cms_WV
Data source: Big Local News · About: big-local-datasette
129 rows where "filedate" is on date 2017-09-01
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6948 | 6948 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 164 | D | 0 | 1 | WVZU11 | Based on a random observation, review of facility policies, and staff interview, the facility failed to provide personal privacy for a medical treatment. A resident received a breathing treatment in the dining room. The treatment continued into the serving and eating of lunch. Resident identifier: #22. Facility census: 59. Findings include: a) Resident #22 During the initial tour of the facility, shortly after entrance at 11:30 a.m. on 06/17/13, Resident #22 was observed in the dining room by two (2) surveyors. He was reclined in a geri-chair and had on oxygen (O2). A staff member approached him and initiated a nebulizer treatment in front of numerous other residents who were awaiting lunch, including a resident who was sitting at Resident #22's table. This treatment was still taking place as lunch was served and as the other resident at the table was served his lunch. On 06/20/12 at 10:10 a.m., the DON was interviewed about breathing treatments. She said it should not happen during meals and it was a daily occurrence. An interview was attempted with Resident #22 on 06/20/13 at 10:30 a.m. He was cognitively unable to complete the interview. A second interview with the DON was held on 06/24/13. She discussed giving nebulizers in dining room and said it was a dignity issue. She provided the facility's medication administration policy which did not include information about giving medications in public. A policy and procedure on aerosol treatments was provided by the Director of Respiratory Therapy at 3:30 on 06/24/13. It did not include information about giving treatments in public areas. The facility practice was discussed and he said they have been doing it for a couple of years, not for the therapist's convenience, but for the resident. He felt it decreased confusion by not dragging residents back to their rooms for a treatment, and then dragging them back. He did not acknowledge a violation of privacy by giving breathing treatments in public. | 2017-09-01 |
| 6949 | 6949 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 279 | D | 0 | 1 | WVZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to develop an individualized care plan for a resident receiving as needed (PRN) anti-anxiety medication and for a resident who developed a pressure ulcer. Two (2) of twenty-three (23) residents whose care plans were reviewed during Stage 2 were affected. The care plan for Resident #65 did not identify specific behaviors to be monitored and did not identify non-pharmacological interventions to be attempted prior to the administration of PRN [MEDICATION NAME]. The care plan for Resident #38 did not identify measurable goals and objectives when this resident developed a pressure ulcer on the left ankle. Resident identifiers: #65 and #38. Facility census: 59. Findings include: a) Resident #65 On 06/19/13 at 12:28 p.m., a review of the physician's orders [REDACTED]. An additional order stated, [MEDICATION NAME] 0.5 MG PRN Q4H. Route: ORAL. Additionally in an E-SIGN PROCESS NOTE, signed by the physician on 04/03/13 at 15:58 (3:58 p.m.), under PLAN 11. Continue p.r.n. medicines . [MEDICATION NAME] IM or p.o. for extreme agitation and restlessness. The care plan, which was initiated on 04/09/13, revealed a problem statement which included the resident had the potential for drug-related complications related to [MEDICATION NAME]. The goal stated, The resident will not develop drug-related complications through review date. The interventions did not include specific behaviors to be monitored or non-pharmacological interventions to be attempted, prior to the administration of the PRN [MEDICATION NAME]. The care plan interventions were, Reduce drug dosage, if possible, administer medications as ordered by physician, encourage adequate fluid intake with meals, with medications, on room visits and with hydration pass at 6a, 2p, and 8p, assess anxiety level, cause of anxiety and develop coping mechanism, provide emotional and spiritual support as needed, pharmacist and [ME… | 2017-09-01 |
| 6950 | 6950 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 323 | K | 0 | 1 | WVZU11 | Based on observations, resident comment, and staff interview, the facility failed to provide an environment free from accident hazards. A resident (Resident #67) was observed to touch a metal heating unit in a room designated for dining on the second floor long term care unit and immediately withdraw his hand. When measured, the temperature on the top surface of this unit was 135 degrees Fahrenheit. The temperature in the area where heat was expelled was measured to be 200 degrees Fahrenheit. This area of the unit was also accessible to anyone who might decide to touch it. The unit was midway down the surface of the wall, immediately below the window, at the level accessible without requiring the resident to bend over. This practice had the potential to affect all residents residing on the 2nd floor long term care unit and rendered the mobile, self-ambulatory residents to be in immediate jeopardy of being burned on the unit. The administrator was advised of the immediate jeopardy at 11:18 a.m. on 06/18/2013. The administrator immediately turned the unit off and had the maintenance department disable the unit. The unit and other like units were subsequently removed from the walls. The immediate jeopardy was removed at 2:25 p.m. on 06/18/2013 and no deficient practice remained relative to the heating units. Census on this unit was 17. However, environmental safety issues were also identified that had a potential for more than minimal harm, but not actual harm or immediate jeopardy. A can of disinfectant deodorizer was left where it was accessible to residents, hand rails had areas that could cause injury to residents, and water temperatures were found to be in ranges above those safe for bathing and which could result in burns with exposure of three (3) to five (5) minutes. Facility census: 59. Findings include: a) While conducting a random tour of the 2nd floor long term care unit of the facility on 06/18/13 at 11:05 a.m., Resident #67 was wheeling about the unit and requested the surveyor look at the plants in th… | 2017-09-01 |
| 6951 | 6951 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 329 | D | 0 | 1 | WVZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview with the medical director, and staff interview, the facility failed to ensure residents drug regimens were free of unnecessary drugs. This was found for two (2) of eleven (11) residents reviewed for unnecessary medications. Resident #65 received [MEDICATION NAME] on an as needed (PRN) basis without sufficient identification of the behaviors to be monitored or evidence of behavioral interventions. Resident #18 received [MEDICATION NAME] (an antipsychotic medication and [MEDICATION NAME] (an antidepressant medication), without a gradual dosage reduction. Resident #18 also did not have laboratory testing as recommended by the pharmacist, to monitor the use of [MEDICATION NAME] (an anticonvulsant). The facility also failed to inform the resident/responsible party of the benefits/risks of medications. Resident identifiers: #65 and #18. Facility census: 59. Findings include: a) Resident #65 On 06/24/13 at 1:30 p.m., a review of the medical record was conducted. The physician's orders [REDACTED].#65 had been ordered [MEDICATION NAME] 0.5 mg orally or IM (intramuscular) every four (4) hours as needed (PRN) with no [DIAGNOSES REDACTED]. In a physician's progress note, dated 04/03/13 at 15:58 (3:58 p.m.), in the section PLAN, it was noted Continue p.r.n. medicines . [MEDICATION NAME] IM or p.o. (by mouth) for extreme agitation and restlessness. The Medication Administration Record [REDACTED]. The Psychoactive Drug Monthly Flow Record, dated April 2013 in Section I Specific Behaviors indicated the monitoring of refusing care, increased agitation and aggression. The flow record documented no behaviors or side effects from 04/10/13 through 04/15/13. The days prior to this documentation and the days following were blank. A further review of Resident #65's MARs noted the following: On 03/28/13 at 8:26 a.m., [MEDICATION NAME] 0.5 mg was administered orally for anxiety. No evidence was discovered as to the reason the … | 2017-09-01 |
| 6952 | 6952 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 371 | F | 0 | 1 | WVZU11 | Based on observation, staff interview, and policy review, the facility failed to ensure food was stored, prepared and distributed under sanitary conditions. Pots/pans were not adequately air dried to prevent moisture from being trapped inside of the item. This created a potential for the growth of microorganisms. A dietary staff member was observed handling a food item with her bare hand. Milk that had been poured into glasses in preparation of meal service, was not maintained at proper temperature. Temperatures of the refrigerators in the pantry area were not monitored in accordance with facility policy. In addition, items were not dated to indicate when they had been opened and/or by when they should be discarded. This had the potential to affect all residents who consumed food orally. Facility census: 59 a) Kitchen During an initial tour, on 06/17/13 at 1:30 p.m., pots were observed stored on top of each other in the sink area. Droplets of water were visible on the outside of them. A second tour, on 06/17/13 at 2:30 p.m., with Employee #192, a registered dietitian (RD) and the dietary supervisor, revealed the pots were still stacked on top of each other. When the RD removed the pots from each other, a large amount of condensation was observed between them. She said the pots should not have been stacked together and would need to be rewashed. An interview and observation with Employee #184, a nutrition service aide, on 06/20/13 at 2:20 p.m., revealed metal loaf-type pans were stacked together on a shelf near the sink. When she removed the pans, condensation was observed beneath them. Another interview with the RD, at 2:25 p.m. on 06/20/13, revealed all dishes were to air dry. The dietary supervisor removed the loaf-type pans from each other and noted water beneath each one. Employee #184 joined the conversation regarding why the dishes were stacked to dry. The RD said, no, it is not okay. She further added the dishes had to be rewashed and placed them back in the sink. Review of the dietetics, nutrition and foo… | 2017-09-01 |
| 6953 | 6953 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 428 | D | 0 | 1 | WVZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to act upon pharmacy recommendations which identified medication irregularities for one (1) of eleven (11) residents reviewed for unnecessary medications. The physician failed to provide a clinical rationale when the pharmacist made recommendations. Resident identifier: #18. Facility census: 59. Findings included: a) Resident #18 1) During a medical record review for unnecessary medications, on 06/19/13 at 12:36 p.m., it was noted the pharmacist had made recommendations which had been declined by the physician. A clinical rationale was not provided. Review of the behavior monitoring sheets indicated the resident had not been exhibiting identified behaviors related to psychotropic medications. The pharmacy recommendations, also indicated the resident had not been exhibiting behaviors and had recommended gradual dose reductions. Pharmacy recommendations were noted as follows: On 11/13/12, the pharmacist had recommended a gradual dose reduction of Risperdal due to the resident having an increase of tremors, but no evidence of hallucinations or paranoia. The physician declined with the rationale the medication was working. However, a gradual dose reduction had been initiated on 01/18/12, and was successful. At that time, the physician's response for accepting the recommendation was, You know, I didn't start this drug in the first place, I don't think. A pharmacy review, completed on 07/25/12, indicated the resident was receiving Cogentin and Risperdal. It noted the resident had a [DIAGNOSES REDACTED]. It noted Risperdal may antagonize levodopa's effects in the treatment of [REDACTED]. If continued a risk versus benefits, indicating it continued to be a valid therapeutic intervention for Resident #18, needed to be completed. The physician declined the recommendation noting the medications were ordered by a neurologist. Employee #98 a licensed practical nurse (LPN), who reviewe… | 2017-09-01 |
| 6954 | 6954 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 431 | E | 0 | 1 | WVZU11 | Based on observations and staff interview, the facility failed to ensure safe medication storage in a medication preparation cart. A medication cart was left unlocked and not visible to attending staff, providing an opportunity for unauthorized access. Facility census: 59 Findings Include: a) On 06/24/13 at 8:20 a.m., an observation on nursing unit two revealed an unattended and unlocked medication cart sitting next to the nursing station. Employee #170 walked out of a resident room, went to the medication cart still sitting next to the nursing desk and stepped away, leaving the cart out of her line of sight. She went into another resident room and returned to the cart. Employee #170 then obtained medications and again went into a resident room leaving the medication cart unlocked and not visible to her. When Employee #170 returned to the medication cart, it was brought to her attention the cart had been left unlocked and not visible to her. Employee #170 stated Usually I have it with me at the door. On 06/24/13 at 8:40 a.m., the director of nursing, referring to Employee #170 leaving the medication unlocked, stated, She did everything, but lock her cart and we can't stress that enough. | 2017-09-01 |
| 6955 | 6955 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 441 | E | 0 | 1 | WVZU11 | Based on observation, staff interview, and policy review, the facility failed to store resident care equipment, and person hygiene items, in a manner to prevent the spread of infection. In addition, oxygen concentrators in the dining room were observed to be unclean. There was no method established to ensure humidification and tubing were changed when necessary. These practices had the potential to affect more than a limited number of residents. Resident identifiers: #18, #39, #12, #64, and #3. Facility census: 59. Findings included: a) Resident #18 During a Stage 1 observation, on 06/19/13 at 8:20 a.m., a urinary hat (used to collect urine specimens) was observed on the bathroom floor. An interview and observation with Employee #101, a licensed practical nurse (LPN), acknowledged storing the hat on the bathroom floor posed a potential for infection and cross contamination. b) Resident #39 On 06/18/13 at 10:06 a.m., an observation revealed a urine hat stored in a bedpan, which was stored on the floor under the commode. Additionally a urine graduate was stored on the back of the commode seat. An observation on 06/19/13 at 10:01 a.m., revealed the items were stored in the same manner. The director of nursing confirmed the graduate was soiled with urine. She said the items were not to be stored in the bathroom, and posed a source of infection and cross contamination. In addition, personal hygiene items, which included toothpaste, a toothbrush, and a denture cup, were stored on the shelf above the sink. The items were unlabeled. A container of mouthwash was stored without a lid. The director of nursing (DON) said she was unable to identify to whom the items belonged. She acknowledged they were stored in an unsanitary manner and posed a potential for cross contamination. c) Resident #12 A Stage 1 observation, on 06/19/13 at 8:49 a.m., revealed a bedpan stored on the bathroom floor. Employee #101 (LPN) looked in the bathroom and said, I'll take care of this. She said the bedpan was not to be stored in the bathroom. Add… | 2017-09-01 |
| 6956 | 6956 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 456 | E | 0 | 1 | WVZU11 | Based on observation and staff interview, the facility failed to ensure kitchen equipment was maintained in a safe operating condition. This had the potential to affect all dietary staff. Facility census: 59. Findings included: a) During a tour of the kitchen, on 06/18/13, at 1:30 p.m., with Employee #192, (dietary supervisor), observation revealed a knob to the stove was missing, and the stove door had a cloth in the side of the door. A note on the front of the door indicated it was out of order. The dietary supervisor said maintenance had to fix the stove door. She said it needed a spring to stay shut because it flies open. She also said a line inside of the oven needed replaced. The dietary supervisor said she replaced the missing knob for the burner. Further observation revealed the floor of the walk-in freezer was covered with ice. Employee #192 said the door needed to be replaced, because it did not seal properly. She said temperatures were taken twice daily to ensure proper temperatures were maintained. | 2017-09-01 |
| 6957 | 6957 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 469 | E | 0 | 1 | WVZU11 | Based on observation and staff interview, the facility failed to maintain a pest free environment. The dining room/solarium on nursing unit one was found to have numerous dead gnats trapped in cobwebs behind the blinds and found to have living gnats under a cloth placed on the floor and against the windows which extended to the bottom of the floor. Insects were also found in a resident's room. Facility census: 59 Findings Include: a) Upon entry to the facility, and initial observation of the dining room/solarium, a cloth was observed to have been placed on the floor and up against the window. On the second day of the survey, 06/18/13 at 11:45 a.m., the same cloth was again observed on the dining room/solarium floor. The cloth was picked up off of the floor and revealed living gnats under the cloth. Also noted were cobwebs behind the blinds with numerous gnats in the cobwebs. On 06/18/13 at 2:28 p.m., the maintenance supervisor, Employee #77 was interviewed in the dining room/solarium on nursing unit one. He acknowledged there were numerous cobwebs with insects trapped in them on the blinds, baseboard electric heaters, and rolled up towels that were placed against the heaters and at the bottom of the windows. He said the cloths were placed there to prevent water from flowing onto the floor when it rained, but the staff did not always remember to remove them. The cloths were observed to be partially stuck to the floor. (Employee #77 stated the circuit breakers for the floor heaters were turned off. The circuit breakers were observed in the off position.) b) During a Stage 1 observation on 06/18/13 at 9:22 a.m., gnats, too numerous to count, were observed in the residents' windows. One live gray insect was on the inside window sill. The unit charge nurse confirmed the presence of insects. She stated she would notify housekeeping. Observations on 06/24/13 at 3:15 p.m., revealed dead gnats, other dead bugs which looked like spiders, and beetles were present in the window. Bugs were noted in the heater unit also. Emplo… | 2017-09-01 |
| 6958 | 6958 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 490 | F | 0 | 1 | WVZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations, record reviews, review of personnel files, review of the State of West Virginia Hospital Licensure, Code 64CSR12, and staff interviews, it was determined the facility was not being 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. Multiple systems related concerns were found. Issues were identified with the electronic medical record program used by the facility. Environmental issues were identified, including a situation that posed an immediate jeopardy to the ambulatory residents on the second floor nursing facility unit not being recognized by the facility. The facility did not have a system in place to monitor hot water temperatures in residents' rooms, did not have effective systems to ensure residents were free of unnecessary medications and that pharmacist's recommendations were acted upon. The facility did not ensure kitchen equipment was maintained in a safe operating manner or that the facility was free of pests. The facility also did not have a system in place to ensure nurse aides were registered and that nurse aides were provided with twelve (12) hours of in-service education annually as required. Also, the facility did not have a dedicated long term care administrator other than the hospital administrator as required by State of West Virginia Hospital Licensure, Code 64CSR12). These systemic problems had the potential to result in harm to more than a minimal number of residents. Facility census: 59 Findings include: a) The facility did not have a dedicated long term care administrator other than the full time hospital administrator as required by State of West Virginia Hospital Licensure, Code 64CSR12. b) Multiple, continuing environmental concerns were identified during the survey, including the existence of a situation that represented immediate jeopardy f… | 2017-09-01 |
| 6959 | 6959 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 492 | F | 0 | 1 | WVZU11 | Based upon record review and staff interview, the facility failed to comply with with State of West Virginia Hospital Licensure, Code 64CSR12, which requires that the governing authority appoint a full time hospital administrator and that if there is a nursing facility unit with more than sixty (60) resident beds, the governing body shall also appoint a qualified administrator who holds a current valid license or emergency permit issued by the West Virginia Nursing Home Administrator's Licensing Board. This had the potential to result in harm to more than a minimal number of residents. Facility census: 59. Findings include: a) Review of entrance documents and interview with acting administrator, employee #3, on 6/20/13 at 4:00 p.m. found that he was acting as both the full time hospital administrator and as the administrator of the seventy-six (76) bed long term care unit under an emergency permit. He said that the former long term care administrator had quit on 4/19/13, and the position had been vacant for the last two (2) months. He said the vacancy had been advertised, and some applications received, but no applicants had been interviewed or considered. State of West Virginia Hospital Licensure, Code 64CSR12 requires that the governing authority appoint a full time hospital administrator and that if there is a nursing facility unit with more than sixty (60) resident beds, the governing body shall also appoint a qualified administrator who holds a current valid license or emergency permit issued by the West Virginia Nursing Home Administrator's Licensing Board. The hospital administrator voiced understanding that Hospital licensure rules prohibit him from serving in both positions concurrently. | 2017-09-01 |
