cms_WV
Data source: Big Local News · About: big-local-datasette
194 rows where "filedate" is on date 2018-04-01
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Suggested facets: facility_name, facility_id, address, scope_severity, inspection_date (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6226 | 6226 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 272 | D | 1 | 0 | 0UGG11 | **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 two (2) comprehensive minimum data sets (MDSs) for two (2) of six (6) residents whose MDSs were reviewed. Resident #920's Annual MDS did not accurately reflect the number of days the resident received anticoagulation medications. Resident #923's admission MDS inaccurately indicated the resident had contractures. Resident Identifiers: #920 and #923. Facility Census: 38. Findings Include: a) Resident #920 A review of Resident #920's medical record at 10:28 a.m. on 04/22/15 found an Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/29/15. Review of the MDS found Section N0410 E. Anticoagulant coded with a seven (7) to indicate Resident #920 received anticoagulation medication seven (7) of the seven (7) days in the look back period. Resident #920's Medication Administration Record [REDACTED]. The medication was held on the other two (2) days at the direction of the attending physician. An interview with the Director of Nursing (DON) at 1:00 p.m. on 04/22/15, confirmed Resident #920 only received her [MEDICATION NAME] (an anticoagulant medication) on five (5) of the seven (7) days during the look back period. When asked if the MDS with the ARD of 01/29/15 Section N0410 E. Anticoagulant was coded accurately she replied, No it should have been a five (5) and I put seven (7). b) Resident #923 Review of Resident #923's medical record at 10:00 a.m. on 04/23/15, found an Admission MDS with an ARD of 10/23/15. Review of this MDS found Section S3100 Contractures - A. Hand, coded with a three (3) indicating Resident #923 had contractures of both hands. Additionally, Section S3100 Contractures -F. Ankle, indicated Resident #923 had a contracture of her right ankle. Further review of the medical record found no indication Resident #923 had contractures of her hands or right ankle. An interview with the Director of Nursing (DON) at 2:48 p.m. on … | 2018-04-01 |
| 6227 | 6227 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 274 | D | 1 | 0 | 0UGG11 | Based on record review, staff interview, review of the guidance for this regulation, review of Chapter 2 of the Resident Assessment Instrument Manual, and family interview, the facility failed to complete a significant change in status minimum data set (MDS) assessment within 14 days after the facility determined, or should have determined, one (1) of six (6) sampled residents experienced a significant change in status. Resident #931 had declines in bed mobility, transfers, ambulation, dressing, eating, toilet use, personal hygiene, bladder and bowel continence, and weight. Resident identifier: #931. Facility census: 38. Findings include: a) Resident #931 On 04/20/15 at 1:10 p.m., during an interview with the Medical Power of Attorney (MPOA) for Resident #931, the MPOA voiced concern over the resident's decline in health. The MPOA said the resident's appetite had decreased over the past few months and she was losing weight, as well as declining in her functional abilities. She said the resident used to walk in the facility using a walker, but had not walked in a few months. Record review, on 04/20/14 at 1:40 p.m. found the following: 1. Quarterly MDS with an assessment reference date (ARD) of 12/11/14 Coding for G0110 indicated -- Bed mobility - coded 3/2 - indicating the resident required extensive assistance of one (1) staff member for the seven (7) day look back period. -- Transfers, Walk in room, Walk in corridor, Dressing, Toilet Use, and Personal Hygiene - coded 2/2 - indicating the resident required the limited assistance of one (1) staff member for the activity during the seven (7) day look back period. -- Eating - coded 0/1 - indicating the resident was independent and required only set-up assistance from staff during the seven (7) day look back period. Items H0300 and H0400 - indicated the resident was always continent of urine and bowel during the seven (7) day look back period. Item K0200 identified the resident's weight was 129 pounds Item K0300 indicated the resident had not had a weight loss of 5% … | 2018-04-01 |
| 6228 | 6228 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 278 | D | 1 | 0 | 0UGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the minimum data set (MDS)assessments, for one (1) of six (6) residents whose MDSs were reviewed, was not accurate. Resident #923 had two (2) quarterly MDSs which did not accurately reflect contractures. Resident Identifier: #923. Facility Census: 38. Findings Include: a) Resident #923 1. Review of Resident #923's medical record, at 10:00 a.m. on 04/23/15, found a quarterly MDS, with an Assessment Reference Date (ARD) of 01/08/15. The assessor coded this MDS, Item S3100 - Contractures to indicate the resident had contractures of both hands. Additionally, the assessment identified the resident had a contracture of her right ankle. Further review of the medical record found no indication Resident #923 had contractures of her hands or right ankle. 2. Review of Resident #923's medical record at 10:00 a.m. on 04/23/15 found a quarterly MDS with an ARD of 03/26/15. This assessment also indicated the resident had contractures of both hands and her right ankle. Further review of the medical record found no indication Resident #923 had contractures of her hands or right ankle. 3. An interview with the Director of Nursing (DON) at 2:48 p.m. on 04/23/15, confirmed Resident #923 did not have contractures. The DON indicated the [DIAGNOSES REDACTED].#923 had not been diagnosed as having a contracture. She confirmed the quarterly MDSs with ARDs of 01/08/15 and 03/26/15 were inaccurate related to contractures and needed corrected. | 2018-04-01 |
| 6229 | 6229 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 279 | D | 1 | 0 | 0UGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop an interdisciplinary care plan describing the services needed to meet the needs of one (1) of six (6) residents reviewed during the complaint investigation. The facility failed to develop a care plan addressing Resident #931's urinary tract infection [MEDICAL CONDITION], which was treated in February 2015. Resident identifier: #931. Facility census: 38 Findings include: a) Resident #931 A review of the resident's medical records, on 04/21/15, identified Resident #931 received a course of antibiotics for a UTI. A urinalysis (UA) and culture and sensitivity (C&S) were ordered on [DATE], due to a functional decline. The results of the UA identified the microorganism Proteus Mirabilis, with a colony count greater than 100,000. On 02/02/15, after receiving the C&S results, the physician ordered [MEDICATION NAME] (an antibiotic) 500 milligrams (mg) to be given by mouth three (3) times a day for seven (7) days. At 11:40 a.m. on 04/21/15, a review of the care plan for Resident #913 found no evidence in the current care plan, or resolved episodic care plans, which indicated the resident had a UTI and received an antibiotic, or had a history of [REDACTED]. On 04/23/15 at 11:00 a.m., when asked to provide any episodic care plans regarding the UTI in February 2015, which might have been thinned from the resident's record, the Director of Nursing (DON) said she would check. At 11:30 a.m. on 04/23/15, the DON verified there was no care plan for the UTI treated in February 2015. She confirmed an episodic plan should have been established. | 2018-04-01 |
| 6230 | 6230 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 282 | D | 1 | 0 | 0UGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observation, record review, and staff interview, the facility failed to ensure implementation of the care plans for three (3) of six (6) residents whose care plans were reviewed. Resident #894's care plan related to her risk of elopement was not implemented. Resident #920's care plan related to her risk of falls was not implemented. In addition, Resident #913 had a care plan for restorative services. Staff were unable to describe the restorative services they provided the resident. Resident Identifiers: #894, #920, and #913. Facility Census: 38 Findings Include: a) Resident #894 Review of Resident #894's care plan, at 2:15 p.m. on 04/20/15, found a problem of, At risk for elopement. The goal was, Will have 0 (zero) further elopement attempts qd (daily). The interventions to achieve this goal were (typed as written): Keep behavior log QS (every shift). Make sure she has an ID (identification) bracelet on AAT (at all times). Orange runner on door. Info (information) in Kardex so staff are aware. Frequent monitoring. Observations of Resident #894, at 3:15 p.m. on 04/20/15, found she did not have an orange runner on her door and she was not wearing an identification bracelet. A review of Resident #894's Kardex found no mention of her risk for elopement, nor her interventions to prevent elopement. (The Kardex was the method used by the facility to communicate care plan interventions to direct care staff.) Additional observations of Resident #894 with the Director of Nursing (DON), at 3:37 p.m. on 04/20/15, confirmed Resident #894 did not have an orange runner on her door, nor was she wearing an identification bracelet. The DON reviewed the resident's Kardex upon request. After reviewing the Kardex, she confirmed the resident's risk for elopement and the interventions to prevent elopement were not documented on the Kardex. She also confirmed facility staff did not implement Resident #894's care plan interventions related to elopem… | 2018-04-01 |
| 6231 | 6231 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 311 | D | 1 | 0 | 0UGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, family interview, and staff interviews, the facility failed to ensure one (1) of six (6) residents reviewed for Activities of Daily Living (ADLs) was provided services to maintain and maximize the resident's functional ability. Prior to, and in the beginning of January 2015, the resident was able to perform most ADLs with limited assistance of one (1) staff member. The resident subsequently became dependent for her ADLs. She had declines in bed mobility, transfers, ambulation, dressing, eating, toilet use, personal hygiene, and bladder and bowel continence. Resident identifier: #913. Facility census: 38. Findings include: a) Resident #913 On 04/20/15 at 1:10 p.m., during an interview with the Medical Power of Attorney (MPOA) for Resident #931, the MPOA voiced concern over the resident's decline in health. The MPOA said the resident suffered a decline in her functional abilities. She said the resident used to walked in the facility using a walker, but had not walked in a few months. b) On 04/20/15 at 1:40 p.m. the resident's quarterly MDS, with an assessment reference date of 12/11/14, and the annual MDS with an ARD of 03/05/15 were reviewed. The review revealed declines in bed mobility, transfers, ambulation, dressing, eating, toilet use, personal hygiene, and bladder and bowel continence between the 12/11/14 and 03/05/15 assessments. Record review, on 04/20/14 at 1:40 p.m. found the following: 1. Quarterly MDS with an assessment reference date (ARD) of 12/11/14 Coding for G0110 indicated -- Bed mobility - coded 3/2 - indicating the resident required extensive assistance of one (1) staff member for the seven (7) day look back period. -- Transfers, Walk in room, Walk in corridor, Dressing, Toilet Use, and Personal Hygiene - coded 2/2 - indicating the resident required the limited assistance of one (1) staff member for the activity during the seven (7) day look back period. -- Eating - coded 0/1 - indicating… | 2018-04-01 |
| 6232 | 6232 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 315 | D | 1 | 0 | 0UGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, the facility failed to ensure three (3) of four (4) residents observed for the provision of incontinence care were provided care in a manner to prevent, to the extent possible, urinary tract infections (UTIs). Resident identifiers: #913, #890, and #920. Facility census: 38. Findings include: a) Resident #913 On [DATE] at 2:15 p.m., a review of the physician's orders [REDACTED]. At 11:40 a.m. on [DATE], a review of the care plan for Resident #913 found no evidence in the current care plan, or resolved episodic care plans to indicate the resident had a history of [REDACTED]. On [DATE] at 11:10 a.m., during observation of the provision of incontinence care for Resident #913, Nurse Aide (NA) #60 gathered the needed supplies. This consisted of a basin of warm water, soap, towels, washcloths, a pair of gloves, and two (2) plastic trash bags. The resident was lying in her bed. The NA donned a pair of gloves without first washing her hands. She unsecured, and lowered the front of the resident's brief in order to provide care. The resident had had a large loose bowel movement. The NA used two (2) warm, soapy washcloths to remove the fecal matter from the resident's perineal area, and from the inner thighs, rinsing the washcloths in the basin of warm soapy water. She then assisted the resident onto her left side, and wiped the fecal matter from the resident's inner and outer buttocks, rinsing the washcloths in the basin of water. After removal of the visible fecal matter, she assisted the resident onto her back. The NA explained to the resident she was going to go change the water in the pan. She placed the soiled wash clothes into one (1) of the plastic bags. The NA carried the washbasin into the resident's bathroom, emptied the soiled water into the toilet, and flushed the commode. While still wearing the same pair of soiled gloves she had worn to remove the fecal matter from th… | 2018-04-01 |
| 6233 | 6233 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 325 | D | 1 | 0 | 0UGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, family interview, and staff interview, the facility failed to ensure one (1) of six (6) residents reviewed maintained acceptable parameters of nutritional status. The resident's weight loss was not assessed for necessary changes in the resident's plan of care. In addition, the plan of care was not implemented and/or evaluated as the resident experienced continual weight losses. The facility also failed to effectively monitor and track the nutritional supplements provided to the resident. Between December of 2014 and April of 2015, the resident had a cumulative weight loss of 17.65% of her total body weight. Resident identifier: #913. Facility census: 38. Findings include: a) Resident #913 Medical record review revealed Resident #913 experienced the following weight losses, between the month of December of 2014 through the month of April of 2015: -- From 12/04/14 to 01/04/15, the resident lost 10 pounds (#), from a weight of 129.2 # to 119.2 #. This was 7.74% of her body weight in one (1) month, a severe weight loss. -- From 01/04/15 to 02/04/15, the resident lost 7.6 #, from a weight of 119.2 # to 111.6 #. This was another severe weight loss. Between 12/04/14 and 02/04/15, the resident lost 13.62% of her total body weight. -- From 02/04/15 to 03/04/15, the resident gained 1 #, from a weight of 111.6 # to 112.6 #, reducing the total weight loss in three (3) months to 12.85%, which still represented a severe weight loss. -- From 03/04/15 to 04/04/15, the resident lost another 6.2 #, from a weight of 112.6 # to 106.4 #. This was another severe weight loss (5.5%) in one (1) month. The weight loss from 129.2 on 12/04/14 to the last available weight of 106.4 on 04/04/15 represented a cumulative severe total body weight loss of 17.65% in four (4) months. The percentage of weight losses were calculated using the following formula: % of body weight loss = (usual weight-actual weight) / (usual weight) X 100. (The re… | 2018-04-01 |
| 6234 | 6234 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 367 | D | 1 | 0 | 0UGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, family interview, and staff interview, the facility failed to ensure one (1) of six (6) residents reviewed was provided foods in the form prescribed by the physician. The resident received a pureed diet without an order for [REDACTED].#913. Facility census: 38 Findings include: a) Resident #913 On 04/20/15 at 1:10 p.m., the resident was lying in bed. Her Medical Power of Attorney (MPOA) was seated beside her. The noon meal tray for the resident was on the resident's over-the-bed table. The tray consisted of three (3) types of pureed foods. A review of the quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/11/14, and the annual MDS assessment with an ARD of 03/05/15, on 04/20/15 at 1:40 p.m., found both indicated only that the resident had received a therapeutic diet. Neither MDS assessment indicated the resident received a mechanically altered diet. At 2:15 p.m. on 04/20/15, a review of the physician's orders revealed an order, dated 11/14/13, for a therapeutic diet of no added salt (NAS). There was not an order for [REDACTED]. On 04/21/15 at 2:10 p.m., the Director of Nursing (DON) and the Dietitian were asked if the facility changed diet orders, from regular consistency to other consistencies, without a physician's order. Both replied saying, there would have to be an order to change a diet. Both were asked to provide the order for Resident #913 to receive pureed foods. When both were unable to locate an order in the resident's medical record, the dietitian said she would look in the kitchen. At 3:30 p.m. on 04/21/15, the Dietitian provided an undated communication slip indicating a diet change for the resident. The diet change was for pureed foods. The Dietitian verified there was no physician's order to change resident's diet consistency. She further verified the resident should not have received a mechanically altered diet without an order. On 04/22/15 at 1:20 p.… | 2018-04-01 |
| 6235 | 6235 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 441 | D | 1 | 0 | 0UGG11 | Based on observation, staff interview, and policy review, the facility failed to maintain an Infection Control Program to prevent, to the extent possible, the onset and spread of infections for three (3) of four (4) residents observed for the provision of incontinence care. Observations revealed omissions of handwashing and the improper use of gloves. In addition, staff failed to provide incontinence care and perineal care in a manner to prevent potential infections and disease transmission. Resident identifiers: #913, #890, and #920. Facility census: 38. Findings include: a) Resident #913 On 04/21/15 at 11:10 a.m., the resident's provision of incontinence care, provided by Nurse Aide (NA) #60, was observed. The NA gathered her supplies, consisting of a basin of warm water, soap, towels, washcloths, a pair of gloves, and two (2) plastic trash bags. The resident was lying in bed. The NA donned gloves without first washing her hands. She unfastened and lowered the front of the resident's brief to provide care. Observation revealed the resident had a large loose bowel movement. The NA used two (2) warm, soapy washcloths to remove the fecal matter from the resident's perineal area and inner thighs. She rinsed the washcloths in the basin of warm soapy water. The NA then assisted the resident onto her left side, and wiped the fecal matter from the resident's inner and outer buttocks, then rinsed the washcloths in the basin of water. After removing the visible fecal matter, the NA assisted the resident onto her back, and explained to the resident that she was going to go change the water in the pan. She placed the soiled washcloths into one (1) of the plastic bags. The NA carried the washbasin into the resident's bathroom, emptied the soiled water into the toilet, and flushed the toilet. While still wearing the same pair of soiled gloves she wore to remove the fecal matter from the resident, the NA turned on the water in the resident's sink, rinsed the washbasin, and refilled the basin with fresh water. NA #60 carried t… | 2018-04-01 |
| 6236 | 6236 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 502 | D | 1 | 0 | 0UGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain timely laboratory services for one (1) of six (6) sampled residents. The results of an ordered sputum culture and sensitivity (C&S) laboratory test were not obtained for eight (8) days after the specimen was obtained. Resident identifier: #927. Facility Census: 38. Findings include: a) Resident #927 On 04/23/15 at 10:25 a.m., a review of the physician's orders [REDACTED]. At 1:00 p.m. on 04/23/15, a review of the nurses' notes identified an entry written on 04/22/15 at 5:00 p.m. The note indicated the results from the sputum culture were obtained, and the physician was notified of the results. Upon notification of the results, on 04/22/15, the physician ordered a continuation of the antibiotic, [MEDICATION NAME] 100 milligrams twice a day for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA), until 04/24/15, then to continue at the same dosage for four (4) more days. The physician also wrote an order to start respiratory isolation precautions due [MEDICAL CONDITION]. On 04/23/15 at 1:17 p.m., Registered Nurse (RN) #42, was asked when and how the results of the sputum culture, ordered and obtained on 04/14/15, were received. RN #42 stated when the physician was in the facility on 04/22/15, he inquired about the results of the sputum culture he ordered on [DATE]. RN #42 said when she was unable to locate the results, she called the laboratory and had the results faxed to the facility for review by the physician. RN #42 confirmed, after reviewing the results the physician wrote orders to continue the [MEDICATION NAME] and to start respiratory precautions [MEDICAL CONDITION]. At 2:40 p.m. on 04/23/15, the Director of Nursing (DON) was made aware of how and when the lab results were obtained. She said her expectation and facility practice was to call the laboratory for the results if the results were not received the third day after sending a specimen. The DON said … | 2018-04-01 |
| 6237 | 6237 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-04-23 | 514 | D | 1 | 0 | 0UGG11 | Based on resident observation, record review, and staff interview, the facility failed to ensure one (1) of six (6) residents on the sample had a complete and accurate medical record. Observations found the resident required extensive assistance from staff to transfer; however, documentation on the Activities of Daily Living (ADL) flow sheet, indicated she was totally dependent on staff for transfers. Resident identifier: #920. Facility Census: 38. Findings Include: a) Resident #920 At 10:45 a.m. on 04/22/15, observation revealed Resident #920 being transferred from her bed to her Geri-Chair. Nurse Aide (NA) #12 assisted the resident in the transfer. The resident was assisted to the standing position and was then pivoted to her Geri-Chair. An interview with NA #12, at 1:00 p.m. on 04/22/15, confirmed the resident assisted with the transfer. NA #12 confirmed Resident #920 was able to stand up, bear weight, and assist with the transfer. A review of Resident #920's ADL flow sheet related to transferring, at 9:00 a.m. on 04/23/15, found on 04/22/15 during day shift, documentation indicated the resident was being totally dependent (full staff performance) with transfers with the assist of one (1) person. An interview with the Director of Nursing (DON) at 9:30 a.m. on 04/23/15, confirmed if Resident #920 was able to bear weight and assist with the transfer, then she was not totally dependent. She stated the documentation should have indicated the resident needed extensive assistance with transfers. | 2018-04-01 |
