 04/01/13 through 04/03/13. The resident was discharged on [DATE]. On 04/09/13 at 2:15 p.m., Employee #54, nurse supervisor, and Employee #20, the coordinator of health information (CHI) were interviewed. When asked about nursing assistant flow sheets from 02/04/13 through 03/31/13, regarding documentation of toileting Resident #122, they confirmed the flow sheets could not be found for Resident #122. They stated they had no documented evidence Resident #122 received this… | 2017-04-01 |
| 7450 | 7450 | WEIRTON GERIATRIC CENTER | 515037 | 2525 PENNSYLVANIA AVENUE | WEIRTON | WV | 26062 | 2013-06-06 | 272 | D | 0 | 1 | L2MN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, and staff interview, the facility failed to comprehensively assess 3 residents (#101, 113, and 138) out of 26 residents whose comprehensive assessments were reviewed. Findings include: a) Resident #101 This resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #101 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] and the annual MDS assessment dated [DATE] both indicated there was no dental caries or dental issues listed in section L (Dental) on the assessments. The medical record was reviewed and indicated the resident was seen by dentist on 1/2/13. The dentist recommended the extraction of all of the resident's teeth and a denture be made. The dentist prescribed an antibiotic for a dental infection. The resident was seen again by the dentist on 6/4/13. The dentist's progress note indicated the resident had numerous fractured and decayed teeth. The dentist prescribed an antibiotic for a dental infection. On 6/6/13 at 11:00 A.M., MDS nurse #171 was interviewed. The MDS nurse verified the resident was seen by the dentist on 1/2/13 for dental caries and was treated with antibiotics for a dental infection. The MDS nurse verified the annual MDS and the quarterly MDS assessments were not accurate and did not include the resident's dental caries on Section L. The MDS nurse verified an oral assessment should have been completed and included on both MDS assessments dated 1/2/13 and 4/13/13. b) Resident #113 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was dependant on the staff for bed mobility and transfer. The MDS did not indicate the resident used any type bed rails or chair that may prevent rising. The medical record was reviewed. There was no assessment of the bed side rails or the Geri-Chair that would have indicated if the devices were used for be… | 2017-04-01 |
| 7451 | 7451 | WEIRTON GERIATRIC CENTER | 515037 | 2525 PENNSYLVANIA AVENUE | WEIRTON | WV | 26062 | 2013-06-06 | 282 | D | 0 | 1 | L2MN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, and staff interviews, the facility failed to implement one resident's (#125) plan of care related to nutrition out of 3 residents who were reviewed for nutrition out of 7 residents with concerns related to significant weight loss since admission. Findings include: a) Resident #125 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) assessment dated [DATE] indicated the resident required set up only for eating and was not on a physician's prescribed weight loss regimen. The medical record was reviewed and the resident's weights were as follows: The Admission Weights for this resident are: Weight at Admission (05/03/2013): 79 Weight at 15 days after Admission on (05/17/2013): 74 (which is 5 pounds less than at Admission or a 6.3% weight loss) Weight at 30 days after Admission on (06/01/2013): 75 (which is 4 pounds less than at Admission or a 5.1% weight loss). The Dietician assessed the resident on 5/8/13. The progress note indicated an initial assessment. The resident was on a regular diet, the resident's oral intakes were good and the resident weighed 79 pounds. The resident's body mass index was 15.4 which indicated the resident was underweight and at risk for skin breakdown. On 5/23/13 the Dietician re-assessed the resident due to significant weight loss. The resident had an 8.7% weight loss in one week, a 6.3% weight loss in two weeks and the resident's current body weight was 74 pounds. The Dietician documented the resident's oral intake had declined with some meal refusals. The Dietician documented that per the staff the resident was taking fluids better than food and liked juice versus milk products. The Dietician recommended adding a supplement Ensure clear or [MEDICATION NAME] one box to all meal trays to increase calories and continue to monitor for changes. On 5/23/13 the [MEDICATION NAME]/Ensure clear one box to all meal… | 2017-04-01 |
| 7452 | 7452 | WEIRTON GERIATRIC CENTER | 515037 | 2525 PENNSYLVANIA AVENUE | WEIRTON | WV | 26062 | 2013-06-06 | 325 | D | 0 | 1 | L2MN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, and staff interviews, the facility failed to provide appropriate care and services related for one resident's (#125) related to nutrition out of 3 residents who were reviewed for nutrition out of 7 residents with concerns related to significant weight loss since admission. Findings include: a) Resident # 125 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) assessment dated [DATE] indicated the resident required set up only for eating and was not a physician's prescribed weight loss regimen. The medical record was reviewed and the resident's weights were as follows: The Admission Weights for this resident are: Weight at Admission (05/03/2013): 79 Weight at 15 days after Admission on (05/17/2013): 74 (which is 5 pounds less than at Admission or a 6.3% weight loss) Weight at 30 days after Admission on (06/01/2013): 75 (which is 4 pounds less than at Admission or a 5.1% weight loss). The Dietician assessed the resident on 5/8/13. The progress note indicated an initial assessment and the resident was on a regular diet, the resident's oral intakes were good, the resident weighed 79 pounds, a body mass index was 15.4 which indicated the resident was underweight and at risk for skin breakdown. On 5/23/13 the Dietician re-assessed the resident due to significant weight loss. The resident had an 8.7% weight loss in one week, a 6.3% weight loss in two weeks and the resident's current body weight was 74 pounds. The Dietician documented the resident's oral intake had declined with some meal refusals. The Dietician documented that per the staff the resident was taking fluids better than food and liked juice versus milk products. The Dietician recommended adding a supplement Ensure clear or [MEDICATION NAME] one box to all meal trays to increase calories and continue to monitor for changes. On 5/23/13 the [MEDICATION NAME]/Ensure clear one box… | 2017-04-01 |
| 7453 | 7453 | WEIRTON GERIATRIC CENTER | 515037 | 2525 PENNSYLVANIA AVENUE | WEIRTON | WV | 26062 | 2013-06-06 | 329 | D | 0 | 1 | L2MN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure that 3 residents (#27, 138, and 142) received appropriate drug monitoring out of 10 residents whose medication regimen was reviewed. Findings include: a) Resident #27 This resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed a recapitulation of physician orders [REDACTED]. Further review of the clinical record revealed an order for [REDACTED]. Review of the clinical record failed to reveal the results of the ordered laboratory tests for the uric acid level and the HgA1c. During an interview conducted on 6/5/2013 at 10:15 am staff member #148, verified the HgbA1c and Uric Acid level laboratory test results were not in the clinical record. She stated the resident returned from the hospital on [DATE] and that the aforementioned laboratory test may have been conducted while resident #27 was in the hospital; however the current clinical record was silent for the lab test results. During an interview conducted on 6/6/2013 at 10:30 am staff member #194 verified the aforementioned laboratory tests were not drawn as ordered by the physician. b) Resident #138 This resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed a recapitulation of physician orders [REDACTED]. Also included were orders to assess and document Routine Vitals: Monitor B/P and pulse as directed. Review of the Medication Administration Records (MARs) for March, April and May 2013 included the order to monitor B/P and pulse every Friday. Further review of the clinical record failed to reveal documentation for the B/P and pulse on the following Fridays: 3/29/13, 4/12/13, 4/25/13, and 5/3/13. During an interview conducted on 6/5/2013 at 3:01 pm staff member #194 verified the lack of blood pressure and pulse monitoring on the aforementioned dates. c) Resident #142 This resident was admitted on [DATE] with [DIAGNOSES R… | 2017-04-01 |
| 7454 | 7454 | WEIRTON GERIATRIC CENTER | 515037 | 2525 PENNSYLVANIA AVENUE | WEIRTON | WV | 26062 | 2013-06-06 | 428 | D | 0 | 1 | L2MN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure that the pharmacist identified irregularities related to drug monitoring for 3 residents (#27, 138, 142) out of 10 residents whose drug regimen was reviewed. Findings include: a) Resident #27 This resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed a recapitulation of physician orders [REDACTED]. Further review of the clinical record revealed an order for [REDACTED]. Review of the clinical record failed to reveal the results of the ordered laboratory tests for the uric acid level and the HgA1c. During an interview conducted on 6/5/2013 at 10:15 am staff member #148, verified the HgbA1c and Uric Acid level laboratory test results were not in the clinical record. She stated the resident returned from the hospital on [DATE] and that the aforementioned laboratory test may have been conducted while resident #27 was in the hospital; however the current clinical record was silent for the lab test results. During an interview conducted on 6/6/2013 at 10:30 am staff member #194 verified the aforementioned laboratory tests were not drawn as ordered by the physician. Review of the Consultant Pharmacist Communication to Physician form dated 5/28/2013 was silent for the missed Hgba1c laboratory test and the missed Uric Acid level laboratory test. During an interview conducted on 6/6/2013 at 10:30 am staff member #194 verified the aforementioned laboratory tests were not drawn as ordered by the physician and verified the lack of identification and reporting of the missed laboratory tests by the consultant pharmacist. b) Resident #138 This resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed a recapitulation of physician orders [REDACTED]. Also included were orders to assess and document Routine Vitals: Monitor B/P and pulse as directed. Review of the Medication Administration Record… | 2017-04-01 |
| 7455 | 7455 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 158 | B | 0 | 1 | TA7B11 | Based on resident interview and staff interview, the facility failed to ensure personal funds are available at all times. The facility does not provide access to resident funds in the evenings or on the weekends. This practice has the potential to affect more than a limited number of residents. Facility census: 113. Findings include: a) On 06/03/13 at 1:47 p.m., Resident #24 stated during a Stage 1 interview she did not have access to her personal funds on the weekends. On 06/11/13 at 4:00 p.m., during an interview with the Administrator, Employee #162, a Consultant, Employee #159, and the Director of Nursing Services, Employee #11, it was revealed resident funds are not available at all times. The Administrator verified resident funds are not available in the evenings or on the weekends unless there is a manager on duty in the facility. | 2017-04-01 |
| 7456 | 7456 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 164 | D | 0 | 1 | TA7B11 | Based on observation and staff interview, the facility failed to ensure the personal privacy of a resident during a physician's visit. During a physician's visit a resident was examined in the hallway and a progress note was dictated at the nurses' station in front of staff and other residents. This was a random observation. Facility census: 113. Findings include: a) Resident #127 On 06/04/13 at 08:30 a.m., Resident #127 was examined in the hallway by a physician (Employee #160). After examining Resident #127, the physician then proceeded to dictate a progress note on a recording device at the nurses' station in front of several other residents and staff. At 9:30 a.m. on 06/04/13, Employee#28, who was present when the physician examined the resident and dictated the progress note, was interviewed regarding the observations. She verified the physician's actions | 2017-04-01 |
| 7457 | 7457 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 225 | E | 0 | 1 | TA7B11 | Based on resident interview, medical record review, observation, and staff interview, the facility failed to ensure allegations of mistreatment, neglect, misappropriation of property, and/or abuse were reported and investigated for six (6) of eight (8) residents reviewed. The family of Resident #43 alleged neglect and verbal abuse. Resident #212 and her family alleged neglect. Resident #61 reported a missing wedding band. Resident #145 alleged verbal abuse. The family of Resident #69 alleged physical abuse. The family of resident #116 alleged neglect. There was no evidence any of these allegations were investigated. In addition, five (5) of six (6) of these allegations were not reported. Resident identifiers: #43, #212, #61, #145, #69, and #116. Facility census: 113 Findings include: a) Resident #43 At 12:30 p.m. on 06/11/13, observation revealed this resident's legal representative approached the nurse supervisor at the north nurses station (Employee #155) with several allegations of neglect. She told the nurse the resident was taken to the dining room for the noon meal without her dentures or glasses. She stated this had happened before and she had reported it before. She stated staff scolds the resident for not eating. She added that the resident would eat if she had her dentures. The representative stated she visited at mealtime because she was concerned about the resident not eating. A review of the medical record revealed Resident #43 weighed 130 pounds on 05/08/13. As of 06/11/13, she had lost to a weight of 125 pounds. Employee #155 retrieved the resident's dentures and glasses from her room and gave them to the aide (Employee #96), who was caring for the resident. The aide apologized to the representative, but said that she had not cared for the resident until that day. Employee #155 filed a Resident Concern Form which was retrieved from the Social Worker (Employee #62) at 9:30 a.m. on 06/12/13. The Resolution documented on the form was to educate staff. There was no evidence of an investigation to deter… | 2017-04-01 |
| 7458 | 7458 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 241 | D | 0 | 1 | TA7B11 | Based on resident interview, medical record review, staff interview, and review of the complaint/concern files, the facility failed to provide care in a manner that maintained residents' dignity, self esteem, and /or self worth. Resident #33 was not groomed as she desired. In addition, grooming was not provided to the resident in a dignified manner. Resident #10 was not provided dignity during dining. The resident waited a long time for a meal, after the resident seated at the same table received her meal. Resident identifiers: #33 and #10. Facility census: 113. Findings include: a) Resident #33 During Stage 1 of the survey, on 06/04/13 at 10:51 a.m., the resident was interviewed and was asked, Do staff treat you with dignity and respect? The resident responded by stating, I was in the shower and a girl just pulled out the fingernail clippers and clipped my nails way too short. While showing her nails, she stated, Just look at this, I don't like my nails too short, this happened a while ago and they are still too short. The resident then stated, She pulled out a razor and shaved my face, I didn't think I had any hair that needed to be shaved. When asked if she told anyone about the situation the resident responded, I told the girl about it and I yelled so loud when she was shaving my face because it hurt, that I think I even scared the girl. The resident did not know the name of the staff member. On 06/05/13 at 3:00 p.m., when this was brought to the attention of the social service worker, Employee #62, she stated she was unaware of the situation. She stated she would talk to the resident. Employee #62 returned at approximately 4:00 p.m. on 06/05/13, and stated the same complaint was made to her when she spoke with the resident. The facility completed a written concern regarding the incident on 06/05/13. Review of the concern form found the following: Resident states that about a month ago her fingernails were cut and face shaved without permission. She stated this was done in the tub room. She states she does no… | 2017-04-01 |
| 7459 | 7459 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 242 | D | 0 | 1 | TA7B11 | Based on resident interview, medical record review, and staff interview, the facility failed to allow two (2) of three (3) residents, who triggered the care area of choices, the right to exercise autonomy regarding what these residents considered important aspects of their lives. Residents #33 and #116 were not allowed the opportunity to make a choice regarding their preferences for showers or tub bathing. In addition, Resident #33 was not allowed an opportunity to choose the days and times preferred for bathing. Resident identifiers: #33 and #116. Facility census: 113. Findings include: a) Resident #33 Resident #33 was interviewed during Stage I of the QIS (quality indicator survey) at 10:50 a.m. on 06/04/13. She was asked, Do you choose whether you take a shower, tub or bed bath? The resident responded by stating, No, I don't think they even have a tub. She indicated she would like a tub bath if one was available. When asked, Do you choose how many times a week you take a bath or shower, the resident responded, They just come in and say, roll over you are going to the shower room. b) Resident #116 Resident #116 was interviewed on 06/04/13 at 7:54 a.m. during Stage I of the QIS process. When asked, Do you choose whether you take a tub, shower or bed bath, the resident's response was, I would rather have a bath. I don't even know if they have a tub here because I get a shower. c) Observation of the north hall shower room (both residents resided on north hall), with Employee #155, a registered nurse, at 1:30 p.m. on 06/05/13, found the facility did have a bath tub. The tub was covered with a sheet. When the sheet was lifted, observation found a large clear trash bag, which contained socks and other items, stored in the tub. The director of nursing was interviewed at approximately 2:00 p.m. on 06/05/13. She stated she believed the social worker asked each resident upon admission if they wanted a tub or shower and when they preferred to be bathed. She thought this information was in the resident's admission packet. … | 2017-04-01 |