| 6960 | 6960 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 496 | B | 0 | 1 | WVZU11 | Based on record review and staff interview, the facility failed to obtain registry verification for one (1) of fourteen (14) employees indicating she was a registered long term care nursing assistant before allowing her to serve as a nurse aide. Employee identifier: #116. Census: 59. Findings include: a) Employee #116 Personnel records for fourteen (14) employees were requested and reviewed on 06/19/13 and 06/24/13. The file of a nursing assistant, Employee #116, contained no evidence she was a registered long term care nursing assistant. During an interview, on 06/20/13 at 11:00 a.m., nursing home administrative consultant, Employee #176, confirmed the required checks were not available. She provided a verification of active registration for NA #116 that had been obtained by the facility on 06/20/13 at 7:48 a.m. About an hour later, a certificate stating that NA #116 had successfully passed the West Virginia Nursing Assistant Written and Skills Performance Examination on 04/14/12 was provided. Employee #176 acknowledged that this documentation had not been maintained as part of the official personnel file. | 2017-09-01 |
| 6961 | 6961 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 497 | E | 0 | 1 | WVZU11 | Based on record review and staff interview, the facility failed to provide regular in-service education sufficient to ensure the continuing competence of nurse aides (NA), with a minimum of twelve (12) hours per year. This was found for five (5) of five (5) NA files reviewed. Employee identifiers: #103, #104, #107, #109, and #111. Facility census: 59. Findings include: a) Employees #103, #104, #107, #109, and #111 Personnel files were requested and reviewed for these nurse aides on 06/24/13 at 1:30 p.m. The review of the records found no evidence indicating the NAs received the annual required minimum of twelve (12) hours of in-service education to ensure their continuing competence. On 06/24/13 at 2:45 p.m., the administrative assistant, Employee #6, provided a copy of the annual in-service power point called Annual Required Education Day (A.R.E.D.) which all staff were to attend. The education included infection control, fire safety and disaster, resident privacy, rights and dignity, and abuse. She verified this mandatory training did not add up to 12 hours of in-service education. During an interview with the director of nursing, Employee #178, and the long term care administrative assistant, Employee #177, on 06/24/13 at 4:00 p.m., they confirmed they do not count the NAs yearly education hours. The facility does not have a policy indicating the number of hours or type of education required annually by the nursing assistants to maintain competency and they could not verify any of the nursing assistants had received the required minimum number of twelve (12) hours of in-service training to maintain their competencies. | 2017-09-01 |
| 6962 | 6962 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 514 | C | 0 | 1 | WVZU11 | Based on record review and staff interview, the facility failed to ensure the accuracy of the medical record by recording that weights were measured on a certain date when, in fact, there was no evidence of the exact date the resident was weighed. This was true for all thirty-two (32) residents in the Stage 1 sample. Resident identifiers: #1, #3, #5, #7, #10, #12, #14, #18, #20, #21, #23, #24, #25, #27, #28, #31, #34, #35, #38, #39, #40, #41, #42, #43, #48, #49, #53, #59, #63, #64, #65, and #66. Facility census: 59. Findings include: a) Residents #1, #3, #5, #7, #10, #12, #14, #18, #20, #21, #23, #24, #25, #27, #28, #31, #34, #35, #38, #39, #40, #41, #42, #43, #48, #49, #53, #59, #63, #64, #65, and #66. While reviewing the medical record for required resident weights, at 10:00 a.m. on 06/18/13, it was revealed that the weight books located at the nurses' station contained only the month and year, although when the medical record was accessed, an exact date was entered for the weights. The nurse on duty (Employee #125) was interviewed at 10:30 a.m. on 06/18/13. She verified that when the residents were weighed by the aides, the weights were documented in the weight book and that only the month and year were entered. She stated that all weights are done on the 1st of the month. When she was shown on the computer that there were different days indicated on different residents, she was surprised and had no answer. During an interview with Employee #162 (aide) at 10:50 a.m. on 06/18/13, she stated that residents were weighed between the 1st and the 5th of each month and verified they are not required to enter the day of the month when they record the weight. When interviewed at 9:00 a.m. on 06/20/13, the Director of Nurses (Employee #178) stated that weights were supposed to be taken during the last week of each month. After reviewing both the Weight Book and the computer record, she admitted that there was no way to tell which day the weight was taken. She had no explanation for the source of the entry date used in t… | 2017-09-01 |
| 6963 | 6963 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 516 | F | 0 | 1 | WVZU11 | Based on record review, policy review, observation, and staff interview the facility failed to maintain the safety and confidentiality of the residents' medical record by using an electronic medical record that does not have built-in safeguards to prevent unauthorized access of information in the medical record; and by having no written policies at the health care facility describing the attestation policies in force at the facility. This had the potential to affect all residents residing in the facility. Facility census 59. Findings include: The American Health Information Management Association (AHIMA) is the worldwide professional association of recognized leaders in health information management, informatics, heath data technology, and innovation. AHIMA proactively promotes the technological advancement of health information systems that enhance the delivery of quality healthcare. AHIMA recognizes that quality health and clinical data are critical resources needed for efficacious healthcare and works to assure that the health information used in care, research, and health management is valid, accurate, complete, trustworthy, and timely. Health issues, disease, and care quality transcend national borders. AHIMA's professional interest is in the application of best health information management practices wherever they are needed. AHIMA: LTC Health Information Practice and Documentation Guidelines ? Part of the facility policies on confidentiality should be an access grid that outlines which employees and contractors are considered authorized users of the medical record and any restrictions or limitations on what can be accessed. The grid should identify the authorized user by department and position and the limitations on access to information. If subcontractors are used for certain services (billing service, laundry, dietary, etc.), language needs to be included in the contracts outlining the employee's responsibility to maintain resident confidentiality and their authority to access the medical record. a) Dur… | 2017-09-01 |
| 6964 | 6964 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 520 | F | 0 | 1 | WVZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility's quality assessment and assurance (QA&A) committee failed to ensure their facility-wide policy on confidentiality contained verbiage that outlined which employees and contractors were considered authorized users of the medical record and any restrictions or limitations on what could be accessed, prior to implementing the use of an electronic medical record for all resident information. The facility did not identify the authorized user by department and position and the limitations on access to information. After the implementation of the electronic medical record, the facility failed to recognize the electronic medical records charting program in use did not preserve the confidentiality of the resident's medical record by allowing nursing assistants and others to access aspects of the record beyond their scope of need. Additionally, the QA&A committee did not identify and establish effective systems to ensure environmental issues were identified, including a situation that posed an immediate jeopardy to the ambulatory residents on the second floor nursing facility unit not being recognized by the facility. The QA&A committed did not have a system in place to monitor hot water temperatures in residents' rooms, did not have effective systems to ensure residents were free of unnecessary medications and that pharmacist's recommendations were acted upon, did not have an effective maintenance program to ensure kitchen equipment was maintained in a safe operating manner and that the facility was free of pests, did not have a system in place to ensure nurse aides were registered and that nurse aides were provided with twelve (12) hours of in-service education annually as required, did not have a system in place to ensure care plans were established to address the residents needs, and did not have a system in place to ensure the dates weights were taken were identified in the me… | 2017-09-01 |
| 6965 | 6965 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2013-11-12 | 159 | E | 0 | 1 | X5R211 | Based on staff interview and record review, the facility failed to ensure resident's funds in excess of $50.00 were deposited in an interest bearing account. Forty-three (43) of sixty-five (65) residents with funds handled by the facility had more than $50.00 in their accounts as of 11/04/13. Facility census: 95. Findings include: a) A review of the Trust - Current Account Balance as of 11/4/13 by Posting Date found sixty-five (65) residents had funds deposited in this account. Forty-three (43) residents had balances in excess of $50.00 according to this report. An interview was held at 9:00 a.m. on 11/06/13 with the Business Office Manager (Employee #6). She was asked to provide evidence showing the resident funds were in an interest bearing account. On 11/07/13 at 11:30 a.m., the Administrator provided a letter from the bank where the resident funds account was held. This letter stated on 11/06/13 the account had been changed to an interest bearing account. The Administrator acknowledged the resident funds had not been in an interest bearing account until 11/06/13, after the surveyor had requested documentation it was in an appropriate account. | 2017-09-01 |
| 6966 | 6966 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2013-11-12 | 161 | E | 0 | 1 | X5R211 | Based on staff interview and record review, the facility failed to ensure the security of resident personal funds. The amount of the surety bond was not sufficient to cover the highest account balance of the resident funds account. This was true for sixty-five (65) of sixty-five (65) residents whose funds were handled by the facility. Facility census: 95 Findings include: a) The current surety bond provided by the facility, dated 12/26/12, was for $35,000.00. A review of the transaction history for the resident funds account was completed on 11/06/13. There were multiple days over the past six (6) months with a daily balance exceeding the surety bond amount. On 10/07/13 the daily balance of the account was $63,183.93. This was discussed with the Administrator at 11:00 a.m. on 11/07/13. She acknowledged the current surety bond amount was not sufficient. She stated the facility had applied to increase the amount. She provided a copy of the new bond at that time for an amount of $62,500.00. This was still not sufficient to cover the highest single daily account balance. | 2017-09-01 |
| 6967 | 6967 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2013-11-12 | 225 | D | 0 | 1 | X5R211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, family interview, staff interview, and policy review, the facility failed to ensure all alleged violations involving abuse were thoroughly investigated and reported immediately to the appropriate State agencies. Resident #164 reported her roommate, Resident #162, had been grabbed by her arms and forced to stand up causing a skin tear. She had reported this incident to a nurse on 11/03/13 and on 11/04/13 she had reported it to Employee #140, an Occupational Therapist (OT) and the social worker (SW). There was no evidence Resident #164, who had witnessed the incident, was interviewed as part of the facility's investigation. Resident #162's daughter, who was aware the resident had not had the injury on 11/02/13, but did have one when she visited on 11/03/13, had not been interviewed. In addition, the allegation was not reported to the appropriate State agencies by the facility until 11/07/13. This had the potential to affect more than a limited number of residents. Resident identifier: #162 and #164. Facility census: 95. Findings include: a) Resident #162 On 11/04/13 at 11:10 a.m., an interview was conducted with Resident #162 and her daughter during the initial tour of the facility. Resident #162 was noted to have a large bruise and a skin tear measuring six (6) centimeters (cm) in length with steri-strips intact on her left forearm. During the interview, Resident #162 commented the injury happened Saturday night on night shift, the nurses aides were rough and grabbed me by my arm when they helped me to the bathroom. The resident's daughter agreed her mother and her mother's roommate had told her this on Sunday when she had come to visit. The daughter stated her mother did not have the bruise or skin tear on Saturday, but they were present on Sunday morning when she came to visit her Mother. She said she had reported it to the nurse. On 11/11/13 at 8:10 a.m., an interview was conducted with Resident #… | 2017-09-01 |
| 6968 | 6968 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2013-11-12 | 247 | D | 0 | 1 | X5R211 | Based on record review, resident interview, policy review, and staff interview, it was determined there was no evidence Resident #148 was notified prior to her room being changed. This was found for one (1) of three (3) residents on the sample who were reviewed for concerns regarding room change notification. Resident identifier: #148. Census: 95. Findings include: a) Resident #148 During Stage 1 interviews, on 11/05/13 at 10:35 a.m., Resident #148 said she was not notified of her room change. The resident stated she had been out to a doctor's appointment and when she returned, she was placed in another room. She had not been consulted or informed in advance about a room change. The social worker and Administrator were asked at 11:10 a.m. on 11/06/13 about room change notification. At that time it was determined there was no evidence regarding the notification of a room change for this resident. A review of the facility policy entitled Change in Resident's Condition or Status, with a revision date of June 2012 , Section 3, Item c stated that . unless otherwise instructed by the resident, the nurse supervisor /charge nurse will notify the resident's family or representative if there is a request to change the resident's room assignment. There was no evidence the resident, or the resident's family or representative had been notified of the room change. | 2017-09-01 |
| 6969 | 6969 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2013-11-12 | 371 | F | 0 | 1 | X5R211 | Based on observation, review of menus, and staff interview, it was determined the facility had not ensured foods were stored under sanitary conditions. Items were not dated when opened/prepared and the temperatures of cold foods were not consistently monitored. This had the potential to affect all residents as all were served foods from this central location. Census: 95. Findings include: a) During the initial dietary tour, at 11:25 a.m. on 11/04/13, it was found the walk-in refrigerator contained packages of shredded cheese and parmesan cheese which had no date of when they had been opened. This did not allow the dietary staff to ensure how long the product had been opened and was safe for consumption. A tray which had slices of coconut pie did not have any evidence of when the pies had been sliced and ready for use. A review of the facility's approved menu did not show that type of pie had been on the menu recently. b) Review of food temperature records showed there were temperatures recorded for hot food items, but cold food items were recorded sporadically. Discussion with the dietary manager, on 11/06/13 at 11:05 a.m., identified the cook took hot food temperatures and recorded those, but the dietary aide placed cold items on the tray and did not routinely record the temperatures of these cold items. The dietary manager stated she would instruct aides to record the cold food temperatures as well. | 2017-09-01 |
| 6970 | 6970 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2013-11-12 | 431 | E | 0 | 1 | X5R211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure safe medication storage. Two (2) bags of intravenous fluids (IVF) containing 0.9% sodium chloride 250 milliliters (ml), with an expiration date of [DATE], were stored on a shelf in the North medication room. This had the potential to affect any resident should the IVF be used. Facility census: 95. Findings include: a) North medication room On [DATE] at 9:30 a.m., an inspection of the North medication room was conducted with Employee #112, the Assistant Director of Nursing (ADON) on North. During the inspection, two (2) 250 milliliter bags of 0.9% sodium chloride IVF were observed stored on an open shelf. The expiration date stamped on both bags was [DATE]. On [DATE] at 9:35 a.m., Employee #112 observed and acknowledged the bags of IVF had expired. The ADON commented it is not the normal practice of the facility to keep expired IVF. She disposed of the two (2) bags of IVF. | 2017-09-01 |
| 6971 | 6971 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2014-09-05 | 241 | B | 1 | 0 | SG0I11 | Based on observation and staff interview, the facility failed to promote care for a resident in a manner that maintained the resident's dignity and respect. While one (1) resident was being pushed forward, another resident was pulled backwards to the dining room. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #58 and #15. Facility census: 88. Findings included: a) Resident #58 On 09/04/14 at 5:20 p.m., observed a nursing assistant (NA#104) pushing Resident #15 and pulling Resident #58 backwards down the hall. The nursing home administrator ((NHA) was notified at 5:40 p.m. of this event and said she would investigate. On 09/05/14 at approximately 10:00 a.m., a review of the hallway security tapes with the NHA, revealed NA #104 did pull Resident #58 down the hallway backwards. The NHA stated the NA involved, as well the other facility NAs, would be inserviced regarding treating residents with dignity and respect. | 2017-09-01 |
| 6972 | 6972 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2014-01-16 | 164 | F | 0 | 1 | ONOL11 | Based on observation and staff interview, the facility failed to provide confidentiality of medical records. During random observations, the medication administration records of two (2) residents were exposed while placed on top of medication carts in the hallways. This practice had the potential to affect all facility residents who received medications. Resident identifiers: #44 and #129. Facility census: 87. Findings include: a) A random observation was conducted on the Two West Unit on 01/13/2014 at 12:35 p.m. During this observation, the Medication Administration Record [REDACTED]. The medication cart was unattended. An interview was conducted with Employee #76 (Licensed Practical Nurse-LPN) on 01/13/14 at 12:40 p.m. The LPN stated she ran off quickly to assist a resident and forgot to cover the medication administration record. She said the Medication Administration Record [REDACTED]. b) A random observation was conducted on 01/15/14 at 9:45 a.m. on the One East Unit. The Medication Administration Record [REDACTED]. The medication cart was unattended. An interview with Employee #100 (Licensed Practical Nurse-LPN) was conducted on 01/15/14 at 9:48 a.m. The LPN stated she was giving a resident his/her medication and forgot to cover the medication administration record. She stated the Medication Administration Record [REDACTED] | 2017-09-01 |
| 6973 | 6973 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2014-01-16 | 242 | D | 0 | 1 | ONOL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interviews, and staff interviews, the facility failed to allow one (1) of two (2) sample Stage 2 residents, and one (1) residents identified during random opportunities, the opportunity to make choices regarding an aspect of his/her life in the facility which was significant to each resident. These residents were not given the opportunity to choose a tub bath instead of a shower or bed bath. Resident identifiers: #38 and #98. Facility census: 87. Findings Include: a) Resident #38 On 01/14/14 at 1:20 p.m., an interview was conducted with Resident #38. During the interview the resident stated she did not know there was a bathtub in the facility, was not given an opportunity to choose a tub bath, but would love to have one. Review of the admission minimum data set (MDS), with an assessment reference date (ARD) of 09/05/13, found Item F0400, How important is it to you to choose between a tub bath, shower or bed bath?, Resident #38's response was was coded as very important. On 01/15/14 at 4:10 p.m., an anonymous staff member stated he/she was not aware of a resident receiving a tub bath in the facility for at least two (2) years. Another anonymous staff member also stated he/she was not aware of a resident receiving a tub bath, in the facility for at least two (2) years. At 4:40 p.m., on 01/15/14, maintenance staff member, Employee #92, was asked about the whirlpool bathtub on the first floor. He stated the tub did work and was used with residents who preferred a tub bath or had a physician order [REDACTED]. He stated he did know of the tub being used for at least two (2) years. While demonstrating the whirlpool bathtub on the first floor was in working order, Employee #92 also demonstrated how to safely use the whirlpool tub to the housekeeping supervisor, (Employee #88), the laundry supervisor (Employee #18), registered nurse supervisor (Employee #67, and nursing assistant (Employee #4). During a random … | 2017-09-01 |
| 6974 | 6974 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2014-01-16 | 253 | E | 0 | 1 | ONOL11 | Based on observation and staff interview, the facility failed to ensure effective maintenance services. The physical environment was not in good repair. The wallpaper located on the walls of the hallways had multiple holes and the carpet on the floor of the hallways was stained. All units in the building, One East, One West, Two East, and Two West were affected. This practice had the potential to affect more than a limited number of residents. Facility census: 87. Findings include: a) An initial tour of the facility was conducted on 01/13/14 at 11:30 a.m. The wallpaper in the hallways on One East, One West, Two East, and Two West was observed to have multiple scrapes and holes. The carpets in the hallways on One East, One West, Two East, and Two West had multiple stains. An interview with Employee #130 (Administrator) was conducted on 01/16/14 at 10:00 a.m. Employee #130 stated she was aware of the condition of the carpet and wallpaper in the hallways. The administrator stated the facility was working on a plan to replace the carpet in the hallways. | 2017-09-01 |