| 6238 | 6238 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 161 | E | 0 | 1 | EXXT11 | Based on financial record review and staff interview, the facility failed to guarantee the security of all personal funds deposited with the facility. The facility did not have a surety bond of sufficient value to cover the total amount of residents' funds as of the most recent quarter. This had the potential to affect all residents with a resident trust fund account with the facility. Fifty (50)residents had a personal funds account with the facility. Facility census: 50. Findings include: a) On 08/12/14 at 10:00 a.m. a review of the resident funds on deposit revealed the most recent quarterly balance, according to the Account Summary, was April 2014: $16,595.24; May 2014: $15,030.23; and June 2014: $16,655.19. The facility's current surety bond was for $10,000.00. The bond was insufficient to cover the resident trust fund accounts of the fifty (50) residents who had a trust fund account with the facility. b) On 08/12/14 at 10:30 a.m., an interview was conducted with Employee #100 (Business Office staff). Employee #100 acknowledged the account summary balances for the most recent quarter had exceeded the amount of the current surety bond. | 2018-04-01 |
| 6239 | 6239 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 253 | E | 0 | 1 | EXXT11 | Based on observation and staff interview, the facility failed to ensure effective housekeeping and maintenance services to maintain a sanitary, orderly, comfortable interior which was free from esthetic imperfections. Observations of resident rooms found multiple pieces of spackling was missing and broken, entrance doors had multiple scratches or mars or chipped wood, dresser finishes were scratched and sometimes down to the bare wood, knobs were missing on dressers, wooden bed rails were scratched and marred, a closet door had a hole through the wood, shower floor tiles contained a black substance, shower wall tiles contained a black substance, tile and caulking was discolored around a commode, and a rusted and dirty heating and cooling unit was observed. These findings were observed in thirteen (13) of twenty-four (24) resident rooms in Stage I of the Quality Indicator Survey. Room numbers: A100, A102, A107, A108, B100, B101, B103, B105, B107, B108, B109, C102 and C108. Resident census: 50. Findings include: a) A Hall A tour was conducted with Environmental Employees #98 and #96 on 08/11/14 between 11:00 a.m. and 12:00 p.m. The findings for esthetic imperfections were as follows: - Room 100. The closet door contained multiple scratches. - Room 102. The finish of the entrance door had deep scrapes down into the wood. There were multiple scrapes on the wooden part of the bed side rails. - Room 107. The white paint was scraped off the inner and outer bathroom door trim in several areas. It had black/brown discoloration in place of the white paint. Two (2) knobs were missing from a dresser in the room. - Room 108. Two (2) knobs were missing from a dresser in the room. b) B Hall A tour was conducted with Environmental Employees #98 and #96 on 08/11/14 between 11:00 a.m. and 12:00 p.m. The findings for esthetic imperfections and areas of uncleanliness were as follows: - Room 100. A dresser in the room was scratched down to the bare wood, and one (1) knob was missing. The closet door contained a hole broken through th… | 2018-04-01 |
| 6240 | 6240 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 256 | D | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview and medical record review, the facility failed to ensure the provision of adequate and comfortable lighting for one (1) of twenty-four (24) residents observed in Stage I of the Quality Indicator Survey. A resident with known visual impairment lacked the necessary lighting she felt she needed in order to see and read more easily while in bed. Resident identifier: #2. Facility census: 50. Findings include: a) Resident #2 During an interview on 08/05/14 at 4:22 p.m., Resident #2 stated, I like to read and the light is not bright enough. Told the nurse. An observation of the resident's room, during the environmental tour on 08/11/14, at approximately 11:00 a.m., revealed the light over her bed was on and put off a fair amount of light. Resident #2 said she preferred more light. She told the maintenance crew during this environmental tour she would like to have more light to read by. She also said she told a nurse about it, but could not remember the nurse's name. She said she told everyone. The resident's medical record was reviewed on 08/12/14 at 10:00 a.m. The most recent minimum data set (MDS), with an assessment reference date (ARD) of 07/07/14, assessed this resident had a [DIAGNOSES REDACTED]. A leisure interest assessment, dated 04/03/14, assessed the resident did in room activities (reading, radio, television) with the comment, can't see well to read. The MDS nurse, Employee #15, was interviewed on 08/12/14 at 11:45 a.m. She said she had not heard this resident ask or say anything about her lighting. She was aware this resident had a history of [REDACTED]. An interview was conducted with the Person in Charge, Employee #31, on 08/12/14 at 2:15 p.m. She said it would help if the resident would allow the staff to draw her curtains, but she generally did not want the curtains opened. Employee #31 said she would see about getting a separate light for Resident #2's room. | 2018-04-01 |
| 6241 | 6241 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 279 | D | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview, the facility failed to develop a care plan based on the comprehensive assessment for one (1) of fourteen (14) Stage 2 sampled residents. A resident who had a [DIAGNOSES REDACTED]. Resident identifier: #2. Facility census: 50. Findings include: a) Resident #2 During an interview on 08/05/14 at 4:22 p.m., Resident #2 stated, I like to read and the light is not bright enough. Told the nurse. Observations were made during the environmental tour on 08/11/14 at approximately 11:00 a.m. The light over her bed was on and put off a fair amount of light, but she said she preferred more light. She told the maintenance crew during the environmental tour she would like to have more light to read by. She said she told a nurse about it, but could not remember the nurse's name. She said she told everyone. The resident's medical record was reviewed on 08/12/14 at 10:00 a.m. The most recent minimum data set (MDS), with an assessment reference date (ARD) of 07/07/14, assessed this resident had a [DIAGNOSES REDACTED]. A leisure interest assessment, dated 04/03/14, assessed that the resident did in room activities (reading, radio, television), with the comment, can't see well to read. The MDS nurse, Employee #15, was interviewed on 08/12/14 at 11:45 a.m. She said she had not heard this resident ask or say anything about her lighting. She was aware this resident had a history of [REDACTED]. The MDS nurse printed off a quarterly nurse assessment. Quarterly assessments included side rail, dental, vision, pain, and various types of assessments the facility completed quarterly on each resident. The vision assessment, dated 07/04/14, addressed the resident had vision problems and wore glasses. It noted her pupils were equal but slow to react, and that the resident reported a history of cataract surgeries on both eyes. The care plan was reviewed. It contained nothing about her vision problems. Ther… | 2018-04-01 |
| 6242 | 6242 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 323 | K | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and a review of the Centers for Medicare and Medicaid (CMS) State Operations Manual, the facility failed to provide an environment that was as free as possible from accident hazards over which it had control. Water temperatures in the public restrooms, that could be accessed by more than an isolated number of residents, were too high for safety. The public restrooms, for men and women, registered 160 degrees Fahrenheit (F) on 08/13/14. Those restrooms were unlocked and could be accessed by mobile residents. Also, water temperatures were high in two (2) resident common use restrooms, registering 120 degrees (F) on 08/13/14. Those restrooms were unlocked and could be accessed by mobile residents. These situations created a potential for serious injury to residents. Affected areas included the men's and women's public restrooms that were located in the corridor between the front hall and back hall resident living quarters, and the two (2) common use restrooms located at the entrance to the C hall resident living quarters. The former resulted in a determination of immediate jeopardy (IJ). A facility maintenance employee verbally reported that they check the water temperatures in all the resident areas once per month. However, they do not keep a log, or records, of when the water temperatures were tested , and/or the results of the testing. There was no evidence the facility monitored and/or used the results of the monitoring of hot water temperatures to ensure resident safety. On 08/13/14 at 1:02 p.m., the State office directed to call an immediate jeopardy (IJ) related to the hot water temperatures of the men's and women's restrooms located in the corridor between the front and back halls. Employee #31, the Person in Charge (PIC), was notified immediately. On 08/13/14 at 1:50 p.m., Employee #31 provided a plan of correction. The correction was that the bathrooms had been locked, and were out of working orde… | 2018-04-01 |
| 6243 | 6243 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 329 | D | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the Center for Medicare and Medicaid Services (CMS) State Operations Manual (SOM) guidelines for unnecessary medication, the facility failed to ensure one (1) of five (5) residents reviewed for unnecessary medications, during Stage 2 of the Quality Indicator Survey (QIS), was free from unnecessary medications. There was no evidence of a gradual dose reduction (GDR) for Resident #46 for a psychopharmacological medication (any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders) used for depression, anxiety and/or sleep induction. The resident received [MEDICATION NAME] (antidepressant) for over one (1) year without evidence of an attempted GDR. Resident identifier: #46. Facility census: 50. Findings include: a) Resident #46 A review of Resident #46's medical record, on 08/11/14 at 10:50 a.m., revealed [DIAGNOSES REDACTED]. The record revealed the resident had received [MEDICATION NAME] (antidepressant), 20 milligrams (mg) since 03/25/13. The [MEDICATION NAME] was ordered for depression with specific behaviors of withdrawn and tearfulness. A concurrent review of this resident's behavior sheets found no behaviors of being withdrawn and/or tearfulness for the past four (4) months. On 08/12/14 at 9:30 a.m., a confidential interview was conducted with a licensed practical nurse. This employee stated the resident had had no behaviors for months. On 08/12/14 at 10:18 a.m., a review of the monthly drug regimen review (DRR), from 03/25/13 through the current DRR, found no recommendations for a dosage reduction of the [MEDICATION NAME] from the consulting pharmacist. On 08/12/14 at 4:00 p.m., in an interview with the Person in Charge (PIC), she said she did not know if Resident #46 had had an attempted dose reduction of the ordered antidepressant. She stated it might be in the thinned records and she would attempt to find the information An interview wi… | 2018-04-01 |
| 6244 | 6244 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 371 | F | 0 | 1 | EXXT11 | Based on observation and staff interview, the facility failed to ensure food was served in a safe and sanitary manner for seven (7) residents identified during a random opportunity for discovery. Observation found that nursing staff touched the residents' food with their bare hands, touched an unsanitary inanimate object, then immediately touched food contact surfaces. In addition, foods were not stored in a safe and sanitary manner. Food items in the freezer were found undated when opened and/or outdated. Opened foods in the freezer were also not securely re-closed to prevent potential contamination. These practices had the potential to affect all residents who received nourishment from the dietary kitchen. Resident identifiers: #46, #49, #56, #41, #20, #57, and #8. Facility census: 50. Findings include: a) During the noon meal on 08/05/14, between 11:35 a.m. and 12:00 p.m., the foods of several residents were touched by the bare hands of facility staff. - Employee #4 (nursing assistant) touched Resident #46's bread with her bare hands. - Employee #4 touched Resident #49's bread with her bare hands. - Employee #4 touched Resident #56's bread with her bare hands. - Employee #46 (nursing assistant) touched Resident #41's corn muffin with her bare hands. - After touching and positioning an unclean object (geri-chair of Resident #30), and without first sanitizing her hands, Employee #46 touched the spoon and bowl of beans of Resident #20. She then placed the bowl of beans and spoon into the hands of Resident #20 to begin feeding herself. - Resident #57. Employee #46 touched her corn muffin with her bare hands. - Resident #8. Employee #7 touched her bread with her bare hands. She also peeled the banana removed the banana from the peel with her bare hands and gave it to the resident. An interview was conducted with the certified dietary manager (CDM) and the registered dietitian on 08/06/14 at 12:00 p.m. They agreed staff were not allowed to have direct contact with residents' food. They also said staff must first san… | 2018-04-01 |
| 6245 | 6245 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 428 | D | 0 | 1 | EXXT11 | Based on medical record review, staff interview, and the State Operations Manual (SOM) Appendix PP, the consulting pharmacist failed to identify and report a medication irregularity for one (1) of five (5) residents reviewed for unnecessary medications in Stage II of the Quality Indicator Survey (QIS). The resident had not had a gradual dose reduction (GDR) for Celexa, a psychopharmacological medication (any mediation used for managing behavior, stabilizing mood, or treating psychiatric disorders), used by a resident for depression. The pharmacist failed to identify and report this irregularity. Resident identifier: #46. Facility census: 50. Findings include: a) Resident #46 Review of the medical record, on 08/11/14 at 10:50 a.m., found the resident was prescribed Celexa (antidepressant) 20 mg (milligrams) by mouth every day at 2000 (10:00 p.m.) due to depression. The beginning date for this medication was 03/25/13. On 08/12/14 at 10:18 a.m., a review of the monthly drug regimen review (DRR), from 03/25/13 through the most current DRR, found no recommendations for a dosage reduction for Celexa from the consulting pharmacist. An interview was conducted with the consultant pharmacist, on 08/14/14 at 9:30 a.m. The consultant pharmacist stated he did not recommend a dosage reduction for any resident receiving an antidepressant unless the dosage was above the maximum recommended dosage. If a resident was receiving an antidepressant above the recommend maximum dosage, he would make a recommendation to the physician for a dosage reduction. He further stated Resident #46 was not receiving a dosage above the maximum recommended dosage, so he had made no recommendations for a dosage reduction. In addition, he stated he did not agree with dosage reductions for antidepressants even though he knew the regulation and had received a citation before. A review of the Centers for Medicare and Medicaid Services SOM guidelines at 483.25 (l) Unnecessary Drugs: .when monitoring all psychopharmacological medications and sedative/hypnot… | 2018-04-01 |
| 6246 | 6246 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 431 | E | 0 | 1 | EXXT11 | Based on observation and staff interview, the facility failed to provide safe and secure storage of medications. Controlled medications and other medications subject to abuse were not stored in a separately locked, permanently affixed compartment as required for medications listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976. The emergency medication supply box (labeled as narcotics) containing these medications, was observed locked and sitting on the counter top in the Hall B and C medication room. The box was not affixed to a secure location. This practice had the potential to affect more than a limited number of residents. Facility census 50. Findings Include: a) Observation of the B and C hall medication room, at 3:35 p.m., on 08/11/14, revealed a locked box marked narcotics. The box was not permanently affixed to a surface. Licensed Practical Nurse (LPN) #27 was present during the observation and said this was the emergency supply box of medications. The situation was reported to the Person in Charge (PIC). On 08/14/14 at 11:55 a.m., the emergency medication supply box was observed locked, but still was not permanently affixed. At that time, the PIC stated she had already ordered a box that could be permanently affixed. The contents of the emergency medication supply box were counted by the PIC. It contained the following: -- Hydrocodone with Tylenol 5/325 mg (milligrams) - two (2) tabs, -- Hydrocodone with Tylenol 10/325 mg - eight (8) tabs, -- Hydrocodone with Tylenol 10/500 mg - two (2) tabs, -- Ativan 0.5 mg - four (4) tabs, -- Phenergan 125 mg - seventeen (17) tabs, -- Oxycodone 5 mg - ten (10) tabs, -- Oxycodone with Tylenol 5/325 mg - nineteen (19) tabs, -- Valium 5 mg - three (3) tabs, -- Tylenol with Codeine 300/30 mg - three (3) tabs, -- Fentanyl Patch 25 mch, (micrograms) - three (3), -- Fentanyl Patch 75 mch - three (3), -- Morphine Sulfate 10 mg per 5 ml (millimeters), five (5) containers, -- Demerol 25 mg - nine (9) injections, -- Valium Injectable 10 mg/2 m… | 2018-04-01 |
| 6247 | 6247 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 441 | E | 0 | 1 | EXXT11 | Based on observation and staff interview, the facility failed to maintain an effective infection control program to prevent and control, to the extent possible, the onset and spread of infection within the facility. During a meal served in the fine dining room, employees touched residents' food items with bare hands. In addition, a nursing assistant (NA) touched an inanimate unclean object, then immediately served food to a resident without first completing hand sanitation. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: #46, #49, #56, #41, #20, #57, #8. Facility census: 50. Findings include: a) During the noon meal on 08/05/14, between 11:35 a.m. and 12:00 p.m., the food of several residents was touched by the bare hands of facility staff: - Employee #4 (NA) touched Resident #46's bread with her bare hands. - Employee #4 touched Resident #49's bread with her bare hands. - Employee #4 touched Resident #56's bread with her bare hands. - Employee #46 (NA) touched Resident #41's corn muffin with her bare hands. - Employee #46, after touching and positioning an unclean object (geri-chair of Resident #30), and without first sanitizing her hands, touched the spoon and bowl of beans of Resident #20. She then placed the bowl of beans and spoon into the hands of Resident #20 to begin feeding herself. - Employee #46 touched Resident #57's corn muffin with her bare hands. - Employee #7 touched Resident #8's bread with her bare hands. She also peeled the banana removed the banana from the peel with her bare hands and gave it to the resident. An interview was conducted with the certified dietary manager (CDM) and the registered dietitian on 08/06/14 at 12:00 p.m. They agreed staff members are not allowed to have direct contact with residents' food. Also, staff must first sanitize their hands before coming into contact with food and eating utensils belonging to the residents. An interview was conducted with the Person in Charge, Employee #31, on 08/12/14 at 8:00 a.m. S… | 2018-04-01 |
| 6248 | 6248 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 490 | E | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and a review of the Centers for Medicare and Medicaid (CMS) State Operations Manual, 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 physical well-being of each resident. Facility administration failed to ensure residents were as free as possible from accident hazards over which it had control. Water temperatures in the public restrooms, that could be accessed by more than an isolated number of residents, were too high for safety. The public restrooms, for men and women, registered 160 degrees Fahrenheit (F) on 08/13/14. Those restrooms were unlocked, and could be accessed by mobile residents. Also, water temperatures were high in two (2) resident common use restrooms, registering 120 degrees (F) on 08/13/14. Those restrooms were unlocked, and could be accessed by mobile residents. These situations created a potential for serious injury to more than an isolated number of residents. Affected areas included the men's and women's public restrooms that were located in the corridor between the front hall and back hall resident living quarters, and the two (2) common use restrooms located at the entrance to the C hall resident living quarters. A facility maintenance employee verbally reported that they check the water temperatures in all the resident areas once per month. However, they do not keep a log, or records, of when the water temperatures were tested , and/or the results of the testing. There was no evidence the facility monitored and/or used the results of the monitoring of hot water temperatures to ensure resident safety. Census: 50. Findings include: a) Men and Women public restrooms between the front and back resident halls While completing the survey, it was noticed that the water temperature of the sink in the female public restroom seemed hot to touch. This prompted further investiga… | 2018-04-01 |
| 6249 | 6249 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 520 | E | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and a review of the Centers for Medicare and Medicaid (CMS) State Operations Manual, the quality and assessment (QA) committee failed to identify and implement a plan of action to correct a quality deficiency over which it had knowledge, or should have had knowledge. Water temperatures in the public restrooms, that could be accessed by more than an isolated number of residents, were too high for safety. The public restrooms, for men and women, registered 160 degrees Fahrenheit (F) on 08/13/14. Those restrooms were unlocked, and could be accessed by mobile residents. Also, water temperatures were high in two (2) resident common use restrooms, registering 120 degrees (F) on 08/13/14. Those restrooms were unlocked, and could be accessed by mobile residents. These situations created a potential for serious injury to more than an isolated number of residents. Affected areas included the men's and women's public restrooms that were located in the corridor between the front hall and back hall resident living quarters, and the two (2) common use restrooms located at the entrance to the C hall resident living quarters. A facility maintenance employee verbally reported that they check the water temperatures in all the resident areas once per month. However, they do not keep a log, or records, of when the water temperatures were tested , and/or the results of the testing. There was no evidence the facility monitored and/or used the results of the monitoring of hot water temperatures to ensure resident safety. Facility census: 50 Findings include: a) Men and Women public restrooms between the front and back resident halls While completing the survey, it was noticed that the water temperature of the sink in the female public restroom seemed hot to touch. This prompted further investigation of water temperatures in public and common use restrooms. An interview was conducted with Maintenance Employee #99 on 08/13/14 at… | 2018-04-01 |