| 7460 | 7460 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 253 | E | 0 | 1 | TA7B11 | Based on observation and staff interview, it was determined the facility failed to ensure effective maintenance services. The physical environment was not in good repair. Doors and walls had black marks and scratches on them, ceilings and floors were stained, and door frames were scratched and were missing paint. This practice affected six (6) of thirty-seven (37) rooms observed. Room numbers of affected rooms: #122, #126, #132, #146, #147, #148. This practice had the potential to affect more than an isolated number of residents. Facility census: 113. Findings include: a) Observations of the facility, during Stage I of the Quality Indicator Survey, revealed the following rooms had environmental concerns: 1) Room #122 The bathroom door had black scuffs on it. Paint was missing from the door frame inside the bathroom. 2) Room #126 The ceiling above bed B had a yellow stain. Paint was missing on the wall behind and beside the toilet in the bathroom. 3) Room #132 The bathroom floor in front of the toilet was scuffed and stained with black and brown marks. The bathroom wall beside the toilet was scuffed and stained with black marks. 4) Room #146 The wall beside bed A had black marks. The bathroom door had black marks. The bathroom door frame was scratched and was missing paint. The bathroom ceiling was stained. The wall behind the main door to the room had two large holes. 5) Room #147 The wall beside bed A had scrapes in the wallpaper. The bathroom door had black marks. The bathroom door frame was scratched and was missing paint. 6) Room #148 The bathroom door had black marks and a gash. The bathroom door frame was scratched and was missing paint. The ceiling above bed B had cracks and was discolored. b) These concerns were discussed and verified with the Maintenance Director, Employee #142, during an interview and a tour on 06/11/13 at 8:30 a.m. | 2017-04-01 |
| 7461 | 7461 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 279 | D | 0 | 1 | TA7B11 | Based on medical record review and staff interview, the facility failed to develop a care plan, based on the comprehensive assessment, for one (1) of twenty-five (25) residents reviewed in Stage 2 of the survey. Resident #42 had contractures for which therapy was discontinued. The facility did not develop a care plan to assist the resident to maintain her level of functioning after the therapy was discontinued. Resident identifier: #42. Facility census: 113 Findings include: a) Resident #42 The comprehensive assessments, dated 05/26/12 and 05/03/13, indicated this resident had contractures of both knees. This was confirmed by observation at 3:25 p.m. on 06/03/13. The resident was seated in her wheelchair in the hall. She exhibited some self-locomotion skills, but required assistance to reach a certain location. During an interview with Employee #80 (nurse) at 3:15 p.m. on 06/03/13, the nurse stated the resident could straighten her legs out partially, but when she was in bed, she kept her legs together and drawn up. The nurse stated the resident had therapy in the past but no longer. She said the resident used no devices for the support of her legs and had no specific instructions for positioning. According to the medical record, the resident's last therapy was discontinued on 10/08/12. Therapy was discontinued because the resident had reached her maximum potential due to increased pain with ambulation attempts and poor cognition. In an interview with Employee #24 (Physical Therapist) at 2:00 p.m. on 06/11/13, she stated she did not feel progressive contractures were avoidable because of the resident's inability to follow instructions. The resident was screened for rehabilitation after a fall on 03/16/13 and again on 06/07/13, by occupational therapy, with the following evaluation note: No sig (significant) change. A review of the resident's care plan revealed the resident's contractures were not addressed as a focus of need. There were no measurable goals which addressed the contractures, and no interventions we… | 2017-04-01 |
| 7462 | 7462 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 280 | E | 0 | 1 | TA7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to revise the care plans, for four (4) of twenty-five (25) Stage 2 sample residents, to reflect changes in the residents' conditions. The care plans/interventions for maintenance of weight for Residents #204 and #116 were not revised after they experienced weight losses. Resident #122's care plan was not revised when deep tissue injury developed into a pressure ulcer. The nutritional care plan goals and interventions for Resident #157 were not revised when the resident began receiving hospice services. Resident identifiers: #204, #122, #116, and #157. Facility census: 113. Findings include: a) Resident #204 Medical records, reviewed on 06/12/13 at 9:30 a.m., disclosed a weight of 134.4# (pounds) on 04/23/13. On 05/14/13, the resident's weight was 126.4#. On 05/15/13, the dietitian noted the resident had experienced a weight loss of 7.8# in one month. This was a 5.8% (percent) weight loss in thirty (30) days, which was a significant weight loss. Further review revealed a recommendation by the dietitian for house shakes three (3) times a day between meals. Review of the resident's current care plan revealed a problem onset was noted on 03/14/13 stating, Nutritional status as evidenced by actual/potential weight loss to inadequate oral intake, mechanically altered diet, [MEDICAL CONDITIONS], constipation, depression, dysphasia, tobacco,[MEDICAL CONDITION] GERD. The care plan contained nothing regarding the resident's significant weight loss which was identified by the dietitian on 05/15/13. These findings were presented to Employee #28, a Registered Nurse (RN) and the Director of Direct Care (DCD) on 06/12/13 at 11:00 a.m. It was confirmed the care plan had not been revised to accurately reflect the weight loss and current needs of the resident. b) Resident #122 On 06/11/13 at 1:30 p.m., medical record review disclosed a suspected deep tissue injury (DTI) on th… | 2017-04-01 |
| 7463 | 7463 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 309 | D | 0 | 1 | TA7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide necessary care and services for one (1) resident, of a sample of one (1), who triggered the care area of death in Stage 2 of the survey. The facility failed to maintain the emergency supply of [MEDICATION NAME] sulfate in the facility. This medication was ordered for this resident, who had to wait an hour for for it to be administered. The resident was in the active dying process and the [MEDICATION NAME] sulfate was unavailable at the time it was ordered by the physician. Resident identifier: #75. Facility census: 113. Findings include: a) Resident #75 A review of the resident's closed medical record was conducted on [DATE] at 10:36 a.m. Resident #75 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. The history and physical, dated [DATE], from a local area hospital was reviewed. In the section allergies [REDACTED]. An additional entry stated, She has had altered mental status and respiratory suppression with higher dose [MEDICATION NAME] and [MEDICATION NAME] in the past. The allergy to [MEDICATION NAME] was noted in the allergy section of the resident's monthly orders, on the Medication Administration Record [REDACTED]. Review of accident/incident reports revealed an incident, on [DATE] at 11:20 a.m., documented in an SBAR (situation, background, assessment, recommendation) (typed as written) When the resident became unresponsive and while being transferred from her w/c (wheelchair) to bed. She received two skin tears . There was further documentation regarding the skin tears. There was no documentation or other evidence of an assessment of the resident's unresponsive state. The vital signs on this report were those of [DATE], not [DATE], the date of the incident. In an interview, with a licensed practical nurse, (LPN - Employee #132), on [DATE] at 1:25 p.m., in the presence of other members of the survey team, Employee #132 stated she… | 2017-04-01 |
| 7464 | 7464 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 329 | D | 0 | 1 | TA7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure residents were free from unnecessary medications for two (2) of ten (10) residents reviewed for unnecessary medications. For Resident #116, the facility administered a PRN (as needed) anti-anxiety medication ([MEDICATION NAME]) without consistently documenting the indications for use, the non-pharmacological interventions provided before administration, and the effects of the medication. This resident was also receiving an excessive dose of [MEDICATION NAME]. The facility failed to ensure the resident's physician addressed the consulting pharmacist's recommendations for a gradual dose reduction and/or the excessive dose of [MEDICATION NAME]. Resident #225 was administered duplicate medications without conformation of the benefits of multiple medications from the same class with similar therapeutic effects. In addition, the consultant pharmacist did not identify this as an irregularity during the monthly medication regimen review. Resident identifiers: #116 and #225. Facility census: 113. Findings include: a) Resident #116 Review of the resident's medical record, on 06/10/13, found the resident was receiving the following anti-anxiety medication: -[MEDICATION NAME] 1 mg. (milligram) by mouth at bedtime for anxiety, prescribed on 05/10/13. -[MEDICATION NAME] 0.25 mg. by mouth, three times a day (TID), PRN (as needed) for anxiety, prescribed on 01/7/13. Review of the pharmacist consulting reports found two (2) recommendations to the resident's physician regarding the use of [MEDICATION NAME]. One was dated 04/24/13, the other was dated 05/20/13: -04/24/13, (Name of resident) PRN order for alprozolam ([MEDICATION NAME]) is up for GDR (gradual dose reduction) review. She is on 0.25 mg TID PRN. She uses it about once daily. The pharmacist recommended, For the initial attempt at gradual dose reduction (GRD) in the facility, please consider decreasing to 0.25 mg daily P… | 2017-04-01 |
| 7465 | 7465 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 386 | E | 0 | 1 | TA7B11 | Based on medical record review and staff interview, the facility failed to ensure the physician was taking an active role in supervising the care of four (4) of ten (10) residents reviewed for unnecessary medications during Stage 2 of the Quality Indicator Survey. Physician's orders for these residents were not signed and dated in a timely manner. Resident identifiers #45, #157, #89, and #86. Facility census: 113. Findings include: a) Resident #45 Medical record review, on 06/06/13, found the following telephone orders were signed by the physician, but were not dated by the physician: 04/05/13; 03/27/13; 02/19/13; 02/14/13; 02/18/13; 01/17/13; 12/20/12; 12/17/13; and 11/30/12. The director of nursing (DON) was made aware of the findings on 06/06/13 at approximately 2:00 p.m. The DON was again advised of the findings at 1:45 p.m. on 06/10/13. On 06/11/13 at 4:00 p.m., the above findings were discussed with Employee #159, the DON and the administrator. No further information was provided prior to exit. b) Resident #157 Medical record review, on 06/06/13, found the following monthly re-capitulation (re-cap) of the physician's orders were not signed by the physician: 10/12, 12/12, 02/13, 03/13, 04/13, and 05/13. Further review of the medical record found the following telephone orders were not signed or dated by the physician: 10/31/12, 11/02/12, 11/07/12, 11/09/12, 11/11/12, 11/13/12, 11/15/12, 11/20/12, 11/28/12, 12/01/12, 12/10/12, 12/12/12, 12/13/12, 12/23/12, 02/04/12, 02/18/13, 02/27/13, 02/29/13, 03/03/13, 03/07/13, 03/22/13, 03/25/13, 03/28/13, 04/22/13, 04/22/13, 04/24/13, 04/26/13, 05/03/13, 05/04/13, and 05/26/13. The following telephone orders for diet / tube feedings were not signed or dated by the physician: 10/19/12, 05/03/13, 05/28/13 and 05/26/13. The DON was made aware of the findings on 06/06/13 at approximately 2:00 p.m. The DON was again advised of the findings at 1:45 p.m. on 06/10/13. On 06/11/13 at 4:00 p.m., the above findings were discussed with Employee #159, the DON and the administrator. … | 2017-04-01 |
| 7466 | 7466 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 387 | D | 0 | 1 | TA7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a newly admitted resident was seen by the physician within the required thirty (30) day time frame after admission to the facility. Resident identifier:#61. Facility census: 113. Findings include: a) Resident # 61 A medical record review for Resident #61 was conducted on 06/11/13 at 3:00 p.m. The resident was admitted to the facility on [DATE]. As of 06/11/13, there was no evidence the resident had seen by a physician since admission. Allowing for a grace period of ten (10) days after the required 30 day requirement, the resident should have been seen by a physician by 06/05/07. This resident had experienced multiple condition changes, requiring new physician orders, without face-to-face contact with the physician. On 06/11/13 at 4:00 p.m., a meeting was held with the administrator and the director of nursing (DON). During this meeting, they acknowledged Resident #61 had not been seen by a physician since admission on 04/26/13. | 2017-04-01 |
| 7467 | 7467 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 411 | D | 0 | 1 | TA7B11 | Based on medical record review and staff interview, the facility failed to ensure one (1) of four (4) residents, who triggered dental services during Stage II of the Quality Indicator Survey, received dental services for broken and/or damaged teeth. The facility did not follow through with a request from the resident's family for a dental consult. Resident identifier: #116. Facility census: 113. Finds include: a) Resident #116 Review of the resident's minimum data set (MDS) with an assessment reference date (ARD) of 04/10/13, found section L0200D noted the resident had obvious or likely cavity or broken natural teeth. Further review of the medical record revealed the following nurse's note, written on 04/16/13: Pt. (patient) family member advised 2 broken teeth on upper set. Teeth are natural and have broken in half at the gum line with jagged edges Faxed MD (doctor) to request ortho (sic) -consult to have teeth checked . Employee #80, a licensed practical nurse working on the resident's unit, was interviewed at 9:45 a.m. on 06/11/13. She stated she was unable to find documentation a dental consult was scheduled for this resident. She stated to ask Employee #36, identified as the facility staff person who makes appointments. On 06/11/13 at 10:05 a.m., Employee #36, administrative assistant, confirmed she had not scheduled an appointment for this resident. Employee #36 presented a nurse's note, dated 01/16/13, which stated the resident did not want an oral consult. The author of the 04/16/13 nurses note, Employee #132, a licensed practical nurse, was interviewed on 06/11/13 at 11:00 a.m. in the presence of the administrator and director of nursing. She stated she had written the note on 04/16/13 because the resident's family member had come to the nurses desk and wanted to know if Resident #116 had fallen because she had two teeth which were broken. According to Employee #132, the family member thought they may have broken during a recent fall. This employee stated she faxed a request to the resident's physician f… | 2017-04-01 |
| 7468 | 7468 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 412 | D | 0 | 1 | TA7B11 | Based on medical record review, resident interview, and staff interview, the facility failed to obtain dental services to meet the needs of one (1) of three (3) residents who triggered dental services during Stage 2 of the Quality Indicator Survey. The facility failed to promptly address the resident's need for the extraction of all of her teeth. Resident identifier: #2. Facility census: 113. Findings include: a) Resident #2 During a Stage 1 interview, on 06/04/13 at 1:30 p.m., this resident stated, I had my upper teeth all extracted and was supposed to have the lower teeth extracted a month after that, but I don't know why it hasn't happened. Medical record review, on 06/05/13 at 10:30 a.m., revealed Resident #2 was admitted to facility on 10/26/11. Review of the attending physician's progress notes showed the following: -- 11/02/12 note read, Refer to oral surgeon reason consideration of extracting remaining teeth. --12/03/12 note read, Didn't see oral surgeon. --01/02/13 note read, Order again to schedule appointment with oral surgeon reason for extraction of remaining teeth. ---02/08/13 note read, Has an appointment with oral surgeon for oral exam next week. --03/07/13 note read, Due for lower teeth extraction next month. --04/08/13 note read, Due for rest of dental extraction later this month. Five (5) remaining lower teeth. --05/08/13 returned from attending physician appointment with a request to Please schedule follow-up appoint with oral surgeon for extraction of remaining teeth. --06/05/13 attending physician completed annual history and physical, and per plan, Schedule follow-up with oral surgeon to complete dental extractions. Review of Resident #2's scheduled appointments revealed she was scheduled on 02/11/13 for a dental consultation, but it was rescheduled. No reason for the cancellation was found. A consultation appointment with an oral surgeon was rescheduled for 02/18/13. The treatment plan was for a follow-up for the extraction of all remaining teeth with local anesthesia in the dental office.… | 2017-04-01 |