| 6975 | 6975 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2014-01-16 | 309 | D | 0 | 1 | ONOL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of incident/accident reports, and staff interview, the facility failed to ensure one (1) of two (2) Stage 2 residents reviewed for accidents received care and services to ensure the individual's highest practicable level of physical well-being. Resident #105's assessment for falls identified the resident had orthostatic [MEDICAL CONDITION] (a sudden fall in blood pressure when a person stands - defined as a decrease in systolic blood pressure of 20 millimeters of mercury (mm Hg) or 10 mm Hg diastolic within three (3) minutes of standing). No further assessments of the resident's blood pressures were conducted after the physician ordered a medication for high blood pressure (hypertension) be discontinued. Resident identifier: #105. Facility census: 87. Findings include: a) Resident #105 On 01/16/2014 at 8:27 a.m., a review of accident/incident reports revealed Resident #105 had experienced falls on 09/12/13, 09/25/13, 09/28/13, 09/29/13, and 09/30/13. The attending physician ordered an evaluation for orthostatic [MEDICAL CONDITION] on 10/01/13. The results were positive with a lying blood pressure (BP) of 134/60, sitting BP 116/74, and standing BP of 90/68. The physician was notified and ordered this resident's [MEDICATION NAME] (a medication for hypertension) be discontinued. Resident #105 experienced additional falls on 10/11/13, 10/22/13, and 10/27/13. Review of the resident's medical record found no evidence of further evaluations of this resident's orthostatic [MEDICAL CONDITION] after the medication was discontinued and in light of the additional falls. In an interview with the director of nursing (DON), on 01/15/2014 at 3:58 p.m., the DON stated there was no further follow-up of the resident's orthostatic [MEDICAL CONDITION]. The DON could not provide any further evidence the resident's orthostatic [MEDICAL CONDITION] was re-evaluated after the initial positive results. On 01/16/14, the DON reporte… | 2017-09-01 |
| 6976 | 6976 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2014-01-16 | 431 | E | 0 | 1 | ONOL11 | Based on observation and staff interview, the facility failed to safeguard medications by keeping them in a locked compartment. The facility did not have medication carts located on the hallways locked on two (2) separate occasions. This was observed on two (2) random observations. This practice had the potential to affect more than a minimal number of residents. Facility census: 87. Findings include: a) During a random observation on 01/13/14 at 12:35 p.m., it was found the medication cart on the Two West Unit was unlocked. Employee #76 (Licensed Practical Nurse-LPN) was dispensing medication from this cart. This employee was out of sight from this cart for approximately five (5) minutes from the time it was first observed to be unlocked. An interview was conducted with Employee #76 (LPN) on 01/13/14 at 12:40 p.m. This LPN stated a resident was yelling and she forgot to lock her medication cart before attending to the resident. This employee verbalized the medication cart was to be locked at all times when not attended by a nurse. b) During a random observation of the One East Unit on 01/15/14 at 9:45 a.m. the medication cart in the hallway was observed to be unlocked. No employees were in view of the medication cart when it was discovered to be unlocked. At 9:48 a.m., Employee #100 (LPN) approached the medication cart and stated she had forgotten to lock the cart before administering medications to a resident. This employee stated the medication carts were to always be locked when unattended. | 2017-09-01 |
| 6977 | 6977 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2014-01-16 | 463 | D | 0 | 1 | ONOL11 | Based on observation and staff interview, the the facility failed to ensure call lights were in good working order for one (1) of thirty-three (33) Stage 1 sample residents. Room identifier: #111 West. Facility census: 87. Findings include: a) Room 111 West During Stage 1 of the Quality Indicator Survey, the call light function was tested in Room 111 West on 01/13/14 at 2:45 p.m The call light would not turn off. Employee #128 Nursing assistant (NA) was in the room at the same time, and she stated the call light normally turns off, but sometimes she had to push the call light a little bit harder in order for the call light to turn off. Employee #128 tried to turn the call light off, but could not. She said six (6) month ago the staff had this problem with this call light. Employee #128 stated she would get someone to fix the call light. Employee #93, a housekeeper, came into the room at 2:53 p.m. on 01/13/14. He assessed the call light functioning and confirmed that the call light would not turn off. He stated that the wires need changed. Employee #93 left, and then returned at 2:55 p.m., with a different cord. After he changed the cord, the call light would turn off. He stated it was the wire. Interview on 01/16/14 at 8:45 a.m., with Employee #92, environmental service director (ED) confirmed the call light was stuck. He stated, when the call lights get moisture inside, or from use over time, the call light would stick. He stated that Employee #93 called him and informed him that the call light was not working, and he had fixed the call light. | 2017-09-01 |
| 6978 | 6978 | MEADOW GARDEN | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2014-03-20 | 279 | D | 0 | 1 | LHVS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan detailing how fluid restrictions would be provided and monitored for a resident diagnosed with [REDACTED]. This was true for (1) one of (17) seventeen residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey. Resident identifier: #63. Facility census: 58. Findings include: a) Resident #63 Review of the resident's medical record, on 03/19/14, found the resident had a [DIAGNOSES REDACTED]. The resident received outpatient [MEDICAL TREATMENT] on Mondays, Wednesdays and Fridays. The resident had a physician's orders [REDACTED]. The resident's care plan, initiated on 02/05/13, was reviewed at 11:00 a.m. on 03/19/14. A care plan focus problem addressed the resident's [MEDICAL CONDITION] with dependence on [MEDICAL TREATMENT]. An approach associated with this focus was, Fluid restriction per physician's orders [REDACTED]. A licensed practical nurse (LPN), Employee #3, was interviewed at 11:46 a.m. on 03/19/14. She explained the facility used a daily beverage plan worksheet to keep track of the resident's fluid consumption. Dietary staff were responsible for sending 760 ml of fluid daily, and nursing provided 240 ml of fluid daily. Employee #3 further stated the fluid distribution was outlined on the facility's Kardex (care plan information) which was available to nurses and nursing assistants. Review of the daily beverage plan confirmed dietary would provide 760 ml of fluid daily with meals, and nursing would provide 240 ml of fluid daily. Each nursing shift was responsible for providing 80 ml of fluid. The Kardex contained an entry for food / fluids: Fluid restriction: 1000 ml / 24 hours, NAS (no added salt) diet. Only provide fluids provided on the meal tray. The Kardex did not describe who was responsible for the provision of fluids. Employee #86, the dietary manager, was interviewed at 1:00 p.m. on 03/19/14.… | 2017-09-01 |
| 6979 | 6979 | MEADOW GARDEN | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2014-03-20 | 280 | D | 0 | 1 | LHVS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, and resident observation, the facility failed to revise care plans to accurately reflect each residents status. Resident #36's care plan reflected he took an antipsychotic medication which had been previously discontinued. Resident #32's activity care plan did not accurately reflect her needs as it related to her vision impairments. Resident Identifiers: #36 and #32. Facility Census: 58 Findings Include: a) Resident #36 Resident #36's medical record was reviewed at 1:40 p.m. on 03/18/14. This review revealed a physician's orders [REDACTED].@ (at) hs (bedtime). Give [MEDICATION NAME] 0.125 po (by mouth) every other day X (for) two wks (weeks) then DC dx (diagnosis) Dementia with psychotic features AEB (as evidenced by) hitting, yelling. The resident's Medication Administration Record [REDACTED]. Resident #36's care plan was reviewed. This review revealed a focus statement which read, (typed as written): Potential for verbal/physical aggression as manifested by hx (history) of cursing at and threatening physical actions, hitting and kicking other residents. Received Antipsychotic for dx Dementia with Psychotic features AEB kicking, hitting and verbal aggression and antiepileptic for mood disorder. The care plan also contained the following interventions related to the use of antipsychotic medication, AIMS (abnormal involuntary movement scale) testing per facility guidelines., Reduction in [MEDICAL CONDITION] per Dr. (doctor). Further review of the medical record revealed Resident #36 did not take any other antipsychotic medication and had not received any antipsychotic medication since his [MEDICATION NAME] was discontinued on 02/12/14. Employee #46, the Director of Nursing (DON) was interviewed at 3:27 p.m. on 03/18/14. She reported revision of care plans was a collaborative effort at the facility and numerous nurses shared this responsibility. The DON reviewed Resident #36's care pl… | 2017-09-01 |
| 6980 | 6980 | MEADOW GARDEN | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2014-03-20 | 463 | D | 0 | 1 | LHVS11 | Based on observations and staff interview, the facility failed to ensure the call lights for two (2) of thirty (30) residents was functional. Staff could not receive resident calls through the established call light system in one (1) room observed during Stage 1 of the Quality Indicator Survey. Neither resident in room A-7 were able to notify staff by using the call light system if they needed assistance. Resident Identifiers: #36 and #12. Facility Census: 58 a) Residents #36 and #12 At 12:45 p.m. on 03/17/14, the call light button in room A-7 was pressed. It did not light up to notify nursing staff of the need for assistance in room A-7. There were two (2) call light buttons in room A-7. Each button was pressed. Neither lit up to inform staff of the need for resident assistance. On 03/17/14 at 12:55 p.m., Employee #66, a licensed practical nurse was asked to press the call light buttons which were assigned to Residents #36 and #12. Upon completion of this task she stated, It is not working, I will have to notify maintenance. She later stated, I told maintenance about the call light not working. At 4:35 p.m. on 03/17/14, an interview was completed with Employee #46, the Director of Nursing (DON). She went into Room A-7 and confirmed the call light for Residents #36 and #12 was still not working. She stated they had to go and get a part to repair it. In an interview with the DON, at 9:22 a.m. on 03/20/14, she stated both Residents #36 and #12 were capable of using their call light to notify staff of a need for assistance. She stated they both used their call light when they needed something. | 2017-09-01 |
| 6981 | 6981 | MEADOW GARDEN | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2014-03-20 | 502 | D | 0 | 1 | LHVS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the provision of timely laboratory (lab) testing for one (1) of five (5) residents reviewed. The resident required specific lab tests prior to seeing an oncologist. The facility failed to obtain the ordered lab tests; therefore, the oncologist was unable to evaluate the resident as planned. Resident identifier: #2. Facility census: 58.Findings include:a) Resident #2 Medical record review for this resident was conducted on 03/19/14 at 1:55 p.m. This review revealed the resident was ordered the following labs: a complete blood count with differential (CBC with Diff.) and complete metabolic panel (CMP) monitoring for the use of the medication, [MEDICATION NAME], used in the treatment of [REDACTED].#2's appointment with her oncologist, which was scheduled for 03/17/14. There was no evidence the labs were completed on 03/09/14 as ordered. The resident went to the appointment on 03/17/14; however, the oncologist was unable to evaluate Resident #2 at her appointment due to the unavailability of the lab tests required for the resident's evaluation. An interview, on 03/19/14 at 3:15 p.m., with Employee #46, the Director of Nursing (DON), verified the labs had not been completed according to the physician's orders [REDACTED].#2 was not seen by the oncologist on 03/17/14 because the lab tests were not obtained. | 2017-09-01 |
| 6982 | 6982 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2014-02-27 | 225 | E | 0 | 1 | JUVV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon personnel file review, staff interview, and policy and procedure review, the facility failed to ensure they did not hire an employee who was unfit to work at the facility. The facility did not check the State nurse aide registry to ensure a prospective employee, Employee #146, staff nurse-licensed practical nurse, did not have a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. This was found for one (1) of five (5) employees whose files were reviewed. The had the potential to affect more than an isolated number of residents. Employee identifier: #146. Facility census: 83.Findings include:a) Employee #146A review of five (5) employee personnel files was conducted on 02/26/14 at 3:00 p.m. The personnel file of a licensed practical nurse (LPN), Employee #146, contained no evidence the State nurse aide registry was checked to determine whether the individual had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. Review of the facility's policy and procedure, on 02/26/14 at 4:00 p.m., revealed the names of all new employees, regardless of positions would be checked through the State registry to ensure the potential employee, regardless of position, did not have a finding entered against him or her. During an interview, on 02/27/14 at 9:30 a.m., the contracted administrator, Employee #166, confirmed there was no evidence the required check was completed prior to permitting Employee #146 to provide care to residents. After intervention during the survey, on 02/27/14 at 9:34 a.m., Employee #5, the inventory control clerk, obtained verification through the State nurse aide registry for Employee #146 (LPN). | 2017-09-01 |
| 6983 | 6983 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2014-02-27 | 241 | D | 0 | 1 | JUVV11 | Based on observation and staff interview, the facility failed to maintain resident dignity during the dining experience for one (1) of eight (8) residents in the assisted dining room. During two (2) of three (3) dining observations, staff placed food in the resident's mouth while she was still chewing. In addition, staff did not attempt to converse with the resident as they fed her. Resident identifier: Resident #8. Facility census: 83. Findings include: a) Resident #8 During an initial dining observation, on 02/24/14 between 11:45 a.m. and 12:45 p.m., Employee #13, a nursing assistant (NA), fed Resident #8 her lunch. She gave the resident large bites of food. While chewing the food, the resident would move the bolus to her left jaw, chew, swallow, move the bolus to her tongue and repeat. The NA continued to try to place food in the resident's mouth before she had swallowed all of the current bite. After a few attempts, the resident opened her mouth and took a bite. During the course of the meal, the resident accepted bites of food before she had swallowed the food in her mouth. The resident never spoke during the meal, and the staff member did not talk to her, or ask her if she was ready for the next bite. Resident #8 received her meal tray at 5:46 p.m. on 02/25/14. Employee #119, a nursing assistant, fed the resident. The resident ate slowly, chewing her food numerous times. The NA placed the spoon at the resident's lips multiple times until the resident opened her mouth. The resident accepted multiple bites while she still had food in her mouth from the previous bite. The NA did not attempt to converse with the resident during the meal. The director of nursing was interviewed on 02/26/14 at 10:00 a.m. After discussing the dining experience, she confirmed the resident had been treated in an undignified manner. | 2017-09-01 |
| 6984 | 6984 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2014-02-27 | 253 | E | 0 | 1 | JUVV11 | Based on observation and staff interview, the facility failed to ensure resident rooms were maintained in a sanitary and comfortable manner. Paint was chipped from the walls in numerous rooms. Wardrobes in several of the rooms contained areas where chunks were knocked off, exposing the particle board. Several entry doors were severely scratched and marred. Some bathroom doors were scratched and marred. Door facings had areas of peeled paint. In some rooms, baseboard molding was in disrepair. There were holes in walls near mirrors in several rooms. Some rooms and/or bathrooms had patches on the walls which were a different color that did not blend with the room's color. Caulking around a sink was cracked. One or more of these issues was evident for twelve (12) of fifty-seven (57) rooms observed. Room identifiers: #405, #407, #410, #411, #412, #413, #210, #402, #403, #109, #113, and #116. Facility census: 83. a) Rooms 405, 407, 410, 411, 412, and 413 1) Observation of room 407 on 02/24/14 at 1:43 p.m. found chipped paint on the bedroom wall. A small amount of drywall on a bathroom wall was scraped and peeled. 2) At 2:20 p.m. on 02/24/14, room 410 was observed. The lower one-fifth of the entry door was very scratched and marred. 3) Observation on 02/24/14 at 2:27 p.m. of room 411, revealed a small square of blue paint immediately above and below the sink. The rest of the room was white. Some dry wall was peeled above the sink. 4) On 02/24/14 at 3:11 p.m., room 413 was observed. Some paint was scraped off the bathroom wall. Some of the drywall in the bathroom was scraped and in disrepair. The lower portion of the bathroom door on the inside was scuffed and marred. The edges of the wardrobe door were scuffed and not smooth. The outside of the entry door on the lower one-fourth portion was scraped and marred. 5) Observation of room 412 was completed on 02/24/14 at 3:18 p.m. The exterior of the entrance doorway was scratched and marred on the lower one-fourth portion. 6) At 3:32 p.m. on 02/24/14, room 405 was observed. … | 2017-09-01 |
| 6985 | 6985 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2014-02-27 | 371 | E | 0 | 1 | JUVV11 | Based on observation, review of the Food and Drug Administration (FDA) Food Code, and staff interview, the facility failed to store and serve food under sanitary conditions. The holding temperature for chicken was 130 degrees Fahrenheit (F). This had the potential to affect more than a limited number of residents. Facility census: 83. Findings include: a) Holding temperatures Review of dining practices indicated lunch was served at 11:45 a.m. daily. During an interview with the dietary manager, on 02/27/13 at 9:27 a.m., she said staff were served first from the steam table tray line, then the food was changed out and hot food was placed on the steam table for residents' trays. Observation of the steam table tray line, on 02/27/13 at 11:50 a.m., revealed Employee #108 (dietary) obtained the resident list and prepared meal trays for the residents. Upon inquiry, she said temperatures were obtained prior to starting tray line, but were not checked again. Upon request, she obtained food temperatures. The chicken breast temperature was 130 degrees F. She said the temperature was too low and the product could not be served. She said it should be over 140 degrees. According to the current Food and Drug Administration (FDA) Food Code, to prevent the rapid and progressive growth of harmful pathogens, hot foods, particularly potentially hazardous foods such as chicken, must be held for service at 135 degrees F or above. An interview with the dietary manager confirmed the holding temperature was too low. She said facility practice was 140 degrees, even though the federal regulation was 135 degrees. | 2017-09-01 |
| 6986 | 6986 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2014-02-27 | 431 | E | 0 | 1 | JUVV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of recommendations from the Centers for Disease Control (CDC), policy review, and staff interview, the facility failed to ensure safety in the use of multi-dose vials of immunizations and/or tuberculin testing serum. They were not discarded after opening for longer than that recommended by the CDC. This had the potential to affect more than a limited number of residents. Facility census: 83. Findings include: a) Purified Protein Derivative (PPD) On 02/25/14 at 5:15 p.m., the 100/200 medication room was observed. An opened, partially used, multi-dose vial of PPD was stored in the refrigerator. This was a five (5) test vial. (PPD test serum is injected beneath the skin, and is used as a test for [DIAGNOSES REDACTED] screening.) This vial was dated 11/21/13 as the initial date it was opened. An interview was conducted with nurse supervisor, Employee #65, on 02/25/14 at 5:15 p.m She said this opened vial of PPD serum, with its remaining test serum, should have been discarded thirty (30) days after opening and it was not. b) Influenza vaccine The 400 hall medication refrigerator was observed on 02/25/14 at 5:30 p.m. An opened, partially used multi-dose vial of influenza vaccine was stored in the refrigerator. The date it was initially opened, 11/19/13, was written on the bottle. An interview was conducted with nurse supervisor, Employee #65, on 02/25/14 at 5:30 p.m. She said this vial of influenza vaccine should have been discarded thirty (30) days after it had been initially opened, and it was not. c) Centers for Disease Control According to the CDC, once a multi-dose vial has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. d) The director of nursing (DON) provided the facility's policy on the storage of influenza vaccine and PPD serum on 02/27/14 at 1:30 p.m. According to… | 2017-09-01 |
| 6987 | 6987 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2014-02-27 | 441 | D | 0 | 1 | JUVV11 | Based on observation and staff interview, the facility failed to provide a safe, sanitary environment to help prevent the development and transmission of disease and infection. During observation of a medication pass, a nurse administered a medication that she had dropped onto the medication cart and had touched with her bare hands. This was evident for one (1) of seven (7) residents observed for medication administration, and for one (1) of thirty-two (32) medications administered. Resident identifier: #48. Facility census: 83. Findings include: a) Resident #48 On 02/25/14 at 4:31 p.m., Employee #29, a nurse, dropped a pill on top of the medication cart. Using bare hands, she picked up the pill and dropped it into the medication cup. She then administered the medication to Resident #48. An interview was conducted with the administrator on 02/27/14 at 9:30 a.m. Upon inquiry, she said medications should be dispensed from the blister pack or stock bottle directly into a medication cup. She said if a medication was dropped on the cart, it should be discarded and another pill dispensed in its place. | 2017-09-01 |