| 6250 | 6250 | GRANT MEMORIAL HOSPITAL | 515045 | 117 HOSPITAL DRIVE | PETERSBURG | WV | 26847 | 2014-02-21 | 225 | D | 0 | 1 | CYPG11 | Based on record review, staff interview, and review of the Center for Medicare and Medicaid Services (CMS) S&C-05-09 letter, the facility failed to investigate and report an injury of unknown source to appropriate agencies. One (1) of one (1) resident reviewed for accidents had a fractured finger. The facility had not investigated the injury or reported the injury to the appropriate outside agencies. Resident identifier #8. Facility census: 11. Findings Include: a) Resident #8 On 02/18/14 at 10:27 a.m., an interview with Employee #9, Registered Nurse (RN), revealed Resident #8 sustained a fracture to the left little finger within the past 30 days. Resident #8's medical record, reviewed at 8:46 a.m. on 2/19/14, revealed the following nursing notes: -- 02/08/14 at 5:40 p.m., .Combative with staff during ADL (activities of daily living) care and bed bath. Scratched one of the CNA's in her right eye and caused her contact lens to come out -- 02/09/14 at 10:48 p.m., (typed as written): .Resident complained of her lt (left) hand hurting. Staff then called me into room to assess. Assessment of lt hand revealed bruising on outside of hand from wrist down to pinkie. Bruising wrapped around to both top and under side of hand. Resident refuses cold packs on hand. resident can not verify how or when she hurt her hand. -- 02/10/14 at 11:31 a.m., (typed as written): (L) (Left) hand 4th and 5th fingers swollen and very bruised. pt. (patient) c/o (complains of) pain in (L) hand. X-ray of (L) hand ordered A review of the X-ray report revealed Resident #8 had a non-displaced fracture involving the proximal phalanx of the little finger. On 02/19/14 at 9:04 a.m., Employee #8,the RN Nursing Manager of the Long Term Care Unit, reported she usually handled the reportable incidents if it happens during the day. She said if it happened in off hours, the nursing manager on call handled the reporting of the incident. Employee #8 stated they had a meeting about Resident #8 and the fracture she sustained to her left hand. She reported they d… | 2018-04-01 |
| 6251 | 6251 | GRANT MEMORIAL HOSPITAL | 515045 | 117 HOSPITAL DRIVE | PETERSBURG | WV | 26847 | 2014-02-21 | 272 | D | 0 | 1 | CYPG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately assess one (1) of nine (9) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The facility did not complete the Care Area Assessment (CAA), a part of the Minimum Data Set (MDS), for Resident #18 in the areas of vision and [MEDICAL CONDITION] drug use. Resident identifier: #18. Facility census: 11. Findings include: a) Resident #18 Resident #18's medical record review, reviewed on 02/19/14 at 11:00 a.m., contained an admission minimum data set (MDS) with an assessment reference date (ARD) of 01/01/14. A review of the CAA summary worksheets for visual function and [MEDICAL CONDITION] drug use revealed the location of the documentation was the CAA worksheet dated 01/03/14. Review of the 01/03/14 CAA summary worksheets revealed no documentation on these summaries related to vision or [MEDICAL CONDITION] drug use. These summaries were blank. During an interview with Employee #9 (MDS Coordinator) at 12:30 p.m. on 02/19/14, she confirmed the CAA summaries for vision and [MEDICAL CONDITION] drug use had not been completed. She stated the facility had a new system and she had not realized the CAA summary portion of the assessment was not completed. | 2018-04-01 |
| 6252 | 6252 | GRANT MEMORIAL HOSPITAL | 515045 | 117 HOSPITAL DRIVE | PETERSBURG | WV | 26847 | 2014-02-21 | 323 | D | 0 | 1 | CYPG11 | **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 one (1) resident reviewed for accidents had an environment as free from accident hazards as possible. Resident #8 was known to hit her hand on the bed side rails while resisting care. The facility did not implement interventions to protect this resident from potentially injuring herself when resisting care. Resident Identifier: #8. Facility Census: 11. Findings Include: a) Resident #8 An interview with Employee #9, Registered Nurse (RN), at 10:27 a.m., on 02/18/14 revealed Resident #8 had a fracture to the left little finger. The RN stated we have no idea how she done it. Resident #8's medical record review, at 8:46 a.m. on 2/19/14, revealed the following nursing notes: -- 02/08/14 at 5:40 p.m., .Combative with staff during ADL (activities of daily living) care and bed bath. Scratched one of the CNA's in her right eye and caused her contact lens to come out -- 02/09/14 at 10:48 p.m., .Resident complained of her lt (left) hand hurting. Staff then called me into room to assess. Assessment of lt hand revealed bruising on outside of hand from wrist down to pinkie. Bruising wrapped around to both top and under side of hand. Resident refuses cold packs on hand. resident can not verify how or when she hurt her hand. -- 02/10/14 at 11:31 a.m., (typed as written) (L) (Left) hand 4th and 5th fingers swollen and very bruised. pt. (patient) c/o (complains of) pain in (L) hand. X-ray of (L) hand ordered -- 02/10/14 at 7:53 p.m., Late entry for 18:45 (7:45 p.m.) pt. (patient) assisted to bed by nursing staff. pt. yelling out. pt. hit staff member and hit (r) arm on bed rail. skin tear observed at old bruised site, cleaned with normal saline and skin smoothed over site and steri strips applied. The X-ray report review revealed Resident #8 had a non-displaced fracture involving the proximal phalanx of the little finger. During an interview with Employee #8, registered nurse … | 2018-04-01 |
| 6253 | 6253 | GRANT MEMORIAL HOSPITAL | 515045 | 117 HOSPITAL DRIVE | PETERSBURG | WV | 26847 | 2014-02-21 | 514 | D | 0 | 1 | CYPG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the accuracy and completeness of the clinical record for one (1) of twenty-four (24) residents. Resident #17 had an incorrect order for [MEDICATION NAME] (antidepressant). Resident identifier: #17. Facility census: 11.Findings include:a) Resident #17A review of the medication administration (MAR) record on 02/18/14 at 3:00 p.m., found an order for [REDACTED]. The director of nursing agreed, at 3:30 p.m. on 02/18/14, that the order for [MEDICATION NAME] was incorrect. She indicated the order for [MEDICATION NAME] should have read, [MEDICATION NAME] 10 mg tablets- give 1/2 tablet which equals 5 mg po daily. | 2018-04-01 |
| 6254 | 6254 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 272 | D | 0 | 1 | 4OKO11 | Based on medical record review and staff interview, the facility failed to accurately assess one (1) of twenty-three (23) Stage 2 residents. A comprehensive assessment was coded inaccurately for pressure ulcers. Resident identifier: Resident #66. Facility census: 88. Findings include: a) Resident #66 This resident's medical record was reviewed on 01/22/14 at 12:16 p.m., and revealed the resident's history of pressure ulcers since admission. The quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 09/18/13, was coded 1 under Item M0210, which indicates the presence of one or more unhealed pressure ulcers at Stage 1 or higher. Item M0900, was coded 1, which indicated pressure ulcers were present on the prior assessment. The annual MDS assessment, with an ARD of 12/18/13, was coded 0, under Item M0900, which indicated pressure ulcers were not present on the prior assessment. An interview conducted with Employee #102 (Registered Nurse Assessment Coordinator), on 01/22/14 at 4:20 p.m., confirmed the MDS assessment was coded incorrectly. | 2018-04-01 |
| 6255 | 6255 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 278 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the health professional who completed Item M0900, healed pressure ulcers, of the comprehensive assessment for one (1) of twenty-three (23) Stage 2 sample residents certified the accuracy of this portion; however, Item M0900 did not accurately reflect the resident's pressure ulcer status. Resident identifier: #66. Facility Census: 88. Findings include: a) Resident #66 Review of the medical record on 01/22/14 at 12:16 p.m., revealed Resident #66 had a history of [REDACTED]. The quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 09/18/13, was coded as 1 for Item M0210, which indicated the presence of one or more unhealed pressure ulcers at Stage 1 or higher. The annual MDS assessment, with an ARD of 12/18/13, was coded 0, for Item M0900, which indicated pressure ulcers were not present on the prior assessment. An interview conducted with Employee #102 (Registered Nurse Assessment Coordinator), on 01/22/14 at 4:20 p.m. confirmed the MDS assessment had been coded inaccurately. | 2018-04-01 |
| 6256 | 6256 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 279 | E | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop care plans which described the care and services necessary to meet the medical, mental, and/or psychosocial needs for four (4) of twenty-three (23) residents in Stage 2 of the Quality Indicator Survey. The care plans lacked nonpharmacologic interventions for conditions being treated with [MEDICAL CONDITION] medications, in an effort to reduce or eliminate the use of the medications. Resident identifiers: #91, #104, #151, and #87. Facility census: 88. Findings include: a) Resident #91 Medical record review revealed Resident #91 was prescribed [MEDICATION NAME] for a [MEDICAL CONDITION],[MEDICATION NAME], and [MEDICATION NAME] for anxiety. Review of the medical records revealed the care plan did not identify specific nonpharmacologic interventions to address the resident's [MEDICAL CONDITIONS], and anxiety. On 01/23/14 at 10:43 a.m., registered nurse, Employee #102, acknowledged there were no nonpharmacologic interventions in the care plan for this resident. b) Resident #104 Medical record review revealed Resident #104 was currently [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME] for anxiety, and [MEDICATION NAME], and [MEDICATION NAME] for a [MEDICAL CONDITION]. Review of the medical records revealed the care plan did not include nonpharmacologic interventions for the resident's [MEDICAL CONDITION], anxiety, or [MEDICAL CONDITION] in an effort to reduce or eliminate the use of the pharmaceuticals. On 01/23/14 at 10:43 a.m., register nurse, Employee #102, acknowledged there were no nonpharmacologic interventions in the resident's care plan to address the conditions for which the resident was receiving medications. c) Resident #151 Medical record review revealed Resident #151 was prescribed [MEDICATION NAME] related to a [MEDICAL CONDITION] to [MEDICAL CONDITION]. Review of the medical records revealed the resident's care plan did not identify specific nonpharm… | 2018-04-01 |
| 6257 | 6257 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 280 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to update a care plan to reflect the resident's current medical condition. This was found for one (1) of twenty-three (23) Stage 2 sample residents. Resident #99's current care plan contained goals and interventions for insulin dependent diabetes, a [DIAGNOSES REDACTED]. Resident identifier: #99. Facility census: 88. Findings include: a) Resident #99 Review of the resident's medical record, on 01/22/14 at 8:30 a.m., revealed Resident #99's current medical [DIAGNOSES REDACTED]. The resident's current care plan, dated 12/16/13, and updated on 12/31/13, listed insulin dependent diabetes as a current diagnosis. Goals and interventions had been established and remained a part of the care plan. Further review of the Medication Administration Record [REDACTED]. An interview was conducted with Employee #102 (registered nurse assessment coordinator) on 01/22/14 at 11:18 a.m. She reviewed the resident's current Medication Administration Record [REDACTED]. She acknowledged the resident was no longer receiving insulin and agreed the care plan needed to be revised to indicate this issue was resolved. | 2018-04-01 |
| 6258 | 6258 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 282 | E | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, and observation the facility failed to provide care as indicated on the care plan for six (6) of twenty-three (23) Stage 2 quality indicator survey, sample residents. Residents #91, #104, #151, #147, and #87's care plans included monitoring for side effects of [MEDICAL CONDITION] medications. This monitoring did not occur. Resident #71's care plan included using a positioning wedge and Prevalon boots which were either not used or used inappropriately. Resident identifiers: #91, #104, #151, #147, #71, and #87. Facility census: 88. Findings include: a) Resident #91 On 01/23/14, review of the care plan, with an initiated date of 01/10/14, revealed a problem related to a potential for drug related complications associated with the use of [MEDICAL CONDITION] medications. The resident was prescribed an anti-depressant. An intervention was, Monitor for side effects and report to physician. Review of medical records revealed no evidence monitoring for side effects of [MEDICAL CONDITION] medications was being done. b) Resident #104 Resident #104's care plan, with an initiated date of 07/12/13, was reviewed on 01/23/14. The care plan revealed a problem related to a potential for drug related complications associated with the use of [MEDICAL CONDITION] medications for for anxiety and depression. Both medications had interventions to: Monitor for side effects and report to physician. Review of medical records revealed no evidence that monitoring for side effects of [MEDICAL CONDITION] medications was being done. c) Resident #151 Review of the 01/23/14 care plan for Resident #151 revealed a problem related to a potential for drug related complications associated with the use of [MEDICAL CONDITION] medications. The resident's current Medication Administration Record [REDACTED]. Care plan interventions for both of these medications included Monitor for side effects and report to physician. Review … | 2018-04-01 |
| 6259 | 6259 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 309 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observation, and policy review, the facility failed to provide the care and services to attain, or maintain the highest practicable physical,mental,and psychosocial well-being for one (1) of three (3) residents reviewed for skin integrity. A resident with impaired skin integrity was not assessed and monitored. Resident identifier: #147. Facility census: 88. Findings include: a) Resident #147 During a Stage 1 interview on 01/20/14 at 4:09 p.m., a white bandage was observed on Resident #147's 5th finger of his right hand. He said he had scratched it on the wheelchair rim. He related it had bled pretty bad, and staff put a bandage on it. The resident said the rim he used to propel himself had a sharp area on it causing the scratch. The interim care plan, dated 01/08/14, was reviewed on 01/22/14 at 12:59 p.m. It indicated staff would monitor the resident for skin tears, and bruising for increased bleeding related to [MEDICATION NAME] therapy. No actual skin impairment was noted. Review of the comprehensive care plan, dated 01/13/14 noted to inspect skin with care. Further review of the medical record, on 01/22/14 at 1:01 p.m. revealed no orders for treatments to the resident's skin. Progress notes, reviewed from the date of admission, indicated the resident's skin was intact. The determination of capacity, completed on 01/08/14, indicated the resident had capacity. Employee #6, a registered nurse (RN) supervisor, was interviewed on 01/22/14 at 1:15 p.m. She said she was not aware of an injury or concern with the wheelchair. She spoke with the resident. He informed her he had cut his finger on the silver part of the wheelchair because It may have been related to the rust lifted. He added, I bled pretty bad. He showed her rust areas along the rim and the taped area. He indicated staff used tape to cover the area where he cut his finger. Employee #6 told the resident she would have someone look at the… | 2018-04-01 |
| 6260 | 6260 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 323 | D | 0 | 1 | 4OKO11 | Based on medical record review, staff interview, resident interview, and observation, the facility failed to ensure the residents environment was as free from accident hazards as was possible for one (1) of three (3) residents reviewed with impaired skin integrity. A resident alleged an injury from a defective wheelchair. The chair had rusted causing sharp areas on the wheel utilized for self-propelling. Resident identifier: Resident #147. Facility census: 88. Findings include: a) Resident #147 During a Stage 1 interview on 01/20/14 at 4:09 p.m., a white bandage was observed on Resident #147's 5th finger of his right hand. He said he had scratched it on a sharp area on the wheelchair rim he used to propel himself. Employee #6, a registered nurse (RN) supervisor, was interviewed on 01/22/14 at 1:15 p.m. She said she was not aware of an injury or concern with the wheelchair. She spoke with the resident and he informed her he had cut his finger on the silver part of the wheelchair because It may have been related to the rust lifted. He added, I bled pretty bad. He showed her rust areas along the rim. He also showed her a taped area, which he said staff used to cover the area where he cut his finger. She told the resident she would have someone look at it, and placed the chair back at the lower side of his bed. He informed the nurse he was concerned someone else may get a bigger cut than he did. An interview with the occupational therapist (OT), on 01/22/14 at 1:17 p.m., indicated she was not aware of a problem with the wheelchair. The OT said therapy provided the chair to the resident. She observed the tape and said it was not there when the chair was given to the resident. She looked at the chair and acknowledged rust along the silver area of the chair. Incident and accident reports were reviewed on 01/22/14 at 1:46 p.m. They revealed no evidence a report had been completed to identify or evaluate hazards or risks associated with the wheelchair. An interview with the therapy program director, a physical therapist (… | 2018-04-01 |
| 6261 | 6261 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 328 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, resident comment, and staff interviews, the facility failed to ensure a resident with a gastrostomy tube received proper treatment and care. A nurse administered a resident's medication through his gastrostomy tube using ice water. Resident identifier: #92. Facility census: 88. Findings include: a) Resident #92 During an observation of medication administration, on 01/22/14 at 3:31 p.m., Employee #73, a licensed practical nurse (LPN) poured the medication [MEDICATION NAME] sulfate 325 milligrams (mg), crushed it, and placed it in a cup. She poured water from the pitcher into the cup to mix the medication. She poured an additional cup of water from the same pitcher. The LPN carried both cups into the room and set them on the bedside stand. She administered the medication via the resident's enteral tube, utilizing the water she had poured from the pitcher. When she first flushed the tube with the water, the resident startled, and his eyes widened. Upon inquiry, the resident said he was okay. An interview with Employee #73 (LPN), on 01/22/14 at 4:45 p.m. confirmed she used ice water to administer the medication and flush the feeding tube. She said she should have used tap water. (Putting the ice water through the tube did not allow warming of the water as would happen if the resident had swallowed the water and it had warmed while passing through the esophagus before reaching the stomach.) Review of the facility's medication administration competency check list for enteral tubes, on 01/22/14 at 4:00 p.m., revealed medications were to be administered with warm water. Review of the pharmacy enteral tube medication administration, on 01/23/14 at 4:30 p.m., also indicated warm water was to be utilized. During an interview with the director of nursing (DON) on 01/22/14 at 4:50 p.m., she confirmed the standard of practice was not followed; and the nurse incorrectly administered the medication to Reside… | 2018-04-01 |
| 6262 | 6262 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 329 | E | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review the facility failed to ensure three (3) of five (5) Stage 2 quality insurance survey sample residents reviewed for unnecessary medications, were free of unnecessary medications. The facility failed to identify nonpharmacological interventions for residents prescribed [MEDICAL CONDITION] medications, failed to monitor for adverse effects of medications and failed to identify the wrong reason for medication administration on a physician order. Resident identifiers: #104, #149, #87, and #22. Facility census: 88. Findings Include: a) Resident #104 Review of medical records, on 01/23/14, revealed Resident #104 received [MEDICATION NAME] and [MEDICATION NAME] for depression,[MEDICATION NAME], and [MEDICATION NAME] for anxiety. Continued review, of Resident #104's medical records, failed to find evidence the facility attempted to implement non-pharmacologic interventions or explore any underlying causes of distressed behavior before administering a psychopharmacologic medication. Employee #102 provided the Behavior Monthly Flow Sheets for the last three (3) months. These flow sheets were completed by the licensed nursing staff each shift. These documents listed the medications and the reason the medication was prescribed. The Behavior Monthly Flow Sheet did not list non-pharmacological interventions specific to Resident #104 and revealed no evidence of monitoring the resident for side effects of the medications. This was confirmed by Employee #102 on 01/23/14 at 2:00 p.m. b) Resident #149 Review of the medical record, on 01/23/14 at 8:23 a.m., revealed Resident #149 was admitted to the facility on [DATE] for rehabilitation services. His admission orders [REDACTED]. The medication orders included an order for [REDACTED]. The Medication Administration Record [REDACTED]. Resident #149 received the [MEDICATION NAME] daily between 01/17/14 and 01/23/14. [MEDICATION NAME] is given for [MEDICAL COND… | 2018-04-01 |