| 7469 | 7469 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 428 | D | 0 | 1 | TA7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the physician addressed and acted upon irregularities reported by the consultant pharmacist in a timely manner for two (2) of ten (10) residents (Residents #110 and #116) whose medical records were reviewed for unnecessary medications during Stage II of the Quality Indicator Survey. In addition, the consultant pharmacist failed to identify and report a medication irregularity for (1) of ten (10) residents (Resident #225) whose medical records were reviewed for unnecessary medications. Resident identifiers: #110, #116 and #225. Facility census: 113. Findings include: a) Resident #110 Review of the resident's medical record, on 06/06/13, found a pharmacy consultation report, dated 04/17/13. The recommendations were, (Name of resident) has diabetes but a recent A1c is not available in the resident record. Please consider monitoring an A1c on the next convenient lab day and then every 3 months if therapy has changed or goals are not being met, or every 6 months if meeting treatment goals. On 06/06/13, the director of nursing (DON) verified the physician had not addressed the pharmacist's report dated 04/17/13. b) Resident #116 review of the resident's medical record revealed [REDACTED]. (Name of resident) receives Alprazolam 1 mg. HS (new) and 0.125 mg. TID (three times a day) PRN (as needed). The recommended maximum daily dose threshold for this medication when used to treat anxiety as outlined in F329 is: alprazolam (Xanax) 0.75 mg. Please re-evaluate continued use of Alprazolam at this dose and, if clinically appropriate, consider a gradual dose reduction, perhaps decreasing to 0/5 mg. HS and 0.25 mg. QD PRN while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. On 04/24/13 the pharmacist reviewed the resident's medication and advised the physician, (Name of resident) PRN order for alprazolam is up for initial GDR (gradual dose reduc… | 2017-04-01 |
| 7470 | 7470 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 431 | E | 0 | 1 | TA7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and facility policy review, the facility failed to ensure safe medication storage and availability of a medication. The emergency supply of liquid morphine sulfate was not available when needed for Resident #89. An expired multi-dose vial of purified protein derivative (PPD) was found in the south hall medication refrigerator. Multiple bottles of over the counter medications and vials of insulin were not dated when opened on medication carts on the south hall. These practices had the potential to affect more than a limited number of residents on the south hallways. Resident identifiers: Resident #89, #122, #101 and #127. Facility census: 113. Findings include: a) Resident #89 A review of Resident #89's medical record, on [DATE] at 10:30 a.m., revealed a physician's orders [REDACTED].#30 ml (milliliters) 20 mg (milligrams)/ (per) ml give ,[DATE] ml q (every) 1 hour prn (as needed) for pain. The order was dated [DATE] at 10:30 a.m. An interview was conducted with Employee #132, licensed practical nurse (LPN), on [DATE] at 1:25 p.m The LPN agreed there was no morphine elixir available in the facility when the par level should have been one (1). Employee #132 further stated the morphine elixir was ordered from a local pharmacy. The Medication Administration Record [REDACTED]. The unavailability of medications was a recurring problem at the facility. A review of the Consultant Pharmacist Summary reports, for March, April, and [DATE], revealed the following: Widespread issues observed, If the medication is removed from the emergency supply and pharmacy is not notified of its removal, it will not be replaced. b) On [DATE] at 9:00 a.m., Employee #28, director of care delivery (DCD), was present during the inspection of the south hall medication storage room. A multi-dose vial of PPD, a medication used to screen residents for [DIAGNOSES REDACTED], had no date on the vial. When shown to Employee #28, she stated th… | 2017-04-01 |
| 7471 | 7471 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 441 | D | 0 | 1 | TA7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain a system of communication to ensure the prevention of the onset and spread of disease and infection when residents had room changes. The facility failed to update their Patient Information Worksheet (PIW), the communication form used to inform line staff of necessary infection control practices, when a resident was moved from one room to another. In addition, the facility failed to ensure all staff members were aware of, and adhered to, the visual methods of determining what type of precautions were necessary prior to entering a resident's room. This was discovered through a random observation during Stage I of the Quality Indicator Survey (QIS). This practice had the potential to affect more than an isolated number of residents. Facility census: 113. Findings include: a) During Stage I of the QIS, forty-seven (47) residents were identified, by the facility, as having one or more of the following infections: VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]), CRKP (Carbapenem-resistant [DIAGNOSES REDACTED] pneumonia), MRSA (Methicillin-resistant Staphylococcus Aureus), ESBL (extended-spectrum beta lactamase),and CDIFF (Clostridium difficile). Signage on these residents' doors indicated contact precautions and a notice that visitors should see the nurse before entering the room. On 06/03/13 at approximately 11:00 a.m., Employee #155, a licensed practical nurse, was asked to explain the protective equipment needed to be worn when conducting interviews and making observations in the rooms identified with residents who were on contact precautions. Employee #155 stated gloves and gowns would need to be worn in each room if a three (3) door cart was in the hallway outside the residents' rooms. Protective equipment would not need to be worn in the others rooms if resident care was not being provided. During observation of the noon meal on 06/03/13 at 1:00 p.m., Employee #53, … | 2017-04-01 |
| 7472 | 7472 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 490 | E | 0 | 1 | TA7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ' Based on record review and staff interview, the administration failed to ensure the facility was administered in an efficient and effective manner to maintain the highest practicable physical, mental, and psychosocial well-being of more than a limited number of residents. In the area of resident behavior and facility practices, the facility failed to investigate and report allegations of abuse, neglect, and misappropriation of resident property. In the areas of resident quality of life practices, the facility failed to ensure resident dignity was maintained during the dining experience; failed to maintain a resident's privacy during a physician's visit; failed to ensure resident choices in regard to bathing was upheld; and, failed to ensure the physical environment of the facility was in good repair. In the area of quality of care practices, the facility failed to ensure care and services were provided for the highest well being of a resident; care and treatment was provided to prevent pressure ulcers and the drug regimen of a resident was free from unnecessary medications. In addition, there were system issues in the areas of resident funds, timely physician visits, revision of resident care plans for change of condition, and assistance in scheduling dental appointments in a timely manner. As well, pharmacy recommendations were not addressed by the physician in a timely manner, medications were not available in an emergency, staff were unaware of infection control practices, physicians were not notified of laboratory results, and medical records were not complete and accurate. These isues were identified during the survey from [DATE] through [DATE]. Facility census: 113. Findings include: a) The facility failed to ensure personal funds were available at all times. Resident funds were not accessible to the residents in the evenings or on the weekends. b) The facility failed to ensure the personal privacy of a resident during a physician's v… | 2017-04-01 |
| 7473 | 7473 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 492 | B | 0 | 1 | TA7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and staff interview the facility failed to comply with WV State Regulations pertaining to the following personnel requirements at Title 64 Legislative Rules, West Virginia Division of Health,Series 13, Nursing Home Licensure Rule: -11.6 Personnel Records. A nursing home shall maintain a confidential personnel record for each employee containing the following information: -11.6.c Results indicating a satisfactory health status for the employees' current job assignment as required in Subsection 8.19 of this rule. -11.6.i A job description signed by the employee. - 8.20.c.3 Employee restrictions. A nursing home shall prohibit employees with a communicable disease or infected [MEDICAL CONDITION] from direct contact with residents or their food, if direct contact will transmit the disease. Findings include. a) Employee #2 On 06/06/13 at 1:30 p.m., a review of Employee #2's personnel file was conducted. This employee was hired on 05/20/13. There was no evidence this employee had a pre-employment physical. b) Employee #52 On 06/06/13 at 1:30 p.m., a review of Employee #52's personnel file was conducted. This employee was hired on 05/20/13. There was no evidence this employee had a pre-employment physical. In an interview, with the human resources director, on 06/06/13 at 2:00 p.m., she could find no evidence of a pre-employment physical in the personnel files of Employee #2 or Employee #52. She stated the facility had recently changed the procedure for employees to have a pre-employment physical and agreed Employee #2 and Employee #52 did not have a pre-employment physical. c) Employee # 148 Review of personnel records for Employee # 148, on 06/11/13 at 2:00 p.m., revealed no evidence of a job description for this employee's position: appointment scheduler/transporter for residents. This was confirmed by Employee #124, human resource director, HR on 06/11/13 at 3:15 p.m. d) The facility failed to ensur… | 2017-04-01 |
| 7474 | 7474 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 505 | D | 0 | 1 | TA7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the physician was notified of laboratory results for one (1) of twenty-five (25) sampled residents. This resident was receiving a medication which required monitoring to ensure the resident received therapeutic doses of the medication. Resident identifier: #86. Facility census 113. Findings include: a) Resident #86 A review of the medical record revealed Resident #86 was a [AGE] year old male with [DIAGNOSES REDACTED]. The resident had been receiving [MEDICATION NAME] ([MEDICATION NAME] sodium) 500 mg by mouth twice daily for behaviors since 03/29/12. A Vallproic Acid ([MEDICATION NAME]) level was done on 01/30/13, and reported as: 28 with a reference range of (50 - 100). It was to be re-checked every 6 months. There was no evidence the physician received and/or reviewed the laboratory (lab) results, although the lab form was dated 1/31/13 and marked faxed. There were no changes to the dosage, nor mention of the lab results in the resident's progress notes. The resident had a psychiatric consultation on 03/29/13, which was ordered for the purpose of the management of his medication. The consultant suggested continuance of all medications and obtaining a [MEDICATION NAME] level. The physician did not mention the consultant's suggestions in the resident's History and Physical visit on 04/17/13 and ordered no lab tests or medication changes. On 05/06/13, the pharmacist recommended a [MEDICATION NAME] Acid level be done. A written notice of this was placed on the resident's chart on 05/07/13 by Employee #155 (nurse). an order for [REDACTED]. There was no evidence in the record the physician was notified of the results. The form had no notation of being faxed, no signatures to indicate a review, no nurses notes, and there was no order for medication changes. During an interview with the director of nursing (DON) and the administrator, at 4:35 p.m. on 06/05/13, they w… | 2017-04-01 |
| 7475 | 7475 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 514 | E | 0 | 1 | TA7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the completeness and/or accuracy of the medical records within acceptable professional standards for eight (8) of twenty-five (25) sample residents. Resident identifiers: #225, #122, #204, #175, #86, #4, #42, and #174. Facility census: 113. Findings include: a) Resident #225 Review of medical records, on 06/10/13 at 2:00 p.m., revealed an order for [REDACTED]. On 06/13/13 at 4:00 p.m., during a meeting with director of nursing (DON) (Employee # 11) and administrator (Employee # 162) it was confirmed Resident #225 had never had a secure care alarm. b) Resident #122 On 06/12/13 at 10:00 a.m., medical record review found a chest radiology report in which the physician had ordered an increase in dosage in [MEDICATION NAME], to reach a therapeutic dosage in a three (3) week period. This was for treatment of [REDACTED]. Further review revealed Employee #153, licensed practical nurse (LPN), had transcribed the order inaccurately. The order was written for the [MEDICATION NAME] to be discontinued after four (4) weeks. When Resident #122, was discharged home on[DATE], her discharge medication summary was inaccurate because [MEDICATION NAME] was left off the medication list. When the faxed order was reviewed with the DON (Employee # 11) on 06/12/13 at 11:00 a.m., it was confirmed the order had been transcribed incorrectly and the resident's discharge summary was inaccurate. The DON immediately notified the physician and the resident to correct the error. c) Resident #204 Review of physician orders [REDACTED]. Further review revealed the June recapitulation orders were written for [MEDICATION NAME] for tingling and [MEDICATION NAME] for depression. On 06/06/13 at 3:00 p.m., an interview was conducted with the DON. It was verified the orders were incorrect. The DON said the pharmacy had incorrectly transcribed the [DIAGNOSES REDACTED]. d) Resident #175 Review of the resident's medi… | 2017-04-01 |
| 7476 | 7476 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 520 | E | 0 | 1 | TA7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's incident and accident reports, observation, review of reported incidents of abuse and neglect, staff interview, resident interview, review of facility policies and procedure, it was determined the facility's quality assessment and assurance committee (QA&A) failed to identify and act upon quality deficiencies in the daily operation of the facility in which it did have, or should have had knowledge. During the survey, from [DATE] to [DATE], it was identified the facility had multiple issues, which included the following: - Resident funds were not available on a ,[DATE] basis; - Resident privacy was not ensured during physician visits and discussions at the nurses station; - Allegations of abuse, neglect, and misappropriation of resident property were not reported and investigated; - Resident dignity was not maintained during dining and during assistance with activities of daily living (ADLs); - The facility failed to allow choices regarding the type of bath, as well as when the residents could bathe; - The facility's physical environment was not in good repair; - The facility failed to revise the care plan when there was a change in residents' health care status and failed to develop a care plan for a resident's assessed needs; - A resident was not assessed during an acute change in condition; - The facility failed to provide services to prevent the development of pressure ulcers; - The facility failed to ensure residents did not receive unnecessary medications, and failed to ensure non-pharmacological interventions were attempted prior to giving medication; - The facility failed to ensure the physician signed and dated orders; - Physician visits were not made within the required thirty (30) days after admission; - The facility failed to ensure a follow up with a dentist and failed to schedule a dental appointment; - The facility failed to ensure pharmacy recommendations were followed up in a timely manner; - … | 2017-04-01 |
| 7477 | 7477 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2014-04-04 | 441 | E | 1 | 0 | 93YF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review, the facility failed to ensure the implementation of an Infection Prevention and Control Program to prevent and control, to the extent possible, the onset and spread of infection. The facility failed to place isolation signage, for four (4) of five (5) residents on contact precautions, to alert staff and visitors to implement the necessary precautions to prevent the transmission of disease and infection. The facility also failed to ensure an isolation cart was placed off the floor. In addition, the facility failed to ensure soiled resident water pitchers were maintained in a manner to prevent use by other residents. These practices had the potential to affect more than an isolated number of residents. Facility census: 85. Findings Include: a) On 04/01/14 at 9:15 a.m., on the North unit, a three (3) drawer plastic isolation cart which contained personal protective equipment (PPE) was observed outside of room [ROOM NUMBER]. It was sitting directly on the floor. The isolation cart did not have wheels or risers to prevent it from direct contact with the floor. In addition, no alert or isolation signage was visible to alert staff or visitors of necessary isolation precautions in room [ROOM NUMBER]. At 11: 15 a.m. on 04/01/14 Employee #105 the assistant director of nursing (ADON) for North unit verified the isolation cart outside of room [ROOM NUMBER] was sitting directly on the floor. She agreed it was an infection control issue. An interview was conducted with Employee #11, the infection control nurse, on 04/01/14 at 11:18 a.m. After viewing the isolation cart outside of room [ROOM NUMBER], she verified it was sitting directly on the floor. Employee #11 confirmed it was an infection control issue, and stated it would be taken care of immediately. b) At 9:25 a.m. on 04/01/14 on the South unit, a three (3) drawer plastic isolation cart containing PPE was observed outside of rooms #214, #223 an… | 2017-04-01 |