| 6988 | 6988 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2014-02-27 | 463 | E | 0 | 1 | JUVV11 | Based on observation and staff interview, the facility failed to ensure call lights in each room were functioning properly. During Stage I of the survey, the call lights in four (4) of fifty-seven (57) rooms did not function when tested . Resident identifiers: #9, #83, #75, and #81. Facility census: 83. Findings include: a) Resident #9 On 02/24/14 at 2:16 p.m., the resident pushed her call button, and tried unsuccessfully to ring her call bell. The surveyor was also unable to make it work. The resident gave a directive to pull the cord out from the wall entirely, then to reinsert it. She instructed to hit the resent button, and then it would work. She was correct. Upon inquiry as to how often the call light failed to operate, she stated It does that sometimes. They know about it. She said she did not know what she would do if she were sick and needed staff right away and the call signal did not work. She said she was unable to walk, and she cannot get out of bed without assistance. b) Resident #83 A test of the signaling device was attempted on 02/14/13 at 3:40 p.m. It did not ring, light up at the doorway, or light up on the wall by the resident's bed. c) Resident #75 On 02/24/14 at 3:43 p.m., a test of the signaling device was attempted. It did not ring, light up at the doorway, or light up on the wall by the resident's bed. The resident's nurse said he resident spends most of his time sitting in a chair at the nurse's desk. She said he would not cognitively be able to use a call bell. A brief interview was conducted with the administrator on 02/24/14 at 4:30 p.m. She was informed of the above three (3) residents whose call lights were not functioning when tested . On 02/27/14 between 9:00 a.m. and 10:00 a.m., every call light in the facility was tested for functionality. Every call light was working at that time. d) Resident #81 During a room observation, on 02/24/14 at 2:19 p.m., with Employee #85, a nursing assistant (NA), the call bell did not work when she pushed the button. She checked the wall extension,… | 2017-09-01 |
| 6989 | 6989 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 155 | D | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure a resident was afforded the right to formulate an advanced directive. This was found for one (1) of four (4) sample residents reviewed for the care area of choices during Stage 2 of the survey. The resident's code status was determined by a medical decision maker during a time the resident did not have capacity to make medical decisions. The code status was not reevaluated with the resident when she regained capacity to make health care decisions. Resident Identifier: #91. Facility Census: 130. Findings Include: a) Resident #91 Resident #91's medical record was reviewed at 1:00 p.m. on 12/17/13. This review revealed two (2) Physician's Determination of Capacity forms. The first form was dated 12/04/13 and determined the resident had capacity to make medical decisions. The second form was dated 12/07/13, and also determined the resident had capacity to make medical decisions. The record also contained a social service progress note, dated 12/11/13, written by Employee #62, Social Worker. This note revealed Resident #91 was reevaluated for capacity because she had scored a 15 on her latest Brief Interview for Mental Status (BIMS). She indicated Resident #91 was reevaluated by two (2) physicians and had regained her ability to make medical decisions. Further review of Resident #91's medical record revealed a Do Not Resuscitate form. This form contained the following paragraph, I, the undersigned resident or duly authorized legal representative, have made a decision regarding resuscitation in the event that I (the above named resident) am discovered without respiration or pulse. The affected resident or legal representative wishes that medical personnel in attendance would NOT initiate cardiopulmonary resuscitation. I understand I may revoke these directions at any time. This form contained Resident #91's name. It was signed by her Legal Representative … | 2017-09-01 |
| 6990 | 6990 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 225 | D | 0 | 1 | EUXT11 | Based on review of the facility's reportable allegations of abuse/neglect, staff interview, and review of the facility's abuse policy, the facility failed to immediately report allegations of abuse/neglect to adult protective services as required by West Virginia Code 9-6-9. The facility also failed to prevent further potential abuse while the investigation was in progress by failing to suspend an employee, as required by facility policy, who was alleged to have been physically abusive to the resident. This was true for one (1) of ten (10) investigations of abuse / neglect reviewed during the survey. Resident identifier: #52. Facility census: 130. Findings include: a) Resident #52 During Stage I of the Quality Indicator Survey (QIS) a facility resident, (who wished to remain anonymous) answered, Yes, to the question, Have you seen any resident here being abused? Further investigation during Stage 2 of the QIS identified the resident, who was alleged to have been abused, as Resident #52. Review of the facility's reportable allegations of abuse/neglect found an immediate reporting of allegations to the nurse aide registry for two (2) nursing assistants, Employees #49 and #104, regarding an allegation of abuse/neglect reported by Resident #52. According to the written investigation material presented by the facility's social worker, Employee #66, on 12/10/13 at 7:54 a.m., Resident #52 accused two (2) nursing assistants, Employees #49 and #104, of being abusive. Review of the nurse aide registry immediate fax reporting of allegations on 12/10/13 found Resident #52 made the following allegation regarding Employee #49 on 11/27/13: Resident states CNA (certified nursing assistant) was mean to her, When I asked her for a pillow, she acted like it would kill her. Stated I've never been treated so bad before. Stated the CNAs told her not to put her light on again. On 11/27/13, Resident #52 provided the following statement regarding Employee #104 (identified by facility staff): Resident states CNA with long hair in pony tai… | 2017-09-01 |
| 6991 | 6991 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 226 | D | 0 | 1 | EUXT11 | Based on review of the facility's reporting of allegations of abuse/neglect to the proper state agencies, staff interview, and review of facility policy (entitled - Abuse), the facility failed to implement their policy for protection of residents during an investigation of alleged abuse/neglect for one (1) of ten (10) allegations reviewed and reported by the facility. Resident identifier: #52. Facility census: 130. Findings include: a) Resident #52 During Stage 1 of the Quality Indicator Survey (QIS) a facility resident, (who wished to remain anonymous) answered, Yes, to the question, Have you seen any resident here being abused? Further investigation during Stage 2 of the QIS identified the resident, who was alleged to have been abused, as Resident #52. Review of the facility's reportable allegations of abuse/neglect found an immediate reporting of allegations to the nurse aide registry for two nursing assistants, Employees #49 and #104, regarding an allegation of abuse/neglect reported by Resident #52 on 11/27/13. According to the written investigation material presented by the facility's social worker, Employee #66, on 12/10/13 at 7:54 a.m., Resident #52 accused Employee #49 of verbal abuse and Employee #104 of both verbal and physical abuse on 11/27/13. Review of the nurse aide registry immediate fax reporting of allegations on 12/10/13 found Resident #52 made the following allegation regarding Employee #49 on 11/27/13: Resident states CNA (certified nursing assistant) was mean to her, When I asked her for a pillow, she acted like it would kill her. Stated I've never been treated so bad before. Stated the CNAs told her not to put her light on again. On 11/27/13, Resident #52 provided the following statement regarding Employee #104: Resident states CNA with long hair in pony tail hit me in the side, pointing to left side. States I've never been treated so bad and I don't know why they are so mean to me. Then the resident started crying. Upon assessment - no bruising or reddened areas noted. (The facility ident… | 2017-09-01 |
| 6992 | 6992 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 241 | E | 0 | 1 | EUXT11 | Based on observation, resident interview, and staff interview, the facility failed to ensure nine (9) residents were treated with dignity and respect. Staff entered resident's rooms without knocking, announcing themselves, or otherwise ask for permission to enter. Residents were not positioned close enough to the table during dining, and residents seated at the same table were not fed at the same time. This was identified for five (5) of six (6) residents observed during medication administration observations, for three (3) residents randomly observed during observation of the dining experience, and for one (1) Stage 2 sampled resident. Resident identifiers: #69, #55, #36, #136, #19, #115, #77, #125, and #20. Facility Census: 130. Findings include: a) Resident #69 During a medication administration observation on 12/12/13 at 8:25 a.m., Employee #32 was observed entering the room of Resident #69. She walked into the resident's room without knocking, announcing herself, or otherwise ask for permission to enter this resident's room. b) Resident #55 During a medication administration observation on 12/12/13 at 8:45 a.m. Employee #140 entered this resident's room and did not knock, announce herself, or otherwise ask for permission to enter this resident's room. c) Resident #36 During a medication administration observation on 12/10/13 at 9:30 a.m., Employee # 23 entered this resident's room and did not knock, announce herself, or otherwise ask for permission to enter this resident's room. d) Resident #115 During a medication administration observation on 12/11/13 at 11:55 a.m., Employee #114 entered this resident's room and did not knock, announce herself, or otherwise ask for permission to enter this resident's room. e) Resident #19 During a medication administration observation on 12/11/13 at 8:45 a.m., Employee # 95 entered this resident's room and did not knock, announce himself, or otherwise ask for permission to enter this resident's room. f) Resident #136 An interview was conducted with this resident in her roo… | 2017-09-01 |
| 6993 | 6993 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 246 | D | 0 | 1 | EUXT11 | Based on observation, resident interview, and staff interview the facility failed to provide a reasonable accommodation of individual needs for one (1) resident identified during a random opportunity for observation. The call bell for a resident in bed was out of reach and on the floor for forty-five minutes. Resident identifier: #63. Facility census: 130. Findings include: a) During an observation on 12/09/13 at 11:00 a.m., the call bell for Resident #63 was observed on the floor beside the bed. Upon observation on 12/09/13 at 11:45 a.m., the call bell was still on the floor out of reach of the resident. Resident #63 was observed in bed on both occasions. An interview was conducted on 12/09/13 at 11:50 a.m. with Resident #63. This resident stated his call bell was on the floor more than it was on his bed. On 12/09/13 at 11:55 a.m., an interview was conducted with Employee #32, a licensed practical nurse, in Resident #63's room. This employee placed the call bell on the resident's bed and stated the call bell should always be within reach of the resident. | 2017-09-01 |
| 6994 | 6994 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 253 | E | 0 | 1 | EUXT11 | 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. The walls had holes, black marks, and scrapes. The doors were scratched and were missing paint. This practice affected fifteen (15) of thirty-eight (38) rooms observed. Room numbers of affected rooms: #103, #105, #106, #107, #108, #116, #119, #129, #303, #305, #307, #315, #320, #337, #350. Facility census: 130. Findings include: a) Observations of the facility during Stage 1 and 2 of the Quality Indicator Survey, revealed the following rooms had environmental concerns: 1) Room #103: The bathroom door and door frame was scraped and had paint missing. 2) Room #105: The bathroom door was scraped and had paint missing. 3) Room #106: Both vents in the bathroom were rusted. 4) Room #107: The bathroom door was scraped and had paint missing. 5) Room #108: The door to the room and the bathroom were scraped and had paint missing. 6) Room #116: The door to the room was scraped and had missing paint. 7) Room #119: The room had multiple holes in the wall beside and behind bed A. The door to the room was scraped and had missing paint. 8) Room #129: The door to the room was scraped and had missing paint. 9) Room #303: The room had multiple holes in the walls throughout the room. The door to the room was scraped and had missing paint. 10) Room #305: The bathroom door was scraped and had paint missing. 11) Room #307: The bathroom door was scraped and had paint missing. The drain in the bathroom shower was rusted. 12) Room #315: The room had a hole in the wall beside bed B. 13) Room #320: The room had missing paint and black scrapes on the closet door. The ceiling was stained orange. 14) Room #337: The door to the room had scrapes, holes, and paint missing. 15) Room #350: The wall behind the television had missing paint. The door to the room was scraped and had paint missing. These concerns were discussed and verified with Employee #133 (administrator) on 12/16/1… | 2017-09-01 |
| 6995 | 6995 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 256 | D | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to provide adequate and comfortable lighting.The lighting level was dim in two (2) of thirty-eight (38) resident bathrooms observed. Rooms with affected lighting in the bathrooms were #118 and #119. Facility census: 130. Findings include: a) Upon observation on 12/09/13 at 9:30 a.m., the bathrooms in rooms #118 and #119 were observed with lighting that was dim. An interview was conducted with Resident #80 on 12/09/13 at 9:35 a.m. This resident resided in room [ROOM NUMBER]. The resident stated the lighting in the bathroom could be much brighter for her needs. Employee #105, a nursing assistant (NA), was interviewed on 12/09/13 at 9:40 a.m. The NA confirmed the dim lighting and stated there were several bathrooms that had dim lighting. | 2017-09-01 |
| 6996 | 6996 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 272 | E | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately assess twelve (12) of forty-three (43) residents reviewed in Stage 2 of the Quality Indicator Survey (QIS). The comprehensive Minimum Data Set (MDS) did not accurately reflect the current status for three (3) of twelve (12) residents. The Care Area Assessment (CAA), a part of the comprehensive assessment, was not accurately completed for eleven (11) of twelve (12) residents. The MDS for Resident #13 did not accurately reflect the resident's active [DIAGNOSES REDACTED]. Resident #72's MDS did not accurately reflect the resident's urinary incontinence status. Resident #166's MDS did not accurately reflect the resident's pressure ulcer. The CAA for falls was not accurately completed for Resident #37. In the area of [MEDICAL CONDITION] drug use, the CAA summary for Residents #37, #68, and #38 was not accurately completed. The CAA summary for activities of daily living functional/rehabilitation potential was not accurately completed for Residents #69, #91, #65 and #27. Resident #163's CAA summary for nutritional status was not accurately completed. The CAA summary for urinary incontinence and indwelling catheter was not accurately completed for Resident #72. Resident #132's CAA summary for dental care was not accurately completed. The CAA summary for pressure ulcers was not accurately completed for Resident #166. Resident Identifiers: #13, #163, #91, #132, #65, #72, #37, #69, #68, #166, #27, #38. Facility Census: 130. Findings Include: a) Resident #13 Resident #13's medical record was reviewed at 12:33 p.m. on 12/05/13. The resident had an active [DIAGNOSES REDACTED]. He also had a physician's orders [REDACTED]. The [DIAGNOSES REDACTED].#86, the Director of Nursing Services (DNS) was interviewed at 1:02 p.m. on 12/05/13, regarding how long Resident #13 had the [DIAGNOSES REDACTED]. This history and physical indicated the resident had a longstanding history of [MEDICAL CO… | 2017-09-01 |
| 6997 | 6997 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 279 | D | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to develop a care plan to describe the provision of services needed to meet the needs of two (2) of forty-three (43) residents whose care plans were reviewed. Resident #166 had a scabbed area present on his heel that was not included in his care plan. Resident #65 had [MEDICAL CONDITION] present that was not fully addressed in her care plan. Resident identifiers: #166 and # 65. Facility Census: 130 Findings include: a) Resident #166 Record review on 12/04/13 at 2:00 p.m., revealed this resident was admitted to the facility on [DATE]. Prior to admission, he had been in the hospital since 10/20/13. His admission skin assessment, dated 11/20/13, revealed an area to his left buttock and a blister to his right heel. The physician's orders [REDACTED]. According to the record, on 11/21/13 the treatment nurse assessed the resident's wounds and discontinued the treatment to his right heel. On 11/22/13, a wound assessment and progress review note was written at 12:00 p.m. According to this note, the resident had a small scab present to his right heel. No measurements of the scabbed area were recorded. The resident's initial minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/27/13 was reviewed. Section M1200, Skin and Ulcer Treatments, revealed in section i, the resident had received an application of dressings to the feet during the look back period. Section V of the MDS assessment was reviewed and indicated the care area of Pressure Ulcers triggered for further review. It noted the decision was made to proceed with a care plan. The CAA worksheet dated 11/27/13 for Pressure Ulcers for Resident # 166 was reviewed. This worksheet noted a scabbed area to the resident's right heel and his heels were off loaded. The care plan initiated on 11/21/13 and revised on 12/06/13 did not address a scabbed area to his right heel as identified in the CAA assessme… | 2017-09-01 |
| 6998 | 6998 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 280 | E | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to update five (5) of forty-three (43) care plans reviewed during Stage 2 of the Quality Indicator Survey. Resident #38's care plan was not updated when the resident was placed on fluid restriction. Resident #39's care plan was not updated when the resident's contracture to her shoulder was resolved. Resident #91's care plan was not updated when padding was added to the side rails. Resident #25's care plan was not updated when side rails were changed from half side rails to quarter side rails. Resident #27's care plan was not updated to include the amount of assistance required to complete activities of daily living. Resident identifiers: #38, #39, #91, #25 and #27. Facility census: 130. Findings include: a) Resident #38 Review of the current care plan, which was revised on 09/16/13, found a problem identified as: Risk for dehydration related to diuretic use and fluid restriction related to [MEDICAL CONDITION]. An approach, initiated on 03/19/13, related to this problem was, keep fresh ice water at bedside. Review of the physician's orders [REDACTED]. The order specified how many cc of fluid the resident would receive with each meal and how many cc of fluid would be administered during each shift by nursing. Three (3) employees: a nursing assistant (Employee #132), a registered nurse (Employee #15), and a licensed practical nurse (Employee #140) were all interviewed at 2:46 p.m., on 12/09/13. All three (3) employees verified the resident could not have a water pitcher at his bedside. Employee #15 stated,It would be impossible to keep track of the amount of fluid consumed daily if the resident was allowed free access to a water pitcher. The author of the care plan, Employee #131, the registered nurse care plan coordinator, was interviewed at 3:30 p.m. on 12/09/13. She stated the resident's care plan should have been updated when the facility received the new order for flui… | 2017-09-01 |
| 6999 | 6999 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 282 | D | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observation, record review, and staff interview, the facility failed to implement the care plan for two (2) of forty-three (43) residents reviewed during Stage 2 of the Quality Indicator Survey. Resident #13 had a care plan for a low bed with landing strips which was not implemented. Resident #16 had a care plan for a low bed which was not implemented. Resident Identifiers: #13 and #16. Facility Census: 130. Findings Include: a) Resident #13 Resident #13's medical record was reviewed at 12:33 p.m. on 12/05/2013. This review revealed a physician's orders [REDACTED]. The care plan for Resident #13 was reviewed. The resident had a care plan with a problem identified as [MEDICAL CONDITION]. The goal was, will have minimal injury from [MEDICAL CONDITION] episode. The approach was for landing strips beside the bed and for the bed to be in the the in lowest position. This care plan was added to the resident's care plan on 12/3/13. Observation at 11:05 a.m. on 12/10/13 found the resident in bed. His bed was not in the lowest position, nor were landing strips on the floor by his bed. At 11:13 a.m. on 12/10/13, Employee #67, the Assistant Director of Nursing Services (ADNS), was interviewed. She confirmed the resident had an order and care plan for his bed to be in the lowest position and for landing strips to be on the floor at his bedside bilaterally. She observed the resident and confirmed he was in his bed, the bed was not in the lowest position, and his landing strips were not at his bedside. b) Resident #16 Review of the resident's current care plan on 12/16/13 found the resident had a care plan for the problem, Potential for injury from falls due to use of a daily antidepressant and poor sitting balance. This problem was initiated on 10/11/13. An intervention associated with this problem was to place the resident in a low bed. On 12/16/13 at 3:38 p.m. the resident was observed in her bed. The bed was not in the low position. Em… | 2017-09-01 |