| 6263 | 6263 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 332 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure the medication error rate was below five percent. Observation of medication administration pass identifed two (2) errors in the thirty (30) opportunities observed. This resulted in an error rate of 6%. A resident's blood pressure and pulse were not obtained for a resident as required by the physician's orders [REDACTED]. Resident identifiers: #106 and #144. Facility census: 88. Findings include: a) Resident #106 Observation of medication administration was completed with Employee #11, a licensed practical nurse (LPN), on 01/22/14 at 4:40 p.m. Resident #106 was not in his room. The LPN went down the hallway to find the resident. The nurse returned to the cart and the resident propelled himself up the hallway to the medication cart. The LPN poured the medications and administered them to the resident. Vital signs (VS) were not taken at that time. Review of the physician's orders [REDACTED]. Review of vital signs through 01/23/14 noted the last blood pressure taken was dated 01/21/14. Review of the Medication Administration Record [REDACTED]. Additionally, the progress notes were reviewed and revealed no evidence vital signs were obtained prior to administering the medication. An interview with the director of nursing (DON),on 01/23/14 at 1:00 p.m., confirmed no evidence was available to indicate vital signs were obtained prior to administering the medication. Review of the administration procedures for all medications, on 01/23/14 at 4:30 p.m., revealed prior to removing the medication package/container from the cart/drawer, the nurse was to check the Medication Administration Record [REDACTED]. b) Resident #144 Observation of medication administration with Employee #85, a licensed practical nurse (LPN), on 01/23/14 at 8:41 a.m., revealed [MEDICATION NAME] 100 mg (one capsule) was administered orally to Resident #144. Review of the med… | 2018-04-01 |
| 6264 | 6264 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 428 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and staff interview, the pharmacist failed to identify a medication irregularity during her monthly medication review and report it the attending physician and the director of nursing. This was found for one (1) of five (5) Stage 2 sampled residents. Resident #149's admission orders [REDACTED]. Resident identifier: #149. Facility census: 88. Findings include a) Resident #149 Review of the medical record, on 01/23/14 at 8:23 a.m., revealed Resident #149 was admitted to the facility on [DATE] for rehabilitation services. His admission orders [REDACTED]. The medication orders included an order for [REDACTED]. The order stated (typed as written): Prilosec capsule delayed release 20 mg (milligrams) (Omeprazole) Give 1 capsule by mouth one time a day related to depressive disorder not elsewhere classified (311). (Prilosec is given for gastrointestinal disorders.) The medication administration record (MAR) also stated (typed as written): Prilosec capsule delayed release 20 mg (Omeprazole) Give 1 capsule by mouth one time a day related to depressive disorder not elsewhere clasiffied (311). Resident #149 received the Prilosec daily between 01/17/14 and 01/23/14. The clinical pharmacist medication regimen review summary indicated the pharmacist (Employee #104) reviewed the resident's medications on 01/17/14 and documented she had no recommendations. The facility policy titled, Medication Monitoring Medication Regimen Review, section 9.1, included in section E The consultant pharmacist's evaluation includes, but is not limited to reviewing and/or evaluating the following: 1) A written diagnosis, indication, or documented objective findings support each medication order. Part 3 of section E states: Indications for use and therapeutic goals are consistent with current medical literature and clinical guidelines. During an interview on 01/23/14 at 1:20 p.m., Employee #23 (director of nursing) reviewed Resident #149's MA… | 2018-04-01 |
| 6265 | 6265 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 431 | E | 0 | 1 | 4OKO11 | Based on observation, staff interview, review of manufacturer's instructions, and policy review, the facility failed to ensure medications were stored appropriately or according to pharmacy recommendations. A resident's medication was stored with stock medications, a multi dose vial was not labeled with the date opened, tuberculin serum was not refrigerated, and intravenous fluids with and without medications added were expired. This had the potential to affect more than a limited number of residents. Facility census: 88. Findings include: a) Medication Storage 1) North hall During an observation of the north hall medication room, with Employee #68, a licensed practical nurse (LPN), on 01/21/14 at 2:00 p.m., heparin lock flush belonging to a resident, was stored with stock medications. The nurse said, It shouldn't be here. Review of the south hall medication room with Employee #5 (LPN), on 01/21/14 at 2:15 p.m., found expired intravenous (IV) solutions. The IV solutions were: -- Lactated Ringers 1000 milliliters (ml), expired June 2013 -- Lactated Ringers 1000 ml, expired July 2013 -- 0.45 Normal Saline (NS) 1000 ml, expired June 2013 -- 0.9% (percent) Sodium Chloride (NaCl) attached to piperacillin/tazopactum (an antibacterial agent) 50 ml x 5 doses, expired December 2013 -- 0.9% NaCl 50 ml with meropenem (an antibiotic) expired October 2013 0.9% NaCl 50 ml with cefepime (an antibiotic) x 2 doses expired December 2013 0.9% NaCl 50 ml with Rocephin (an antibiotic) expired December 2013 0.9% NaCl 50 ml with Rocephin expired July 2013 0.9% NaCl 50 ml with Rocephin expired August 2013 Additionally, the pharmacy label was removed from one bag of 0.9% NaCl 50 ml with meropenum. Employee #5, (LPN) said the pharmacy representative reviewed the medications in September. She said the pharmacy came in Labor Day. The LPN also related the medications and intravenous fluids were to be checked monthly. 2) South hall Review of the south hall medication cart 2, with Employee #11 (LPN) on 01/22/14 at 3:00 p.m., found an open mult… | 2018-04-01 |
| 6266 | 6266 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 441 | E | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and review of infection control organism reports, the facility failed to maintain an infection control program to provide a safe, sanitary environment, and to help prevent the development and transmission of disease and infection. The infection control program did not conduct surveillance and investigate identified organisms in the facility in order to attempt to identify possible transmission of organisms from one resident to another. This practice had the potential to affect more than a limited number of residents residing in the facility. In addition, staff failed to adhere to posted contact precautions by not wearing personal protective equipment (PPE) during an observed dressing change. This was true for one (1) resident of the one (1) dressing change observed. Resident identifier: #99. Facility census: 88. Findings include: a) Infection Control Program On 01/23/14 at 9:00 a.m. a review of the infection control program and reports was conducted. During this review of the available reports, for August, September and October 2013, revealed a Query Summary Report from the local area hospital conducting the facility's culture and sensitivity laboratory reports. August reports revealed the following organisms: -- [MEDICATION NAME] faecium (2) -- Proteus mirabilis September reports revealed the following organisms: -- [DIAGNOSES REDACTED] Pneumoniae -- Morganella morganii -- Proteus mirabilis -- Escherichia coli October reports revealed the following organisms: -- [MEDICATION NAME] faecium -- Escherichia coli (3 residents) -- Pseudomonas aeruginosa -- Providencia stuartii An additional report, titled Golden Living Center Infection Control Committee Meeting Minutes for August, September and October 2013, was reviewed at this same time. This report did not identify any of the above organisms present in the facility during these months. On 01/23/14 at 9:55 a.m., an interview with the infection… | 2018-04-01 |
| 6267 | 6267 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 514 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the clinical health status/change of condition guideline, and staff interview, the facility failed to ensure the accuracy of the medical record for one (1) of three (3) residents reviewed for impaired skin integrity. The medical record did not reflect the status of an accident with injury. Resident identifier: #147. Facility census: 88. Findings include: a) Resident #147 During a Stage 1 interview on 01/20/14 at 4:09 p.m., a white bandage was observed on Resident #147's 5th finger of his right hand. He said he had scratched it on the wheelchair rim. The resident said the rim he used to propel himself had a sharp area on it. The interim care plan, dated 01/08/14, was reviewed on 01/22/14 at 12:59 p.m. It indicated staff was to monitor the resident for skin tears and bruising for increased bleeding. No actual skin impairment was noted. Review of the comprehensive care plan, dated 01/13/14 noted to inspect skin with care. No indication of skin impairment was evident. Further review of the medical record, on 01/22/14 at 1:01 p.m. revealed no order for treatment. Progress notes, reviewed from the date of admission, indicated the resident's skin was intact. Employee #6, a registered nurse (RN) supervisor, was interviewed on 01/22/14 at 1:15 p.m. She said she was not aware of an injury or concern with the wheelchair. She spoke with the resident and he informed her he had cut his finger on the silver part of the wheelchair because it may have been related to the rust lifted. He added, I bled pretty bad. An interview with director of nursing (DON and executive director (ED), on 01/22/14 at 2:06 p.m.,revealed they were unaware of an injury or problem with the wheelchair. The DON said the policy was to complete a DQI (incident report) and the facility would follow up with the problem. The DON reviewed the progress notes and DQI reports and said no information was available. She also reviewed the medical record a… | 2018-04-01 |
| 6268 | 6268 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 520 | F | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview the Quality Assessment and Assurance (QAA) committee failed to identify and/or act upon quality deficiencies within the facility operations of which it did have (or should have had) knowledge, and implement plans of action to correct these deficiencies, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. The facility failed to address deficiencies identified during pharmacy audits which included improper storage and labeling of medications, and expired medications. The facility failed to identify, monitor and track infections and there were no audits in place to evaluate isolation precaution practices. This had the potential to affect all residents. Facility census: 88. Findings include: a) The medication safety system assessments were reviewed for the months of November 2013, December 2013, and January 2014 on 01/23/14 at 3:50 p.m. Deficiencies identified by the pharmacist included: medication stored without a label, a multidose vial not dated, and expired medications. An interview was conducted with Employee #37 (executive director), Employee #149 (assistant director of nursing), and Employee # 23 (director of nursing) on 01/24/14 at 10:45 a.m. They reported there was no plan of correction in place to correct the ongoing issues related to the improper storage and labeling of medications or the presence of expired medications. On 01/24/14 at 11:00 a.m., Employee #37 (executive director and QAA Contact Person) reported the QAA committee had stopped performing audits six (6) months ago after completing a mock survey. The QAA committee reviewed resident care areas including activities of daily living, pressure ulcers, infections, incontinence, catheter care, pain, psychiatric medication use, behaviors, falls, elopement, [MEDICATION NAME] and grievances monthly. The committee was aware of the pharmacy audi… | 2018-04-01 |
| 6269 | 6269 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2015-04-16 | 225 | D | 1 | 0 | AU7811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to report potential neglect to the appropriate state agencies for one (1) of ten (10) residents reviewed. Staff failed to secure the lift pad when transferring Resident #11 with a mechanical lift, which resulted in a fall. Resident identifier: Resident #11. Facility census: 112. Findings include: a) Resident #11 During a medical record review, on 04/15/15 at 11:15 a.m., a progress note, dated 03/02/15, indicated Resident #11 required a total lift with transfers and activities of daily living (ADLs). The current care plan, reviewed on 04/15/15 at 11:41 a.m., indicated the resident required assistance with transfers and locomotion due to disease/compromising functional ability. It specified the use of a mechanical lift for transfers. The care plan also indicated Resident #11 was at risk for additional falls. The care plan falls history noted the resident had a change in condition, dated 03/09/15, related to a recent fall. A change of condition note, dated 02/18/15 at 7:25 p.m. indicated an accident/incident/fall in the past 72 hours. The note indicated the resident experienced back pain, which started after the fall. Further review of the medical record, on 04/15/14 at 12:45 p.m., revealed a progress note, dated 02/28/15 at 7:25 p.m. which indicated the resident was experiencing back pain and was sent to the emergency room for evaluation. Another progress note, at 7:57 p.m., indicated the resident sustained [REDACTED]. A progress note at 10:59 p.m. indicated the resident was transferred to the emergency room for a computerized tomography (CT) scan. The risk management report, supplied upon request on 04/15/15 at 1:45 p.m., indicated on 02/18/15, two (2) nursing assistants attempted to transfer Resident #11 from the shower chair to the bed, utilizing the mechanical lift. According to the report, the lift straps came off lift and resident fell to floor. The re… | 2018-04-01 |
| 6270 | 6270 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2015-04-16 | 280 | D | 1 | 0 | AU7811 | Based on medical record review, observation, and staff interview, the facility failed to revise a care plan for one (1) of ten (10) sample residents. Resident #25's care plan was not revised to include the required use of a gait belt. Resident identifier: #25. Facility census: 112. Findings include: a) Resident #25 Review of risk management reports, on 04/14/15 at 2:30 p.m., revealed Resident #25 fell while being transferred from the shower chair to the bed, on 01/20/15 at 6:30 a.m. The report indicated the nursing assistant lowered the resident to the floor, and the resident was assisted back to bed via a lift. The assessment noted a large abrasion running vertically down the resident's back. The report did not note whether or not a gait belt was utilized. On 04/16/15 at 8:30 a.m., review of the resident's most recent lift-transfer-repositioning evaluation, dated 11/29/14 (before the fall), revealed the resident required the use of a gait belt for transfers. The most recent evaluation, completed on 03/01/15, also indicated the resident required the use of a gait belt with transfers. The care plan, reviewed on 04/16/15 at 8:46 a.m., provided no indication Resident #25's transfer status required the use of a gait belt. An interview with the director of nursing (DON) confirmed the comprehensive care plan did not indicate the resident required a gait belt for transfers. The DON also confirmed the Kardex (care plan utilized by nursing assistants) did not indicate the resident required the use of a gait belt for transfers. | 2018-04-01 |
| 6271 | 6271 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2015-04-16 | 315 | D | 1 | 0 | AU7811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, the facility failed to ensure one (1) of ten (10) residents reviewed received treatment and services to maintain or restore as much bladder function as possible. The facility failed to fully implement a planned voiding diary to assess the resident's bladder continence/incontinence; therefore, appropriate interventions were not planned and implemented to maintain or restore as much bladder function as possible. Resident identifier: #114. Facility census: 112. Findings include: a) Resident #114 Review of the electronic medical record (EMR), on 04/14/15 at 2:49 p.m., revealed Resident #114 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Her brief interview for mental status (BIMS) score was 14, which indicated minimal cognitive impairment. A score of 15 is the highest available score. The minimum data set (MDS), with an assessment reference date (ARD) of 01/30/15, reviewed on 04/14/15 at 2:51 p.m., revealed urinary incontinence triggered under section V, with a decision to care plan the problem. The care plan, reviewed on 04/14/15 at 3:17 p.m., indicated Resident #114 required extensive/ total assist with activities of daily living (ADL) care, which included toileting. The care plan indicated the resident was cognitively impaired and unable to participate in a toileting program, even though the BIMS score was 14. Urinary incontinence nursing interventions, dated 02/13/15, noted functional incontinence with use of absorbent products. A nursing assessment, dated 01/30/15, indicated Resident #114 believed she was able to improve in some areas of activities of daily living (ADLs.) Another nursing assessment, dated 02/18/15, noted the resident was frequently incontinent of bowel - not on a toileting program and frequently incontinent of urine - not on a toileting program. A third nursing assessment, dated 03/17/15, indicated Resident #114 was always incontinent of bowel… | 2018-04-01 |
| 6272 | 6272 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2015-04-16 | 323 | D | 1 | 0 | AU7811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and observation, the facility failed to provide an environment that was as free as possible from accident hazards, over which the facility had control, for two (2) of ten (10) residents reviewed. Resident #11 fell from a mechanical lift related to a failure to properly secure the lift pad. In addition, a lift -transfer-evaluation indicated Resident #25 required the use of a gait belt for transfers. This was not identified in the resident's care plan or identified by any other means for staff awareness. Resident identifiers: #11 and #25. Facility census: 112. Findings include: a) Resident #11 During a medical record review, on 04/15/15 at 11:15 a.m., a progress note, dated 03/02/15, indicated Resident #11 required a total lift with transfers and activities of daily living (ADLs). The current care plan, reviewed on 04/15/15 at 11:41 a.m., indicated the resident required assistance with transfers and locomotion due to disease/compromising functional ability. It specified the use of a mechanical lift for transfers. The care plan also indicated Resident #11 was at risk for additional falls. The care plan falls history noted the resident had a change in condition, dated 03/09/15, related to a recent fall. A change of condition note, dated 02/18/15 at 7:25 p.m. indicated an accident/incident/fall in the past 72 hours. The note indicated the resident experienced back pain which started after the fall. Further review of the medical record, on 04/15/14 at 12:45 p.m., revealed a progress note, dated 02/28/15 at 7:25 p.m. which indicated the resident was experiencing back pain and was sent to the emergency room for evaluation. Another progress note, at 7:57 p.m., indicated the resident sustained [REDACTED]. A progress note at 10:59 p.m. indicated the resident was transferred to the emergency room for a computerized tomography (CT) scan. The risk management report, supplied upon request on 04/15/15 at 1:45 … | 2018-04-01 |
| 6273 | 6273 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2015-04-23 | 241 | D | 1 | 0 | 4O0D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview the facility failed to ensure staff interactions with residents and their family members were conducted in a respectful, professional manner that respected their dignity and accommodated their needs and expectations. An inappropriate, confrontational encounter related to medication administration took place between a nurse and a family member of Resident #114. This was found for one (1) of seven (7) residents reviewed. Facility census: 112. Findings include: a) The medical record review, on 04/21/15 at 11:49 a.m., revealed Resident #114 was admitted to the facility on [DATE] and discharged home on[DATE]. b) During an interview with a family member of Resident #114, on 04/21/15 at 11:12 a.m., the family member related that on the evening of 02/12/15 a nurse was in the resident's room to give her 9:00 p.m. medication at 12:00 midnight. The family member said the nurse awoke the resident and spoke to her in a loud voice that the family member felt was inappropriate. A second nurse intervened, sending the assigned nurse out of the room and administered the medication. The next morning, the family member spoke to someone who they thought was in some type of management position and asked them who they should speak with to report a concern with one of the nurses. This person said she would have someone contact them, but no one ever did. c) Review of schedules for February 2015, on 04/22/15 at 10:30 a.m., identified licensed staff working the 7:00 p.m. to 7:00 a.m. shift on 02/12/15. Two (2) nurses were interviewed on the evening of 04/22/15. Nurse #7, interviewed on 4/22/15 at 7:18 p.m., was asked if they recalled any incident involving Resident #114 on the night of 02/12/15. Nurse #7 said they recalled hearing a heated discussion in Resident #114's room around midnight. Nurse #7 went to the room to intervene. The concern appeared to involve administration of Resident #114's medication, [… | 2018-04-01 |
| 6274 | 6274 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 253 | D | 0 | 1 | FSTL11 | Based on observation and staff interview, the facility failed to ensure the physical environment was in good repair. The adjoining shower room, shared by residents occupying rooms 33 and 35 on B-hall, had missing floor tiles. A black substance was observed between the floor tiles, on the wooden base board and the lower walls of the shower stall. Observation of room 26-B found the back wall, facing the outside of the facility, was in need of repair. Three (3) of the thirty-four (34) rooms observed during Stage 1 of the Quality Indicator Survey were affected. Room numbers of the affected rooms: #33-B, #35-B, and #26-B. Facility census: 66. Findings include: a) Observation of the facility during Stage 1 of the Quality Indicator Survey, on 11/04/13, revealed the following rooms had environmental concerns: 1) Rooms 33-B and 35-B On 11/04/13 at 2:25 p.m., observation of the bathroom shared by residents in rooms 33-B and 35-B found the bathroom was equipped with a private shower stall. Further observation of the shower stall, at 2:25 p.m. on 11/04/13, found a black substance was present on the tiled area at the entrance of the shower stall. This substance could be scraped off with a fingernail. The black substance was also found along the wooden baseboards in the shower stall and covered an area approximately two (2) feet upward from the baseboard on the back wall and the right wall of the shower stall. Four (4) floor tiles were missing along the edge of the floor beside the right wall, leaving an uneven area on the shower floor. Observation of the shower stall by two (2) surveyors and the maintenance supervisor, Employee #5, was made at 2:00 p.m. on 11/07/13. Employee #5 stated he had the materials to fix the shower, but he had not had time to complete the repairs. Employee #9 (a nursing assistant) and Employee #69 (a register nurse) were interviewed at 2:45 p.m. on 11/07/13. Both employees verified the two (2) residents in room #35 and one resident in room #33 were bathed in the adjoining shower room. 2) Room 26-B Obs… | 2018-04-01 |