| 7478 | 7478 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2013-08-07 | 241 | E | 0 | 1 | TWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random opportunities for observation, staff interview, and policy review, the facility failed to treat four (4) residents with dignity and respect . Resident #186 and #16 were fed while staff stood up over them, and not at eye level with the residents. This practice had the potential to make the residents feel rushed and could result in poor meal intake. Medication was administered to Resident #63 while the resident was eating in the dining area. Resident #123 was assisted at one (1) meal by multiple staff members. These staff members talked to each other instead of interacting with the resident. In addition, staff did not respond to Resident #36 in a dignified manner when she was calling out for assistance, but instead told her not to yell. These practices had the potential to affect more than an isolated number of residents. Resident identifiers: #186, #16, #63, and #36. Facility Census: 159. Findings include: a) Resident #186 During an observation on 07/29/13 at 5:30 p.m., in the second floor dining room, Employee #43, a registered nurse, was observed standing beside of Resident #186 feeding him his dinner. She did not sit so she could be eye level with the resident. Employee #43 stood over the resident during the entire meal. b) Resident #16 During on observation on 07/29/13, in the second floor dining room at 5:30 p.m., Employee #136, a nurse aide (NA) was observed standing beside of Resident #16 feeding him his dinner. She did not sit so she could be eye level with the resident. Employee #136 stood over the resident during the entire meal. The nurse supervisor (Employee #145) was made aware of this observation at 6:05 p.m. on 07/29/13. He agreed staff should not stand over residents to feed them. c) Resident #63 During a medication administration observation, on 08/01/13 at 8:45 a.m., Employee #26 administered Resident #63's medication in the dining area while the resident was having her breakfast. The resident had to stop eati… | 2017-04-01 |
| 7479 | 7479 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2013-08-07 | 247 | D | 0 | 1 | TWIF11 | Based on medical record review, staff interview, resident interview, and policy review, the facility failed to provide notification to Resident #98 and Resident #170 prior to moving them from one room to another room within the facility. Additionally, the facility did not provide notification to Resident #15 prior to moving other residents into her room. This was true for three (3) of four (4) Stage 2 sampled residents reviewed for notification of room changes. Resident Identifiers: #98, #170, and #15. Facility Census: 159. Findings Include: a) Resident #15 A resident interview was conducted with Resident #15 at 10:12 a.m. on 07/30/13 during Stage 1 of the Quality Indicator Survey (QIS). The resident stated she gets new roommates and staff does not let her know she is getting a new roommate. She stated, They just bring them in. Review of the facility's action summary for 06/06/13 to 08/06/13, revealed Resident #15 received new roommates three (3) times: -- 06/07/13, -- 07/23/13, and -- 07/25/13. The resident's medical record was reviewed on 08/07/13. The medical record did not reveal any indication the resident was notified about receiving a new roommate. The admission director, Employee #20 was interviewed at 10:05 a.m. on 08/07/13. She stated Resident #15 had some behavioral problems and this was likely the cause of the roommate changes. b) Resident #98 Record review of the facility's action summary for the dates of 06/06/13 through 08/05/13 revealed the following room changes for Resident #98: -- from 108-B to 317-A on 06/18/13, -- from 317-A to 316- A on 07/23/13, and -- from 316-A to 317-A on 07/25/13. Resident #98's medical record was reviewed at 9:00 a.m. on 08/07/13. There was no indication found in the medical record the resident was notified of these room changes. Employee #20, the Admissions Director, was interviewed at 10:05 a.m. on 08/07/13. The admissions director confirmed there was no information contained in the resident's medical record to indicate Resident #98 was notified of the room change wh… | 2017-04-01 |
| 7480 | 7480 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2013-08-07 | 253 | E | 0 | 1 | TWIF11 | Based on observations and staff interview, it was determined the facility failed to ensure effective maintenance services. The physical environment was not in good repair. The walls had holes, black marks, and scratches, and doors were scratched and missing paint. Six (6) of thirty-seven (37) rooms observed were affected. Room numbers of affected rooms: #214, #217, #223, #225, #226, #307. This had the potential to affect more than an isolated number of residents. Facility census: 159. Findings Include: a) Observations of the facility, during Stage 1 of the Quality Indicator Survey, revealed the following rooms had environmental concerns: 1) Room #214 - at the foot of bed A there was a hole and blue markings on the wall. 2) Room #217 - The wall behind the head of bed B had black markings on it. The bathroom door was scraped. The bathroom walls had scrapes and paint missing. 3) Room #223 - The wall beside bed A had black markings and scrapes. 4) Room #225 - The wall beside the sink in the room had a hole, paint missing, and black scrapes. The wall beside the bed had black markings and scrapes. 5) Room #226 - The wall behind the head of bed A had paint missing. The wall at the foot of bed A had paint missing. 6) Room #307 The bathroom door was heavily scratched on the inside of the bathroom. b) These concerns were discussed and verified with the Maintenance Director, Employee #131, during an interview on 08/07/13 at 1:30 p.m. This employee stated the building is very large which makes it difficult to keep up with every scratch and mark on the walls. | 2017-04-01 |
| 7481 | 7481 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2013-08-07 | 279 | D | 0 | 1 | TWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and resident observations, the facility failed to develop a care plan related to a skin condition to the right lower extremity of Resident #187. The resident had blisters and open areas on her right lower extremity which were not addressed on her care plan. This was true for one (1) of thirty-one (31) care plans reviewed during Stage 2 of the survey. Resident Identifier: #187. Facility Census: 159. Findings include: a) Resident #187 During Stage 1 of the Quality Indicator Survey, conducted 07/29/13 through 08/07/13, Resident #187 was observed with a bandage on her right lower leg. The resident stated, during a Stage 1 interview, the bandage was covering an area where she had been sunburned and the blisters had burst. The resident's medical record was reviewed on 08/05/13 at 12:21 p.m. This review revealed the resident had an order for [REDACTED].#186, on 07/22/13. The resident also had an order for [REDACTED]. Review of the resident's care plan found no mention of the blisters and open areas on the resident's right lower extremity. Employee #120, Registered Nurse (RN), Unit Manger, was interviewed at 3:34 p.m. on 08/05/13. Employee #120 reported the blisters to the resident's right lower extremity occurred on 07/22/13. She reported the area was ten (10) by ten (10) centimeters and it was weeping on 07/22/13. Employee #120 stated she thought this was on the resident's care plan. She provided a care plan which had an intervention related to the resident's independent smoking. The intervention was, Provide Sun screen to resident to use when going to smoke and encourage to use to prevent skin break down. The Director of Nursing (DON), Employee #122, was interviewed at 10:14 a.m. on 08/06/13. The DON confirmed Employee #120 had not completed the care plan for the skin condition and sun. She confirmed the information was not on the care plan at the time of the initial review at 12:20 p.m. on 08/05/13… | 2017-04-01 |
| 7482 | 7482 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2013-08-07 | 282 | D | 0 | 1 | TWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, and resident observations, the facility failed to provide Resident #187 sunscreen in accordance with her plan of care. Resident #187 had physician's orders [REDACTED]. The facility had not provided the resident with sunscreen to use; therefore, it was not possible to implement the order or the care plan. This was true for one (1) of thirty-one (31) resident's reviewed during Stage 2 of the survey. Resident Identifier: #187. Facility Census: 159. Findings include: a) Resident #187 During Stage 1 of the Quality Indicator Survey, conducted 07/29/13 through 08/07/13, Resident #187 was observed with a bandage to her right lower leg. The resident stated the bandage was covering an area where she had been sunburned and the blisters had burst. The resident's medical record was reviewed on 08/05/13 at 12:21 p.m. This review revealed the resident had an order for [REDACTED].#186, on 07/23/13. The resident's care plan was reviewed. The care plan contained an intervention related to the focus of independent smoking, Provide sun screen to resident to use when going to smoke and encourage use to prevent skin breakdown. Employee #120, Registered Nurse (RN), Unit Manger, was interviewed at 3:34 p.m. on 08/05/13. Employee #120 confirmed the resident's care plan related to her independent smoking included, Provide Sun screen to resident to use when going to smoke and encourage to use to prevent skin break down. She stated the resident should have the sunscreen in her room. Resident #187 was interviewed at 9:37 a.m. on 08/06/13. The resident stated she did not use sunscreen because the facility had not given her any sunscreen to use. She reported she could not use something she did not have, but would use sunscreen if she had some. The resident's Kardex was reviewed at 9:51 a.m. on 08/06/13 . The Kardex, under safety, had Provide Sunscreen to resident to use when going to smoke and encourage u… | 2017-04-01 |
| 7483 | 7483 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2013-08-07 | 323 | E | 0 | 1 | TWIF11 | Based on observation and staff interview, the facility failed to provide an environment that was free from accident hazards over which the facility had control. The soiled utility closets on the transitional care unit and the third floor were found intermittently unlocked upon inspection. Both closets contained cleaning supplies, sharps containers, and soiled linens. This had the potential to affect more than an isolated number of residents. Facility Census: 159. Findings include: a) An observation, on 08/06/13 at 10:00 a.m., revealed the soiled utility room on the transitional care unit was intermittently unlocked. The door was unlocked on two (2) of six (6) attempts to open the door. This room contained cleaning supplies, soiled linens, and full sharps containers. An observation on 08/06/13 at 10:20 a.m., revealed the third floor soiled utility room was also intermittently unlocked. This room was unlocked three (3) of six (6) attempts to open the door. This room contained cleaning supplies, trash bags, and full sharps containers. An interview with Employee #92, the third floor Unit Manager, on 08/06/13 at 10:30 a.m., revealed the soiled utility rooms were to be locked at all times. Upon inspection, Employee #92 verified the third floor soiled utility room was intermittently unlocked. Interview with Employee #131, the Maintenance Services Director, on 08/06/13 at 10:45 a.m., also revealed the soiled utility rooms should always be locked on all floors. | 2017-04-01 |
| 7484 | 7484 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2013-08-07 | 371 | F | 0 | 1 | TWIF11 | Based on observations and staff interview, it was determined the facility failed to ensure food was served in a sanitary manner. Dietary staff used the same gloves to handle food and non-food items when serving foods. Food items were found outdated. A refrigerator did not have an internal thermometer for monitoring of temperatures. A container of food thickener available for use in the dining room had passed its use by date. A staff member was observed blowing on food before giving it to a resident. A resident was observed assisting in setting up a dining area for meal service. He was not washing or otherwise sanitizing his hands when indicated, creating a potential for cross contamination. All residents who consumed foods by oral means had the potential to be affected. Census: 159. Findings include: a) The initial tour of the dietary department, on 07/29/13, revealed a refrigerator unit did not have an internal thermometer to determine if foods stored inside were maintained at correct temperatures. b) During meal observations on the third floor at dinner on 07/29/13, Employee #11, the dietary aide who was serving the food items, was noted to use the same gloves to handle food and non-food items, creating a potential for food contamination. The employee touched surfaces while wearing gloves, then handled bread/buns with the same gloves. c) At the dinner observation on third floor, on 07/29/13, Employee #39, a student, was observed blowing on food to cool the food before feeding it to Resident #123. This practice could cause contamination of the food. d) On 07/29/13 at 6:00 p.m., during an observation of the dinner meal on the facility's Homestead Unit (Alzheimer's/dementia unit), Resident #161 was observed handling plates, and utensils with his bare hands. The resident was assisting staff in setting the tables for the residents' fine dining program. The resident touched various objects in the dining area, then pick up plates and utensils to give to residents. Staff members did not ask him to wash or otherwise san… | 2017-04-01 |
| 7485 | 7485 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2013-08-07 | 441 | E | 0 | 1 | TWIF11 | Based on observation and staff interview, the facility failed to maintain an environment to minimize contamination and prevent the spread of infection to the residents in the facility. The second floor nursing assistants were observed passing ice and placing the ice scoop directly into the ice in the container after touching it with their bare hands, thus contaminating the ice. During medication pass on the second floor, the nurse was observed to have poor infection control practices during her administration of eye drops. The infection control practices observed had a potential to affect more than an isolated number of residents. Facility Census: 159. Findings include: a) Ice Pass During the dining observation on 07/27/13 on the second floor at 6:00 p.m., the nursing assistants were observed passing drinks to the residents who were in their rooms on the hall. Employee #12 was observed to take the ice scoop full of ice and fill cups with ice to take to the residents. She was observed placing the ice scoop back into the container of ice after touching it with her bare hands, thus contaminating the ice remaining in the container. Employee #103 then was observed to pick the scoop up out of the ice in the container and fill cups with ice to serve drinks to her residents. She then laid the scoop back in the ice in the container after touching the scoop with her bare hands. The nurse manager Employee # 145, was made aware of this observation on 07/27/13 at 6:10 p.m. He verified this was not an acceptable practice and he would educate the staff on this issue. b) Resident #63 During a medication administration observation on 08/01/13 at 8:45 a.m., the nurse (Employee #26) was observed administering eye drops to Resident #63. This resident was in the dining area eating breakfast at the time the eye drops were administered. The nurse administered the eye drop in the right eye and used a facial tissue to remove excess solution. She then placed the soiled tissue she had used to wipe the eye on the table where residents were … | 2017-04-01 |
| 7486 | 7486 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2013-08-07 | 497 | E | 0 | 1 | TWIF11 | Based on employee record review and staff interview, the facility failed to ensure the provision of in-service education which addressed areas of weakness as identified in performance reviews. The facility did not complete a performance review of each nursing assistant at least every twelve (12) months to identify areas of weakness. This evaluation was necessary to ensure in-service training addressed the competency needs of the nursing assistants who provided care to residents. Review of personnel files for nursing assistants revealed eight (8) of fifteen (15) employees reviewed did not have an annual performance evaluation completed in the last twelve (12) months. Staff identifiers: #182, #150, #52, #36, #29, #2, #12, and #55 Facility census: 159 Findings: a) Employee #182 The employee records were reviewed on 08/07/13 at 11:40 a.m. Employee #182, a nursing assistant, was hired 03/22/11. No annual performance evaluation had been completed since the employee was hired. b) Employee #150 Employee #150, a nursing assistant, was hired 04/19/11. An annual performance evaluation had not been completed since the beginning of Employee #150's employment. c) Employee #52 Employee #52, a nursing assistant, was hired 04/24/12. An annual performance evaluation was not located since the beginning of employment. d) Employee #36 Employee #36, a nursing assistant, was hired 10/12/05. The latest annual performance evaluation located in the employee's record was completed 10/23/07. e) Employee #29 Employee #29, a nursing assistant, was hired 01/10/12. An annual performance evaluation had not been completed since hire. f) Employee #2 Employee #2, a nursing assistant, was hired 03/01/99 the latest annual performance evaluation located in the employee's record was completed 11/09/00. g) Employee #12 Employee #12's last performance evaluation was completed on in November 2008. The employee is a nurse aide who began working on 11/12/07. h) Employee #55 Employee #55's last performance evaluation was completed on 08/04/11. The employee i… | 2017-04-01 |