| 7000 | 7000 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 314 | D | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, staff interview, and policy review, the facility failed to identify and monitor the presence of a pressure ulcer for one (1) of three (3) residents reviewed for the care area of pressure ulcers in Stage II of the survey. The resident had a scabbed area on his right heel which was not regularly monitored and/or assessed to prevent potential complications. Resident identifier: #166. Facility Census: 130 Findings include: a) Resident #166 Record review, on 12/04/13 at 2:00 p.m., revealed this resident was admitted to the facility on [DATE]. Prior to coming to the facility he was in the hospital since 10/20/13. His admission skin assessment, dated 11/20/13, revealed he had an area to his left buttock and a blister to his right heel. The physician's orders [REDACTED]. According to the record, the next day, on 11/21/13, the treatment nurse assessed the resident's wounds and discontinued the treatment to his right heel. She placed him on a speciality air mattress due to a stage III wound on his left distal gluteal. There was no recorded observation the skin to the right heel was no longer impaired, but there was a physician's orders [REDACTED]. On 11/22/13 at 12:00 p.m., a wound assessment and progress review note was written at 12:00 p.m. According to this note, the resident had a small scab present to his right heel and he was wearing heel protector boots. There were no recorded measurements of the scabbed area. The resident's initial minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/27/13 was reviewed. It noted the resident required extensive assist of two (2) people for bed mobility. It also noted he did not ambulate and had a [DIAGNOSES REDACTED]. Section M (Skin Conditions), M0300 for current number of unhealed pressure ulcers at each stage was coded as follows: 0 Stage I pressure ulcers 0 Stage 2 pressure ulcers 1 stage 3 pressure ulcer (present on admissio… | 2017-09-01 |
| 7001 | 7001 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 323 | K | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I Based on observation, resident interview, staff interview, review of the facility's policy for Bed Safety Assessment Guidelines, and review of the 03/10/06, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued by the United States Department of Health and Human Services, Food and Drug Administration Center for Devices and Radiological Health, it was determined the facility failed to ensure the resident environment, over which the facility had control, remained as free of accident hazards as possible. With the slight touch of a hand, half side rails on the beds of two (2) resident's, Resident #37 and Resident #63, were able to be tilted inward and outward, forward and backwards. When moved outward, the gap between the mattress and the side rails measured four (4) inches on Resident #37's bed and three (3) inches on Resident #63's bed, resulting in a potential for entrapment. Side rails on an additional nineteen (19) residents' beds were observed and found loose, allowing a slight touch of the hand to rock the rails forward and backwards and inward and outward. Interviews with facility staff, residents, and review of the bed safety assessments for two (2) residents (Residents #52 and #44) confirmed the facility was aware of the ill-fitting side rails. On 12/02/13 at 7:30 p.m. the loose side rails were discussed with the administrator and no further information was presented to verify the facility had assessed the situation or implemented a plan of action for correction. The administrator stated the facility would have work orders to verify the action taken when occurrences of loose rails were reported; however, this information was never presented. At 8:00 p.m. on 12/02/13, the administrator was informed of the ill-fitting side rails and the unsafe conditions present resulting in immediate jeopardy. An acceptable plan of correction was provided on 12/02/13 at 10:20 p.m. Observations of the corrective action… | 2017-09-01 |
| 7002 | 7002 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 325 | D | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to evaluate and address the nutritional needs of one (1) of three (3) residents reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey. When Resident #72 was admitted to the facility, an admission weight was recorded. The next day the resident was weighed. This weight indicated the resident had a 4.5% weight loss in one (1) day. The facility did not implement their policy to confirm this resident's recorded weight loss. At the time of the survey, the facility had not identified a need to assess the resident's nutritional status to determine appropriate interventions, if the resident had actually lost weight and/or to determine if nutritional interventions were needed. Resident Identifier: #72. Facility Census: 130. Findings Include: a) Resident #72 . Resident #72's medical record was reviewed at 2:49 p.m. on 12/12/13. The resident was admitted to the facility on [DATE]. This review revealed the following weights for Resident #72: 08/02/13 142 pounds (lbs) 08/03/13 135.6 lbs 08/06/13 136.8 lbs 08/14/13 133.6 lbs 08/20/13 136.0 lbs 08/27/13 140.0 lbs 09/05/13 134.4 lbs 09/10/13 135.2 lbs 09/19/13 136.8 lbs 09/24/13 134.6 lbs 10/01/13 134.8 lbs 10/09/13 133.6 lbs. 10/16/13 131.8 lbs 10/23/13 130.6 lbs 10/29/13 131.8 lbs 11/06/13 132.0 lbs 11/12/13 131.2 lbs 11/18/13 131.8 lbs 11/26/13 129.8 lbs 12/02/13 126.6 lbs Resident #72's weight was reviewed using the initial admission weight of 142 lbs as documented on 08/02/13. On 08/03/13, the resident's weight was recorded as 135.6 lbs. This represented a weight loss of 6.4 lbs (4.5%) in one (1) day. There was no evidence this weight loss was recognized or addressed. On 09/05/13 the resident's weight was recorded as 134.4 lbs. This represented a weight loss of 7.6 lbs (5.35%) since admission. A weight loss of 5% in one (1) month is a significant weight loss. A weight loss of greater than 5% i… | 2017-09-01 |
| 7003 | 7003 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 329 | D | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the drug regimen for two (2) residents was free from unnecessary medications. Resident #68's antidepressant was reduced based on a recommendation from the pharmacist. The facility resumed the medication after 11 days without evidence of increased behaviors and without evidence of non-pharmacological interventions attempted before the increase. Resident #37 received two (2) antidepressants (duplicate therapy), without documentation of the rational for and the benefits of duplicate therapy. Two (2) of five (5) residents reviewed for unnecessary medications were affected. Resident identifiers: #68 and #37. Facility census: 130. Findings include: a) Resident #68 1) Medical record review on 12/05/13 found a current physician's orders [REDACTED]. Further review of the medical record found the pharmacist had recommended a dose reduction of [MEDICATION NAME] on 10/24/13. The rationale for the dose reduction was described as, (Resident #68) has received [MEDICATION NAME] 120 mg daily since 02/20/12 for [MEDICAL CONDITION] disorder. According to Clinical Pharmacology, The adult maximum recommended dose is 60 mg/day po (by mouth). Up to 120 mg a day po has been used, but no clinical advantage has been demonstrated. Please consider a gradual dose reduction, perhaps decreasing to 90 mg daily x (for) 30 days then 60 mg daily while concurrently monitoring for re-emergence of depressive and/or withdrawal symptoms. If therapy is to continue at the current dose please provide rationale describing a dose reduction as clinically contraindicated. The physician agreed with the recommendation made by the pharmacist on 10/24/13 and a order was written on 11/01/13 to decrease the [MEDICATION NAME] to 90 mg, po, daily for 30 days, then decrease [MEDICATION NAME] to 60 mg po, daily. Further review of the physician's orders [REDACTED]. Review of the nursing notes from 11/01/13 to 11/11/13 … | 2017-09-01 |
| 7004 | 7004 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 332 | D | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to assure they were free of medication error rates of five percent or greater. The facility had a medication error rate of six and twenty- five one hundreds (6.25) percent. There were two (2) medication errors observed during thirty- two (32) observed opportunities for errors. Resident identifiers: #55 and #80. Facility Census: 130 Findings include: a) Resident # 80 During a medication administration observation on 12/10/13, Employee #14 (licensed practical nurse) was observed administering medications to Resident #80. This resident received [MEDICATION NAME] five (5) mg (milligrams) scheduled every four (4) hours at 9:40 a.m. At 11:55 a.m. on 12/10/13 a second observation of Employee #14 revealed he administered this resident's [MEDICATION NAME] Five (5) mg (milligrams) again at 12:00 p.m. The physician's orders [REDACTED]. This second observation occurred two (2) hours and 40 minutes after the first observation. During an interview with Employee #14 on 12/10/13 at 12:30 p.m., he verified he administered Resident #80's [MEDICATION NAME] two(2) hours and 40 minutes apart. He stated this was because the morning dose was late. He confirmed he administered the 9:40 a.m. dose late and it he should have given at 8:00 a.m. He indicated this made the doses too close together. b) Resident # 55 During an observation of this resident's medication administration on 12/12/13 at 8:45 a.m., Employee #140 ( licensed practical nurse) administered Insulin [MEDICATION NAME] 70/30 subcutaneous (SQ) (20) units. The nurse got the medication out of the medication cart drawer and drew up twenty (20) units into her syringe. At no time did the nurse roll or mix the insulin prior to this administration. The director of nursing (Employee #86) was made aware of the observation of not mixing the insulin prior to administration. She agreed this was an error and insulin should be rolled prior to administration.… | 2017-09-01 |
| 7005 | 7005 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 363 | D | 0 | 1 | EUXT11 | Based on menu review, observation and staff interview the facility failed to follow their menu to ensure they met the nutritional needs of residents. Resident #35, #44, #55, #68, #162, #86, #152, #20, #82, #52, and #138 had the potential to receive more or less, than the menu specified amount of spaghetti noodles during the lunch meal on 12/09/13. This practice affected eleven 11 of 11 residents who received a regular diet from the Market Street Cafe, (north hall dining room) on 12/09/13. Resident identifiers: #35, #44, #55, #68, #162, #86, #152, #20, #82, #52, #138. Facility Census: 130. Findings Include: a) An observation of meal service in the market street cafe occurred on 12/09/13. Employee #18, (dietary cook) served spaghetti noodles with a set of tongs. During an interview with Employee #18 at 1:05 p.m. on 12/09/13, she stated each resident should get four (4) ounces of noodles on their plate. When asked how she knew each resident got four (4) ounces, she stated, I eyeballed it. She stated she did not think the noodles would stay in a four (4) ounce scoop so that is why she was using the tongs. Employee #88, Certified Dietary Manger (CDM) was interviewed at 1:10 p.m. on 12/09/13 he stated the employee serving the noodles should have done so with a four (4) ounce scoop and not with tongs. He confirmed resident #35, #44, #55, #68, #162, #86, #152, #20, #82, #52, and #138, received spaghetti noodles from the market street cafe. A review of the menu spread- sheet for the lunch meal on 12/09/13 revealed a resident on a regular diet should receive four (4) ounces of spaghetti noodles. | 2017-09-01 |
| 7006 | 7006 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 372 | F | 0 | 1 | EUXT11 | Based on observation and staff interview, the facility failed to ensure they maintained the garbage in a manner that would prevent the attraction of vermin. This practice had the potential to affect all residents. Facility Census: 130.Findings include:a) The garbage dumpster area was observed on 12/05/13 at 9:40 a.m. The facility had three (3) dumpster's that contained bags of garbage. The lid's of two (2) of the three (3) dumpsters were open. The third dumpster had a bag of garbage sitting on top of the closed lid. On 12/05/13 at 9:41 a.m., during an interview with Employee #88, (certified dietary manager) he confirmed the garbage was not contained within a closed dumpster. He stated the lids should be closed and the bag of garbage should be in the dumpster not on top of the dumpster lid. | 2017-09-01 |
| 7007 | 7007 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 412 | D | 0 | 1 | EUXT11 | Based on observation, staff interview, record review, and resident interview, the facility failed to provide or obtain from and outside resource routine dental services for one (1) of three (3) residents reviewed for the care area of dental status and services during Stage 2 of the quality indicator survey. Resident #132 was identified as needing dental services on his admission minimum data set (MDS) on 05/2013. The facility failed to obtain these services. Resident Identifier: #132. Facility census: 130. Findings include: a) Resident #132 Resident #132's medical record was reviewed at 8:45 a.m. on 12/10/13. The resident's admission minimum data set (MDS) with an assessment reference date (ARD) of 05/15/13 was reviewed. The MDS identified the resident as having obvious cavity or broken natural teeth under section L0200D. The care area assessment (CAA) summary worksheet was reviewed for the area of dental care. The nature of the problem/condition was described as, Resident has broken teeth, but overall teeth are in fair condition. He denies mouth pain, and has no difficulty with his regular diet. He will be referred to the dentist. The resident was observed at 2:32 p.m. on 12/03/13 and did have visible broken natural teeth, but he denied mouth pain at that time. Resident #132 was interviewed at 5:05 p.m. on 12/16/13. He stated he has not been seen by a dentist since he has been at the facility. He stated if they wanted him to go to the dentist then he would. He stated it could not hurt to be seen by a dentist. He did report his mouth did not hurt and his broken teeth did not give him any problems. He reported he was use to it. At 10:27 a.m. on 12/17/13, Employee #15, Registered Nurse (RN), Unit Manager, was interviewed. She confirmed she did not see anything in the residents medical record which would indicate the resident had seen by a dentist. She stated social services usually handles dental arrangements so they my know more about it. At 3:39 p.m. on 12/17/13, Employee #66, social worker was interviewed. She s… | 2017-09-01 |
| 7008 | 7008 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 428 | D | 0 | 1 | EUXT11 | **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 responded to a pharmacy request in a timely manner for one (1) of five 5) residents reviewed for unnecessary medications. They failed to ensure the physician provided rationale the use of duplicate medications treating the same condition for one (1) of five (5) residents reviewed for necessary medications. In addition, the pharmacist did not identify a drug irregularity for one (1) resident observed during the medication pass. The physician had not responded to the pharmacy recommendation in a timely manner for Resident #38. For Resident #37, the physician failed to provide rational for duplicate medications. The pharmacist did not identify an irregularity in Resident #36's medication regimen. Resident identifiers: #38, #37, and #36. Facility census: 130. Findings include: a) Resident #38 On 04/22/13 the pharmacist reviewed the resident's medications and identified the resident was receiving Celexa 20 mg (milligram) daily, Clozapine 100 mg bid (twice a day) and Depakote 375 mg bid (increased). The pharmacist noted all the medications were for schizophrenia. The pharmacist further advised: Please consider a gradual dose reduction or documentation, if therapy is to continue at the current dose, please provide rational describing a dose reduction as clinically contraindicated. The director of nursing (DON) provided a copy of the 04/22/13 recommendation at 12/21/13 at 12:50 p.m., which the physician had not signed. She was asked to provide verification the physician had responded to the pharmacist request. At the close of the survey, the DON did not provide the physician's response to the recommendations. On 06/25/13, the pharmacist again reviewed the resident's medications and provided the same suggestions/recommendations. At this time, the physician reduced the Celexa from 20 mg to 10 mg. daily but failed to provide rational as why a dose reduction of… | 2017-09-01 |
| 7009 | 7009 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 441 | F | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, review of the facility's surveillance data, and review of the facility's infection control policies and procedures, it was determined the facility failed to maintain an effective infection control program to ensure the investigation, control and prevention of the development and transmission of infectious diseases. The facility did not have an effective monthly surveillance of active infections and had no effective mechanism in place to identify or track residents who were colonized with multiple drug resistant organisms (MDRO). There was no evidence education had been provided to staff regarding the precautions needed for residents with extended-spectrum beta-lactamase ( ESBL) infections. Additionally, staff did not employ effective hand washing techniques during medication pass and resident care. One (1) nurse exited an isolation room without washing her hands. This had the potential to affect all residents residing in the facility. Facility census: 130. Findings include: a) Monthly surveillance Review of the monthly surveillance documentation for September, October, and November 2013, found a room list using a color coding system to track the infection. This system did not list resident's names, date of admission, the onset date of infection, the site of the infection, the name of organism (if known), whether the infection was facility or community acquired, and the date the infection was resolved. Review of December 2013 monthly surveillance form found it had been updated to include all the information needed to accurately track infections. However, it was noted not all residents with active infections were added to the surveillance form to enable tracking and effective analysis for trends, patterns, and/or clusters of specific infections. For example, Residents #162 and #155 were noted to have Clostridium difficile (C. diff) on 11/28/13 and 11/29/13 respectively. These residen… | 2017-09-01 |
| 7010 | 7010 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 490 | F | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable well-being for more than a limited number of residents. In the care area of quality of care, the facility failed to ensure the resident environment was free from accident hazards over which the facility had control. Twenty-one (21) residents were observed with loose side rails which posed a potential for injury and possible entrapment. These included Residents #7, #63, #81, #20, #52, #27, #91, #16, #45, #88, #25, #128, #58, #167, #163, #82, #79, #106, #13, #44, and #11. Facility census: 130. Findings include: a) Observation, resident interview, staff interview, review of the facility's policy for Bed Safety Assessment Guidelines, and review of the 03/10/06, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued by the United States Department of Health and Human Services, Food and Drug Administration Center for Devices and Radiological Health, revealed the facility failed to ensure the resident environment, over which the facility had control, remained as free of accident hazards as possible. With the slight touch of a hand, half side rails on the bed of Resident 63 was able to be tilted inward and outward, forward and backwards on 12/01/13 at 5:25 p.m. The same side rail problem was identified on Resident #37's bed on 12/02/13 at 4:28 p.m. When moved outward, the gap between the mattress and the side rails measured four (4) inches on Resident #37's bed and three (3) inches on Resident #63's bed, resulting in a potential for entrapment. On 12/02/13 at 5:30 p.m., side rails on an additional nineteen (19) residents' beds were observed and found loose, allowing a slight touch of the hand to rock the rails forward and backwards and inward and outward. These included Residents #81, #20, #52, #27… | 2017-09-01 |
| 7011 | 7011 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 514 | D | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medical record accurately reflected the services provided to the resident. Records were incomplete or inaccurate regarding the medication being administered, orders that were discontinued and remained on active order recapitulation, neurocheck forms not being thoroughly completed, and the times medications were administered was inaccurately recorded. This practice was found for four (4) of forty nine (49) sampled stage II residents. Resident identifiers: #36, #13, #27, #80. Facility Census: 130 Findings include: a) Resident #36 During a medication administration observation on 12/10/13 at 9:50 a.m., Employee #23 was observed administering medications to Resident #36. Forty five (45) milliliters (ml) of the medication [MEDICATION NAME] was observed to be prepared and administered to this resident at that time. The label on the bottle of [MEDICATION NAME] liquid was observed and stated 13.5 (gm) per 15 ml give 45 ml. The Medication Administration Record [REDACTED]. This was also verified in the physician's orders [REDACTED]. (This would total 40,500 mg (milligrams) if forty -five (45) milliliters were administered at this strength) The nurse was questioned about this order 12/10/13 at 10:30 a.m. She stated that is not written right we will have to get that clarified. A request was made at that time for the original order that was written on 05/23/13. The unit manager , Employee # 77 (registered nurse) was questioned about this order on 05/23/13. It was verified this was a transcription error. The original order written on 05/23/13 at 3:00 p.m. stated [MEDICATION NAME] forty- five (45) milliliters by mouth (po) qd (every day) for constipation. She verified this was just written incorrectly when it was put in the computer. It was verified this had been incorrect on each monthly order sheet and Medication Administration Record [REDACTED]. _________ b) Resident # 80 Durin… | 2017-09-01 |
| 7012 | 7012 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 520 | F | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interview and policy review, the facility's quality assurance program failed to act upon quality deficiencies during the daily operation of the facility in which it did have or should have had knowledge. Systemic problems were identified related to accident hazards related to side rails on twenty-one (21) residents' beds. The facility was not tracking the location or date of the [DIAGNOSES REDACTED]. In addition, the facility failed to ensure effective maintenance services, the accuracy and completion of the comprehensive minimum data sets, and the updating of care plans. Resident furniture, as required by State Law, was not available in the Alzheimer's unit. These practices had the potential to affect more than an isolated number of residents. Facility census: 130. Findings include: a) Observation, resident interview, staff interview, review of the facility's policy for Bed Safety Assessment Guidelines, and review of the 03/10/06, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued by the United States Department of Health and Human Services, Food and Drug Administration Center for Devices and Radiological Health, revealed the facility failed to ensure the resident environment, over which the facility had control, remained as free of accident hazards as possible. With the slight touch of a hand, half side rails on the bed of Resident 63 was able to be tilted inward and outward, forward and backwards on 12/01/13 at 5:25 p.m. The same side rail problem was identified on Resident #37's bed on 12/02/13 at 4:28 p.m. When moved outward, the gap between the mattress and the side rails measured four (4) inches on Resident #37's bed and three (3) inches on Resident #63's bed, resulting in a potential for entrapment. On 12/02/13 at 5:30 p.m., side rails on an additional nineteen (19) residents' beds were observed and found loose, allowing a slight touch of the hand to … | 2017-09-01 |