| 6275 | 6275 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 272 | E | 0 | 1 | FSTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, observations, and staff interview, the facility failed to ensure resident assessments were accurate and complete. Four (4) of twenty-four (24) residents on the sample had inaccurate assessments. Dental assessments for Resident #144 and #102 did not reflect the residents had broken teeth. The assessment for Resident #52 did not identify that a toileting program had been implemented. The assessment for Resident #45 did not accurately reflect the assistance the resident required for toileting. Resident identifiers: #144, #102, #52, and #45. Facility census: 66. Findings include: a) Resident #144 An observation of Resident #144's mouth on 11/04/13 at 3:43 p.m., revealed she had broken and loose teeth. The resident stated her teeth were broken and loose on the top and the bottom. On 11/06/13 at 10:16 a.m., Resident #144 said she had some loose and broken teeth. An observation of the resident's mouth revealed she did have broken teeth. The initial nursing assessment, dated 10/21/13, indicated the resident did have broken natural teeth. However, the expanded nursing assessment, dated 10/28/13 did not capture the resident had broken natural teeth. The minimum data set (MDS) admission assessment, assessment reference date (ARD) 10/28/13, did not capture the resident's broken natural teeth in Section L (oral/dental status). At 10:40 a.m. on 11/06/13, Employee #62 (MDS/care plan registered nurse) and Employee #4 (MDS/care plan registered nurse) both said the MDS and assessment did not capture the resident's dental status. They indicated two (2) nursing assessments were completed prior to the admission MDS. The second nursing admission assessment (nursing assessment expanded) did not capture the resident's broken natural teeth. This prevented the MDS from capturing it in Section L (oral/dental status). b) Resident #102 During an interview on 11/04/13 at 4:21 p.m., Resident #102 said she had a broken too… | 2018-04-01 |
| 6276 | 6276 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 278 | E | 0 | 1 | FSTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure four (4) of twenty- four (24) residents had assessments that accurately reflected their status in the areas of toileting and oral/dental status. Resident identifiers: #144, #102, #52, and #45. Facility census: 66. Findings include: a) Resident #144 An observation of Resident #144's mouth on 11/04/13 at 3:43 p.m., revealed she had broken and loose teeth. The resident stated her teeth were broken and loose on the top and the bottom. The initial nursing assessment, dated 10/21/13, indicated the resident did have broken natural teeth. However, the expanded nursing assessment, dated 10/28/13 did not capture the resident had broken natural teeth. The minimum data set (MDS) admission assessment, assessment reference date (ARD) 10/28/13, did not capture the resident's broken natural teeth in Section L (oral/dental status). At 10:40 a.m. on 11/06/13, Employee #62 (MDS/care plan registered nurse) and Employee #4 (MDS/care plan registered nurse) both said the MDS and assessment did not capture the resident's dental status. They indicated two (2) nursing assessments were completed prior to the admission MDS. The second nursing admission assessment (nursing assessment expanded) did not capture the resident's broken natural teeth. This prevented the MDS from capturing it in Section L (oral/dental status). b) Resident #102 During an interview on 11/04/13 at 4:21 p.m., Resident #102 said she had a broken tooth on top. Observation revealed the resident did have a broken top tooth. The expanded nursing assessment, dated 01/21/13, indicated the resident had a broken or loosely fitting full or partial denture. The expanded nursing assessment, dated 04/26/13, did not indicate the resident had any dental issues. The expanded nursing assessment dated [DATE] indicated the resident had broken or loosely fitting full or partial denture. The expanded nursing assessment of 10/13/13 did not… | 2018-04-01 |
| 6277 | 6277 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 279 | D | 0 | 1 | FSTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to ensure the resident's comprehensive care plan included all of the specific interventions, detailed in the physician's orders [REDACTED]. This was true for one (1) of twenty-four (24) residents' care plans reviewed during Stage 2 of the Quality Indicator Survey. Resident identifier: #10. Facility census: 66. Findings include: a) Resident #10 Observation of the resident during Stage 1 of the Quality Indicator Survey, at 2:20 p.m. on 11/04/13, found the resident's right hand was contracted. On 11/06/13, further review of the medical record found a current physician's orders [REDACTED]. Instructions: Perform right hand hygiene and PROM (passive range of motion) prior to splint application. Start PROM at shoulders and work towards hands/fingers. Perform 3 X (times) 10 with PROM. Apply splint. Goal: Patient will tolerate right hand WHFO (wrist, hand, finger, orthotic) 6 hours per day - off for self feeding. Patient will tolerate PROM and gentle stretch at end of range of motion to bilateral upper extremities. A review of the daily restorative nursing record for November 2013 found instructions to apply the splint at 8:00 a.m. and to remove the splint at 2:00 p.m. Review of the resident's current care plan on 11/06/13, found the following care plan related to prevention of contractures: The focus: Restorative splint and brace assistance: Patient cannot apply and remove the splint/brace Functional deterioration. The goal, Prevent contractures and maintain skin integrity x 6 days per week. The interventions associated with this goal were: Inspect skin daily for signs of redness or irritation. Inspect splint daily. Perform hand hygiene prior to splint application. Perform passive range of motion exercises to bilateral upper extremities prior to splint application. RNA (restorative nursing assistant) program for splinting of right hand 6 days per… | 2018-04-01 |
| 6278 | 6278 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 280 | D | 0 | 1 | FSTL11 | Based on medical record review and staff interview, the facility failed to revise the care plan of one (1) of twenty-four (24) residents when new interventions for an identified problem were implemented. Resident #88 was assessed as being at risk for falls. The facility failed to update the resident's care plan to include all of the interventions being utilized to prevent falls for this resident. Resident identifier: #88. Facility census: 66. Findings include: a) Resident #88 A review of the medical record on 11/07/13 at 3:23 p.m., revealed Resident #88 was sitting in his wheelchair in front of the nurses' desk when he slid out of his wheelchair and onto the floor at 9:55 p.m. on 10/30/13. According to the record, this was witnessed by staff. Employee #1 (assistant director of nursing) said after this fall, the facility had put Dycem (non-slip material that helps to effectively grip and hold items in place) between the bottom of the cushion and the wheelchair seat in the resident's wheelchair. A review of the resident's care plan for falls, created on 10/16/13, revealed the resident's care plan had not been revised to reflect the use of Dycem as a part of the plan for falls prevention. On 11/07/13 at 4:00 p.m., Employee #1 was informed that the resident's care plan did not include the Dycem intervention. | 2018-04-01 |
| 6279 | 6279 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 312 | D | 0 | 1 | FSTL11 | Based on observation, medical record review, review of shower sheets, and staff interview, the facility failed to ensure a resident, who was totally dependent upon staff for activities of daily living (ADL) care, was free of odors. The resident did not receive scheduled showers and no efforts were made to address possible refusal of showers or how the facility would maintain good personal hygiene for this individual. This was true for one (1) of four (4) residents reviewed for activities of daily living (ADL) care during Stage 2 of the Quality Indicator Survey. Resident identifier: #6. Facility census: 66. Findings include: a) Resident #6 Observation of the resident during meal time, on 11/04/13 at 11:45 a.m., by (3) three surveyors, found the resident had a strong, foul urine odor. The urine odor was so strong it could be detected when the surveyors were at least five (5) feet from the resident. Observation again, at 12:10 p.m. on 11/07/13, found the resident was sitting directly beside the front door of the facility. Three (3) surveyors again detected a strong urine odor emanating from this resident. Review of the resident's bathing schedule with Employee #4, the registered nurse care plan coordinator, at 9:00 a.m. on 11/08/13, found the resident was to receive showers on Mondays and Thursdays by the night shift nursing assistants (11:00 p.m. to 7:00 a.m. shift). Further review of the documentation on the daily ADL record, by the night shift nursing assistants on 11/07/13, found the resident's last shower occurred on 10/17/13. The resident's current minimum data set (MDS), a quarterly MDS with an assessment reference date (ARD) of 08/21/13, was reviewed on 11/08/13. The resident was coded as being always incontinent of urine in Section H, bowel and bladder, and totally dependent upon staff for showers in Section G, bathing. The director of nursing (DON) was interviewed at 9:20 a.m. on 11/08/13. The observations 11/04/13 and 11/07/13 were discussed with the DON. She stated she would see if she had any documentat… | 2018-04-01 |
| 6280 | 6280 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 315 | D | 0 | 1 | FSTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, the facility failed to ensure a resident, who had a decline in bladder functioning shortly after admission to the facility, received a thorough assessment to determine if any services could be provided to restore or improve bladder functioning. This was true for one (1) of three (3) residents reviewed for urinary incontinence. Resident identifier: #19. Facility census: 66. Findings include: a) Resident #19 Review of the medical record, on 11/07/13, found the resident was admitted to the facility on [DATE]. This was the resident's first admission to the facility. The admission minimum data set (MDS), with an assessment reference date (ARD) of 07/29/13, was coded to indicate the resident was frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) in Section H0300, urinary continence. The next MDS, a fourteen (14) day assessment, with an ARD of 08/03/13, found the resident's urinary continence had declined to always incontinent (no episodes of continent voiding) in Section H0300, urinary incontinence. Both the admission MDS and the fourteen day MDS found the resident was totally dependent upon two (2) staff members for toileting in Section G, functional status of the MDS. On 07/24/13, a urinary incontinence evaluation was completed by a registered nurse. The actions identified on the assessment were, If no clinical symptoms or transient / reversible causes identified OR unable to be reversed ( e.g. meds cannot be changed), urinary incontinence is persistent. Initiate Three - Day Continence Management Diary and complete Urinary Incontinence Nursing Interventions. Further review of the Urinary Incontinence Evaluation found no clinical factors or transient / reversible factors were identified as contributing to the urinary incontinence. Review of the facility's policy titled, Continence Management, found, The Urinary Incont… | 2018-04-01 |
| 6281 | 6281 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 329 | D | 0 | 1 | FSTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that each resident's medication regimen was free of unnecessary medications. Two (2) of five (5) residents reviewed for unnecessary medications were found to be receiving antipsychotic medications without adequate indications for its use. Resident #1's [MEDICATION NAME] dose was increased without evidence of behaviors indicating a need for an increased dose. Resident #4 received an increase in the dose of [MEDICATION NAME] without evidence warranting the increase of [MEDICATION NAME]. Resident identifiers: #1 and #4. Facility census: 66. Findings include: a) Resident #1 Medical record review, on 11/06/13 at 8:45 a.m., found the resident was prescribed the medication [MEDICATION NAME] 0.5 milligram (mg) by mouth every twelve (12) hours for hitting, kicking, and yelling, related to chronic [MEDICAL CONDITION] disorder. A review of the resident's care plan found the resident had a history of [REDACTED]. The behavior monitoring logs for the months of August, September, and October 2013 indicated staff were monitoring for the behaviors of hitting, kicking, yelling and cursing. The logs did not identify the resident had exhibited any behaviors during this period. The pharmacist had completed monthly medication regimen reviews with recommendations for gradual dose reductions. A dose reduction recommendation for the medication [MEDICATION NAME] was made 07/25/13. The physician accepted the recommendation on 08/20/13, decreasing the dose from [MEDICATION NAME] 0.5 mg two (2) times a day to [MEDICATION NAME] 0.25 mg two (2) times a day. The psychiatric physician saw the resident on 09/08/13 and increased the resident's [MEDICATION NAME] back to 0.5 mg twice a day. The physician made a note stating the following; According to the staff, she has had episodes where she was screaming, cursing the staff, and was having some hallucinations or delusions. A review of the resident… | 2018-04-01 |
| 6282 | 6282 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2013-11-08 | 371 | F | 0 | 1 | FSTL11 | Based on observation and staff interview, it was determined the facility failed to maintain a sanitary environment in the kitchen. Drinking glasses were not adequately air dried to prevent moisture from being trapped inside the glasses. This created a potential for the growth of microorganisms. This practice had the potential to affect all residents who received meals from the kitchen. Facility census: 66. Findings include: a) During the initial tour of the dietary department, beginning at 11:23 a.m. on 11/04/13, the following sanitation infraction was observed with the dietary manager, Employee #41. 1) Observation of a small storage cabinet, mounted on the wall of the kitchen, at 11:30 a.m. on 11/04/13, found drinking glasses had been stacked together before air drying. There was moisture trapped between the glasses. When the glasses were picked up, rings of water were visible on the shelf. The dietary manager stated she would wash the glasses again. | 2018-04-01 |
| 6283 | 6283 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2014-07-25 | 282 | D | 0 | 1 | OTV811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and record review, the facility failed to implement the care plan for one (1) of eighteen (18) residents whose care plans were reviewed. Resident #37 had a [MEDICAL CONDITION] due to a fall. The care plan for falls included maintaining a clutter free environment, which was not implemented. A bedside table was observed covering approximately one-third of the fall mat. Resident identifier: #37. Facility census: 68. Findings include: a) Resident #37 Resident #37 was readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 07/02/14, assessed this resident was moderately impaired with regards to cognition with total dependence on two (2) staff for physical assistance with bed mobility and transfers. In an interview with licensed practical nurse (LPN) #46 on 07/21/14, the LPN stated the resident had a [MEDICAL CONDITION] within the previous 30 days as a result of a fall. Review of the resident's current care plan revealed a plan for falls prevention with interventions to maintain a clutter free environment, low bed, and fall mats next to the bed. Observation of the resident on 07/22/14 at 10:55 a.m. revealed the resident was in a low bed with fall mats next to the bed; however, there was a bedside table placed next to the bed which covered approximately the upper 1/3 of the fall mat. In an interview with the Director of Nursing (DON) #66 on 07/22/14 at 11:02 a.m., the DON verified the placement of the bedside table over the fall mat and stated the bedside table should not have been placed over the fall mat. Nurse aide (NA) #11, on 7/22/14 at 11:30 a.m., stated she had not placed the bedside table over the fall mat next to the bed. The NA stated that perhaps the staff that had assisted resident to eat her ice-cream had not repositioned the bedside table appropriately. NA #11 stated fall mats should be unobstructed and clear of bedside tables. | 2018-04-01 |
| 6284 | 6284 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2014-07-25 | 323 | E | 0 | 1 | OTV811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observation, and record review, the facility failed to ensure the environment remained as free from accident hazards as possible. Two (2) (#2 and #53) of four (4) residents reviewed for accidents had bed rails that were ill-fitting. Additionally, the facility failed to ensure one (1) medical supply closet with hazardous chemicals was locked. These issues had the potential to affect more than a limited number of residents. Resident identifiers: #2 and #53. Facility census: 68. Findings include: a) Resident #2 Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), dated [DATE], found Resident #2 was cognitively impaired, dependent on the assistance of two (2) staff members for bed mobility, and had functional limitation in range of motion to both bilateral upper and lower extremities. Review of the current physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the activity of daily living records for May, June, and July 2014 revealed Resident #2 was dependent on the assistance of two (2) staff for bed mobility. Observations, on 07/22/14 at 10:05 a.m., revealed Resident #2 was in her bed with bilateral half side rails in the up position and the air mattress in place on the bed. There were gaps noted between both of the side rails and the outer sides of the air mattress. The gaps measured 5 1/2 inches and the mattress was noted to have a slick surface. During this observation the resident was noted to be in a fetal position. She was positioned with pillows that were partially covering the gap between the side rail and the side of the air mattress. Interview with Nurse Aide (NA) #23 and NA #95, at the time of the observation, revealed they place the pillows bedside the resident to position her hands and arms due to contractures. They both stated they did not attempt to position the pillows to decrease the amount of space between … | 2018-04-01 |
| 6285 | 6285 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2014-07-25 | 428 | D | 0 | 1 | OTV811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to act upon the consultant pharmacist's recommendation for one (1) of five (5) residents whose medications were reviewed. Although the director of nursing (DON) and the physician had signed acknowledgement of the pharmacist's recommendations, a reduction in the dosage of a medication had not been implemented. Additionally, the pharmacist's recommendation for documenting the risks and benefits of continuing dual therapy had not been addressed. Resident identifier: #79. Facility census: 68. Findings include: a) Resident #79 Review of the resident's medical record, at 10:00 a.m. on 07/23/14, noted Resident #79 was admitted to the facility on [DATE], and had multiple [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].#79 had an order for [REDACTED].>A review of the consultant pharmacist's report for the month of June 2014 revealed the pharmacist had recommended, Please re-evaluate the need for both antidepressants, perhaps giving consideration to reducing Trazodone to 25 mg at bedtime. Additionally, the section of the consultant pharmacist's report entitled Physician's Response revealed a checkmark next to the statement, I accept the above recommendation(s) above, please implement as written. The physician also wrote a note on the same consultation form to reduce the other antidepressant Remeron from 30 mg to 15 mg. The consultant pharmacist report was signed by both the physician and the Director of Nursing (DON) #66 on 06/16/14. A review of the June 2014 Medication Administration Record [REDACTED]. That order originated on 06/17/13 during the resident's admission to the facility. Further review of the MAR indicated [REDACTED]. The consultant pharmacist's report also included, If dual therapy is to continue, it is recommended that the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for th… | 2018-04-01 |
| 6286 | 6286 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2014-07-25 | 514 | D | 0 | 1 | OTV811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to maintain organized medical records for two (2) residents who were receiving [MEDICATION NAME] therapy. Documents pertaining to Resident #103 were found in Resident #93's medial record. Two (2) of twenty-four (24) Stage 2 sample residents were affected. Resident identifiers: #93 and #103. Facility census: 68. Findings include: a) Resident #93 Review of the resident's medical record, on 07/23/13, at 9:30 a.m., found Resident #93 was readmitted to facility on 05/05/14. The resident had multiple [DIAGNOSES REDACTED]. Resident #93 resided on the 400 hallway of the facility. Resident #103 was also a resident in the facility, and resided on the on the 200 hallway of the facility. Upon review of the medical record for Resident #93, thirteen (13) medical record documents for Resident #103 were found within the medical record of Resident #93. Those thirteen (13) documents included the following: -- Nine (9) pages of medication administration records (MAR's),with numerous order changes; -- One (1) PRN (as necessary) sheet; -- One (1) Flow sheet for monitoring customers taking [MEDICATION NAME], with numerous order changes; -- One (1) psychoactive medication monthly flow record; and -- One (1) peripheral catheter treatment record. In and interview with the director of nursing (DON), on 7/23/2014 at approximately 10 a.m., she stated she was aware on the previous day that there were documents in Resident #93's chart that actually belonged to Resident #103. The DON stated she was not sure how the documents for Resident #103 actually ended up within the medical record of Resident #93. The DON also stated when she made the copies of the documents for this surveyor, she noticed the error and further stated she had removed the 13 documents after noticing they belonged to Resident #103, not Resident #93. An interview was also conducted with the 400 hall Unit Manager #80 on 07/23/14 at 2:00 p.m. … | 2018-04-01 |