| 7487 | 7487 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2015-03-27 | 166 | D | 0 | 1 | G4YW11 | Based on resident interview, policy review and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for personal property received prompt efforts by the facility to resolve a grievance. Resident #105 complained to the staff about missing clothing. This complaint was not documented and the facility failed to communicate with Resident #105 regarding their efforts to locate her missing clothes. Resident identifier: #105. Facility census: 118. Findings include: a) Resident #105 On 03/24/15 at 9:41 a.m., during an interview, Resident #105 said she had some missing clothing. She said she had told the lady from laundry about the missing clothes. At 3:00 p.m. on 03/24/15, Employee #12, social worker (SW), said the facility did not have a grievance/complaint form from Resident #105 regarding missing clothing. The SW interviewed the resident on 03/24/15 at 3:30 p.m. The resident described her missing clothing to the SW. The resident specifically mentioned missing a gray Evrerlast brand sweat-pants without an elastic band at the bottom and a charcoal gray sweatshirt. Resident #105 told the social worker she had mentioned these missing items to a woman from laundry. The SW interviewed Laundry Aide (LA) #104 on 03/24/15 at 4:00 p.m. LA #104 knew about the resident's missing clothes and said she had looked for them. She said she had not reported the missing clothing to her supervisor. LA #104 also said she had not talked to the resident and updated her on the efforts made to find her clothing. The SW interviewed Housekeeping/laundry Supervisor #111 on 03/24/15 at 4:15 p.m. Employee #111 said laundry staff had not documented any missing clothing for Resident #105. She agreed LA #104 should have documented Resident #105's missing clothes. The SW said if LA #104 had documented the missing clothing, then the social services department would have become aware of the missing clothing, and would have filled out a grievance report. A review of the facility grievance/concern policy, with a revision date o… | 2017-04-01 |
| 7488 | 7488 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2015-03-27 | 241 | E | 0 | 1 | G4YW11 | Based on observation and staff interview, the facility failed to provide and promote care in a manner and environment which enhanced residents' dignity. The facility failed to ensure residents were not referred to using labels in a setting in which others could overhear. The facility also failed to ensure staff conducted themselves in respectful manner in the dining room, in the presence of the residents eating there. In addition, the facility failed to ensure staff knocked on a resident's door, or otherwise asked for permission to enter,prior to entering the resident's room. These practices had the potential to affect more than a limited number of residents. Resident identifier: #166. Facility census: 118. Findings include: a) Dining observations At 12:35 p.m. on 03/23/15, during observation of the noontime meal on the 100 and 200 halls, Nurse Aide (NA) #50 was asked how many residents required assistance with dining. While standing in the hall beside of the meal cart, NA #50 replied, We have several feeders. On 03/26/15 at 12:40 p.m., the Director of Nursing (DON), was made aware of the observation and the NA's response. The DON agreed the term feeder was an undignified manner in which to reference residents who required assistance with meals. She further stated she would educate the NA on the matter. b) Resident #166 At 1:40 p.m. on 03/23/15, during an interview with Resident #166, NA #50, entered the resident's room without first knocking or receiving permission to enter. Resident #166 said that he and his roommate preferred to have their door closed, and that some of the staff knocked, and others forgot to knock. A sign was posted inside the resident's room, on the left side of the door, which stated, Please close the door when you leave, thank you. Resident #166 said he had the sign posted a week ago. On 03/23/15 at 1:57 p.m., upon inquiry as to the way in which a resident's room should be entered by staff, NA #50 said, Knock first or announce yourself. At 12:40 p.m. on 03/26/15, the DON was made aware of t… | 2017-04-01 |
| 7489 | 7489 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2015-03-27 | 246 | D | 0 | 1 | G4YW11 | Based on observation, medical record review, and staff interview, the facility failed to ensure two (2) of 40 residents observed during Stage 1 of the quality indicator survey (QIS) had reasonable accommodations of individual needs and preferences. Resident #70 could use her call light, but did not have access to it. Resident #49 could not turn the outside doorknob on the door to her room. Resident identifiers: #70 and #49. Facility census: 118. Findings include: a) At 10:00 a.m. on 03/24/15, an observation in Resident #49's room revealed the door knob from the outside of the door would not turn easily. The door would not open as it should. The doorknob had to be turned, while pushing on the door, in order to get it to open. Employee #100 (nurse aide) said the staff had trouble getting the door open. At 1:00 p.m. on 03/25/15, Resident #49 said she had trouble getting the door open when she went outside of her room, if she closed the door. She said the door previously had a different type of lever on it. Resident #49 pointed to the lever on the door's interior side, and said the one on the outside was just like it. She said did not know what happened to the lever on the door's exterior side. An interview with the maintenance director (Employee #2), on 03/25/15 at 4:00 p.m., revealed he hoped to replace all the doorknobs at the facility with a lever handle. He said he would order a replacement part for Resident #49's doorknob. Employee #118 (physical therapy assistant) said she knew Resident #49's door once had an assistive device type of doorknob, but she did not know what happened to it. b) Resident #70 On 03/23/15 at 3:50 p.m., Resident #70 was observed sitting in a chair beside her bed. The resident's call light was observed on the bed, and not within the resident's reach. The resident was asked if she would push her call light to ensure the system was functioning. Resident #70 said, I don't know where mine is. The resident's roommate told her, Your cord is lying on your bed. Resident #70 then attempted to stan… | 2017-04-01 |
| 7490 | 7490 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2015-03-27 | 247 | D | 0 | 1 | G4YW11 | Based on resident interview, record review, and staff interview, the facility failed to notify one (1) of one (2) residents reviewed for the care area of admission, transfer and discharge, he was receiving a new roommate. Resident identifier: #176. Facility census: 118. Findings include: a) Resident #176 An interview, with Resident #176, during Stage 1 of the Quality Indicator Survey, at 1:33 p.m. on 03/24/15, found he had not been notified he was receiving a new roommate. An interview with Employee #95, the admissions director, on 03/26/15 at 8:35 a.m., found Resident #176 received a new roommate on 12/24/14. Resident #167 was the new roommate assigned to Resident #176. Employee #95 stated she would have told Resident #176 he was getting a new roommate, but she did not document this information. She suggested speaking with the social worker to see if the social worker had written a note in the medical record. In an interview with Employee #12, (social worker), at 8:40 a.m. on 03/26/15, she verified she had not notified Resident #176 he was receiving a new roommate. She stated that maybe the nurses had written a note. Review of the nursing notes found no documentation Resident #176 was notified he was receiving a new roommate on 12/24/14. | 2017-04-01 |
| 7491 | 7491 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2015-03-27 | 253 | E | 0 | 1 | G4YW11 | Based on observation and staff interview, the facility failed to ensure effective housekeeping and maintenance services to maintain a sanitary and comfortable environment in six (6) of 33 rooms observed. Various maintenance and housekeeping issues were identified during Stage 1 and Stage 2 of the quality indicator survey (QIS). Room numbers: #307, #103, #409, #303, #304, #247, and #209. Facility census: 118. Findings include: a) Room #307 An observation on 03/24/15 at 9:41 a.m., revealed sheet rock was missing from the wall by the window and the bed. A second observation was made with Employee #80 (maintenance assistant) and Employee #2 (maintenance director), at 1:25 p.m. 03/25/15. They confirmed sheet rock was missing from the wall by the window and the bed. The maintenance employees stated they would repair the areas. b) Room #103 An observation on 03/24/15 at 9:29 a.m., revealed the walls of the room had areas of paint missing. A second observation, on 03/25/15 at 1:29 p.m., with Employees #80 and #2, confirmed the walls of the room had areas of paint missing. In addition, the corner of the wall had a wall guard missing. Employee #80 said he would put up a metal guard on the corner of the wall. An observation also revealed the door frame leading out of the room had missing paint. Employee #2 said he planned to put up plastic door facings, but could only do one (1) room a month. c) Room #409 An observation, on 03/24/15 at 9:15 a.m., revealed two (2) places above the bed had dry wall damage. A second observation, with Employees #80 and #2, on 03/25/15 at 1:28 p.m., confirmed two (2) places above the bed had dry wall damage. Employee #80 and Employee #2 said they would be repairing this damage. They said it occurred because a family member had put up sticky tape. d) Room #303 An observation, on 03/23/15 at 4:00 p.m., revealed the wall at the side of the bathroom had missing paint. A second observation, with Employees #80 and #2, on 03/25/15 at 1:20 p.m., confirmed the wall on the side of the bathroom had missing… | 2017-04-01 |
| 7492 | 7492 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2015-03-27 | 274 | D | 0 | 1 | G4YW11 | Based on record review and staff interview, the facility failed to conduct a significant change minimum data set (MDS) assessment after a resident experienced a significant change in status. Resident #126 experienced a decline in her cognition, physical abilities, abilities to perform her activities of daily living (ADLs), and a decline in her bowel and bladder continence. A comprehensive significant change MDS was not completed to address these changes in condition. This practice was identified for one (1) of 22 assessments reviewed. Resident identifier: #126. Facility census: 118. Findings include: a) Resident #126 1. The MDS assessment, with an assessment reference date (ARD) of 11/11/14 reflected the following: -- Section C0500 - BIMS (brief interview for mental status) score was fifteen (15) -- Section G 0110 (ADL abilities): A. Bed mobility - 3/2 - this indicated extensive assistance of one (1) (person). B. Transfer ability - 3/2 - this indicated extensive assistance of one (1) . C. Walking in Room - 3/2 - this indicated extensive assistance of one (1) . D. Walking in corridor - 3/2 - this indicated extensive assistance of one (1). E. Locomotion on unit - 3/2 - this indicated extensive assistance of one (1). F. Locomotion off unit - 3/2 - this indicated extensive assistance of one (1). G. Dressing - 3/2 - this indicated extensive assistance of one (1). I. Toileting-3/2- this indicated extensive assistance of one (1). J. Personal Hygiene - 2/2 - this indicated limited assistance of one (1). -- Section H 0300, urinary incontinence. This was coded 0. This indicated always continent of bladder. -- Section 0400, bowel incontinence. This was coded a 0. This indicated always continent of bowel. 2. Resident #126's abilities from the MDS assessment with the ARD date of 11/11/14 was compared to a quarterly MDS assessment with an ARD of 01/21/15. The quarterly assessment reflected the resident's abilities had declined. The 01/21/15 assessment was coded as follows: -- Section 0500 - BIMS score was eight (8). -- Section… | 2017-04-01 |
| 7493 | 7493 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2015-03-27 | 280 | D | 0 | 1 | G4YW11 | Based on record review, staff interview, and observation, the facility failed to revise the care plan for one (1) of 22 residents reviewed in Stage 2 of the quality indicator survey (QIS). Resident #87 suffered a fall resulting in a skin tear. The care plan was not revised to include a new intervention, Mat to the left side of bed, to prevent injuries from future falls. Resident identifier: # 87. Facility census: 118. Findings include: a) Resident #87 A review of a change in condition form for Resident #87, dated 03/22/15, revealed the resident experienced a fall. He was found in the floor beside his bed at 4:40 a.m. The change of condition form listed under section W, additional interventions, Mat to left side of bed. An observation, on 03/25/15 at 2:20 p.m., revealed Resident #87 did not have a mat on the floor by his bed. An interview, on 03/25/15 at 2:28 p.m., with Nurse Aide (NA) #31 revealed she cared for this resident frequently. She stated, He does not have a mat beside his bed. The NA obtained the care card with the instructions for his care. A floor mat was not listed as an intervention on the resident's care plan. The interdisciplinary care plan was reviewed. There was no evidence the resident's care plan was revised after the resident's fall on 03/22/15. The care plan did not include the new intervention, as written on the change of condition form, for a mat by the bed. The director of nursing (DON) was interviewed on 03/25/15 at 2:50 p.m. She verified the intervention for the mat to the left side of the bed was written on the risk management report. She also verified the immediate action taken was for a Mat to left side of bed. The DON verified this was what the change of condition form indicated as an intervention. She said the facility should have put the new intervention in place, and should have added it to the resident's care plan. | 2017-04-01 |
| 7494 | 7494 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2015-03-27 | 323 | D | 0 | 1 | G4YW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to maintain an environment which was free of accident hazards, over which the facility had control, for two (2) of four (4) residents reviewed for accidents. Fall interventions were not included in the care plan and/or implemented for Resident # 87. Resident #247 had a television (TV) sitting on an unstable milk crate in his room. Resident identifiers: #87, and #247. Facility census: 118. Findings include: a) Resident #87 Medical record review, on 03/25/15, revealed Resident # 87 was admitted to the facility on [DATE]. A change in condition form, completed on 03/22/15, stated the resident had a fall at 4:40 a.m. In section W of this form, an additional intervention was noted. It was, Mat to left side of bed. Review of the resident's care plan revealed it was last revised on 03/23/15. It identified the resident was at risk for falls and stated the resident had actual falls. The goal stated, Resident will have no falls with injury resulting in ER (emergency room ) visits thru review. The care plan contained an intervention to utilize low bed. There were no interventions on the care plan for a mat on the floor beside of the bed. An observation of Resident #87, on 03/25/15 at 2:20 p.m., revealed his bed was in a high position. In addition, there was no mat on the floor beside the bed. The resident was leaning toward the left side of the bed. During an interview with Nurse Aide (NA) #31, on 03/25/15 at 2:28 p.m., concerning the resident's fall risk, she stated she was the regular NA for Resident #87. She said had never known the resident to have a mat on the floor. When questioned about the height of the bed, NA #31 immediately lowered the bed to a low position. Review of the Kardex (the NA's care plan) revealed it did not contain instructions to keep the resident's bed in a low position, or for a mat on the floor to prevent injuries. On 03/25/15 at 2:30 p.m., NA #31 co… | 2017-04-01 |
| 7495 | 7495 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2015-03-27 | 371 | E | 0 | 1 | G4YW11 | Based on observation and staff interview, the facility failed to ensure food was prepared, served, and stored in a manner which prevented, to the extent possible, foodborne illnesses. A dietary employee was observed touching food, then nonfood items, with the same gloved hands during meal service. An ice scoop was also observed inside the ice machine on top of ice which was used for residents. These practices had the potential to affect more than an isolated number of residents who received meals and/or ice from the kitchen. Facility census: 118 Findings include: a) Kitchen Observation During an observation of meal preparation, on 03/23/15 at 11:30 a.m., the cook (Employee #36) prepared trays, which included making chicken sandwiches on buns. With gloved hands, the cook touched plates, lids, and scoops, then obtained a piece of aluminum foil. After touching these non-food items with gloved hands, she handled unwrapped buns while wearing the same gloves. The interim dietary manager (Employee #125), was questioned about this process on 03/23/15 at 11:35 a.m. He immediately told the cook she could not touch food items with the same gloved hand she used to touch nonfood items. This had the potential to affect 53 residents who received chicken sandwiches. b) Ice Machine During an observation of the kitchen storage area, on 03/23/15 at 11:40 a.m., the lid of the ice machine was open. A scoop was observed inside, on top of the ice. There was an empty holder for the scoop on the side of the ice machine. Employee #126 (Corporate Staff) was standing by the ice machine at the time of the observation. After he was made aware, he asked Nurse Aide #20 to remove the scoop. During an interview with the Administrator (Employee #88), on 03/24/15 at 8:30 a.m., she stated they emptied the ice machine and bought ice to replace it. The administrator said the facility had one (1) resident who did not receive anything by mouth (NPO) and six (6) residents who would not receive ice because they were on thickened liquids. All other residen… | 2017-04-01 |