| 7013 | 7013 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-08-29 | 152 | D | 0 | 1 | 30TC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident was evaluated for capacity to make medical decisions, according to the law. The medical record contained two (2) conflicting statements regarding the resident's capacity to make health care decisions. Both statements were completed by the same physician. This was true for one (1) of twenty (20) residents reviewed during Stage 2 of the quality indicator survey. Resident identifier: #177. Facility census: 73. Findings include: a) Resident #177 Medical record review found the resident was admitted to the facility on [DATE]. Further review of the medical record, on 08/26/13, found two (2) conflicting statements of determination of capacity for health care decision-making in the resident's medical record. The first determination of capacity was completed by the facility physician on 07/07/13. It indicated the resident did not have capacity to make medical decisions based on cognitive loss and an inability to understand or make medical decisions. The expected duration of incapacity (long term or short term) was not completed by the physician. A second determination of capacity, dated only July 2013, indicated the resident had capacity to make medical decisions. This was completed by the same physician. The physician did not document the exact day this capacity determination was completed. The director of nursing (DON), Employee #23, was interviewed on 08/26/13 at 2:00 p.m. After she reviewed the conflicting statements for determination of capacity she verified she did not know if the resident had capacity or did not have capacity to make medical decisions. The DON reviewed the physician's progress notes in an attempt to determine when the undated determination of capacity form was completed. She presented a copy of the physician's progress note, dated 07/04/13, which contained the following information: His daughter was in today . She would also like to have him de… | 2017-09-01 |
| 7014 | 7014 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-08-29 | 242 | D | 0 | 1 | 30TC11 | Based on observation, resident interview, record review, and staff interview, the facility failed to allow one (1) of three (3) residents who triggered the care area of nutrition and (1) 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. The facility failed to honor Resident #54's food preferences. For Resident #7, the facility failed to honor the resident's preference for daily showers. Resident identifiers: #54 and #7. Facility census: 73. Findings include: a) Resident #54 Resident #54 was interviewed during Stage 1 of the quality indicator survey on 08/20/13 at 8:31 a.m. When asked Does the food taste good and look appetizing?, the resident replied, My card says I dislike milk and cereal and today I have milk and cereal on my tray. The resident provided her tray card dated 08/20/13. It listed her dislikes as fish, cereal, and milk. Employee #67, the registered nurse practice educator, was asked to observe the resident's tray and tray card on 08/20/13 at 8:31 a.m. Employee #67 agreed the resident should not have been served milk and cereal. On 08/22/13 at 8:45 a.m. the registered dietitian (RD), Employee #101, was informed of the observations made by the surveyor and Employee #67. The RD stated, I didn't see the tray but I will tell the dietary manager. The administrator and the director of nursing were made aware of the above findings on 08/28/13 at 2:30 p.m. No further information was provided. b) Resident #7 An interview was completed with Resident #7 on 08/20/13 at 1:59 p.m., during Stage I of the Quality Indicator Survey When asked how many showers a week she received, she replied that she received two (2) showers a week. The resident said said she had told nursing assistants she would like to shower every day, but they told her they cannot shower her daily because they are too busy. An interview was conducted with the Administrator and the Director of Nursing on 08/22/13 at 12:00 p.m. They… | 2017-09-01 |
| 7015 | 7015 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-08-29 | 279 | D | 0 | 1 | 30TC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility's interdisciplinary team failed to develop a comprehensive care plan with measurable goals and/or goals which were developed to meet residents' identified needs for two (2) of twenty (20) residents reviewed in Stage 2 of the survey. The care plan for Resident #43 did not reflected the actual reason the resident had a Foley catheter. The care plan indicated the catheter was because the resident had a pressure sore, but did not identify the resident had [MEDICAL CONDITION]. Resident #124's care plan related to behavioral and emotional status, indicated the resident refused care; however, it did not specify what care the resident refused. For this reason, the resident's goal for this problem was not measurable. Resident identifier: #43 and #124. Facility census: 73. Findings include:a) Resident #43 Review of the resident's care plan, on 08/28/13 at 1:20 p.m., revealed a problem of I have a Foley catheter in place due to my coccyx wound and for my comfort. This places me at risk for uti (urinary tract infection). Review of Resident #43's medical record, on 08/28/13 at 1:30 p.m., revealed a physician order [REDACTED]. An interview was conducted on 08/28/13 at 1:50 p.m. with Employee #70, the clinical reimbursement coordinator (CRC). When asked if the care plan was correct regarding the use of the Foley catheter due to a pressure ulcer, the CRC stated the resident had the Foley catheter for [MEDICAL CONDITION]. When asked why the care plan stated the reason for the Foley catheter was due to the pressure ulcer, the CRC stated the care plan was inaccurate, as the Foley catheter use was related to a [DIAGNOSES REDACTED]. b) Resident #124 Review of the resident's minimum data set (MDS) found an admission assessment with an assessment reference date (ARD) of 02/18/13. Section E, item E0800, contained documentation the resident rejected care one (1) to three (3) days during … | 2017-09-01 |
| 7016 | 7016 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-08-29 | 280 | D | 0 | 1 | 30TC11 | Based on medical record review, grievance and complaint log review, and staff interview, the facility failed to revise a care plan related to hydration for one (1) of two (2) residents reviewed for hydration out of twenty (20) Stage 2 sampled residents. Resident identifier: #7. Facility census: 73. Findings include: a) Resident #7 An interview was conducted with Resident #7 on 08/20/13 at 3:47 p.m., during Stage 1 of the Quality Indicator Survey. During this interview, Resident #7 said she had a hard time getting ice water. She said staff brought white Styrofoam cups of ice water with straws protruding from the lids. She said there was no set routine for dispensing ice water. The resident said she primarily received ice water because she asked for it. A grievance and complaint form, dated 08/02/13, was reviewed on 08/22/13 at 12:15 p.m. In this grievance report, Resident #7 complained she did not have fresh water at her bedside to drink. This grievance allegedly was resolved by the facility with the plan to give her fresh water each shift, and as needed, upon the resident's request. Staff were directed to please check each time you enter her room. Staff education on this topic was completed on 08/09/13. Eight (8) registered nurses, seven (7) licensed practical nurses, and seventeen (17) nursing assistants signed their names, indicating they attended the in-service education on this and other topics. Observation on 08/26/13 at 12:30 p.m., found Resident #7 had a Styrofoam cup of water on her over-the-bed tray that was dated 8/26/13. There was no ice in the cup. On 08/26/13 at 5:00 p.m., observation found a white Styrofoam cup on her over-the-bed tray, that was dated 8/26/13. It contained lukewarm water, and there was no ice in the cup. The resident was not in her room at that time. Observation on 08/27/13 at 1:30 p.m., found a white Styrofoam cup on her over-the-bed tray, that contained water, but no ice. Her flavored drink cup had no ice in it, and was nearly empty. The resident was out of her room at activities … | 2017-09-01 |
| 7017 | 7017 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-08-29 | 282 | E | 0 | 1 | 30TC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and policy review, the facility failed to ensure implementation of established care plans for five (5) of twenty (20) residents whose care plans were reviewed during Stage 2 of the quality indicator survey. The residents' care plans identified specific approaches direct care staff were to employ to address each identified problem. The care plans which were not consistently implemented included the care plan for falls for Resident #19. In addition, the care plans for restorative therapy services for Residents #161, #177, #95, and #22 were not consistently provided. Resident identifiers: #19, #161, #177, #95, and #22. Facility census: 73. Findings include: a) Resident #19 Review of the medical record found the resident fell from her bed on 08/15/13. On that date, the facility added two (2) new approaches to her existing care plan addressing falls. These included the use of fall mats by the bed and for the bed to be in the low position when staff were not working with the resident. On 08/21/13 at 2:20 p.m. the resident was observed sleeping in bed. The bed was not in the low position. During the observation, a nursing assistant (NA), Employee #73, entered the resident's room with a beverage. The NA offered the resident a drink. Before leaving the room, the NA lowered the resident's bed. The NA was asked if the resident's bed had been in a low position when she entered the room. The nursing assistant stated the resident was not her regular assignment for the day, but when she saw fall mats in place, she knew to lower the bed before leaving the room. She verified the bed was not in a low position when she entered the room. On 08/27/13 at 3:00 p.m., the director of nursing (DON) and the administrator (NHA) were made aware of the observation. On 08/28/13 at 9:30 a.m., the administrator stated she had spoken with the NA. The administrator stated sometimes it was not possible to keep the bed low, especially if … | 2017-09-01 |
| 7018 | 7018 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-08-29 | 309 | D | 0 | 1 | 30TC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide care and services to ensure the highest practicable well-being for two (2) of five (5) residents reviewed for medications during Stage 2 of the survey. Vital signs were not obtained as ordered by the physician for Resident #13. [MEDICATION NAME] was not re-started after it was held during antibiotic therapy for Resident #19. Resident identifiers: #13 and #19. Facility census: 73. Findings Include: a) Resident #13 review of the resident's medical record revealed [REDACTED]. A physician's orders [REDACTED]. This order did not change during the remainder of the resident's stay. The resident was discharged on [DATE]. On 08/28/13 at 9:30 a.m., review of the medical record revealed the facility failed to obtain vital signs every shift on the following dates: night shift on 04/29/13, day and evening shift on 05/05/13, night shift on 05/07/13, day shift on 05/08/13, day and evening shift on 05/09/13, day shift on 05/13/13, day shift on 05/14/13, night shift on 05/15/13, day shift on 05/17/13 and day and evening shift on 05/18/13. On 08/28/13 at 11:00 a.m., registered nurse, Employee #70 stated she could not find evidence vitals sign were obtained on these days and shifts listed above. Employee #70 also stated the resident was not out of the facility on those dates. b) Resident #19 Review of the resident's medical record found the resident was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. On 07/31/13, the physician increased the [MEDICATION NAME] to 1.5 mg daily after review of the resident's lab work. The physician prescribed an antibiotic, [MEDICATION NAME], for five (5) days for chest congestion on 08/01/13. On that date, the physician also ordered the resident's [MEDICATION NAME] to be held while receiving the antibiotic. Observation of the Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. On 08/21/13 at 1:00 p.m., th… | 2017-09-01 |
| 7019 | 7019 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-08-29 | 311 | E | 0 | 1 | 30TC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to provide treatment and services to maintain or improve functional abilities for four (4) of four (4) residents reviewed for restorative services during Stage 2 of the survey. These residents were not consistently provided restorative services to assist the residents in maintaining or attaining their highest levels of functioning. Resident identifiers: #95, #161, #177, and #22. Facility census: 73.a) Resident #95 Review of the physician's orders [REDACTED].#95 had a restorative order dated 11/10/12 for ambulation six (6) times a week, and to use the Omnicycle six (6) times a week. Review of the restorative nursing record on 08/27/13 at 9:45 a.m., revealed Resident #95's restorative ambulation and use of the Omnicycle did not occur six (6) times a week. This resident had 143 missed opportunities to receive restorative therapy from 11/11/12 to 08/24/13. On 08/27/13 at 10:00 a.m., an interview was conducted with Employee #7, a registered nurse (RN). Upon inquiry regarding who evaluated residents in the restorative program, she stated she was the person responsible for the restorative nursing program. Employee #7 said she reviewed the restorative nursing records at the end of the month for each resident on the program. At that time she made the determination of whether the therapy was effective. Employee #7 said if the therapy program was not effective for a resident, she held a meeting with the physical therapy program to determine what changes were needed. Resident #95's restorative nursing record was reviewed with Employee #7. She confirmed the resident was not provided restorative therapy as ordered. When asked why, she said, A nursing assistant may call in and then the restorative person is pulled to go to provide direct care because direct care is more important. She added, The restorative therapy is missed for these days. b) Resident #161 On 07/08/13, a physic… | 2017-09-01 |
| 7020 | 7020 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-08-29 | 318 | D | 0 | 1 | 30TC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for range of motion (the extent of movement of a joint) was provided services, to assist in maintaining the highest level of functioning. The resident, who had multiple sites of contractures, was ordered Restorative Nursing Services for range of motion (ROM) to the left upper extremity and to the bilateral lower extremities six (6) times per week. The resident received less than half of the amount ordered over a 21 (twenty-one) week period. This had the potential to negatively affect the resident's ability to maintain or improve her current level of functioning. Resident identifier: #22. Facility census: 73. Findings include: a) Resident #22 Review of the medical record found [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/10/13 was reviewed. The resident was coded for contractures of the left hand, left wrist, left elbow, left shoulder, and the left ankle. The right side was the resident's dominant side. physician's orders [REDACTED]. The physician ordered a restorative nursing program for ROM to the right lower extremity six (6) times weekly. He ordered a restorative nursing program for gentle passive ROM of the left hand, wrist, and elbow six (6) times weekly. In addition, the physician ordered a restorative nursing program for passive ROM to the left lower extremity six (6) times weekly. Review of the care plan, on 08/28/13 at 1:00 p.m., found an area of focus for the resident to participate in the Restorative Nursing Program to sustain her current functional status. Interventions included gentle passive range of motion (PROM) to the left hand/wrist/elbow as tolerated by the resident, six (6) times per week to decrease the further risk of contractures. The care plan also directed she would participate in passive range of motion (PROM) six (6) times weekly for b… | 2017-09-01 |
| 7021 | 7021 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-08-29 | 323 | D | 0 | 1 | 30TC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure interventions implemented to prevent falls were in place. A resident had experienced a recent fall from her bed. After the fall, the facility added an intervention to place the bed in a low position. Observation found the bed was not in the low position as directed by the care plan. This was true for one (1) of three (3) residents reviewed for the care area of accidents during Stage 2 of the survey. Resident identifier: #19. Facility census: 73. Findings include: a) Resident #19 Review of the medical record found the resident was admitted to the facility on [DATE]. On 08/15/13 the resident experienced her first fall. She fell out of her bed. After the fall on 08/15/13, the facility added two (2) new approaches to her existing care plan which addressed a potential for falls. These included fall mats and for the bed to be in the low position when staff were not working with the resident. On 08/21/13 at 2:20 p.m. the resident had been observed for approximately (10) minutes when a nursing assistant (NA) entered the resident's room. The NA, Employee #73, offered the resident a glass of juice. Before leaving the room, the NA lowered the resident's bed. The NA was asked if the resident's bed was in a low position when she entered the room. The NA stated the resident was not her regular assignment for the day, but when she saw fall mats in place, she knew to lower the bed before leaving the room. She agreed the bed was not in a low position when she entered the room. On 08/27/13 at 3:00 p.m., the director of nursing and the administrator were made aware of the observation. On 08/28/13 at 9:30 a.m., the administrator stated she had spoken with the NA and sometimes it was not possible to keep the bed low, especially if a resident had a catheter. She agreed this resident did not have a catheter in place. | 2017-09-01 |
| 7022 | 7022 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-08-29 | 329 | D | 0 | 1 | 30TC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of five (5) residents reviewed for the care area of unnecessary medications was free from unnecessary medications. There was no evidence the facility attempted to implement non-pharmacological interventions or explore any underlying causes of distressed behavior before prescribing a psychopharmacological medication for a resident who was a new admission to the facility. Resident identifier: #177. Facility census: 73. Findings include: a) Resident #177 Review of the medical record found the resident was admitted to the facility on [DATE]. The resident had been living at home with family prior to his admission. admitting [DIAGNOSES REDACTED]. A physician's progress note, dated 07/01/13, found the resident stated to the physician, I have pain all over. The physician's note included, He described the pain all over an aching pain that has gone on for several years now. It is constant and is relieved with Tylenol. On 07/01/13 the physician prescribed Tylenol 500 mg every 12 hours for pain. On 07/02/13, a physician progress notes [REDACTED]. follow-up visit for behavior problems-yelling out all night, continually trying to get out of bed, also noted to have cyanosis L (left) foot. The physician prescribed the psychopharmacological medication, [MEDICATION NAME] 50 mg at bedtime. Review of the Medication Administration Record [REDACTED]. Review of the medical record revealed no evidence the facility made an attempt to determine causal factors and/or attempted to address the resident's behaviors through non-pharmacological interventions prior to using a psychopharmacological medication. A nurse's note, dated 07/02/13 at 9:27 p.m., found, Resident exhibited behaviors this shift. Unsteady on feet. Unable to obtain VS (vital signs) due to combative behavior. Was yelling out and combative during care. Attempted to call 911. Refused medications. Note left for MD (doctor). On 0… | 2017-09-01 |
| 7023 | 7023 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-08-29 | 428 | D | 0 | 1 | 30TC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a thorough review to identify medication irregularities and/or action regarding identified medication irregularities for two (2) of five (5) residents reviewed for unnecessary medications during Stage 2 of the survey. A recommendation from the pharmacist regarding duplicate therapy was not acted upon for Resident #23. In addition, the pharmacist did not identify a medication irregularity for Resident #34 who had an allergy to aspirin noted, but was receiving low dose aspirin. Resident identifiers: #23 and #34. Facility census: 73. Findings Include: a) Resident #23 A monthly pharmacist review, dated 06/21/13, revealed Resident #23 had orders for duplicate therapy for hyperphosphatemia which included 1000 mg Fosrenol with meals and Renvela 1600 mg twice daily and with meals. The pharmacist recommended the physician re-evaluate the use of both mediations, perhaps discontinuing one of the therapies. On 07/17/13, the physician responded with, Speak with nephrology. Further review of the records revealed no evidence the facility followed through with this directive from the physician. At 10:00 a.m. on 08/22/13, the director of nursing (DON), stated there was no evidence in the nursing notes the physician's directive regarding the pharmacist's recommendation was implemented. b) Resident #34 The nursing assessment for this resident, under Section 8 Comments, noted the resident was allergic to Aspirin (ASA). The physician's initial History and Physical also noted an allergy to Aspirin. Review of the resident's physician's orders [REDACTED]. The Medication Administration Records (MARs), dated 06/26/13 through 08/22/13, indicated she received Aspirin 81 mg. tablets daily. On 08/22/13 at 8:15 a.m. an interview was completed with a licensed nurse, Employee #47. She said this resident took ASA 81 mg daily. When asked, she said it was not enteric coated. When asked if this resident ha… | 2017-09-01 |