| 6287 | 6287 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2014-06-04 | 309 | J | 0 | 1 | 7QU811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, the facility failed to ensure a resident received the necessary care and services to maintain the highest practicable physical, mental and psychosocial well being, in accordance with the comprehensive assessment. On 05/28/14, one (1) of five (5) residents with food allergies (Resident #249) was served food to which he was allergic. This situation was determined an immediate jeopardy (IJ), requiring an immediate plan of correction (P(NAME)) by the facility. The facility implemented an appropriate P(NAME) at 7:36 p.m. on 05/28/14; however, the P(NAME) was not implemented the following day, 05/29/14, resulting in continuing non-compliance at an IJ level. The continuing non-compliance affected one (1) of four (4) residents with allergies, who remained in the facility (Resident #264). The continued non-compliance as a result of the IJ was abated at 3:36 p.m. on 05/29/14. The scope and severity was then reduced to a D. Resident identifiers: #249 and #264. Facility census:23. Findings include: a) Resident #249 During a conversation with Resident #249, on 05/28/14 at 9:15 a.m., he asked, Can you do me a favor? The resident said he received grape jelly on his tray, and said he was very allergic to it. He requested it be disposed of and requested strawberry jelly. Review of the tray ticket, found it identified he was allergic to grape. He had one (1) packet of reduced sugar grape spread on his tray. The resident added, It is on my record, I am not allowed to have it. My lips would swell turn inside out, my eyelids would swell shut, and my tongue would swell. The case manager, Employee #22 , a registered nurse (RN), reviewed the tray ticket at 9:25 a.m. on 05/28/14. The RN confirmed the resident had an allergy to grapes, and disposed of the grape jelly. On 05/28/14 at 9:50 a.m., three (3) nursing assistants (NAs), Employees #69, #70, and #31 (NA) said nursing assistants' respo… | 2018-04-01 |
| 6288 | 6288 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2014-06-04 | 371 | E | 0 | 1 | 7QU811 | Based on observation and staff interview, the facility failed to ensure foods were served under conditions which reduced the potential for foodborne illness. Plastic drinking cups were stacked inside of each other prior to air drying, creating a medium for the growth of bacteria. This practice had the potential to affect more than a limited number of residents who received nourishment from the dietary department. Facility Census: 23 Findings Include: a) On 05/27/14 at 10:15 a.m. the initial tour of the kitchen began. Employee #10, Director of Food Services (DFS), guided the tour. At 10:45 a.m., a cart was observed being taken from the dishwashing area. Two (2) inverted, nested stacks of plastics drinking cups were observed on the cart. The two (2) stacks were comprised of four (4) cups each, for a total of eight (8) cups. The cups were observed wet on the inside, creating a medium for the growth of bacteria. Employee #10 separated two (2) of the cups, and agreed they were not air dried prior to stacking them together. She said the cups should have stayed on the drying rack longer, and should not have been stacked until they were dry. | 2018-04-01 |
| 6289 | 6289 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2014-06-04 | 497 | F | 0 | 1 | 7QU811 | Based on employee personnel file reviews and staff interviews, the facility failed to ensure annual performance reviews were completed for each nursing assistant. The facility only completed performance evaluations every three (3) years. This practice had the potential to affect all residents. Facility census: 23. Findings Include: a) Review of personnel files revealed the last annual performance review for Employee #69, a nursing assistant, was completed on 07/25/11. At 3:00 p.m. on 06/03/14, Employee # 2, Human Resources (HR) reported the facility's policy was to complete performance evaluations every three (3) years, not annually. On 06/04/14 at 10:45 a.m., Employee #1 (HR) confirmed the facility policy regarding employee evaluations, stating they were completed every three (3) years. She said she would make the necessary changes to comply with federal regulations where the distinct part of the hospital was concerned. | 2018-04-01 |
| 6290 | 6290 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 155 | D | 0 | 1 | ZU6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, interviews with the contracted facility staff, and interview with the resident's medical power of attorney, the facility failed to ensure a resident's rights were honored for one (1) of twenty-nine (29) residents reviewed in Stage 2 of the Quality Indicator Survey. The resident received anticoagulant therapy at the [MEDICAL TREATMENT] center. His medical record indicated he did not want anticoagulant therapy due to religious beliefs. Resident identifier: #169. Facility census: 105. Findings include: a) Resident #169 A medical record review, completed on 04/14/14 at 9:00 a.m., revealed Resident #169 received [MEDICAL TREATMENT] services. The current care plan indicated the facility would coordinate care with the [MEDICAL TREATMENT] center. A hospital discharge summary, dated 03/08/14, noted the resident did not receive anticoagulation therapy related to his religious beliefs. In addition, a physician's progress note included, (name of religion) . no anticoagulant therapy. During an interview with the medical power of attorney, on 04/14/14 at 4:30 p.m., she conveyed Resident #169's religious preferences were very important to him. She confirmed he did not want anticoagulant therapy. Upon inquiry, she related she was unaware of the [MEDICAL TREATMENT] process. She said the [MEDICAL TREATMENT] center had spoken with her, but she did not know how the process worked. An interview with [MEDICAL TREATMENT] staff, on 04/14/14 at 5:30 p.m., revealed they were not aware of the resident's refusal of anticoagulant therapy. Staff member #182, a registered nurse (RN) and Staff member #183 (RN) said information regarding the resident's preference for refusal of anticoagulant therapy was not conveyed to them. Employee #183 said communication with the facility was usually limited to communication forms. In addition, the [MEDICAL TREATMENT] center staff related they were not invited, and had never participated in… | 2018-04-01 |
| 6291 | 6291 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 225 | E | 0 | 1 | ZU6S11 | Based on record review, review of staff training records, employee personnel file review, review of incident documentation, and staff interview, the facility failed to report and investigate an allegation of resident neglect. The resident was improperly lifted with a mechanical lift, resulting in a fall. In addition, the facility failed to ensure a pre-employment statewide criminal background check was completed for one (1) of five (5) newly hired employees. These practices had the potential to affect more than an isolated number of residents. Resident identifier: #30. Employee identifier: #35. Facility census: 105 Findings include: a) Resident #30 The resident's nursing progress notes were reviewed on 04/09/14 at 1:10 p.m. According to the notes, on 04/04/14, Resident #30 was being assisted to stand with the Sara lift and the resident slipped off the lift and onto the floor. When examined, a nurse noticed the resident's left leg was a different length than the right leg. The resident complained of pain in her leg, hip, and back when she was moved. The resident was transported to an acute care hospital. The hospital found no evidence of a fracture and there was no evidence the pain persisted. A review of an incident report, with an incident date of 04/04/14, for Resident #30, on 04/09/14 at 1:15 p.m., revealed the resident was being assisted to stand using the Sara 3000 lift to enable staff to perform incontinence care. She slipped off the lift and fell on to the floor. An interview was conducted on 04/09/13 at 1:45 p.m. with Employee #159, a nursing assistant (NA). During the interview, she stated she and Employee #33 were attempting to use the Sara 3000 lift to stand the resident. She stated she had put the sling around the resident's mid-torso region, and put the resident's feet on the platform. The NA said she applied the clips to the attachment on the lift. The device required the resident to hold onto the bars on the front of the lift. The NA said the resident took both hands off the bars, placed one (1) ar… | 2018-04-01 |
| 6292 | 6292 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 253 | E | 0 | 1 | ZU6S11 | Based on observation and staff interview, the facility failed to ensure effective maintenance and housekeeping services. The physical environment was not in good repair. Observations revealed peeling paint and wallpaper, broken grout and dark brown substance around the commode, a black substance beneath a heater, and broken wall board with metal exposed. There were also pinholes in a wall, holes around an outlet cover, and a chest of drawers had missing finish and scratches which exposed discoloring. A bathroom mirror was missing the silver backing, and plaster was missing on the corner edge of a bathroom wall, exposing metal. This practice affected nine (9) of sixty-two (62) rooms observed during Stage 1 of the Quality Indicator Survey. Rooms numbers of affected rooms: #207, #208, #211, #214, #305, #309, #312, #409, and #410. Facility census: 105. Findings include: a) Observations of the facility, during Stage 1 of the Quality Indicator Survey, revealed the following rooms had environmental concerns: 1) Room 207: The wall behind the bed had torn wall paper. 2) Room 208: The grout around the commode was broken and a dark brown substance around the commode. A black substance was also observed beneath the heater in the room. 3) Room 211: The grout around the commode was loose, and there was a dark brown substance around the commode. The wall board was broken, exposing 4 inches of metal sheath. There were three (3) areas of peeling paint on the right side of the wall at the entrance of the bathroom. 4) Room 214: The bathroom had scratches and paint peeling halfway up the wall. 5) Room 305: There were multiple pinholes all over the wall. 6) Room 309: Paint was missing on the wall behind the door, measuring three (3) inches long by three (3) inches wide. There were also four (4) holes around an outlet cover. 7) Room 312: The wallpaper was peeling behind the bed. 8) Room 409: The chest of drawers had missing finish on numerous areas on the top and around the bottom. There were scratches on the chest of drawers revealin… | 2018-04-01 |
| 6293 | 6293 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 258 | D | 0 | 1 | ZU6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to provide comfortable sound levels for one (1) of twenty-nine (29) residents reviewed during Stage 1 and Stage 2 of the Quality Indicator Survey. Resident #120 was disturbed by how loud the television was turned up in room [ROOM NUMBER]. Resident identifier: #120. Facility census: 105. Findings include: a) Resident #120 On 04/08/14 at 10:19 a.m., during Stage 1 of the Quality Indicator Survey, Resident #120 was asked if he had any problem with the temperature, lightening, noise or anything else in the building that affected his comfort. He stated the residents in room [ROOM NUMBER] left their television on all the time, and that he could hear their televisions in his room. He said had reported the problem on several occasions, but could not remember who he had told. An observation and interview was conducted with Resident #120, in his room, on 04/10/14 at 10:15 a.m. The televisions in room [ROOM NUMBER], across the hall, which were on different stations, were so loud they could be heard in Resident #120's room. He stated it was very disturbing to him. During a tour of Resident #120's room, on 04/10/14 at 10:25 a.m., with Employee #124, the maintenance director, he confirmed the television across the hall in room [ROOM NUMBER] was very loud, and could be heard in Resident #120's room. He said they had been this way for sometime. Employee #124 stated the facility was aware of the loud televisions in room [ROOM NUMBER]. He said he was not certain why nothing was done to alleviate the noise problem for Resident #120. | 2018-04-01 |
| 6294 | 6294 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 279 | G | 0 | 1 | ZU6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to ensure the development of a care plan for one (1) of three (3) residents reviewed for nutritional services, in a total sample of twenty-nine (29) Stage 2 residents. This resulted in actual harm for the resident, who experienced three (3) severe weight losses, each over 5%, in a forty-two (42) day period. Weight loss was indicated on the minimum data set (MDS) assessment; however, the facility failed to care plan for the weight loss until the resident had already experienced an overall weight loss of 15.64% in that forty-two (42) day period. Resident identifier: #147. Facility census: 1 05. Findings include: a) Resident #147 Review of Resident #147's medical record, on 04/10/14 at 9:00 a.m., revealed the resident was admitted on [DATE]. The resident's admission weight was recorded as 104.8 pounds (lbs). The resident's five (5) recorded weights from 11/06/13 to 12/18/14 were as follows: 1. 11/06/13 = 104.8 2. 11/20/13 = 97.6 (loss of 6.87%) The facility rounded this weight up to 98 pounds for the minimum data set (MDS) 3. 11/27/13 = 92.2 (additional loss of 5.3%) 4. 12/04/13 = 94.2 (increase of 2.12%) 5. 12/18/13 = 88.4 (loss of 6.15%) The resident's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 11/20/13, was reviewed on 04/10/14 at 9:17 a.m. Item K0300, indicating a weight loss of five (5) percent or more in the last month was coded Yes. It also noted the resident was not on a physician-prescribed weight-loss regimen. On 04/15/14 at 11:50 a.m., an interview was conduced with Employee #142, the MDS coordinator. She was asked about the completion of the 11/20/13 MDS and Item K0300 for Resident #147, related to a weight loss of five (5) percent in the last month or a loss of ten (10) percent or more in last six (6) months. Employee #142 said she looked at the weights seven (7) days back from the ARD to determine the weig… | 2018-04-01 |
| 6295 | 6295 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 309 | D | 0 | 1 | ZU6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to implement interventions in accordance with a resident's needs, goals, the facility's policies, and in accordance with the comprehensive assessment and plan of care for one (1) of twenty-nine (29) residents reviewed in Stage 2 of the survey. The facility failed to monitor a [MEDICAL TREATMENT] and failed to ensure the resident went to a follow-up appointment related to his [MEDICAL TREATMENT]. Resident identifier: #169. Facility census: 105. Findings include: a) Resident #169 A medical record review, completed on 04/14/14 at 9:00 a.m., revealed a minimum data set (MDS) with an assessment reference date (ARD) of 03/26/14. It indicated Resident #169 had received [MEDICAL TREATMENT] services. Review of the current care plan indicated staff would monitor/assess the [MEDICAL TREATMENT] for bruit and thrill. In addition, the care plan indicated the site would be monitored for signs/symptoms of complications. The policy for assessment of arteriovenous shunts, fistulas, and grafts was provided and reviewed on 04/14/14 at 1:30 p.m. It indicated staff would palpate for the presence of a thrill and auscultate for the presence of a bruit, with a minimum frequency of every twenty-four (24) hours. An interview with the director on nursing (DON) and the corporate consultant (Employee #181) on 04/14/14 at 3:00 p.m., revealed the facility had no additional policies regarding evaluation of a resident receiving [MEDICAL TREATMENT]. The DON said standard nursing practices were utilized. An interview with Employee #70, licensed practical nurse (LPN), on 04/14/14 at 2:45 p.m., revealed staff recorded information regarding the [MEDICAL TREATMENT] on the treatment administration record (TAR). She reviewed the TAR and confirmed no record of assessments and monitoring were present. The Medication Administration Record [REDACTED].m She related she was not aware of a specific asses… | 2018-04-01 |
| 6296 | 6296 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 323 | D | 0 | 1 | ZU6S11 | Based on record review, staff interview, review of the facility's documentation of incidents, review of in-service records, and an interview with a representative from the mechanical lift company, the facility failed to ensure the resident's environment was as free as possible from avoidable accidents. One (1) of three (3) residents reviewed for accidents in Stage 2 of the survey was lifted with an altered sling attached to a mechanical lift, resulting in a fall. In addition, there was no evidence of adequate training in the use of the mechanical lift to prevent avoidable accidents. Resident identifier: #30. Facility census: 105. Findings include: a) Resident #30 The resident's nursing progress notes were reviewed on 04/09/14 at 1:10 p.m. According to the notes, on 04/04/14, Resident #30 was being assisted to stand with the Sara lift and the resident slipped off the lift and onto the floor. When examined, a nurse noticed the resident's left leg was a different length than the right leg. The resident complained of pain in her leg, hip, and back when she was moved. The resident was transported to an acute care hospital. The hospital found no evidence of a fracture and there was no evidence the pain persisted. A review of the incident report for the date of 04/04/14 for Resident #30, on 04/09/14 at 1:15 p.m., revealed the resident was being assisted to stand in the Sara 3000 lift to perform incontinence care. She slipped off the lift and fell on to the floor. An interview was conducted on 04/09/13 at 1:45 p.m., with Employee #159, a nursing assistant (NA). During the interview she stated she and Employee #33 were attempting to use the Sara 3000 lift to stand the resident. She stated she had put the sling around the mid-torso region, and put the resident's feet on the platform. The NA said she applied the clips to the attachment on the lift. The device required the resident to hold onto the bars on the front of the lift. The NA said the resident took both hands off the bars, placed one (1) arm under the sling, and fe… | 2018-04-01 |
| 6297 | 6297 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 325 | G | 0 | 1 | ZU6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for nutritional services, in a total sample of twenty-nine (29) Stage 2 residents, was provided services to maintain acceptable parameters of nutritional status, resulting in actual harm to the resident. The facility did not identify, assess, or address the resident's severe weight losses. In a forty-two (42) day period, the resident experienced three (3) weight losses of over 5% each. The weight losses were not recognized, assessed, or addressed by the facility until the resident had already experienced an overall weight loss of 15.64% in forty-two (42) days. Resident identifier: #147. Facility census: 105. Findings include: a) Resident #147 Review of Resident #147's medical record, on 04/10/14 at 9:00 a.m., revealed the resident was admitted on [DATE]. The admission weight was recorded as 104.8 pounds (lbs). The resident's five (5) recorded weights from 11/06/13 to 12/18/14 were as follows: 1. 11/06/13 = 104.8 2. 11/20/13 = 97.6 (loss of 6.87%) - The facility rounded this up to 98 for the minimum data set (MDS) 3. 11/27/13 = 92.2 (additional loss of 5.3%) 4. 12/04/13 = 94.2 (increase of 2.12%) 5. 12/18/13 = 88.4 (loss of 6.15%) The resident's minimum data set (MDS), with an assessment reference date (ARD) of 11/20/13, was reviewed on 04/10/14 at 9:17 a.m. Item K0300, indicating a weight loss of five (5) percent or more in the last month was coded Yes. It also noted the resident was not on a physician-prescribed weight-loss regimen. Review of the resident's care plan, on 04/10/14 at 9:22 a.m., revealed Resident #147 had no care plan related to weight loss until 02/13/14. The resident experienced a significant weight loss between 11/06/13 and 11/20/13, and again between 12/04/13 and 12/18/13. An interview was conducted with Resident #147 on 04/10/14 at 9:49 a.m. She said when she first came to the faci… | 2018-04-01 |
| 6298 | 6298 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 456 | D | 0 | 1 | ZU6S11 | Based on record review, review of the facility's documentation or incidents, staff interview, and an interview with a representative from the mechanical lift company, the facility failed to ensure resident care equipment was maintained in a safe and operating condition. One (1) of three (3) residents reviewed for accidents had a fall due to faulty equipment. Resident identifier: #30. Facility census: 105. Findings include: The resident's nursing progress notes were reviewed on 04/09/14 at 1:10 p.m. According to the notes, on 04/04/14, Resident #30 was being assisted to stand with the Sara lift and the resident slipped off the lift and onto the floor. A review of the incident report for the date of 04/04/14 for Resident #30, on 04/09/14 at 1:15 p.m., revealed the resident was being assisted to stand in the Sara 3000 lift to perform incontinence care. She slipped off the lift and fell on to the floor. An interview was conducted on 04/09/13 at 1:45 p.m., with Employee #159, a nursing assistant (NA). During the interview she stated she and Employee #33 were attempting to use the Sara 3000 lift to stand the resident. She stated she had put the sling around the mid-torso region, and put the resident's feet on the platform. The NA said she applied the clips to the attachment on the lift. The device required the resident to hold onto the bars on the front of the lift. The NA said the resident took both hands off the bars, placed one (1) arm under the sling, and fell on to the floor. During the interview, Employee #159 was asked to explain the procedure for using the Sara 3000 lift. She stated they were to put the sling around the resident's mid-torso region and snap the buckles on the sling into place. She stated they then attached the clips from the sling to the attachment on the lift. Employee #159 stated there were no buckles on the sling to snap Resident #30 in place around the mid-torso region. She confirmed she knew she was supposed to snap the buckles to hold the resident in place. An interview was conducted with … | 2018-04-01 |
| 6299 | 6299 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 465 | D | 0 | 1 | ZU6S11 | Based on observation, resident interview, and staff interview, the facility failed to provide a comfortable environment for one (1) of twenty-nine (29) residents reviewed during Stage 2 of the Quality Indicator Survey. The heater was not functioning correctly in Resident #120's bathroom. Facility census: 105. Findings include: a) Resident #120 An interview was conducted on 04/10/14 at 10:10 a.m. with Resident #120. During this Stage 1 interview, the resident stated his room was cold when staff left the bathroom door open. He said leaving the bathroom door open created a draft, causing his bedroom to be cold. An observation of Resident #120's room was conducted with the maintenance director, Employee #124, on 04/10/14 at 10:30 a.m. When the situation was discussed, Employee #124 stated if the resident was cold, the resident could just turn the heater on in the bathroom. When he first entered the bathroom, the maintenance director commented the bathroom temperature was a little bit cooler than the bedroom temperature. Employee #124 checked the air temperature in the bathroom. It was 66.5 degrees Fahrenheit. He then attempted to turn on the heater in the bathroom, but the heater would not function. Employee #124 stated to the resident, I will have the heater fixed. | 2018-04-01 |