| 7496 | 7496 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2015-03-27 | 411 | D | 0 | 1 | G4YW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to assist one (1) of three (3) residents, reviewed for dental status and services, to obtain restorative dental services which were recommended by a dentist. When the resident was unable to go to the scheduled dental appointment, and asked for it to be rescheduled, the facility did not assist the resident in rescheduling the appointment. Resident identifier: #141. Facility census: 118. Findings include: a) Resident #141 Observations during Stage 1 of the quality indicator survey (QIS), on 03/24/15 at 9:55 a.m., revealed Resident #141 had unclean yellowed teeth with some broken and missing teeth. Review of the current care plan revealed Resident #141 was at risk for oral health problems related to a history of dry mouth and natural teeth with darkened areas in front. The medical record, reviewed on 03/26/15 at 4:20 p.m., indicated the resident last saw a dentist on 03/25/14. The dental consultation, dated 03/25/14, revealed the resident had her teeth cleaned and had heavy plague at that time. An appointment for restorative work was recommended. Review of the physician's orders [REDACTED]. A nursing progress note, dated 04/08/14, revealed . resident refuses to go for appt. (appointment) with dentist. States 'I just don't want to go today please reschedule.' On 03/26/15 at 3:07 p.m., the director of nursing (DON) said she was unsure if the resident went to the dentist and had the recommended restorative dental work done. A review with the DON, of the resident's most current oral assessment, dated 03/18/15, revealed the resident had decayed broken teeth with greater than three (3) missing. The DON said she would need to obtain and review the resident's thinned medical records to see if and/or when the resident went to dental appointments. An interview with the DON, on 03/26/15 at 4:40 p.m., revealed the facility had no evidence which indicated another appointment was ma… | 2017-04-01 |
| 7497 | 7497 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2015-03-27 | 463 | D | 0 | 1 | G4YW11 | Based on observation and staff interview, the facility failed to ensure all call lights in resident rooms, toilets, and bathing areas were in working order, to ensure residents have a means of directly contacting caregivers. Two (2) call systems observed in resident bathrooms were not in working order. One call system in a resident bathroom, had only an audible alert, while the call system in another resident bathroom, had neither an audible or visual alert. This practice affected two (2) of 40 resident call systems tested in Stage 1 of the survey process. Room identifiers: #210 and #217. Facility census: 118. Findings include: a) Room #210 During a check of the call light system, on 03/23/15 at 3:42 p.m., the call system in the bathroom was found in non-working order. When the call system was activated, there was only an audible alert. The visual alert over the entrance to the resident's room did not function. On 03/23/15 at 4:40 p.m., upon inquiry, Nurse Aide (NA) #84 verified the call system in the bathroom of Room #210 was not functioning properly. b) Room #217 At 4:20 p.m. on 03/23/15, while conducting a check of the call light system, the call system in the bathroom was found in non-working order. When activated, the call system had neither an audible nor a visual alert. On 03/23/15 at 4:25 p.m., upon inquiry as to how staff were made aware of a resident requiring assistance while in their bathrooms, NA #70 stated, The residents pull their cords, and a red light flashes over the door. Upon request, she pulled the call system cord located in the bathroom of Room #217. The NA verified the call system was not functioning. c) At 4:00 p.m. on 03/25/15, Employee #30, the Unit Manager, verified the Maintenance Director had worked on the call systems that were not functioning properly. She said the Maintenance Director had replaced the non-functioning switches on the call lights. | 2017-04-01 |
| 7498 | 7498 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 166 | D | 0 | 1 | 9DS111 | Based upon medical record review, policy review, family interview, and staff interview, the facility failed to make prompt efforts to resolve a grievance voiced by a resident's family. The facility staff did not follow the facility's policy and procedure when the resident's family voiced a concern about the way a staff member had spoken to the resident. This was found for one (1) of one (1) resident reviewed. Resident identifier: #145. Facility census: 113. Findings include: a) Resident #145 An interview was conducted with social workers, Employees #146 and #152, on 06/04/13 at 2:30 p.m. When the information requested upon admission regarding the facility's complaints/grievances files was received, it was noted there were no documented complaints of any kind from residents, families, visitors, or staff going back to the year 2012. They were asked how the facility documented complaints. Both social workers said that complaints received by staff were documented in the individual resident's medical record, either in progress notes or in the resident's care plan. They said there was no system of documenting each complaint in writing, or keeping a log of complaints independently of making entries in the medical record. 1) An interview was conducted with a family member of Resident #145 on 06/06/13 at 11:30 a.m. The family member said that shortly after Resident #145's admission to the facility, on 02/08/13, staff had attempted to give her a shower. The family member said this was on a Saturday. When the resident resisted and became agitated, a nurse allegedly said to her (Resident #145), we can do this the easy way, or we can do it the hard way. The family did not observe this interaction personally, but were told about it by someone they trusted. They went to a registered nurse (RN), Employee #31, and, in the presence of the social workers, Employees #146 and #152, they told all three (3) staff about the allegation, saying they were upset that a threat like that may have been made to their family member. Employee #31… | 2017-04-01 |
| 7499 | 7499 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 225 | D | 0 | 1 | 9DS111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon family interview, staff interview, review of facility documents, and medical record review, the facility failed to ensure an allegation of verbal abuse while attempting to shower a resident was reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility also had no evidence the alleged violation was thoroughly investigated. This was found for one (1) of two (2) residents reviewed for possible abuse, and had the potential to affect more than a minimal number of residents. Resident identifier: #145. Facility census: 113. Findings include: a) Resident #145 This eighty-five (85) year old woman was admitted to the facility on [DATE]. Her record was reviewed on 06/06/13 at 9:30 a.m. Review of facility documents, on 06/06/13 at 10:00 a.m. found that there were no documented complaints relating to any resident received since at least 2012. There were three (3) allegations of abuse/neglect that had been reported on 05/19/12, 08/22/12, and 11/05/12. A social worker (Employee #152) was interviewed on 06/06/13 at 11:00 a.m. She was asked about the facility's procedures for abuse/neglect prohibition. She said that all staff were trained in the subject and anyone can report abuse/neglect. She said the social workers generally assist with the investigations following a report, and that the reporting and record keeping was generally done by administrative staff. During an interview on 06/06/13 at 11:30 a.m., the daughter of Resident #145 stated that shortly after her admission on a Saturday (02/08/13), her mother was taken for a shower. The resident became agitated and resisted the efforts of staff to begin the shower. A nurse reportedly said to her (Resident #145), we can do this the easy way, or we can do it the hard way. The daughter said she was told this by a witness to the alleged confrontati… | 2017-04-01 |
| 7500 | 7500 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 241 | D | 0 | 1 | 9DS111 | Based on observation, staff interview, and medical record review, the facility failed to maintain the dignity for two (2) randomly observed residents. The residents were ambulating in the hallway with urinary catheter drainage bags in full view and not covered. Resident identifiers: #154 and #152. Facility census: 113. Findings include; a) Resident #154 On 06/05/13 at 10:00 a.m., Resident #154 was observed ambulating in the hallway with her walker and the assistance of physical therapy staff. The resident's Foley catheter drainage bag was attached to the walker in full view of others and was partially filled with yellow urine. During an interview with a nurse, Employee #121, on 06/05/13 at 10:00 a.m., she said privacy bags were applied to urinary drainage bags when residents were sitting in cardiac chairs. She did not know why this resident's Foley drainage bag was not covered with a privacy bag. The medical record was reviewed on 06/05/13 at 11:00 a.m., and revealed a care plan intervention to keep the drainage bag off the floor and covered for dignity. . b) Resident #152 This resident was observed on 06/05/13 at 8:35 a.m., walking into her room from the hallway, carrying her uncovered catheter bag. | 2017-04-01 |
| 7501 | 7501 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 253 | E | 0 | 1 | 9DS111 | Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Caulking was cracked and discolored around commode bases; tiles were cracked, missing and/or poorly patched; textured wall paper on the 500 wing was stained and discolored; doorways and walls were in disrepair; room furnishings were chipped exposing raw fiber particles; and bathroom mirrors were missing the silver reflective material. This had the potential to affect more than a limited number of residents. Rooms 104, 116, 206, 302, 304, 307, 308, 309, 311, 312, 313, and 504. Facility census: 113. Findings included: a) 300 Hall 1) Observations of resident rooms on the 300 hall/wing, on 06/04/13 and 06/05/13, revealed multiple areas were unclean and in disrepair. - The three (3) drawer dressers in rooms 309 and 308 were chipped across the front and sides, exposing the fiberboard beneath. Employee #76, the maintenance director, agreed they were unable to be cleaned, were in disrepair, and needed replaced. - The corner tile was pulled away from the bathroom wall in Room 302. Employee #76 said the tile had been recently laid in Room 302, but it was separated at some of the seams. A brown substance, the maintenance supervisor identified as glue, also protruded through the seams. - The tile in Room 308 had multiple black spots, had indentations in the flooring, and was separated from the bathroom wall. There was also a large chunk out of the wall, on the left side of the window, near the floor. Large strips of paint were missing from the wall exposing brown wall beneath. A hole was observed in the corner of the wall, at ceiling level. Above the window, three (3) areas with holes were not repaired. On the right side of the window, the wall was damaged. The three (3) drawer chest was broken along top and sides and front. Fiberboard was visible beneath. The border at the base of the bathroom wall was separated from the wall. The walls were dingy… | 2017-04-01 |
| 7502 | 7502 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 280 | D | 0 | 1 | 9DS111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, policy review, and review of incident/accident reports, the facility failed to revise the care plans as the conditions of three (3) of twenty-one (21) Stage 2 residents changed. The care plan for Resident #49 was not updated related to falls. The care plan for Resident #82 was not updated related to missing dentures. The care plan for Resident #31 was not updated related to pressure ulcers. Resident identifiers : #49, #82, and #31. Facility census: 113. Findings included: a) Resident #49 During a Stage 1 interview, Employee #40 (a nurse) said Resident #49 had fallen in the previous 30 days. Review of the medical record, on 06/10/13 at 11:30 a.m., revealed the resident had a serious fall with injury on 03/06/13. The resident was admitted to the hospital intensive care unit with fractured ribs, acute [MEDICAL CONDITION], and a [DIAGNOSES REDACTED]. The resident continued to fall upon return to the facility. Additional fall precautions were initiated on readmission to the facility, including therapy. Further review of the medical record revealed the resident fell on [DATE], 05/04/13, 05/02/13, 04/08/13, and 03/28/13. Nurses' notes revealed the resident continued to attempt independent ambulation without assistance. The care plan was reviewed. There were no additional notations to include the continuation of falls, with the exception of ice to the ribcage and incentive spirometry, related to the fall on 05/02/13, with a contusion to the ribcage. An interview with Employee #118 (RN), resident assessment instrument coordinator (RAI), on 06/11/13, provided no evidence the care plan was updated to include the ongoing falls. No additional interventions were identified for the prevention of falls. The nurse said it was assumed the falls were related to weakness from the hospitalization . b) Resident #82 During a Stage 1 interview, on 06/05/13 at 1:53 p.m., Resident #82 said his lower dentures were m… | 2017-04-01 |
| 7503 | 7503 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 282 | D | 0 | 1 | 9DS111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and observation, the facility failed to follow the care plan for one (1) of twenty- one (21) residents reviewed in Stage 2 of the survey. A resident, who had experienced a previous fall from her wheelchair, had a care plan intervention added to apply Dycem to her wheelchair to help prevent sliding and additional falls. The resident was observed to not have Dycem in her wheelchair. Several staff providing care for her were unaware she was supposed to have the Dycem. Resident identifier: #23. Facility census: 113. Findings include: a) Resident #23 Review of the medical record found this [AGE] year old resident was admitted to the facility in March 2013. She had a history of [REDACTED]. Further review of the medical record revealed Resident #23 sustained a fall at the facility on 06/01/13, after sliding out of her wheelchair. A care plan intervention, dated 06/02/13, directed Dycem be placed in her wheelchair for grip safety. Observation on 06/11/13 at 10:00 a.m., revealed this resident had just been returned to her bed by nursing assistants after being up in her wheelchair. No Dycem was observed in the wheelchair. An interview was conducted with a nurse, Employee #85, on 06/11/13 at 10:00 a.m. She inspected the resident's wheelchair, and confirmed there was no Dycem in the wheelchair. She asked, Should there be?. She said she was not aware this resident had a problem with slippage. The nurse said if the resident had Dycem, it would be placed on her wheelchair cushion, then the lift sling on top of that. An interview was conducted with two (2) nursing assistants, Employees #157 and #117, on 06/11/13 at 10:10 a.m. They said safety measures for this resident included a low bed and placing the call light within her reach. They both agreed that she had no Dycem for her wheelchair, and had she had Dycem, it would remain in her wheelchair and not be stored somewhere else. During an interview with a nurs… | 2017-04-01 |
| 7504 | 7504 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 309 | D | 0 | 1 | 9DS111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (2) of twenty-one (21) Stage 2 sample residents. The facility did not routinely assess Resident #57, who was unable to verbally communicate, for pain. The facility failed to monitor oxygen saturations for Resident #21 and failed to ensure the resident was properly positioned for a nebulizer treatment. In addition, the facility treated the resident with medication for anxiety, instead of assessing the resident for the causal factors related to anxiety. Resident identifiers: #57 and #21. Facility census: 113. Findings include: a) Resident #57 Review of this resident's medication administration records (MARs) for April 2013 revealed the resident received frequent doses of Tylenol on an as needed (PRN) schedule. She received seventeen (17) doses in the month of April, ranging in time from 7:00 a.m. to 8:00 p.m. The medication was then scheduled for twice a day, in addition to the as needed regimen. Pain assessment flow sheets noted assessments from 04/02/13 through 04/30/13. In an interview, a licensed practical nurse (LPN) indicated residents were to be assessed for pain daily. A notebook, kept at the nurses' station, noted which shift was to evaluate pain as a routine assessment, and note it on the pain assessment flow sheet. The LPN looked at the book and said day shift would have documented daily on Resident #57. She said pain would be noted either on the pain flow sheet or on the MAR. Review of the MAR indicated [REDACTED]. The LPN confirmed the daily assessments were not completed according to facility policy. Further review of the medical record, revealed daily assessments were also not completed after the resident began receiving pain medication on a routine basis. An interview with Employee #85 (LPN), on 06/11/13 at 10:52 a.m., revealed the… | 2017-04-01 |