| 7024 | 7024 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-08-29 | 431 | E | 0 | 1 | 30TC11 | Based on observation and staff interview, the facility failed to ensure medications were stored properly for four (4) current residents, two (2) discharged residents, and an unidentified resident. Also a vial of Purified Protein Derivative (PPD) used for tuberculin skin testing for residents and employees, was improperly stored. Resident identifiers: #131, #55, #25, and #59. Facility census: 73. Findings include: a) Medication Cart #1 Observation of medications on Cart #1 on 08/21/13 at 9:00 a.m., found a nearly full vial of Humalog insulin for Resident #131. It was dated as opened on 06/21/13. This vial was open for greater than twenty-eight (28) days. A nearly empty bottle of Lantus insulin for Resident #55 contained no date regarding when it was opened. Also, a nearly full vial of Novalog insulin for Resident #55 contained no date regarding when it was opened. A vial of Levemir insulin for Resident #25 was half full, and was dated as opened on 06/02/13. The vial was open greater than forty-two (42) days. A vial of Lantus Insulin for Resident #59 was nearly empty, and was marked as having been opened on 07/16/13. A vial of Novalog Insulin for Resident #59 was half full, and marked as opened on 09/09/12. These vials were opened greater than twenty-eight (28) days. A vial of Humalog insulin, for a discharged resident, was one-quarter (1/4) full. It had no date indicating when it was opened. There was a vial of Lantus insulin for another discharged resident which was also open, with no date indicating when it was initially opened. The cart contained a vial of Novolog insulin, dated as opened on 07/16/13. It had no box or name indicating to whom it might belong. An interview was completed with the Director of Nursing (DON) on 08/21/13 at 9:30 a.m. She said all of the above medications should have been, and would be, discarded. She produced a copy of Insulin Storage Recommendations from the provider pharmacy. According to the pharmacy protocols, Humalog, Lantus, and Novolog insulins were to be discarded twenty-eight… | 2017-09-01 |
| 7025 | 7025 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-08-29 | 441 | E | 0 | 1 | 30TC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy and procedure review, record review, and staff interview, the facility failed to maintain an infection control program to help prevent the development and transmission of disease and infection. The facility failed to provide isolation signage for Resident #192 to alert staff and visitors of the need for isolation precautions. Also, the facility failed to prevent the spread of microorganisms and pathogens by allowing nurses to sit directly on the floor while counting medications. These practices had the potential to affect more than an isolated number of residents. Resident identifier: #192. Facility census: 73. Findings include: a) Resident #192 Numerous random observations, throughout the day on 08/26/13 and 08/27/13, revealed an isolation cart was present outside Resident #192's room. There was no visible signage to designate this resident was in isolation. An interview was conducted with Employee #47, a Licensed Practical Nurse (LPN), on 08/27/13 at 11:15 a.m. She commented Resident #192 was in isolation for Methicillin Resistant Staphylococcus aureus (MRSA) and [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) in his urine. At 1:20 p.m., on 08/27/13, an interview was conducted with Employee #67, the Infection Control Nurse (ICN) and Nurse Educator (NE). During the interview, she commented the resident was in isolation for VRE and MRSA. She also commented a sign was posted on the door to his room with an isolation cart present outside of his room. Upon informing Employee #67 that during observations the past two (2) days there was no signage posted, she stated there should be. She observed the room and confirmed there was no signage. At that time, she posted an isolation sign on Resident #192's door that stated Please see nurse before entering. A medical record review was conducted on 08/28/13 at 10:35 a.m. for Resident #192. It indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES RED… | 2017-09-01 |
| 7026 | 7026 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-08-29 | 514 | B | 0 | 1 | 30TC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the accuracy of clinical records for one (1) of twenty (20) residents reviewed in Stage 2 of the survey. A physician's response to a pharmacy recommendation was not transcribed to the medical record. Resident identifier: #99. Facility census: 73 Findings include: a) Resident #99 On 08/21/13 at 9:00 a.m., a medical record review was conducted for Resident #99. Review of the Pharmacy consultation report, dated 04/04/13, revealed a recommendation to clarify order to read [MEDICATION NAME] for depression. The attending Physician documented and signed the record on 04/10/13 writing, ok to be for depression. A review of the Medication Administration Records (MAR), dated June, July and August 2013, revealed the MAR indicated [REDACTED]. Employee #13, the Administrator (NHA), provided the requested copies of the attending physician's orders [REDACTED].#99's [DIAGNOSES REDACTED]. Also, the MARs for April and May 2013 had the [DIAGNOSES REDACTED]. At 11:20 a.m. on 08/21/13, an interview was conducted with the NHA. She confirmed an order for [REDACTED]. On 08/21/13 at 11:40 a.m., an interview was conducted with Employee #23, the Director of Nursing (DON). She stated the procedure the facility was supposed to follow regarding pharmacy recommendations was to give the recommendation to the doctor on his visit to the facility. After his signature was obtained, it was to be signed by the DON or the nurse on duty. A physician's orders [REDACTED]. The pharmacy recommendation sheet was then to be placed in the medical record for the pharmacist to review on the next monthly visit. Employee #23 stated, There is not a written policy or procedure regarding this, it was like this when I came here and it has continued. | 2017-09-01 |
| 7027 | 7027 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 156 | B | 0 | 1 | 66WU11 | Based on record review, policy review, and staff interview the facility failed to ensure the information communicated to the residents when there was a change in their skilled status was complete. The liability notices did not identify the services being discontinued and/or the reason for the action for three (3) of six (6) sampled residents who had medicare covered services discontinued. Resident identifiers: #87, #78, and #112. Facility census 68. Findings include: a) Residents # 87, 78, and 112 A review of the Notice of Medicare Provider Non-Coverage document which was provided to the residents and/or their responsible parties revealed the following verbiage: The Effective Date Coverage of Your Current: SKILLED NURSING Services Will End (date). The document did not, in a language the resident can understand, identify all skilled services that were being received by the residents which were being discontinued. The document also did not explain why the service was being discontinued. A review of the medical records of Residents #87, #56, and #86 revealed that they were also receiving Skilled Therapy services. The residents were being asked to make an appeal decision without this information. During an interview with Employee #97 (Physical Therapy Aid) at 8:30 a.m. on 08/07/13, she confirmed Residents #87, #56, and #86 were receiving Physical Therapy services which were discontinued on the date stated in the Medicare Non-Coverage notice. After reviewing the liability notices with the Administrator at 8:45 a.m. on 08/13/13, he acknowledged the notices did not contain what services were being discontinued or why they were being discontinued. During an interview with the Social Worker (Employee #68) at 1:45 p.m. on 08/13/13, she stated she knew the resident or his responsible party should be informed of all services and the reason for discontinuing them. She stated she was not the person who filled out the notices, although she did sign them indicating she issued the notice to Resident #112. | 2017-09-01 |
| 7028 | 7028 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 203 | E | 0 | 1 | 66WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to provide a written notice to six (6) of six (6) sampled residents upon discharge and/or transfer from the facility. The facility did not provide a notice which included the right to appeal the discharge the contact information for the appropriate agency and/or person. Resident identifiers: #25, #4, #78, #69, #28, and #34. Facility census 68. Findings include: a) a) Residents #25, #4, #78, #69, #28, and #34 At 10:00 a.m. on 08/07/13, the Administrator presented a requested copy of the information given to residents upon transfer or discharge from the facility. It did not include written information about bed hold and/or appeal rights. After a second request, the Administrator provided a copy of a Notification of Transfer / Discharge letter, which he stated was used by the facility. The letter did not include the name, phone number, or address of the Ombudsman and the address of the Office of Licensure and Certification (OHFLAC) was incorrect. When this was pointed out to the Administrator, he said to ask the Social Worker (SW), Employee # 68, for an explanation of the use of the notification. When interviewed at 10:20 a.m. on 08/07/13, the SW stated she was not responsible for the notice. She suggested speaking with Employee #79, the Admissions Coordinator. The SW stated she had been in her position for a year. At 10:40 a.m. on 08/07/13, Employee #79 stated she did not supply written information to residents being transferred or discharged . She said she had been in her present position for four (4) years. Review of the records of these six (6) recently transferred or discharged residents revealed no evidence they were provided the required written Notification of Transfer/Discharge information. During an interview with the Director of Nurses, Social Worker, Administrator, and the Corporate Consultant (Employee #93) at 11:50 a.m. on 08/07/13, they were informed n… | 2017-09-01 |
| 7029 | 7029 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 205 | E | 0 | 1 | 66WU11 | Based on record review, policy review, and staff interview, the facility failed to provide written information regarding the facility's bed-hold policy for six (6) of six (6) sampled residents, at the time of their transfer from the facility. Resident identifiers: #25, #4, #78, #69, #28, and #34. Facility census 68. Findings include: a) Residents #25, #4, #78, #69, #28, and #34 At 10:00 a.m. on 08/07/13, the Administrator presented a requested copy of the information given to residents upon transfer or discharge from the facility. It did not include written information about bed hold and/or appeal rights. After a second request, the Administrator provided a copy of a Notification of Transfer / Discharge letter, which he stated was used by the facility which included the facility's Bed-hold policy. Review of the records of these six (6) recently transferred or discharged residents revealed no evidence they were provided written information specifying the duration of the facility's bed-hold policy. When this was pointed out to the Administrator, he asked this question be directed to the Social Worker (SW), Employee # 68, for an explanation of the use of the notification. When interviewed at 10:20 a.m. on 08/07/13, Employee #68 stated she had been in her position for a year and was not responsible for the bed hold notice. She referred the question to Employee #79, the Admissions Coordinator. At 10:40 a.m. on 08/07/13, Employee #79 stated she did not supply written information to residents when they were transferred or discharged . She stated she had been in her present position for four (4) years. Employee #79 stated she phoned the responsible party as soon as possible after the transfer. She said she gave them the status of the bed-hold days available at that time. Employee #79 said she was unsure how long this practice had been followed. Employee #79 presented phone records which indicated she had contacted family members and discussed, among other things, bed-hold information. In a follow-up interview at 10:45 a.… | 2017-09-01 |
| 7030 | 7030 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 225 | D | 0 | 1 | 66WU11 | Based on review of personnel records and staff interview, the facility failed to ensure reasonable efforts were made to verify there were no past criminal prosecutions of a potential employee by not including a West Virginia (WV) statewide investigation for one (1) of ten (10) sampled employees prior to hire. Employee identifier: #67. Facility census 68. Findings include: a) A review of the personnel records at 02:00 p.m. on 08/07/13, accompanied by the Corporate Human Resource Consultant (Employee #94) revealed no evidence of a WV statewide criminal background check for Employee #67, a nursing assistant. Employee #67 had been working full-time since 04/02/13. During a follow-up interview with Employee #64 (Bookkeeper) at 9:00 a.m. on 08/13/13, she confirmed a WV statewide background check was not completed on Employee #67. | 2017-09-01 |
| 7031 | 7031 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 248 | D | 0 | 1 | 66WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the activity log, the facility failed to provide an activity that was important to the resident according to his comprehensive care plan. There was no evidence the facility ensured the resident went outside as identified as important to the resident. This affected one (1) of three (3) residents reviewed in Stage 2 of the Quality Indicator Survey sample of twenty (20) residents. Resident identifier: #35 Facility census: 68 Findings include: a) Resident #35 Medical record review revealed this [AGE] year old resident and former jockey, was enrolled in a hospice program on 01/28/13. His terminal [DIAGNOSES REDACTED]. Multiple observations on 08/05/13 and 08/06/13, found him lying in bed in his room. He made eye contact when he was awake, and sometimes extended his left hand and arm toward the speaker. He was not verbally communicative. A review of the care plan was conducted on 08/07/13 at 8:30 a.m. According to the resident's care plan, the resident Stated it is important to go outside and get fresh air. An interview was completed with the activity director on 08/07/13 at 9:03 a.m. She reviewed the resident's activity participation log from 04/14/13 through the 08/07/13. She said he had no outdoor activities throughout the summer or this quarter provided by activity staff. The activity director said hospice did musical therapy with him with the guitar, but they (hospice) also had not taken the resident outside this summer for any activities. An interview was conducted with the Director of Nursing on 08/13/13 at 4:00 p.m. No further information was provided prior to exit on 08/14/13. | 2017-09-01 |
| 7032 | 7032 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 253 | E | 0 | 1 | 66WU11 | Based on resident interview, water temperature measurement, and staff interview, the facility failed to ensure effective maintenance services. The hot water temperatures in the main shower room, Room A-9, and B-32 were too cool for comfort during showers. This affected two (2) of 58 residents. It had the potential to affect more than an isolated number of residents, as the main shower room had hot water temperatures which were too cool for comfort during showers. Resident identifiers: #113 and #72. Facility census: 58 Findings include: a) Residents #113 and #72 Each of these residents stated, during their interviews in Stage I of the survey, the water temperatures in the showers was not high enough for comfort early in the mornings. Both said they had reported this, but it continued to be too cool. At 7:05 a.m. on 08/08/13, accompanied by Employee #86 (maintenance director) the water temperatures were measured at various sites throughout the facility. The temperature in the main shower room was 85.8 degrees Fahrenheit (F) after allowing is to run. Employee #86 expressed his surprise that the temperature was that low. He stated the temperature should be between 105 - 110 degrees F. He stated the temperatures were monitored daily, but the monitoring was usually in the afternoon. During the same time period, the temperature of the water in resident room B-32 was 84 degrees F. In resident room A-9, the hot water was 99 degrees F. Employee #86 explained Room B-32 was the farthest from the hot water heater. He added he had received a complaint about a month ago and had adjusted the thermostat. A recheck of the temperatures with Employee #86, on 08/08/13 at 10:13 a.m., revealed the hot water was still too cool for comfort during showers. It was only 101.2 degrees F. | 2017-09-01 |
| 7033 | 7033 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 272 | D | 0 | 1 | 66WU11 | Based on medical record review, resident interview, and staff interview, the minimum data set (MDS) assessments for two (2) of twenty (20) Stage 2 residents was not accurate. Bladder function on the admission MDS for Resident #89 was not accurate. In addition, the activities of daily living (ADL) section for dressing for Resident #17 was not accurate. Resident identifiers: #89 and #17 Facility census 68 Findings include: a) Resident #89. Review of the MDS assessment, on 08/12/13 at 11:26 a.m., revealed Resident #89 had an admission MDS with an assessment reference date (ARD) of 04/25/13. Under section H0300, urinary incontinence, this resident was coded as one (1), indicating she was occasionally incontinent of bladder. On 08/12/13 at 11:37 a.m., review of the ADL flow record revealed the resident had seven (7) episodes of incontinence from 04/19/13 through 04/25/13. The ARD was 04/25/13. On the MDS section H0300 urinary incontinence, when a resident has seven (7) or more episodes of bladder incontinence, a resident is coded as two (2), indicating frequent incontinence. An interview was conducted with Employee #83, registered nurse/clinical reimbursement coordinator (RN/CRC), on 08/12/13 at 1:44 p.m. When reviewing the ADL flow record for April 2013, Employee #83 pointed out, according to the ARD of 04/25/13 and counting back seven (7) days, this resident had seven (7) episodes of urinary incontinence. Employee #83 confirmed she had coded the MDS incorrectly. She confirmed the resident should have been coded a two (2) under section H0300, indicating Resident #89 was frequently incontinent. Employee #83 stated a correction request would have to be done. Review of the MDS, on 08/012/13 at 4:50 p.m., revealed a correction request date of 08/12/13. Section H0300 urinary incontinence, was updated to reveal Resident #89 was coded a two (2), indicating she had frequent incontinence. b) Resident #17 Resident #17 was reviewed for a decline in ADLs related to dressing. According to the MDS with an ARD of 07/17/13, Resident… | 2017-09-01 |
| 7034 | 7034 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 278 | D | 0 | 1 | 66WU11 | Based on medical record review, resident interview, and staff interview, the facility failed to ensure the minimum data set (MDS) assessment, for two (2) of twenty (20) residents reviewed in Stage 2 of the survey, accurately reflected their status. The MDSs for these residents were certified accurate by the appropriate qualified health professional; however, they were not accurate. Resident identifiers: #89 and #17. Facility census 68. Findings include: a) Resident #89 Review of the resident's minimum data set (MDS), on 08/12/13 at 11:26 a.m., revealed Resident #89 had an MDS with an assessment reference date (ARD) of 04/25/13. Under section H0300 Urinary incontinence, this resident was coded as one (1), indicating she was occasionally incontinent of bladder. On 08/12/13/at 11:37 a.m., review of the activity of daily living (ADL) flow record revealed the resident had seven (7) episodes of incontinence from 04/19/13 through 04/25/13. The ARD was 04/25/13. On the MDS section H0300 urinary incontinence, when a resident has seven (7) or more episodes of bladder incontinence, the resident is coded as two (2), indicating frequent incontinence. An interview was conducted with Employee #83, a registered nurse, on 08/12/13 at 1:44. This was the nurse who was responsible for the completion of the MDS of 04/25/13. The ADL flow record for April 2013 was reviewed with the nurse. Employee #83 pointed out, according to the flow record and counting back seven (7) days from the ARD of 04/25/13, this resident had seven (7) episodes of urinary incontinence. Employee #83 confirmed she had assessed the resident as having fewer than seven (7) episodes of incontinence, when the resident actually had seven (7) episodes of incontinence. Employee #83 confirmed the MDS was completed inaccurately. She stated a correction request would be completed due to the inaccuracy. Review of the MDS, on 08/12/13 at 4:50 p.m., revealed a correction request date of 08/12/13. Section H0300 urinary incontinence, was updated to indicate Resident #89 was a t… | 2017-09-01 |
| 7035 | 7035 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 280 | E | 0 | 1 | 66WU11 | Based on record review and staff interview, the facility failed to revise the care plan goals, and/or interventions planned to reach those goals, after a significant change for one (1) of twenty (20) Stage 2 sample residents. The resident's health status deteriorated in the performance of activities of daily living (ADLs). The facility did not revise the care plan to include new goals and interventions which accurately reflected the resident's current ADL needs. Resident identifier: #69 Facility census 68. Findings include: a) Resident #69 Review of the medical record revealed a quarterly minimum data set (MDS) assessment, completed on 05/14/13. The assessment indicated the resident required supervision only for activities of daily living (ADL), including bed mobility, transfer, eating, toileting, dressing, and locomotion. Her care plan was appropriate for her needs at that time. The resident's health status declined to the point of requiring the insertion of a gastrostomy tube for feeding on 06/04/13. The facility submitted a Significant Change MDS assessment on 06/05/13. This assessment indicated a decline from need of supervision only in the performance of ADLs to the need for extensive to total dependence in all areas of ADLs. Review of the care plan revealed the resident's goals were reviewed on 06/17/13. Although the resident's health status had clearly declined as of 06/05/13, the goals were not revised to address the declines in ADLs. These declines resulted in increased need for assistance in many areas; therefore, the goals related to self performance of ADLs were no longer appropriate for the resident. Examples included: Resident will continue to eat independently after meal set up x 90 days. The resident was receiving tube feedings after 06/04/13 and could no longer feed herself. The resident will practice good hygiene as evidence by washing hands after toileting over the next 90 days. At the time of the review, the resident required extensive assistance for toileting. Resident will continue to comple… | 2017-09-01 |