| 6300 | 6300 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 492 | C | 0 | 1 | ZU6S11 | Based on staff interview, facility record review, and interview with personnel from the local county health department, the facility failed to operate in compliance with state and local laws, regulations, and codes that apply to professionals providing services. The facility failed to ensure a dietary aide had a food handler's card. The county in which the facility was located required food handler's cards for food service personnel. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 105 Findings include: a) During a review of food handler's cards, on 04/08/14 at 3:30 p.m., no evidence of a card was present for Employee #176, a dietary aide. The food service director was interviewed at 3:45 p.m. She verified the dietary aide did not have a food handler's card. She said the employee had only worked about a month. An inquiry with the local county health department, on 04/09/14 at 8:00 a.m., confirmed a food handler's card was required for food service personnel in the county. Another interview with Employee #181, on 04/09/14 at 9:00 a.m., again confirmed the facility had not complied with the state and local laws requiring a food handler's card. | 2018-04-01 |
| 6301 | 6301 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 498 | D | 0 | 1 | ZU6S11 | Based on record review, review of the facility's documentation of incidents, staff interview, review of the Sara 3000 lift manufacturer's manual, and interview with a representative from the mechanical lift company, the facility failed to ensure nursing assistants (NAs) were competent in the skills and techniques necessary to care for residents. NAs used a Sara 3000 lift with an altered sling, resulting in a fall for one (1) of three (3) residents reviewed for accidents during Stage 2 of the survey. There was no evidence nursing personnel were adequately trained and/or evaluated for competency in using the Sara 3000 lift. Resident identifier: #30. Facility census: 105. Findings include: a) Resident #30 The resident's nursing progress notes were reviewed on 04/09/14 at 1:10 p.m. According to the notes, on 04/04/14, Resident #30 was being assisted to stand with the Sara lift and the resident slipped off the lift and onto the floor. A review of the incident report, for the date of 04/04/14, for Resident #30, on 04/09/14 at 1:15 p.m., revealed the resident was being assisted to stand with the Sara 3000 lift to perform incontinence care. She slipped off the lift and fell on to the floor. An interview was conducted on 04/09/13 at 1:45 p.m., with Employee #159, a nursing assistant (NA). During the interview she stated she and Employee #33 were attempting to use the Sara 3000 lift to stand the resident. She stated she had put the sling around the mid-torso region, and put the resident's feet on the platform. The NA said she applied the clips to the attachment on the lift. The device required the resident to hold onto the bars on the front of the lift. The NA said the resident took both hands off the bars, placed one (1) arm under the sling, and fell to the floor. Employee #159, NA, was asked to explain the procedure for using the Sara 3000 lift. She stated they were to put the sling around the resident's mid-torso region and snap the buckles on the sling into place. She stated they then attached the clips from the sling … | 2018-04-01 |
| 6302 | 6302 | SISTERSVILLE CENTER | 515131 | 201 WOOD STREET OPERATIONS, LLC | SISTERSVILLE | WV | 26175 | 2014-02-28 | 272 | D | 0 | 1 | WS1J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident observation, the facility failed to assess a resident's wounds to identify the underlying cause of his skin condition. This resulted in the resident's significant change assessment being coded incorrectly. One (1) of seventeen (17) Stage 2 sample residents reviewed for accuracy of the comprehensive assessment was affected. Resident identifier: #21. Facility census: 54. Findings include: a) Resident #21 Review of this resident's medical record, on 02/27/14, found his significant change minimum data set (MDS), with an assessment reference date (ARD) of 01/02/14, Item M0300F indicated the resident had three (3) unstageable pressure ulcers present upon entry to the facility. Item M1030 - Number of Venous and Arterial Ulcers, indicated the resident had no venous or arterial ulcers. Section I, Active Diagnoses, Item I0900 indicated the resident had peripheral vascular or [MEDICAL CONDITION]. (The physician's list of [DIAGNOSES REDACTED].) An observation of the resident's wounds, with Employee #5, a registered nurse, at 10:00 a.m. on 02/27/14, revealed the resident had four (4) ischemic ulcers on the toes of his left foot. (One (1) of these ulcers had not been present at the time the significant change MDS was completed.) In an interview with the Director of Nursing, at 11:12 a.m. on 02/27/14, she agreed Resident #21's wounds were vascular (arterial or venous), not pressure ulcers and the MDS had not been coded accurately. | 2018-04-01 |
| 6303 | 6303 | SISTERSVILLE CENTER | 515131 | 201 WOOD STREET OPERATIONS, LLC | SISTERSVILLE | WV | 26175 | 2014-02-28 | 280 | D | 0 | 1 | WS1J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to revise Resident #21's care plan in the regards to the development of skin issues. The resident's care plan was not revised to address actual problems with skin integrity. This was true for one (1) of seventeen (17) Stage 2 sample residents. Resident identifier: #21. Facility Census: 54. Findings include: a) Resident #21 This resident was readmitted to the facility on [DATE]. His admission nursing assessment noted he had unstageable pressure ulcers to left 3rd and 4th digits with intact scabs and unstageable pressure ulcer to right 2nd digit with intact scabs His significant change minimum data set (MDS), with an assessment reference date (ARD) of 01/02/14, indicated the resident had three (3) unstageable pressure ulcers present upon entry to the facility in Item M0300F. Medical record review found a current physician's orders [REDACTED]. Observation performed during Stage 2 at 10:00 A.M. on 02/27/14 found he had black circles on top of left 2nd, 3rd and 4th toe and the right foot 3rd toe. Review of the current care plan found no mention of the ulcers, just that he had a history of [REDACTED]. During an interview with the Director of Nursing, on 12/27/14 at 11:12 a.m., she agreed the care plan about the resident's skin condition had not been revised and the ulcers were not addressed in the current care plan. | 2018-04-01 |
| 6304 | 6304 | SISTERSVILLE CENTER | 515131 | 201 WOOD STREET OPERATIONS, LLC | SISTERSVILLE | WV | 26175 | 2014-02-28 | 309 | D | 0 | 1 | WS1J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's quick reference guidelines, and staff interview, the facility failed to provide care and services necessary to meet the needs of the resident in the order to maintain the highest practicable well-being. The facility failed to accurately assess three (3) vascular ulcers and to identify signs and symptoms of wound infection. There was also a failure to recognize presence of a fourth wound. The facility also failed develop a care plan to address all four (4) wounds present. One (1) of three (3) residents reviewed with pressure ulcers was affected. Resident identifier: #21. Facility census: 54. Findings include: a) Resident #21 When Resident #21 was admitted to the facility on [DATE], his admission assessment stated he had three (3) unstageable ulcers on his toes. Specifically, one on his left 3rd toe, one on his left 4th toe, and on his right foot he had one on his right 2nd toe. A significant change minimum data (MDS) set assessment, with an assessment reference date (ARD) of 01/02/14, identified the resident had three (3) unstageable pressure ulcers present upon entry to the facility. The Wound and skin care procedures quick reference guidelines - physician order [REDACTED]. Review of the physician's diagnosis list found the list included [MEDICAL CONDITION] as a diagnosis, but there was nothing identified about the ulcers on the resident ' s foot. The current care plan described history of ulcers, but did not describe the current ulcers. A review of the treatment sheet for 02/26/14, found the night nurse had not completed a weekly skin assessment 02/26/14. The next morning, on 02/27/14 at 10:00 a.m., the resident's feet were observed with Employee #5, a Registered Nurse. The resident had a total of four (4) ulcers. The facility was unaware of one (1) of the four (4) ulcers. There was no evidence an area on his left 2nd toe had been identified prior to this observation. The ulcer on the left 3rd… | 2018-04-01 |
| 6305 | 6305 | SISTERSVILLE CENTER | 515131 | 201 WOOD STREET OPERATIONS, LLC | SISTERSVILLE | WV | 26175 | 2014-02-28 | 356 | B | 0 | 1 | WS1J11 | Based on observation, staff interview, and review of staff postings, it was determined the facility failed to post the required nurse staffing data in a prominent place in the facility that was readily accessible to residents and visitors. This had the potential to affect more than a limited number. Facility census: 54. Findings include: a) An attempt to locate the required nurse staffing data posting during the initial tour of the facility on 02/24/14 at 12:30 p.m., revealed it was not posted. During an interview with the director of nursing (DON), Employee #12, on 02/24/14 at 12:37 p.m., she verified there was no posting of the current staffing data in the facility. On 02/26/14 at 4:30 p.m., the staffing sheet was found on a clip board at the nurses' desk with the day shift posting only. Registered Nurse (RN), Employee #4, verified the staff posting was not completed for evening shift and stated she would inform the DON. The staffing was posted for the evening shift at 4:50 p.m. | 2018-04-01 |
| 6306 | 6306 | SISTERSVILLE CENTER | 515131 | 201 WOOD STREET OPERATIONS, LLC | SISTERSVILLE | WV | 26175 | 2014-02-28 | 492 | F | 0 | 1 | WS1J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each dietary employee had a valid food handler's permit as required by county regulations. Two (2) dietary employees did not have current food handler's cards. This had the potential to affect all residents who received nourishment from the dietary department. Facility census: 54. Findings include: a) Upon entrance, facility personnel were asked to provide evidence of food handler's permits, if the county in which the facility was located required them. On [DATE] at 11:00 a.m., a review of the food handler's permits, with the food service director (Employee #11), revealed Employees #2 and #65, cooks, did not have valid food handler's permits. Employee #65's card had expired in [DATE], and Employee #2's card had expired in [DATE]. A review of the food service schedules for [DATE] through February 2014, verified Employees #2 and #65 had been working with expired food permits. During a telephone interview on [DATE] at 2:00 p.m., Employee #79, of the county health department, confirmed dietary employees were required to maintain current food handler's permits. | 2018-04-01 |
| 6307 | 6307 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 157 | E | 1 | 0 | J5M711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the family and/or responsible party of changes in condition in a timely manner for one (1) of ten (10) residents reviewed during a complaint survey ending on 04/28/15. There was no evidence Resident #87's family and/or responsible party was notified on multiple occasions when the resident had medication and diet changes, weight loss, and injuries of unknown origin. Resident identifier: #87. Facility census: 86. Findings include: a) Resident #87 Review of Resident #87's medical record, on 04/22/15 at 1:00 p.m., revealed the resident was admitted to the facility on [DATE] at 2:40 p.m. This ninety-one year old female had [DIAGNOSES REDACTED]. Further review of medical records, on 04/23/15, found a Brief Interview for Mental Status (BIMS) completed on 01/28/15. The BIMS score was eight (8). This score indicated a moderately impaired cognitive status. The resident's medical record indicated her son was appointed the Medical Power of Attorney (MPOA). Review of the medical records found no evidence Resident #87's MPOA was notified of the following changes in the resident's medication and diet, weight loss, and injury of unknown origin: - 01/26/15 at 2:40 p.m. - An order noted on admission for [MEDICATION NAME] 5/325 milligrams (mg) by mouth (po); give 0.5 (1/2) tablet every eight (8) hours as needed (prn). On 01/27/15 at 7:49 a.m., a clarification order for [MEDICATION NAME] 5/325 mg every 8 hours as needed for pain. Previous order for 1/2 tablet of [MEDICATION NAME] (2.5 mg) was discontinued. - 01/28/15 at 12:00 p.m. - The resident was seen by the Physician Assistant (PA). The PA's progress note read, . Patient seen today for lethargy . She was started on [MEDICATION NAME] 5/325 mg yesterday and today nursing noted this change and wanted her evaluated. She reports no pain complaints and is difficult to arouse but will speak. Assessment /Plan and Other information: 1) Lethargy… | 2018-04-01 |
| 6308 | 6308 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 225 | D | 1 | 0 | J5M711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's reported allegations to state authorities, staff interview, resident interview, review of grievance/concern forms, and medical record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported to the proper state authorities and/or failed to ensure each situation was identified and thoroughly investigated for two (2) of ten (10) sample residents. One (1) of two (2) resident's (Resident #72) grievances related to an allegation of verbal and physical abuse was not identified, reported, or investigated. In addition, the facility failed to identify and investigate an injury of unknown origin for Resident #87, to rule out neglect or abuse. Resident identifiers: #72 and #87. Facility census: 86. Findings include: a) Resident #72 On 04/22/15 at 1:00 p.m., review of the grievance/concern forms found Resident #72 voiced a grievance with the facility's social worker on 03/04/15. The grievance was (typed as written): Resident concerned about missing leg tx.'s (treatments) not being done. She also has concerns about staff she says they have been talking behind her back-yelling (symbol for at) her because she comes to the desk to get her cigarettes early and taking up space. She alleges that the staff complains about taking her outside because she is so heavy-they don't want to push her. The social worker (SW) signed the form as completed on 03/06/15. The SW noted the resident's grievance was discussed with the assistant director of nursing. Further review of the facility's grievance/concern form revealed staff were required to describe the actions taken to investigate the grievance/concern. It also directed staff to identify the method used to notify the resident of the resolution. This information was not completed on Resident #72's form. At 4:15 p.m. on 04/22/15, the SW stated she discussed the situation with the director of nursing and the assistant director of nursing. She … | 2018-04-01 |
| 6309 | 6309 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 241 | D | 1 | 0 | J5M711 | Based on record review, observation, resident interview, and staff interview, the facility failed to provide an environment and promote care to maintain or enhance the dignity and respect for one (1) of five (5) residents reviewed and for one (1) resident found during a random opportunity for observation. For Resident #72, the facility failed to ensure staff spoke to her in a respectful manner. For Resident #46, the facility failed to keep a urinary catheter bag covered. Resident identifiers: #72 and #46. Facility census: 86. Findings include: a) Resident #72 On 04/22/15 at 1:00 p.m., review of the grievance/concern forms found Resident #72 filed a grievance with the facility's social worker (SW) on 03/04/15. Documentation on the grievance/concern included, . She also has concerns about staff - she says they have been talking behind her back-yelling @ (at) her because she comes to the desk to get her cigarettes early and taking up space. She alleges that the staff complain about taking her outside because she is so heavy - they don't want to push her. At 4:15 p.m. on 04/22/15, the SW confirmed she could not provide verification the resident's concerns on 03/04/15 were investigated. At 4:45 p.m. on 04/22/15, Resident #72 was asked if staff treated her with dignity and respect. She replied, No, they talk about me. She reported staff talked about her behind her back. Further review of the medical record found a nursing note, dated 02/13/15 at 6:58 p.m., which indicated the resident stated staff were making rude remarks to her. These remarks were supposedly made on the resident's night of admission, 02/12/15. There was no evidence the facility explored what rude comments were made. On 04/27/15 at 10:00 a.m., the administrator confirmed the concerns voiced by the resident on 02/13/15 were not investigated at that time. He stated they were investigated on 04/23/15, and provided copies of the investigation. The investigation was not conducted until the situation was brought to the attention of the facility during the su… | 2018-04-01 |
| 6310 | 6310 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 246 | D | 1 | 0 | J5M711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, staff interview, and review of the medical record, the facility failed to ensure reasonable accommodations were provided in a timely manner, based on individual needs. The facility delayed addressing Resident #72's concerns regarding her inability to sleep on her mattress. This was true for one (1) of five (5) residents reviewed for accommodation of needs. Resident identifier: #72. Facility census: 86. Findings include: a) Resident #72 At 2:30 p.m. on 04/23/15, the resident stated she was unable to sleep in her bed when she first entered the facility in February 2015. She stated the mattress was too hard and it caused her hip to hurt. She said she made numerous complaints to staff,but nothing was done until about two (2) weeks ago when they finally gave her a new mattress. The resident said the new mattress was wonderful and she was now able to sleep in her bed every night. She said it was a shame she had to sleep sitting up in her wheelchair for two (2) months before the facility listened to her. Review of the resident's care plan found a problem, dated 02/15/15, Resident is at risk for skin breakdown as evidenced by limited mobility, de-conditioning, refuses to get out of her wheelchair and into bed. An intervention associated with this problem was, Resident refuses to sleep in her bed, refuses to take showers. Review of the nursing notes found the following entries: -- 03/10/15 at 7:19 a.m., Resident up in wheelchair sleeping all night, feet down on floor. -- 03/29/15 at 8:46 p.m., (typed as written), Resident continues to sleep in her wheelchair, refused to sleep in her bed at night, risks and complications explained without success, per resident she has sleep in her wheelchair since she has been here except for a couple of nights. She request a air mattress . -- 03/30/15 8:26 p.m., . Resident is obese and refuses to take showers or baths; she sleeps in her wheelchair and never in her bed . -- 04/… | 2018-04-01 |
| 6311 | 6311 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 278 | D | 1 | 0 | J5M711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the individual completing and certifying the accuracy of information for the sections he/she completed, failed to ensure two (2) minimum data sets (MDS) accurately reflected the status for one (1) of five (5) residents reviewed during a complaint survey. Resident #87's status regarding ambulation in and out of the room was not accurate. Resident identifier: #87. Facility census: 86. Findings include: a) Resident #87 Review of Resident #87's medical record, at 12:40 p.m. on 04/22/15, revealed the resident was readmitted to the facility on [DATE]. A five (5) day minimum data set (MDS), with an assessment reference date (ARD) of 03/09/15, was inaccurate related to ambulation in the room and corridor. Section G 0110, C and D of the MDS reflected Resident #87 walked in her room and in the corridor with supervision (oversight, encouragement or cueing). Further review of Resident #87's medical record revealed a 14-day MDS assessment, with an ARD of 03/14/15, also inaccurately reflected Resident #87 walked in her room and in the corridor with supervision (oversight, encouragement or cueing). in Section G0110, C and D. In an interview, at 10:15 a.m. on 04/24/15, the Clinical Reimbursement Coordinator (CRC)#113, was asked about Resident #87's ability to ambulate. She reviewed the MDSs with the ARDs of 03/09/15 and 03/14/15. The CRC confirmed they were inaccurate and did not reflect Resident #87's status in regards to ambulation. When asked what information she reviewed to determine if the resident had the ability to ambulate, she replied she used the Activities of Daily Living (ADL) sheets, which were completed by the nurse aides. Review of the ADL sheets revealed the area for walking in the hallway and in the resident's room was coded N/A (not applicable). The form also had several undocumented spaces in this area. The CRC also noted, on the MDS, the resident required supervision in this area. Medical record… | 2018-04-01 |
| 6312 | 6312 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 323 | D | 1 | 0 | J5M711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, record review, and policy review, the facility failed to provide an environment that was as free as possible from accident hazards over which the facility had control for one (1) of six (6) residents reviewed for accident hazards. The facility failed to evaluate and/or address injuries to Resident #72 when the resident alerted staff her injuries were caused by facility furnishings. Resident identifier #72. Facility census: 86. Findings include: a) Resident #72 On the morning of 04/23/15, at approximately 10:00 a.m., Resident #72 said she received an injury to the back of her legs from her toilet seat. She stated the toilet seat first pinched her left thigh and then she received another injury to her right thigh. She said the facility finally got her a new toilet seat but not until after she complained and complained. Review of the nursing notes found the following entries: -- 03/15/15 at 7:34 p.m., (name of resident) has a new onset/change in skin integrity as evidenced by abrasion. Location: Abrasion noted to back of left thigh, order noted for Exuderm, not demonstrating symptoms of pain . -- 03/29/15 at 8:46 p.m., The resident requested a padded toilet seat, . due to the toilet seat pinching the back of her legs while sitting on the seat . -- 03/30/15 at 8:26 p.m., (name of resident) has a new onset/change in skin integrity as evidenced by, Location: Orders noted to cleanse back of left and right upper thighs with WC (wound cleanser) apply calcium alginate and cover with border gauze change daily and prn (as needed) . Review of the treatment administration record (TAR) found an order written [REDACTED]. At 1:55 p.m. on 04/23/15, the wound care nurse, Registered Nurse (RN) #52 confirmed she treated abrasions to both the left and right upper thighs for Resident #72. When asked if she was aware the resident said the abrasions occurred as a result of her thighs being pinched by the toilet seat, RN #… | 2018-04-01 |