| 7505 | 7505 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 323 | D | 0 | 1 | 9DS111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and incident/accident review, the facility failed to provide interventions to prevent accidents for two (2) of twenty-one (21) residents reviewed in Stage 2 of the survey. Resident #49 resident had a fall with serious injury and had multiple falls after the injury without a thorough assessment of what additional interventions might be attempted. Resident #23 was to have Dycem placed in her chair, but this was not present, nor were staff aware of this intervention. Facility census: 111. Resident identifiers: #49 and #23. Findings included: a) Resident #49 During a Stage 1 interview, Employee #40 said Resident #49 had fallen in the previous 30 days. Review of the medical record, on 06/10/13 at 11:30 a.m., revealed the resident had a serious fall with injury on 03/06/13. The resident was admitted to the hospital intensive care unit with fractured ribs, acute respiratory failure, and a [DIAGNOSES REDACTED]. Therapy was initiated on readmission to the facility. An interview with the physical therapist, Employee #172, revealed the resident was able to ambulate with contact guard assist of one (limited assist/nonweight bearing), upon discharge from therapy. The family was involved in the decision making process, but said they could no longer come to the facility as before. Review of the current care plan revealed it still noted the family was to be called to assist in the facility if needed. The resident continued to fall upon return to the facility. Further review of the medical record revealed the resident fell on [DATE], 04/08/13, 05/02/13, 05/04/13, and 05/08/13. Nurses' notes revealed the resident continued to attempt independent ambulation without assistance, daily. There was no evidence the care plan was updated to reflect the ongoing falls. Facility records contained the following information related to the resident's falls: - 03/25/13 - Staff spoke with the medical power of attor… | 2017-04-01 |
| 7506 | 7506 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 329 | D | 0 | 1 | 9DS111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, the facility failed to ensure the medication regime for each resident was free from unnecessary medications. Resident #85 was not assessed for all factors related to shortness of breath, including the provision of nonpharmacologic interventions prior to the use of medication. Resident #31 received a medication with the incorrect [DIAGNOSES REDACTED]. Two (2) of ten (10) Stage 2 sample residents were affected. Resident Identifiers: #85 and #31. Facility census: 113 a) Resident #85 Review of the medical record, on 06/12/13 at 3:03 p.m., revealed Resident #85 had a [DIAGNOSES REDACTED]. During an interview with Employee #136 (LPN), she said he would become short of breath, restless, and remove his oxygen. She said he would position toward his left side. Employee #85 (LPN) agreed with this information. A physician's orders [REDACTED]. He was to have an SpO2 (to check oxygen saturation) as needed for dyspnea. Further review of the medical record revealed Resident #85 had received [MEDICATION NAME] on an as needed basis for seven (7) of eleven (11) days in June 2013; and eighteen (18) of thirty-one (31) days in May. The nurses said his anxiety was related to his [MEDICAL CONDITION]. Review of the medication administration records (MARs) and treatment administration records (TARs) for April, May, and June 2013 revealed no entries for an SpO2s. Employee #85 confirmed no evidence was present in the medical record to indicate the resident's oxygen saturation had been evaluated prior to administering the [MEDICATION NAME]. Observation of the resident, on 06/13/13 at 8:15 a.m., revealed the resident was receiving a nebulizer treatment. His bed was in semi fowlers position (about 45 degrees), and he was slumped down in the bed. He was leaning toward his left, holding onto the sidebar. His breathing was fast and he was using his accessory muscles. His abdomen was heaving in and out. Employ… | 2017-04-01 |
| 7507 | 7507 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 371 | E | 0 | 1 | 9DS111 | Based on observation and staff interview, the facility failed to store and serve food under sanitary conditions. The freezer in the pantry did not have a thermometer to ensure foods were maintained at safe temperatures to prevent foodborne illnesses. In addition, a dietary staff member contaminated food products when she touched environmental objects with gloved hands, then handled food products and served foods while wearing the contaminated gloves. This had the potential to affect more than a limited number of residents. Facility census: 111. Findings included: a) Pantry A tour of the pantry on the 400 hall/wing, on 06/02/13 at 2:20 p.m., revealed two (2) opened containers of milk in the refrigerator. Individual cups of ice cream in the freezer were soft to touch. Employee #155 (RN) confirmed the ice cream felt soft. When asked the temperature of the freezer, she was unable to find a thermometer. The RN then called the dietary department. Employee #143, a dietary assistant, checked the refrigerator at 2:30 p.m. on 06/02/13. She said the milk should have been thrown away. She squeezed a container of ice cream, which had been located toward the back of the freezer, and agreed it was soft. She confirmed no thermometer was present. Additionally, a green, white and black substance was observed around the base of the faucet and the drain produced a reddish brown substance when wiped with a paper towel. Employee #155 (RN), Employee #143 (dietary assistant) and Employee #78 (dietary manager) agreed the sink looked dirty. b) Observations in the main dietary kitchen, on 06/04/13 at 11:45 a.m., found dietary Employee #123 with gloved hands. She was plating food for residents. She left her gloves on and went into the storage room. She obtained a package of hamburger buns with her gloved hands. She removed a hamburger bun from the package, while still wearing the same gloves, and placed the bun on the plate. These gloves were contaminated from touching environmental objects in the kitchen. She continued plating the food and… | 2017-04-01 |
| 7508 | 7508 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 428 | D | 0 | 1 | 9DS111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the pharmacist failed to identify a medication irregularity for one (1) of ten (10) Stage 2 sample residents. Resident #31 had an order for [REDACTED]. There was no indication the discrepancy in the [DIAGNOSES REDACTED]. Resident identifier: #31. Facility census: 111. Findings include: a) Resident #31 1) Review of the Medication Administration Record, [REDACTED]. The psychoactive medication quarterly review evaluation sheet, signed by the physician and dated 05/31/13, indicated the Cymbalta 90 mg daily dose was for neuropathic pain, not depression. On the form identified as the Chronological Record of Drug Regimen Review, the consultant pharmacist's progress notes indicated the pharmacist reviewed Resident #31's records on six (6) different dates between 02/25/13 and 06/03/13. No evidence was found to indicate he had identified the the discrepancy in the [DIAGNOSES REDACTED]. During a staff interview on 06/11/13 at 2:45 p.m., with Employee #55 and Employee#155, both registered nurses, they verified the resident had a [DIAGNOSES REDACTED]. They also acknowledged the order for the daily dose of Cymbalta 90 mg, given once a day at 8 a.m., was written for depression, yet the attending physician's psychoactive medication quarterly review stated it was for neuropathic pain. The nurses stated they would contact the physician and obtain clarification on the current order for Cymbalta. A follow up review of the record, on 06/12/13 at 9:00 a.m., identified a clarification order which stated the Cymbalta was for both depression and neuropathic pain. | 2017-04-01 |
| 7509 | 7509 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 441 | F | 0 | 1 | 9DS111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, manufacturers' product descriptions, staff interview, and policy review, the facility failed to develop and implement effective infection control practices. The facility failed to follow manufacturers' product information for single use resident items (wash basins and bedpans), did not ensure linen was handled in a safe and sanitary manner, staff failed to sanitize their hands during dispensing of ice and snacks to residents, failed to ensure Resident #96's toothbrush was stored in a sanitary manner, failed to ensure two (2) residents (#94 and #31) received proper catheter and/or peri care, failed to ensure bedpans were maintained to ensure use by the same person and were stored properly, and failed to ensure two (2) residents (#154 and #23) were cohorted appropriately. Thes issues had the potential to affect more than a limited number of residents. Resident identifiers: #94, #31, #96, #154, #23, #50, and #109. Census: 113. Findings include: a) Resident #94 A nurse aide (NA), Employee #164, was observed performing pericare and catheter care on Resident #94 on 06/11/13 at 9:00 a.m. The employee donned her gloves and then proceeded to pick up the fall mat off of the floor next to the resident's bed. Without changing her gloves, she sprayed baby wipes with an antimicrobial personal cleaner called [MEDICATION NAME] and began wiping the perineal area from front to back without changing wipes or folding them. She then cleaned the catheter tubing twice with the same wipe, wiping from proximal to distal. After the resident was redressed and covered, the NA picked up an alcohol wipe from the bedside table and cleansed the end of the drainage tubing before emptying the catheter bag. After emptying the catheter bag, she picked up a second alcohol wipe from the bedside table and cleaned the tubing before securing it to the catheter bag. She did not change her gloves. A review of the procedure was conducted with Employ… | 2017-04-01 |
| 7510 | 7510 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 465 | F | 0 | 1 | 9DS111 | Based on observation and staff interview, the facility failed to ensure a safe, functional, sanitary and comfortable environment for residents, staff, and the public. A green and black mold-like substance was observed in the residents' community shower rooms. The shower rooms also had tiles that were cracked, missing, and/or poorly patched. Some bathroom mirrors were missing the silver reflective material. This had the potential to affect more than a limited number of residents. Facility census: 113. Findings include: a) Observations of the resident showers on the 100, 200, 300, and 400 halls were conducted on 05/29/13 at 1:15 p.m. and on 06/03/13 at 11:15 a.m. All four (4) of the showers contained cracked and discolored grout in between the tile in several areas including in the floor and wall joints. In addition there was a green and black mold-like substance going up the wall in the corners near the shower heads. 1) 400 hall The shower on the 400 hall was missing floor tiles. During a staff interview, on 06/03/13 at 11:51 a.m., with the building and ground supervisor, Employee #21, and the housekeeping supervisor, Employee #62, both agreed all four (4) showers needed cleaned and repaired. Employee #21 stated she was going to go to the store and find another cleaner to dissolve the green and black mold-like substance on the walls. Both acknowledged the grout was dirty, cracked and needed cleaned and repaired. The 400 shower was immediately closed off until the missing floor tile was replaced. In a staff interview, on 06/03/13 at 1:05 p.m. with housekeeping, Employee #110 stated she reported the poor conditions of the showers and said they keep saying they will get to it. 2) 100 Wing A tour of the 100 wing, at 1:50 p.m. on 05/29/13, noted a green colored mold-like substance on the floor of the shower room. Tiles were also missing around the toilet used by residents in the shower room. It was also observed the mirror in the shower room was missing the silver reflective material which caused the bottom 1/2 inch of… | 2017-04-01 |
| 7511 | 7511 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 490 | E | 0 | 1 | 9DS111 | Based upon observation, record review, resident interview, staff interview, and review of facility documents, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evident from 1. A failure to implement an effective infection control program, 2. A failure to ensure staff were properly trained in facility policies and procedures for reporting any and all allegations of abuse and neglect, 3. A failure to ensure all staff were documenting all resident, family, and visitor complaints they may have received as stated in facility policy and implementing the procedure to ensure a prompt resolution and response, and consequently failed to ensure needed data was made available to the quality assessment and assurance committee (QAA) to allow for the identification of trends and patterns of complaints, and thereby focus the facility's corrective actions, and 4. A failure to maintain a safe, clean, comfortable environment for residents, staff, and visitors. These practices have the potential to affect more than an isolated number of residents. Facility census: 113. Findings include: a) During the survey, multiple deficient practices were identified with the facility's infection control program, the condition of the facility environment and safety, the identification, reporting, and investigation of allegations of abuse, prompt investigation and resolution of complaints, and lack of interdisciplinary recommendations for revision to care plans following review of incidents and accidents. b) Concerns documented with the facility's infection control policies, procedures, and the implementation of those policies and procedures were of a systemic nature rather than merely a series of random, isolated specific deficient practices. c) Investigation of the facility's implementation of their complaint policy and procedures found that the social workers, who were… | 2017-04-01 |
| 7512 | 7512 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 498 | D | 0 | 1 | 9DS111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents. Two (2) nursing assistants were observed performing improper catheter care for Residents #94 and #31. Resident identifiers: #94 and #31. Facility census: 111. Findings include: a) Resident #94 Nurse aide (NA), Employee #164, was observed performing pericare and catheter care on Resident #94 on 06/11/13 at 9:00 a.m. The employee donned her gloves and then preceded to pick up the fall mat off of the floor next to the resident's bed. She sprayed the baby wipes with the facility's antimicrobial personal cleaner called [MEDICATION NAME] and began wiping the perineal area from front to back without changing wipes or folding them. She then cleaned the catheter tubing twice with the same wipe, wiping the tubing from proximal to distal. After the resident was redressed and covered, the NA picked up an alcohol wipe from the bed side table and cleansed the end of the drainage tubing before emptying the catheter bag. After emptying the catheter bag she picked up a second alcohol wipe from the bedside table and re-cleaned the tubing before securing it to the catheter bag. A review of the procedure was conducted with the NA immediately after the procedure. She agreed the bedside table should have been covered to prevent her from contaminating it when she picked up the alcohol wipes with her dirty gloves on. The NA also agreed she should not have completed pericare and catheter care with the same pair of gloves she wore when she picked up the floor mat. In addition, she acknowledged the [MEDICATION NAME] spray bottle she had just used had a brown colored substance in the groves of the cap and needed to be replaced. b) Resident #31 An observation was conducted on 06/11/13 at 1:40 p.m., while another NA, Employee #88, was performing pericare and catheter care on Resident #31. She donn… | 2017-04-01 |
| 7513 | 7513 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2013-06-13 | 520 | E | 0 | 1 | 9DS111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, resident and family interviews, staff interviews, medical record review, facility policy and procedure review, and review of other facility documents, the quality assessment and assurance (QAA) committee failed to identify and/or act upon quality deficiencies within the facility's operations of which it did have (or should have had) knowledge, and implement plans of action to correct these deficiencies, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. In spite of the fact that the area of infection control, incident/accident report review, abuse/neglect reporting and investigation, environmental issues, and complaints were identified as being permanent items on the QAA committee's monthly agendas, the quality deficiencies were not effectively addressed by ensuring all items were thoroughly identified, and investigated with appropriate follow-up to prevent recurrence. The facility failed to identify reportable abuse/neglect situations as well as complaints that could have been recognized from existing quality review systems in place. Because the reportable abuse/neglect situations and complaints were not identified, there was no plan in place to effectively address and remedy these issues, or to implement any preventative measures for other residents. These practices had the potential to affect more than an isolated number of residents. Facility census: 113. Findings include: a) Documents provided upon entrance indicated that the facility's QAA committee meets monthly. Members were identified as the owner, the administrator, the director of nursing, the assistant director of nursing, the consultant pharmacist, both social workers, registered nurse and inservice director, the admissions coordinator, the dietary supervisor, the medical records director, and the RAI (resident assessment instrument) coordinator. This information was con… | 2017-04-01 |
| 7514 | 7514 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2013-07-19 | 253 | E | 0 | 1 | NOYK11 | Based on observation and staff interview, the facility failed to provide maintenance services to maintain resident rooms and furnishings in good repair. in seven (7) rooms on the 300 hall. Rooms #302, #304, #305, #307, #312, #313, and #315 all contained wardrobes for resident clothing which were missing knobs. The knobs were necessary to assist residents in opening and closing the drawers. Room #307 also had a hole in the wall where the cable outlet was connected. The outlet cover was hanging on the cable that ran from the wall to the television. This practice had the potential to affect more than an isolated number of residents. Facility Census: 80. Findings Include: a) Room #307 Random observations completed during Stage 1 of the survey, at 4:54 p.m. on 07/15/13, revealed the wardrobes in Room #307 had drawers with missing knobs. Without the knobs it was difficult to open and close the drawers. Also observed was a square hole in the drywall with a black cable. The cable ran from the hole to the television sitting by the window. The black cable had a cream-colored outlet cover hanging on it with the cable running through a small hole in the center of the outlet cover. The outlet cover appeared to have at one time been screwed into the wall covering the hole. Employee #28, a maintenance employee, was interviewed at 1:45 p.m. on 07/17/13. He made an observation of Room #307 and confirmed the cable outlet cover was pulled from the wall exposing the hole, which was made to run a cable to the room for television access. Employee #28 also confirmed the drawers were missing knobs. He stated they would compile a list to get them replaced. b) Rooms #302, #304, #305, #312, #313, and #315. Random observations were made during Stage 2 of the survey, at approximately 1:00 p.m., on 07/17/13. The observations revealed all of these rooms had missing knobs on the drawers of the wardrobes which contained residents' clothes. This made it difficult to open and close the drawers. Employee #28 confirmed there was a problem on this ha… | 2017-04-01 |
| 7515 | 7515 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2013-07-19 | 272 | D | 0 | 1 | NOYK11 | Based on medical record review and staff interview, it was determined the Minimum Data Set (MDS) assessment for one (1) of twenty-one (21) residents whose medical records were reviewed, contained an assessment which had inaccurate data regarding use of a urinary catheter. Resident #96 had a catheter identified on the current assessment, but this device had been removed months prior to the current assessment being completed. Resident identifier: #96. Facility census: 80. Findings include: a) Resident #96 Review of the quarterly MDS assessment, completed on 06/03/13, indicated the resident had an indwelling Foley catheter. An interview with the director of nursing, Employee #58, at 10:20 a.m. on 07/17/13, revealed the resident did not currently have a catheter and it had been removed back in March 2013. She could not determine why the MDS indicated the resident had a catheter when it had not been used for some time. | 2017-04-01 |
| 7516 | 7516 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2013-07-19 | 323 | E | 0 | 1 | NOYK11 | Based on observation and staff interview, the facility failed to maintain an environment free from accident hazards. During a random observation of the facility's shower room, an electric hairdryer was observed hanging unattended and plugged into an electrical outlet near a water source. This had the potential to affect more than a minimal number of residents. Facility Census: 80. Findings Include: a) During a random observation, at 2:15 p.m. on 07/18/13, an electric hairdryer was observed hanging on a towel hook in the facility shower room. The hairdryer was plugged into the electrical outlet and was located near the sink in the shower room. At 2:20 p.m. on 07/18/13, Employee #79, a Licensed Practical Nurse (LPN), accompanied the surveyor to the shower room. When Employee #79 saw the hairdryer she stated, They know better than this. She unplugged the hairdryer and stated the hairdryer was to be kept in the locked cabinet on the wall across from the sink. She stated when the hairdryer was not in use, the staff should put the hairdryer in the cabinet, and should not leave the hairdryer plugged in unattended. | 2017-04-01 |
| 7517 | 7517 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2013-07-19 | 431 | E | 0 | 1 | NOYK11 | Based on observation, policy review, and staff interview, the facility failed to ensure the safe and secure storage of controlled medications. The refrigerated controlled substances were not stored in a permanently affixed locked compartment. This practice had the potential to affect a limited number of residents. Facility census: 80. Findings include: a) During the visual check of the West wing medication storage room, on 07/17/13 at 2:45 p.m., the medication storage refrigerator was noted to have a clear locked box containing four (4) vials of Lorazepam 2 mg/ml injectable. The box was not secured inside of the refrigerator and the refrigerator was not locked to secure the controlled substances. The facility did not maintain a separately locked, permanently affixed compartment for the storage of controlled medications. During an interview with the director of nursing (DON), on 07/17/13 at 2:50 p.m., she was made aware the vials of Lorazepam were not in a secure box. She asked how this could be done. She stated she felt the medications being in the box that was locked and the medication room door was locked, the medications were secured. She stated she was going to notify the pharmacy to get the box secured inside of the refrigerator. Review of the facility's policy, on 07/18/13 at 10:00 a.m., entitled 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles number twelve (12) Controlled Substances Storage included, Number 12.1 Facility should ensure that Schedule II-IV controlled substances are only accessible to licensed nursing, Pharmacy, and medical personnel designated by the Facility. Number 12.2 was After receiving controlled substances and adding to inventory, Facility should ensure that Schedule II-IV controlled substances are immediately placed in a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable Law). | 2017-04-01 |
| 7518 | 7518 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2013-07-19 | 514 | D | 0 | 1 | NOYK11 | Based on medical record review, facility policy review, and staff interview, the facility failed to ensure the completeness and accuracy of two (2) of twenty-one (21) medical records. Resident #27's medical record did not contain complete documentation pertaining to social services provided by the social worker. Resident #66's medical record did not contain complete documentation for pressure ulcers. Resident identifiers: #27 and #66. Facility census: 80. Findings include: a) Resident #27 On 07/18/13 at 2:00 p.m., the social worker (Employee #50) said she had files for residents she had talked with in her office in a file cabinet. She said these records were secure in her office in the locked cabinet. She said they contained sensitive information and she did not believe she should put that type of information in the resident's electronic medical record. She said she had a file for Resident #27. She explained some of the conversations she had with Resident #27 and did not feel she should put these conversations and their content in the electronic medical record for all staff to view. According to AHIMA (American Health Information Management Association) long-term care guidelines (06/09) a complete medical record contains an accurate and functional representation of the actual experience of the individual in the facility. It must contain enough information to show that the facility knows the status of the individual has adequate plans of care and provides sufficient documentation of the effects of the care provided. Documentation should provide a picture of the resident, including what resident said or did, observations and/or assessments by staff, communications with practitioners and legal representative, response to interventions/treatment. Good practice indicates that for functional and behavioral objectives the clinical record should document change toward achieving care plan goals. The social worker verified Resident #27 had episodes of verbal aggression toward staff and other residents. She said the facilit… | 2017-04-01 |
| 7519 | 7519 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-04-24 | 224 | G | 1 | 0 | HZEQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview, the facility failed to implement procedures to ensure residents were free of neglect. The facility failed to provide care and services to ensure residents received the correct diet to prevent choking. The facility did not ensure restrictions regarding swallowing were implemented for Resident #142. The resident did not receive a mechanical soft diet as ordered by the physician, but was served a whole hot dog (not ground) on a bun. As a result of being served the incorrect diet, the resident experienced actual harm when she choked and was sent to the hospital. Subsequently, the facility's investigation of the occurrence failed to identify the resident did not receive a mechanical soft diet as ordered. As a result the facility did not implement measures to prevent this from reoccurring for this resident or other residents. Staff gave inconsistent responses regarding what swallowing restrictions were in place upon her return from the hospital. This was true for one (1) of nine (9) sampled residents and had the potential to affect more than an isolated number of residents who received a mechanically altered diet. Fifty-two (52) residents were receiving mechanically altered diets at the time of the survey. Resident identifier: #142. Facility Census: 141. Findings include: a) Resident #142 Review of the resident's medical record found a nursing entry, dated 03/26/14 at 19:21 (7:21 p.m.), noting the resident's son and a nursing assistant called for a nurse. The note included, Resident was noted to be choking. [MEDICATION NAME] maneuver performed, resident was transferred from the wheelchair to the bed, abdominal thrusts performed. Resident then began to make eye contact and started to mumble. O2 (oxygen) @ (at) 10L (ten liters) with non-rebreather applied, 20g (20 gauge) IV (intravenous) inserted to left inner arm infusing NS (normal saline). Resident's family stated that resident had cho… | 2017-04-01 |
| 7520 | 7520 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-04-24 | 225 | D | 1 | 0 | HZEQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview, the facility failed to thoroughly investigate and report an incident of neglect. A resident did not receive a diet in the form to meet her needs, a mechanical soft diet, as ordered by the physician. She was served a whole hot dog on a bun. As a result of being served the incorrect diet, the resident choked and was sent to the hospital. The facility's investigation contained inaccurate information in the summary report. The facility failed to identify the type of diet this resident received for that meal which resulted in the choking episode, and failed to interview pertinent staff and family members who were present when the incident occurred. The facility also failed to identify or report this as an incident of neglect because it was based on inaccurate and incomplete information in their investigation. This was identified for one (1) of thirty-eight (38) reportable incidents reviewed for three (3) months. Resident identifier: #142. Facility Census: 141. Findings include: a) Resident #142 Review of the resident's medical record found a nursing entry, dated 03/26/14 at 19:21 (7:21 p.m.), noting the resident's son and a nursing assistant called for a nurse. The note included, Resident was noted to be choking. [MEDICATION NAME] maneuver performed, resident was transferred from the wheelchair to the bed, abdominal thrusts performed. Resident then began to make eye contact and started to mumble. O2 (oxygen) @ (at) 10L (ten liters) with non-rebreather applied, 20g (20 gauge) IV (intravenous) inserted to left inner arm infusing NS (normal saline). Resident's family stated that resident had choked on her hot dog stating 'she put the whole thing in her mouth' . She was transferred to the hospital by ambulance at 7:20 p.m. A review of the facility's investigation files, on 04/21/14 at 2:30 p.m., found this incident was investigated, but was not reported to the State agencies. A Registered … | 2017-04-01 |
| 7521 | 7521 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-04-24 | 253 | E | 1 | 0 | HZEQ11 | Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a clean and orderly environment for four (4) of fifteen (15) resident rooms observed on the A wing. Multiple Styrofoam cups, open cans of Ensure, and other beverages were observed in residents' rooms. Other observations included items stored on the floor, one (1) room had a hole in the ceiling, residents' clothing was not stored neatly, soiled rags and debris were on the floor, trash cans were overflowing, and briefs were not stored properly. The unoccupied bed in one (1) room had various items stored on the bed. This practice had the potential to affect more than an isolated number of residents. Facility Census: 141. Findings include: a) Room ASPC Observation of this room, on 04/22/14 at 2:00 p.m., found a hole in the ceiling, Styrofoam cups with straws on the bedside table the dressers. There was also a laundry hamper overflowing with dirty clothes in the room in plain view. There was an open can of Ensure on the dresser that was not empty. The occupant of this room had been in the hospital for over 24 hours. This room was observed again on 04/22/14 at 4:00 p.m. with a nurse (Employee # 41) present. The hole in the ceiling now had a pan placed under it to catch the plaster falling from the ceiling. The laundry hamper was still overflowing and in plain view as one entered the room. In addition, there were still multiple cups with straws on the dresser, and the can of opened Ensure remained on the dresser. During this observation, Employee #41 confirmed the room was not tidy. b) Room A-2 This room was designated as an isolation room where a resident in isolation resided. During an observation on 04/22/14 at 2:05 p.m., the resident's closet was stuffed with clothes on both sides. Some clothes were hanging, but there were large trash bags full of clothes stuffed in the closet. In addition, there was a box of clothes on the floor, and clothes were thrown over the hanging rod of the clo… | 2017-04-01 |
| 7522 | 7522 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-04-24 | 323 | G | 1 | 0 | HZEQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I Based on record review, staff interview, and family interview, the facility failed to ensure the resident environment was as free of accident hazards as possible for one (1) of nine (9) sample residents,and failed to provide adequate supervision during meal times. A resident with a known swallowing problem received the incorrect diet and was not provided with adequate supervision to prevent choking. Resident #142 was on a mechanical soft diet with ground meat, was not to receive bread, and her foods (fruits and vegetables) were to be cut in small pieces. She was served a whole hot dog on a bun resulting in her becoming choked requiring hospitalization . This practice resulted in actual harm for the resident. Resident identifier: #142. Facility Census: 141. Findings include: a) Resident #142 Review of the resident's medical record found a nursing entry, dated 03/26/14 at 19:21 (7:21 p.m.), noting the resident's son and a nursing assistant called for a nurse. The note included, Resident was noted to be choking. Heimlich maneuver performed, resident was transferred from the wheelchair to the bed, abdominal thrusts performed. Resident then began to make eye contact and started to mumble. O2 (oxygen) @ (at) 10L (ten liters) with non-rebreather applied, 20g (20 gauge) IV (intravenous) inserted to left inner arm infusing NS (normal saline). Resident's family stated that resident had choked on her hot dog stating 'she put the whole thing in her mouth' . She was transferred to the hospital by ambulance at 7:20 p.m. A review of the physician orders [REDACTED].#142 was to receive a mechanical soft diet (ground meat) with no bread and her food (such as fruits and vegetables) was to be cut into small pieces. Further review of the medical record revealed the resident was transferred to the hospital on [DATE]. According to her hospital records, she was admitted due to aspiration. During her hospitalization she received TPN (total pretrial nutrition).… | 2017-04-01 |
| 7523 | 7523 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-04-24 | 365 | G | 1 | 0 | HZEQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview, the facility failed to ensure one (1) of nine (9) sampled residents was provided food in a form to meet her individual needs. The resident had a physician's orders [REDACTED]. This diet called for ground meat. The resident received a whole hot dog instead of ground meat. The resident choked on the hot dog, requiring a transfer to the hospital. Resident identifier: #142. Facility census: 141. Findings include: a) Resident # 142 A nursing note dated 03/26/14 indicated this resident's son and a nursing assistant called for a nurse. The note stated The resident was noted to be choking. [MEDICATION NAME] maneuver performed, resident was transferred from the wheelchair to the bed, abdominal thrusts performed. Resident then began to make eye contact and started to mumble. The resident's family stated that the resident had choked on her hot dog stating she put the whole thing in her mouth. The resident was transferred to the hospital at 7:20 p.m. on 03/26/14. Resident # 142's physician's orders [REDACTED]. This diet called for ground meat. The Director of Nursing was interviewed on 04/23/14 at 2:00 p.m. She stated she was present the night of the choking incident involving Resident #142. She said she was still there that evening and heard the page over the loud speaker for a nurse to come immediately to this resident's room. She stated when she got to the room, staff was performing the [MEDICATION NAME] maneuver on Resident #142. She said she immediately went to her tray and observed one third (1/3) of a whole hot dog on her tray. She stated the resident's tray card was on her tray and indicated she was to get a mechanical soft diet with no bread. She said she immediately identified the resident was served the incorrect diet. She was served a whole hot dog (not ground meat) on a bun. A phone interview was conducted with Resident # 142's son on 04/22/14 at 2:00 p.m He said he and his wife … | 2017-04-01 |
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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 );