| 7036 | 7036 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 282 | D | 0 | 1 | 66WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to implement the care plan for three (3) of four (4) residents reviewed for nutrition (#35, #25, and #9). In addition, the care plan for one (1) of three (3) residents reviewed for accidents (#35) was not implemented. Resident identifiers: #35, #25, and #9 Facility census: 68. Findings include: a) Resident #35 1) Observations on 08/07/13, from 8:30 a.m. to 11:30 a.m., found Resident #35 lying in his bed. The bed was in the low position, and the half side rail was raised. A padded fall mat was positioned against the wall behind the head of the resident's bed. Review of the medical record, on 08/07/13 at 11:00 a.m., found the resident sustained [REDACTED]. On 08/07/13 at 11:00 a.m review of the care plan found this resident was at risk for falls related to impaired mobility and a history of [MEDICAL CONDITIONS] with right sided weakness/[MEDICAL CONDITION]. Interventions included the resident was to have mats on the floor at his bedside, with the bed in the low position. An observation was conducted with the Assistant Director of Nursing (ADON) on 08/07/13 at 11:30 a.m. There was no fall mat beside the bed. The ADON retrieved the fall mat, which was standing against the wail behind his bed, and placed it on the floor beside his bed. She confirmed the resident was supposed to have a fall mat beside his bed. The facility did not ensure the implementation of this resident's care plan to have mats on the floor at his bedside. 2) Review of the care plan found an area of focus, with revision date of 06/10/13, that the resident was at nutritional risk. He was to have a House supplement (frozen supplement) 3 times a day as ordered by the physician (10:00 a.m., 2:00 p.m., and 8:00 p.m.) His care plan included monitoring intake at all meals. There was a care plan goal for the resident to consume greater than 50% of meals and snacks through the next review with a target date of … | 2017-09-01 |
| 7037 | 7037 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 309 | D | 0 | 1 | 66WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide care and services to ensure two (2) of twenty (20) residents reviewed in Stage 2 of the survey maintained or attained the highest practicable well-being according to their individualized plans of care. A physician's orders [REDACTED].#38 was not followed. Medications were held without a physician's orders [REDACTED].#4. Resident identifiers: #38, and #4. Facility census: 68.Finding include: a) Resident #38 Review of the resident's physician's orders [REDACTED]. This is a blood test that measures how long it takes blood to clot. The lab work was to be collected on 04/23/13. Review of the lab requisition and the lab results, on 08/13/13 at 3:10 p.m., revealed the facility collected the blood for the PT-INR on 04/26/13 instead of on 04/23/13 as ordered. An interview was conducted, on 08/13/13 at 4:50 p.m., with Employee #48, the director of nursing (DON). When asked why the facility did not follow the physician's orders [REDACTED]. On 08/13/13 at 4:57 p.m., the DON stated she could not find lab results from 04/23/13. She said staff collected the blood for the PT-INR on 04/26/13, instead of on 04/23/13. She verified no one put in a requisition for the PT-INR to be collected on 04/23/13 as ordered. b) Resident #4 Review of the resident's July 2013 medical administration record (MAR) revealed an order for [REDACTED]. Continued review of the MAR indicated [REDACTED]. The medical record contained no order, no instructions and/or other parameters for holding the [MEDICATION NAME] or the [MEDICATION NAME]. On 08/07/13 at 11:25 a.m., Employee #14, a nurse, stated she could not find a physician's orders [REDACTED]. On 08/07/13 at 2:50 p.m., the director of nursing stated the resident did not have an order to hold the [MEDICATION NAME] or the [MEDICATION NAME]. | 2017-09-01 |
| 7038 | 7038 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 312 | D | 0 | 1 | 66WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure a resident who was unable to independently carry out activities of daily living (ADL) received care and services to maintain good nutrition One (1) of four (4) residents reviewed for nutrition in Stage 2 of the survey . Assistance with eating was not provided to a resident with significant weight loss; and meal/snack consumption records were incomplete. Facility census: 68. Resident identifier: #18. Findings include: a) Resident #18 A Stage 1 medical record review, on 08/05/13 at 3:42 p.m., revealed Resident #18 had a significant weight loss in the past 30 days. He was not receiving a nutritional supplement, but received snacks twice a day. Weights were reviewed and revealed the resident weighed 121 pounds on 07/09/13, and 110 pounds on 07/31/13. (He was hospitalized from [DATE] -07/31/13.) He was transferred to the hospital again on 08/07/13 for a TURP (prostate surgery) and was readmitted on [DATE]. His readmission weight was not obtained until 08/12/13, and was noted as 102 pounds. [DIAGNOSES REDACTED]. Review of the care plan, on 08/07/13 at 10:37 a.m., revealed Resident #18 was identified for risk of weight loss. He had a goal to consume >75% of meals and snacks through his next review. His goal also was to maintain his weight between 110 -115 pounds. Interventions included monitoring intake at all meals, offering alternate choices as needed, and receiving a snack between meals at 10:00 a.m. and 2:00 p.m. Staff was also to supervise and assist the resident in feeding. Meal percentage sheets, contained in the medical record, were reviewed for breakfast, lunch and dinner for July and August 2013. No entries were present for 31 of 45 opportunities in July. Additionally, no entries were present for 10 of 18 opportunities in August. The form contained an area to document bedtime (HS) snacks, but it was blank. There was no area to note the 10:00 a.m… | 2017-09-01 |
| 7039 | 7039 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 323 | E | 0 | 1 | 66WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide adequate supervision and safety measures for one (1) of three (3)residents reviewed for accidents. The care plan for a fall mat was not implemented. Resident identifier: #35. Facility census: 68 Findings include: a) Resident #35 Observations on 08/07/13 from 8:30 a.m. to 11:30 a.m., found the resident lying in bed with the bed in the low position and the half side rail elevated. There were no fall mats in place on the floor by the bedside. Review of incident and accident reports found he sustained falls from his bed without injury on 05/19/13, 06/10/13, and 06/17/13. On 08/07/13 at 11:00 a.m., review of the medical record revealed he had [DIAGNOSES REDACTED] affecting his dominant side, and aphasia (meaning the inability to speak), related to cerebrovascular disease. He also had vascular dementia. Review of the care plan, on 08/07/13 at 11:00 a.m., found the resident was at risk for falls related to impaired mobility and a history of cerebrovascular accident (CVA), with right sided weakness/hemiparesis. According to the care plan, the resident got agitated at times and often rolls himself out of bed. Interventions included mats on the floor at his bedside, and the bed in the low position. An observation was conducted with the Assistant Director of Nursing (ADON) on 8/7/13 at 11:30 a.m. There was no fall mat beside the bed. The ADON retrieved the fall mat, which was standing against the wail behind his bed, and placed it on the floor beside his bed. She said he was supposed to have a fall mat beside his bed. An interview was competed with the Director of Nursing (DON) on 08/07/13 at 2:00 p.m. She read the three (3) incident reports related to falls from his bed. She said the care plan was revised to include fall mats by the bed. | 2017-09-01 |
| 7040 | 7040 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 325 | D | 0 | 1 | 66WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure nutritional care and services which were consistent with the comprehensive assessment and care plan for one (1) of four (4) residents reviewed for nutrition. Assistance with meals was not provided to this resident who had significant weight loss and other known nutritional risk factors. In addition, the facility failed to consistently document and monitor meal and snack consumption to determine effectiveness and/or need for nutritional intervention modifications. Resident identifier: #18. Facility census: 68. Findings include: a) Resident #18 A Stage 1 medical record review, on 08/05/13 at 3:42 p.m., revealed Resident #18 had a significant weight loss in the past 30 days. He was not receiving a nutritional supplement, but received snacks twice a day. Weight records were reviewed. The resident weighed 121 pounds on 07/09/13 and 110 pounds on 07/31/13. (He was hospitalized from [DATE] -07/31/13.) The resident was transferred to the hospital again on 08/07/13 for surgery and was readmitted on [DATE]. His readmission weight, obtained on 08/12/13, showed a weight of 102 pounds. [DIAGNOSES REDACTED]. Review of the care plan, on 08/07/13 at 10:37 a.m., revealed Resident #18 was identified at risk for weight loss. He had a goal to consume >75% of meals and snacks through his next review. His goal also was to maintain his weight between 110 -115 pounds. Interventions included monitoring intake at all meals, offering alternate choices as needed, and receiving a snack between meals at 10:00 a.m. and 2:00 p.m. Staff was also to supervise and assist the resident in feeding. Meal percentage sheets, contained in the medical record, were reviewed for breakfast, lunch, and dinner for July and August 2013. No entries were present for 31 of 45 opportunities in July. Additionally, no entries were present for 10 of 18 opportunities in August. The form contained an area… | 2017-09-01 |
| 7041 | 7041 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 329 | D | 0 | 1 | 66WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and medical record review, the facility failed to ensure two (2) of five (5) residents reviewed were free of unnecessary medications. There was no indication for the use of [MEDICATION NAME], a psychoactive medication, or an attempt at a gradual dose reduction (GDR) for Resident #26. For Resident #9, there was no indication for use of [MEDICATION NAME], a psychoactive medication, and no evidence of an attempt at a GDR. In addition, even though non-pharmacological interventions were described, these interventions were not noted in the care plan for use by all staff who worked with the resident. Resident identifiers #26 and #9. Facility census: 68 Findings include: a) Resident #26 This resident's medical record was reviewed on 08/05/13 at 1:53 p.m. The resident was re-admitted to the facility on [DATE] with a physician's orders [REDACTED]. The medical record indicated Resident #26 was receiving the antianxiety medication for anxiety with behaviors expressed as yelling at his roommate. An interview with the resident, on 08/06/13 at 10:28 a.m., revealed the resident was admitted to the facility in January of 2012. He said he had a difficult time with a room mate, because the roommate was very confused, but things were better now. He said they were compatible. A review of all MDSs completed between 05/01/12 through 05/24/13 was completed on 08/13/13 at 3:48 p.m. Each indicated the resident exhibited no behaviors related to anxiety. Review of the medical record indicated the resident had signs/symptoms of a depressed mood, but there was nothing which suggested the resident experienced anxiety. The resident's behavior sheets were reviewed for June, July, and August 2013. Behaviors were listed as zero (0). Resident observations on 08/06/13, 08/07/13, 08/08/13, 08/12/13, and 08/13/13 revealed the resident was up in his wheelchair daily. His mood was pleasant, and he was talkative. He said he provided most … | 2017-09-01 |
| 7042 | 7042 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 428 | D | 0 | 1 | 66WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure medication irregularities were identified and reported to the physician and/or failed to ensure the physician acted upon pharmacy recommendations for two (2) of five (5) residents reviewed for unnecessary medications. The medications were antipsychotic medications for which there was no evidence of a recommendation for a gradual dose reduction (GDR), no evidence the physician considered attempts at GDRs once recommended by the pharmacist, and/or no rationale by the physician regarding why GDRs were not indicated for the residents. Resident identifiers: #26 and #9. Facility census: 68. Findings include: a) Resident #26 This resident's medical record was reviewed on 08/05/13 at 1:53 p.m. The resident was re-admitted to the facility on [DATE] with a physician's orders [REDACTED]. The medical record indicated Resident #26 received this same dose of antianxiety medication, for anxiety with behaviors (expressed as yelling at his roommate) since 01/27/12. Pharmacy recommendations, reviewed on 08/12/13 at 2:53 p.m., revealed no recommendation related to a gradual dose reduction (GDR) of Ativan since 03/05/12. At that time, the physician declined the recommendation, but did not provide a rationale specific to the resident, for continuing the medication. A comment, written on the consultation form by the Director of Nursing (DON), related there was no documentation of anxiety. The medical record contained no evidence the pharmacist identified there was no indication for use of the Ativan, or that the resident had not had an attempt at a gradual dose reduction since readmission on 01/27/12. Review of the physician's progress notes, on 08/12/13 at 3:42 p.m., indicated no rationale for utilizing the psychotropic medication. physician progress notes [REDACTED]. Nursing progress notes, reviewed on 08/12/13 at 3:50 p.m., provided no indication Resident #26 was exhibiting signs/… | 2017-09-01 |
| 7043 | 7043 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 431 | E | 0 | 1 | 66WU11 | Based on observation, staff interview, and policy review, the facility failed to properly label and store drugs and biologicals in a safe, sanitary, and/or secure manner. Narcotics stored in the medication room were not wasted in a timely manner, insulin medications were not labeled properly, and medications were not stored properly in two (2) of three (3) medication carts. This practice had the potential to affect more than a limited number of residents. Facility census: 68. Findings include: a) Medication carts An observation of the medication cart for B Hall, on 08/07/13 at 7:30 a.m., revealed five (5) gray tablets in a cup, unlabled and undated. Employee #34, a registered nurse (RN), identified them as Centrum Silver. She said the medication was borrowed from another cart. An observation of a cart utilized for part of A Hall and part of B Hall revealed various items stored together. They consisted of unpackaged gauze, electrical connectors, an unpackaged syringe of normal saline, and various other items. Employee #29 confirmed the items were not to be stored together. In addition, six (6) monteleukast sodium 10 mg tablets were observed in a drawer with no name or directions. Employee #29, a licensed practical nurse (LPN) was unable to identify to whom they belonged. Observation of insulin bottles noted a future date on the box. Employee #29 (LPN) said the date noted, was the date the medication expired and was to be discarded. The LPN said the facility's practice followed insulin storage guidelines provided by the pharmacy. Review of those guidelines, on 08/07/13, revealed Lantus, Novolin, and Novolg expired 28 days from the date opened. The LPN said the date opened was no longer documented. Two bottles of Novolog insulin were dated with an expiration date of 09/08/13. The date received from the pharmacy was 07/15/13. The nurse agreed she could not confirm the date the medications were opened. She also confirmed the medication would expire prior to the date noted on the bottle, even if it had only been opened… | 2017-09-01 |
| 7044 | 7044 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 441 | E | 0 | 1 | 66WU11 | Based on observation, staff interview, and policy review, the facility failed to maintain its infection control program to provide a safe, sanitary environment, and to help prevent development and transmission of disease and infection. A resident observed in Stage I of the Quality Indicator Survey had torn and tattered vinyl coverings alongside both arms of his geri-chair. This exposed the materials inside the arms of the chair, and made it not possible to adequately clean and disinfect the chair. Hands were not sanitized when indicated during dining services. An unsanitary technique was observed during medication administration. These practices had the potential to affect more than a limited number of residents. Resident identifier: #12. Facility census: 68 Findings include: a) Resident #12 On 08/16/13 at 8:36 a.m., Resident #12's room and care equipment was observed. His blue geri-chair had tattered and torn vinyl coverings on the sides of both arms of the chair. The inside materials protruded, and were clearly visible on both arms of the chair where they were torn. An observation was conducted with the Assistant Director of Nursing (ADON) on 08/07/13 at 9:45 a.m. She looked at the arms of the geri-chair, and agreed the chair could not be adequately and appropriately cleaned and sanitized with the vinyl covering torn and the inside materials protruding. b) Dining Services During a dining observation, on 08/05/13 between 12:00 p.m. and 1:30 p.m., Employee #78, a nursing assistant (NA), entered a resident's room. She conversed with the resident, touched his shoulder, then went to another resident's room. She did not sanitize her hands She removed a milk carton from the other resident's over the bed table, and discarded it in the trash can. Without sanitizing her hands, she exited the room. A cart in the hallway contained cups, coffee, and other items. She went to the cart, and poured a cup of coffee. After delivering the coffee, the nursing assistant washed and dried her hands. The NA dropped the paper towel on t… | 2017-09-01 |
| 7045 | 7045 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 514 | E | 0 | 1 | 66WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to maintain accuracy and completeness of medical records within acceptable professional standards. Resident supplements and meal intake was not documented and a transcription of a medication order, for seven (7) of twenty (20) sample residents during Stage II of the survey. Resident identifiers: #50, #4, #9, #35,#65, #18, #9, #35, and #25. Facility census: 68. Findings include: a) Resident #50 Review of the resident's current physician's orders [REDACTED]. The resident's medical record contained no documentation regarding the percentage of the supplement the resident consumed each time it was provided. The facility policy 10.0 on supplements was reviewed. The policy had a revision date of 05/05/13. Under number 6, it noted, Nursing documents administration and amount consumed. On 08/12/13 at 2:02 p.m., a registered nurse, Employee #92, confirmed there were no percentages documented regarding how much of the house supplements the resident consumed. b) Resident #4 Review of the resident's July 2013 medical administration record (MAR) revealed an order for [REDACTED]. Continued review of the MAR indicated [REDACTED]. The medical record contained no order, no instructions and/or other parameters for holding the [MEDICATION NAME] or the [MEDICATION NAME]. On 08/07/13 at 11:25 a.m., Employee #14, a licensed practical nurse, stated she could not find a physician's orders [REDACTED]. On 08/07/13 at 2:50 p.m., the director of nursing stated the resident did not have an order to hold the [MEDICATION NAME] or the [MEDICATION NAME]. c) Resident #9 Review of the MARs and the B Hall Meal Percentage sheets, for the period of 07/01/13 through 08/06/13, found that the amount, if any, of the supplement this resident consumed was not recorded. Also, her meal intakes were not consistently recorded. There was no mention of the snack consumption, except on 07/0/13 and 08/06/13, when it… | 2017-09-01 |
| 7046 | 7046 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 520 | F | 0 | 1 | 66WU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to maintain an effective quality assessment and assurance committee. The committee failed to address quality deficiencies the committee knew of, or should have known of, related to documentation, transfer and discharge rights, and liability notices. The facility failed to develop and implement a plan of action to correct these quality deficiencies These deficits affected eleven (11) residents reviewed during the survey, and had the potential to affect all residents. Resident identifiers: #25, #9, #35, #50, #78, #69, #28, #34, #87, #56, and #86. Facility census: 68. Findings include: a) At the time of the survey, the quality assessment and assurance committee had not recognized the residents' medical records were not complete and accurate in the following instances: 1) Residents #25, #4, #78, #69, #28, and #34 The records did not contain evidence these residents were provided written information specifying the duration of the facility's bed-hold policy; however, the facility's policy entitled, Discharge and Transfer included the following statement: All patients will receive a 'Notice of Transfer or Discharge or Discharge Transition Plan whenever a voluntary or involuntary transfer / discharge occurs . 5.1.2 A copy of the written notice of transfer will be placed in the patient's medical record. At 10:00 a.m. on 08/07/13, the Administrator presented a requested copy of the information given to residents upon transfer or discharge from the facility. It did not include written information about the facility's bed hold policy. After a second request, the Administrator provided a copy of a Notification of Transfer / Discharge letter, which he stated was used by the facility which included the facility's Bed-hold policy. A review of the records of these six (6) recently transferred or discharged residents revealed no evidence they were provided written information speci… | 2017-09-01 |
| 7047 | 7047 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2013-09-13 | 159 | D | 0 | 1 | GJXP11 | Based on a review of the facility's accounting records, medical records, and staff interview, the facility failed to ensure the authorization to handle personal funds was completed within legal state guidelines for two (2) of three (3) residents sampled for funds. Resident identifiers: #79 and #43. Facility census 61. Findings include: a) Resident #79 A review of the Trial Balance of the personal funds belonging to Resident #79 indicated he had a balance of $1245.39 in his account. The file did not have evidence of a valid authorization for the facility to act as fiduciary of the resident's funds. This resident, who was deemed by his physician to lack the capacity to form medical decisions, had a financial and medical power of attorney. There was an authorization form in his file dated 04/18/13, but it was unsigned. b) Resident #43 A review of the Trial Balance of the personal funds belonging to Resident #43 indicated he had a balance of $303.10 in his account. The resident was deemed by his physician to lack the capacity to form medical decisions. The only signature on the resident's authorization form was his own, and the form was not dated or witnessed. c) During an interview with Employee #58 (Business Office Manager) at 4:25 p.m. on 09/12/13, she acknowledged the authorizations found were the only ones on file for those residents. She could not state for certain the date of the authorization for Resident #43, who had been a resident since 10/05/12. | 2017-09-01 |
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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 );