| 6313 | 6313 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 325 | E | 1 | 0 | J5M711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to recognize, evaluate, and/or address four (4) of ten (10) residents for potential need for nutritional interventions. Significant weight losses for these residents were documented shortly after their admissions to the facility. The facility did not implement their policy to confirm the weight losses and had not identified a need to assess each residents' nutritional status to determine if nutritional interventions were needed. Resident Identifiers: #17, #52, #64 and #72. Facility census: 86. Findings Include: a) Resident #17 Resident #17's medical record was reviewed at 1:00 p.m. on 04/27/15. The resident was admitted to the facility on [DATE]. This review revealed the following weights for Resident #17: 04/16/15 180 pounds (lbs.), 04/17/15 170 lbs., 04/28/15 168 lbs. Resident #17's weight was reviewed using the initial admission weight of 180 lbs., as documented on 04/16/15. On 04/17/15, the resident's weight was recorded as 170 lbs. This represented a weight loss of 10 lbs. (5.5%) in one (1) day. There was no evidence this weight loss was recognized or addressed. On 04/28/15 (12 days after admission), the resident's weight was recorded as 168 lbs. This represented a weight loss of 12 lbs. (6.67%) since admission. A weight loss of 5% in one (1) month is considered a significant weight loss. A weight loss of greater than 5% in one (1) month is considered a severe weight loss. There was no evidence this weight loss was recognized,assessed, or addressed or addressed. The medical record contained an initial nutrition assessment dated [DATE]. This assessment was completed by the Registered Dietitian (RD). It noted the resident's initial admission weight was 180 lbs. It also noted a 10 lb. weight discrepancy in 24 hours. The RD recommended weekly weights to establish baseline weights, and to liberalize the resident's diet to Regular (if approved by physician). Assist… | 2018-04-01 |
| 6314 | 6314 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 329 | D | 1 | 0 | J5M711 | **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 five (5) residents reviewed was free from unnecessary medication. Resident #7 received excessive doses of [MEDICATION NAME] (Miritazapine), an antidepressant. Resident identifier: #7. Facility census: 86. Findings include: a) Resident #7 A review of Resident #7's medical record, at 10:15 a.m. on 04/27/15, found a 01/22/15 physician's orders [REDACTED]. Prior to this order, Resident #7 was receiving 7.5 mg of [MEDICATION NAME] every night. The Medication Administration Record [REDACTED]. The previous ordered dose of [MEDICATION NAME] 7.5 mg was also initialed as given on 01/23/15, 01/24/15. 01/25/15 and 01/26/15. This resulted in Resident #7 receiving 22.5 mg of [MEDICATION NAME] on 01/23/15, 01/24/15, 01/25/15, and 01/26/15, when she was ordered and should have only received 15 mg of [MEDICATION NAME] on each of these days. An interview with the Director of Nursing (DON), at 11:00 on 04/27/15, confirmed Resident #7's January 2015 MAR indicated [REDACTED]. | 2018-04-01 |
| 6315 | 6315 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 356 | C | 1 | 0 | J5M711 | Based on observation of the staff posting and staff interview, the facility failed to post staffing information that accurately reflected the current date, the total number and actual hours worked by registered nurses, licensed nurses, certified nurse aides per shift, and the current resident census. This had the potential to affect all residents and/or visitors residing or visiting the facility. Facility census: 86. Findings include: a) Observation of the staff posting, during the initial tour of the facility, at 11:25 a.m. on 04/22/15, found the facility staff posting was dated 04/21/15. An interview with the director of nursing, at 11:30 a.m. on 04/22/15, confirmed the facility had not displayed the staff posting information for 04/22/15. | 2018-04-01 |
| 6316 | 6316 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-04-28 | 514 | D | 1 | 0 | J5M711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the accuracy of the medical record for one (1) of ten (10) residents whose medical records were reviewed. Resident #7's Medication Administration Record [REDACTED]. In addition, nurses documented the resident was administered medication which was not available in the facility for administration. Resident identifier: #7. Facility census: 86. Findings include: a) Resident #7 Review of Resident #7's medical record, on 04/27/15 at 10:15 a.m., revealed a new order on 01/22/15 to increase [MEDICATION NAME] ([MEDICATION NAME]) to 15 milligrams (mg) by mouth (po) at night for weight loss. The Medication Administration Record [REDACTED]. In addition, further review of the medical record found the documentation on the MAR for 03/01/15 through 03/17/15 and the MAR for 04/01/15 though 04/02/15, indicated the resident received both the [MEDICATION NAME] 7.5 mg and the [MEDICATION NAME] 15 mg po at bedtime on these dates. During an interview with the Director of Nursing (DON), on 04/27/15 at 11:00 a.m., he acknowledged the MARs for both [MEDICATION NAME] ([MEDICATION NAME]) 7.5 mg and 15 mg. were initialed as given 03/01/15 through 03/17/15 and 04/01/15 though 04/02/15. The DON said it was a paper error, as the pharmacy had only supplied the nurses with [MEDICATION NAME] 15 mg since 01/23/15. The DON said the facility did not received [MEDICATION NAME] 7.5 mg after 01/23/15; therefore, the nurses could not have administered the 7.5 doses, even though they documented it was administered. | 2018-04-01 |
| 6317 | 6317 | GRANT COUNTY NURSING HOME | 515151 | 127 EARLY AVENUE | PETERSBURG | WV | 26847 | 2014-04-16 | 241 | D | 0 | 1 | 6PKC11 | Based on observations and staff interview the facility failed to promote the dignity for two (2) residents dining in the 100 hall dining room. The two (2) residents were not provided their meals at the same time as their tablemates. Resident identifiers: #107 and #68. Findings include: Observations on 4/14/2014 at 12:02 PM revealed four residents were seated at one table in the 100 hall dining room. Two of the four residents, #107 and #68, were observed to be eating their meals and the other two residents had not yet received their meals. The two residents who had not received their meals were observed to watch as the other two residents were fed their lunch by one staff member. The two residents being fed by staff had consumed their entire meal before the other two residents were served their meal tray. Interview with Staff #17 - Stated the two residents would have to wait to be assisted with their meals until a staff member was available to assist them as they both required the assistance of a staff member to eat. She stated a lot of residents in 100 Hall dining room require assistance to be fed so the staff feed residents as they can. Interview with Staff #77 during lunch service revealed the lunch trays come to the dining room for all residents at the same time and they just take the trays and feed the residents as they can. She stated they have a lot of residents on this unit who need assistance to be fed and there are only so many staff available to feed at one time. Interview with the dietary manager on 4/16/2014 at 1:30 PM revealed they had identified a concern with residents on 100 Hall having to wait for assistance to be fed. She stated they had made a change to how breakfast was served so residents would receive assistance with their meals more timely, but they had not made any changes to the the lunch or supper meal services. She verified all the meal trays for all the residents were brought to the 100 Hall dining room for lunch at the same time. She verified they needed to adjust the delivery of the … | 2018-04-01 |
| 6318 | 6318 | GRANT COUNTY NURSING HOME | 515151 | 127 EARLY AVENUE | PETERSBURG | WV | 26847 | 2014-04-16 | 242 | D | 0 | 1 | 6PKC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews and staff interview, the facility failed to honor resident choices regarding how often they would like to receive a shower or bath. This affected 3 of 12 residents interviewed in Stage 1. Resident identifiers #7, #91, and #22. Findings include: 1. Review of Resident #7's clinical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The Admission History and Physical dated 12/31/2013 documented the resident was alert and oriented. Review of the Admission Minimum Data Set assessment dated [DATE] revealed the resident scored a 14 on the Brief Interview for Mental Status, indicating intact cognition. The resident was further assessed to require extensive assistance of two staff members with bathing and that is was very important for him/her to choose mode of bath. The clinical record was silent for assessment of bathing frequency preferences. Review of the current care plan dated 04/02/2014 revealed the following care plan problem: ADL FUNCTIONAL AND PREFERENCES ADL Customary Routine Preferences, expressing interest in specific activities. The care plan goal included preferences in routine will be respected where/whenever possible. The care plan interventions were silent for bathing frequency preferences. During interview on 4/15/2014 1:12 PM, Resident #7 stated I take a tub bath on Sunday and Wednesday night as scheduled by the facility and stated I was never asked how often I would like to bathe. During interview on 4/15/2014 at 3:50 PM, staff member #24 verified they did not assess bathing preferences on admission or at any other times. Staff stated they assess bath mode and will assign the resident a schedule for bathing usually twice weekly. During interview on 4/16/2014 at 7:30 AM, Resident #7 stated he/she would prefer to bathe at least three times per week. 2. Review of Resident #91's clinical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The annual Minimum Data Set ass… | 2018-04-01 |
| 6319 | 6319 | GRANT COUNTY NURSING HOME | 515151 | 127 EARLY AVENUE | PETERSBURG | WV | 26847 | 2014-04-16 | 253 | E | 0 | 1 | 6PKC11 | Based on observations and staff interview, the facility failed to maintain interior walls, woodwork, and wood doors in resident's rooms. This affected 20 of 58 rooms where residents resided in the facility. Findings include: An environmental tour was done on 4/16/14 at 12:15 P.M. with the Maintenance Director #9. The following residents' rooms and bathrooms with observed on the tour: 109, 111, 205, 206, 207, 208, 209, 211, 213, 302, 303, 304, 305, 306, 307, 309, 406, 408, 411 and 414. They were observed with marred walls, chipped drywall, chipped wood trim and chipped wood on bathroom doors. The following rooms were identified with environmental concerns. Room 109,111, 205, 206 and room 207 were observed with marred woodwork around the closet doors. Room 208 was observed with chipped wood around the closet door and bathroom door. Room 209 was observed with chipped wood around the closet door and the wall was chipped by the the closet. The bathroom door and the bathroom trim had chipped wood. There were black marks on the bathroom walls. Room 211 was observed with chipped wood trim around the closet doors, chipped wood on the bathroom door, chipped drywall behind the trash can in the bathroom and chipped drywall beside the closet doors. Room 213 was observed with chipped wood trim around the closet doors and chipped wood on the bathroom door. The drywall was chipped behind the trash can in the bathroom. Room 302 was observed with holes in the drywall in the bathroom and black marks on the wall. Room 303 was observed with chipped drywall in the bathroom and chipped wood on the bathroom door. Room 304 was observed with chipped paint on the bathroom door frame, chipped drywall by the bathroom door and chipped drywall in the bathroom. Room 305B was observed with chipped wood on the room door and chipped drywall in the bathroom and the head of the resident's bed. Room 306 was observed with chipped paint on bathroom door frame, chipped drywall on bathroom walls and chipped wood on the bathroom door. Room 307 was observe… | 2018-04-01 |
| 6320 | 6320 | GRANT COUNTY NURSING HOME | 515151 | 127 EARLY AVENUE | PETERSBURG | WV | 26847 | 2014-04-16 | 282 | D | 0 | 1 | 6PKC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to implement the plan of care for one (1) resident of 16 residents whose care plans were reviewed in Stage 2. Resident identifier: #107. Findings include: Resident #107 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the the most recent Minimum (MDS) data set [DATE] found the resident was severely cognitively impaired, had long and short term memory loss and required the assistance of one staff for eating. The current care plan, dated 4/3/2014, documented Resident #107 was nutritionally compromised with a potential for further decline due to weight loss and low body mass index (BMI). One of the nutrition care plan goals was to provide a dietary supplement of Ensure 8 oz three times a day between meals and at bed time. Interventions were added to the nutrition care plan on 12/27/13 to add double portions at breakfast and increase his/her nutritional supplement (ensure) to 120 ml three times a day. On 2/17/14 a new intervention was added to increase his/her Ensure to 6 oz 3 x a day and on 3/14/14 the Ensure was increased to 6 oz to 8 oz three times a day. Review of the intake logs for 2014, where the staff were required to document the consumption of Resident 107's nutritional supplement, revealed many days with documentation missing. Interview with Staff #77 on 4/16/2014 in 100 hall dining room at 1:33 PM revealed staff that dispense residents' supplements would be required to document how much the resident consumed. She stated they are required to document this in the nurse aide computer. Review of this documentation was located on a report called the Meal Intake Detail Report. Review of this report for Resident #107 for January 2014 revealed staff failed to document consumption of dietary supplement for the morning snack for 19 of 31 days. They failed to document consumption of the afternoon snack in January 2014 for 16 of 31 days and … | 2018-04-01 |
| 6321 | 6321 | GRANT COUNTY NURSING HOME | 515151 | 127 EARLY AVENUE | PETERSBURG | WV | 26847 | 2014-04-16 | 325 | D | 0 | 1 | 6PKC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure one of four residents identified as underweight in a sample of 40 residents from Stage 1 was provided nutritional care and services to maintain acceptable parameters of nutritional status. Resident #107, who was documented with low body weight, was ordered a dietary supplement to promote weight gain. There was a lack of evidence the dietary supplement was consistently provided and/or consumed. Findings include: a) Resident #107 The resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the the most recent Minimum Data Set data 01/07/14 revealed documentation the resident was severely cognitively impaired, had long and short term memory loss, and required the assistance of one staff for eating. The current nutrition care plan dated 4/3/14 documented Resident #107 was nutritionally compromised with a potential for further decline due to weight loss and low body mass index (BMI). The nutrition care plan goal was to attempt to maintain weight at 103-110 pounds. Interventions included provide assistance with meals and record meal intake. Interventions also included were to provide a regular diet as ordered with double portions at breakfast and oral supplement Ensure 8 oz three times a day between meals and at bed time. The nutrition care plan and dietary notes revealed documentation on 12/27/13 of an intervention to increase the dietary supplement of Ensure to 120 ml 3 times a day. On 2/17/14, Ensure was increased to 6 oz 3 x a day and on 3/14/14, increased to 8 oz 3 times a day due to weight loss. Review of the weight record revealed Resident #107's weights were as follows: 09/22/13 .123 10/20/13 .119 11/18/13 .117 12/15/13 .111 01/12/14 .112 02/09/14 .108 03/09/14 .103 040/8/14 .107 Review of the Meal Intake Detail report for Resident #107 revealed no evidence the resident received or consumed snacks in January 2014 as follows: … | 2018-04-01 |
| 6322 | 6322 | FAYETTE NURSING AND REHABILITATION CENTER | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2014-07-23 | 252 | E | 0 | 1 | 5EN111 | Based on observation and staff interview, the facility failed to ensure the environment where residents live was comfortable and homelike. The area designated as a resident sitting area was in the corner area of the dining room. It contained rocking chairs, a sofa, and a television. Empty wheelchairs and geri-chairs were observed stored in front of the furniture preventing access to residents or visitors who desired to sit in these chairs. The residents who were seated in their wheelchairs were sitting in an area where the empty wheelchairs were stored. This did not create a pleasant homelike sitting area. This practice had the potential to affect more than an isolated number of residents. Facility Census: 55. Findings include: a) During an observation on 07/15/14 at 8:00 a.m., the area in the corner of the dining room was observed. This area had carpet, a television, a couch, and several rocking chairs. It was designated as a sitting area where residents could sit and/or watch television. Eight (8) empty wheelchairs were observed stored in the area, blocking access to the rocking chairs and the sofa. On 07/16/14 at 4:00 p.m., nine (9) empty wheelchairs and four (4) empty geri-chairs were observed stored in the dining room. Six (6) of the empty chairs were in the television area in front of the rocking chairs. This prevented access to the area by any resident who desired to sit in the rocking chairs or on the couch. During a confidential employee interview, a nursing assistant was questioned about the chairs being stored in the resident sitting area in the corner of the dining room. The nursing assistant replied, That is where they told us we have to put them. The dining area was observed on various days and times during the survey from 07/15/14 to 07/23/14. There were always several wheelchairs and geri-chairs stored in the resident sitting area. A tour was conducted with the Environmental Service Supervisor (Employee #23) and the facility administrator (Employee #78) on 07/23/14 at 12:00 p.m. They were made awa… | 2018-04-01 |
| 6323 | 6323 | FAYETTE NURSING AND REHABILITATION CENTER | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2014-07-23 | 253 | D | 0 | 1 | 5EN111 | Based on observation and staff interview, the facility failed to ensure effective housekeeping and maintenance services. Four (4) rocking chairs and a geri-chair in the common area designated as a sitting area for residents, were observed with tears, rips, and/or with stuffing of the upholstery exposed. The condition of these items rendered them unable to be effectively sanitized. This practice had the potential to affect more than an isolated number of residents. Facility Census: 55 Findings include: a) On 07/15/14 at 8:00 a.m., four (4) rocking chairs and a geri-chair were observed with tears and rips in the upholstery, and the stuffing was exposed around the bottom parts of the chairs. A tour was conducted with the Environmental Service Supervisor (Employee #23) and the facility Administrator (Employee #78), on 07/23/14 at 12:00 p.m. Observations were made of the four (4) rocking chairs and the geri-chair. They agreed the condition of the rocking chairs and the geri-chair upholstery could result in improper sanitization of the chairs. | 2018-04-01 |
| 6324 | 6324 | FAYETTE NURSING AND REHABILITATION CENTER | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2014-07-23 | 272 | D | 0 | 1 | 5EN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview, the facility failed to complete an accurate comprehensive assessment for one (1) of three (3) residents reviewed in Stage 2 for dental services. The minimum data set (MDS) assessment did not indicate the resident had [MEDICAL CONDITION] on his lower lip. Resident identifier: #14. Facility census: 55 Findings include: a) Resident #14 Resident #14 was admitted to the facility on [DATE]. During an interview with the resident, on 07/15/14 at 9:30 a.m., four (4) black round [MEDICAL CONDITION] were observed on the resident's lower lip. The resident said he believed the spots were from smoking. Review of the resident's admission MDS, with an assessment reference date of 05/21/14, found Section L, related to dental status, did not indicate the resident had [MEDICAL CONDITION] on his lower lip. The failure to indicate the [MEDICAL CONDITION] on the MDS was brought to the attention of the director of nursing (DON). At 1:07 p.m. on 07/23/14, the DON confirmed the [MEDICAL CONDITION] were not identified on the resident's MDS. | 2018-04-01 |
| 6325 | 6325 | FAYETTE NURSING AND REHABILITATION CENTER | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2014-07-23 | 332 | D | 0 | 1 | 5EN111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, the facility failed to ensure a medication error rate of less than five (5) percent. Resident #33's eye drops were not instilled to make contact with the conjunctival sac, and was not washed over the eye for optimal absorption. Also, Resident #13 did not receive the specific Calcium preparation as ordered by the physician. Two (2) errors, of the thirty-one (31) opportunities observed, resulted in a medication error rate of 6.45%. This practice affected two (2) of five (5) residents observed during medication administration observations. Resident identifiers: #13 and #33. Facility Census: 55. Findings include: a) Resident #13 During medication administration observation, on 07/17/14 at 8:30 a.m., Employee # 24 administered one (1) Calcium 600 mg (milligram) + D tablet by mouth to Resident #13. Review of the physician's orders [REDACTED]. The medication observed administered by the nurse was not the same as that ordered by the physician. b) Resident #33 During medication administration observation, on 07/17/14 at 9:20 a.m., Employee #24 was observed administering an eye drop medication, [MEDICATION NAME] ([MEDICATION NAME]) one (1) drop to each eye. The nurse (Employee #24) pulled the resident's upper eyes open from the eye brows and instilled the drop in each eye from the top. Observation revealed the drops did not make full contact with the eye. The facility policy titled Instillation of Eye Drops was reviewed on 7/18/14. The section stated Steps in the Procedure stated: Step 7- Gently pull the lower eyelid down. Instruct the resident to look up. Step 8- Drop the medication into the mid lower eyelid (fornix). Step 9- Instruct the resident to slowly close his/her eyelid to allow for even distribution of the drops. These steps were not performed when Employee #24 administered the eye drops. On 7/23/14 at 11:00 a.m., the Director of Nursing was made aware of the technique o… | 2018-04-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );