cms_WV
Data source: Big Local News · About: big-local-datasette
311 rows where "filedate" is on date 2018-05-01
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5915 | 5915 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2014-10-15 | 160 | D | 0 | 1 | 8R4I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to properly convey a resident's personal funds upon death for one (1) of three (3) residents reviewed for personal funds. The day before Resident #153 expired, a staff member transferred Resident #153's funds to another resident without any authorization to make the transfer. Resident identifier: #153. Facility census: 142. Findings include: a) Resident #153 This resident had a personal funds account managed by the facility. The resident expired on [DATE]. A review of Resident #153's Trust Transaction History report, indicated a cash withdrawal on [DATE] in the amount of $520.88. During an interview and record review with the Director of Finance (DOF), on [DATE] at 9:40 a.m., she stated Resident #153 expired on [DATE]. She further stated the resident's personal funds had been withdrawn on [DATE]. The DOF stated Resident #153 was a ward of the State, and did not have family. She indicated the resident had a close friend, who was also a resident at the facility (Resident #154), and she transferred Resident #153's personal funds into Resident #154's personal funds account one day before Resident #153's death. The DOF stated she did not receive any instructions from the facility's Administration or from Resident #153 on how the personal funds should be conveyed. The DOF made the transfer herself, and stated she thought of the money as a gift to Resident #154 from Resident #153 since they were so close to each other. She stated the residents used to live together, were always sharing their things, and called each other sisters. A review of Resident #154's Trust Transaction History report indicated a deposit on [DATE], in the amount of $520.88. There was no check written to the personal funds account of Resident #154 for the deposit. The DOF stated she made the transfer in the facility's accounting system from Resident #153's account to Resident #154's account. The DOF stated she was … | 2018-05-01 |
| 5916 | 5916 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2014-10-15 | 252 | E | 0 | 1 | 8R4I11 | Based on observations and staff interviews, the facility failed to provide a homelike dining experience for residents eating in three (3) of seven (7) dining rooms. Residents' meals were left on plastic trays when served which did not promote a homelike dining experience. Facility census: 142. Findings include: a) Dining Room - 600 Hall 1. Observation of lunch on service on 10/13/14 at 1:05 p.m. revealed five (5) residents were seated at the dining tables in the 600 Hall Dining Room. All five (5) of the residents were served their meals with their plate and all other food items left on the large square tray that was used to deliver the food to the table. The plate and drinks were not removed from the large plastic tray to promote a more homelike environment for the dining experience. 2. Observation of meal service on the 600 Hall on 10/13/14 at 1:10 p.m. revealed four (4) residents were seated in the dining room and all four (4) residents were served their meals on large square trays. No staff were observed to remove the plates, cups, or other food items from the the large square tray tray that was used to deliver the food to the table to promote a homelike dining experience. b) Dining Room - 700 Hall 1. During an observation on 10/14/14 at 1:30 p.m., four (4) residents were observed eating lunch in the day room on the 700 Hall Dining Room. Three (3)residents were sitting at a half circle table. The residents' plates, utensils, and beverages had been left on the meal tray. One resident was observed sitting at a round table with a decorative tablecloth. The resident's plate, utensils, and beverages had not been removed from the meal tray to promote a homelike dining experience for the resident. 2. During a second dining observation, on 10/15/14 at 12:44 p.m., of the 700 Hall Dining Room, all nine (9) residents in the dining room were served their meals on plastic trays and the plates, coffee, juice, milk containers were all left on the trays. c) Dining Room - 800 Hall 1. During an observation on 10/15/14 at 8:20 a… | 2018-05-01 |
| 5917 | 5917 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2014-10-15 | 253 | E | 0 | 1 | 8R4I11 | Based on observations and staff interviews, the facility failed to provide housekeeping and maintenance services as evidenced by concerns as discussed with Maintenance Supervisor and Director of Operations. Personal items were not labeled to identify to whom they belonged, a wheelchair was in need of repair, urinals were not labeled, emptied, and or cleaned, and walls, floors, and equipment were in need of repair. Facility census: 142. Findings include: a) Observations The following environmental concerns were identified on 10/13/14 and 10/14/14 and verified by Maintenance Supervisor #46 and Director of Operations #94 during an environmental tour conducted on 10/15/14: -- Room 108 - One (1) wheelchair with a torn armrest and the handbrake extension grip taped up -- Room 109 - One (1) unlabeled denture cup containing dentures, and an unlabeled unclean urinal were sitting on the bedside table -- Room 110 - The floor underneath the sink was dirty with splatters and there was stained ceiling tile by the window -- Room 202 - One (1) urinal and measuring container sat on the sill of the bathroom window, the toilet was unflushed, and there was an odor in the room -- Room 208 - Two (2) full urinals sat on the bedside table -- Room 503 - Two (2) scrapes on metal closet/cabinet -- Room 509 - Two (2) corners near the bed had peeling paint -- Room 601 - Two (2) walls behind bed had black marks from the head of the bed going up and down -- Room 611 - Two (2) walls behind a bed had black marks from the head of the bed going up and down -- Room 703 - Two (2) walls had indentations in the sheetrock behind the bed -- Room 807 - Two (2) elevated toilet seats had rusted legs and peeling paint. There were brown splatters on the floor under sink b) Environmental Tour and Staff Interview During an environmental tour conducted on 10/15/14 with Maintenance Supervisor #46 and Director of Operations #94, these concerns were verified as present and existing concerns. Maintenance Supervisor #46 stated that all the identified issues were in … | 2018-05-01 |
| 5918 | 5918 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2014-10-15 | 281 | D | 0 | 1 | 8R4I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of the instructions for administering Fleets enemas, the facility failed to ensure services provided to residents met professional standards of quality. A nurse administered a Fleets enema to a resident while the resident was standing. One (1) of twenty-nine (29) residents reviewed in Stage 2 of the Quality Indicate Survey was affected. Resident identifier: #59. The Stage 2 sample size was 29. Facility census: 142. Findings include: a) Resident #59 Review of the resident's clinical record revealed this [AGE] year-old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS), a significant change in status assessment, dated 09/10/14, documented Resident #59 was cognitively intact and required the extensive physical assistance of two (2) staff for transfers and toileting. Review of the care plan, dated 09/02/14, for Resident #59 documented she required the physical assistance of two (2) staff for transfers and the staff were to use a gait belt during transfers. Resident #59's functional status care plan was updated on 10/10/14 after she fell in the bathroom when only one (1) staff member was assisting her. The updated care plan indicated Resident #59 was unable to perform activities of daily living independently related to weakness, arthritis, balance during transfer, and walking. She was noted to be unsteady when moving from a seated to standing position and was not steady with any surface to surface transfers. The care plan also documented Resident #59 required two (2) staff to assist her with transfers and the staff were to use belt around her waist during transfers. Review of the nurses' notes dated 10/06/14 at 4:26 p.m., revealed Resident #59 was in the hall bathroom with one (1) staff, Licensed Practical Nurse (LPN) #37, and was standing at the toilet holding onto the safety bar while the nurse was administering a Fleets e… | 2018-05-01 |
| 5919 | 5919 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2014-10-15 | 282 | D | 0 | 1 | 8R4I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to implement a fall care plan for one (1) of nineteen (19) residents whose care plans were reviewed. Resident #59 sustained a fall with only one (1) staff member in attendance although the resident's care plan identified two (2) staff members were required. The Stage 2 sample size was 29. Facility census: 142. Findings include: a) Resident #59 Review of the resident's clinical record revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS), a significant change in status assessment, dated 09/10/14, documented Resident #59 was cognitively intact and required the extensive physical assistance of two (2) staff for transfers and toileting. Review of the care plan, dated 09/02/14, for Resident #59 documented she required the physical assistance of two (2) staff for transfers and the staff were to use a gait belt during transfers. Resident #59's functional status care plan was updated on 10/10/14 after she fell in the bathroom when only one (1) staff member was assisting her. The updated care plan indicated Resident #59 was unable to perform activities of daily living independently related to weakness, arthritis, balance during transfer, and walking. She was noted to be unsteady when moving from a seated to standing position and was not steady with any surface to surface transfers. The care plan also documented Resident #59 required two (2) staff to assist her with transfers and the staff were to use belt around her waist during transfers. Review of the nurses' notes dated 10/06/14 at 4:26 p.m., revealed Resident #59 was in the hall bathroom with one (1) staff, Licensed Practical Nurse (LPN) #37, and was standing at the toilet holding onto the safety bar while the nurse was administering a Fleets enema. The resident was noted to start to sit down unexpectedly before a shower chair could be placed under her.… | 2018-05-01 |
| 5920 | 5920 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2014-10-15 | 323 | D | 0 | 1 | 8R4I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide adequate supervision to prevent falls for one (1) of three (3) residents reviewed for accidents. An enema was administered, with only one (1) staff member in attendance, to a resident while she was standing. The resident required the assistance of two (2) staff for transfers and toileting. Additionally, administering an enema to the resident while standing increased the potential for perforating the bowel should the resident be unsteady, and in this case, experience a fall. Resident identifier: #59. The Stage 2 Sample was 29. Findings include: a) Resident #59 Review of the clinical record revealed Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive Minimum Data Set (MDS) assessment, a significant change in status assessment, dated 09/10/14, documented Resident #59 was cognitively intact and required the extensive physical assistance of two (2) staff for transfers and toileting. Resident #59's functional status care plan, dated 09/02/14, documented she required the physical assistance of two (2) staff for transfers and the staff were to use a belt around her waist during all transfers. Resident #59's functional status care plan was updated on 10/10/14 which indicated she was unable to perform activities of daily living independently related to weakness, arthritis, balance during transfer, and walking. She was noted to be unsteady when moving from a seated to standing position and was not steady with any surface to surface transfers. This care plan also documented Resident #59 required two (2) staff to assist her with transfers and the staff were to use belt around her waist during all transfers. Her fall care plan included an intervention dated 10/07/14 for the staff to ensure her chair was close during transfers in case her legs became weak and she was not able to stand. Review of the nurses' notes, dated 10/06/14 at … | 2018-05-01 |
| 5921 | 5921 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2014-10-15 | 441 | D | 0 | 1 | 8R4I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the Centers for Disease Control and Prevention guidelines, observations, and record review, the facility failed to maintain proper handwashing and gloving practices for one (1) of one (1) resident (Resident #158) observed during incontinence care. Resident identifier: #158. Facility census: 142. Findings include: a) Resident #158 A review of Resident #158's medical record, indicated the resident had a [DIAGNOSES REDACTED]. Difficile). According to the Centers for Disease Control and Prevention, Clostridium difficile is a bacterium that causes inflammation of the colon . Clostridium difficile is shed in feces. Any surface, device, or material (e.g., toilets, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the Clostridium difficile spores. A review of Resident #158's Minimum Data Set, dated dated [DATE], indicated the resident required extensive assistance with bed mobility, dressing, and toilet use. The resident was frequently incontinent of bowel. During an observation and interview on 10/13/14 at 10:07 a.m., Nursing Assistant (NA) #66 was observed providing incontinence care for Resident #158. She indicated the resident had [DIAGNOSES REDACTED]icile, and was on contact precautions. She put on an isolation gown and gloves. She prepared a bath basin and towels and provided incontinence care. She then changed her gloves, dressed the resident and transferred the resident to his wheelchair. She did not wash her hands between glove changes. NA #66 then gathered the soiled linens that were used during incontinence care and changed the resident's bed linens. She placed the linens in the soiled linen bin. NA #66 did not wash her hands or change her gloves after disposing of the soiled linens. She then proceeded to get the resident's toothbrush, toothpaste, and basin for the resident to brush his teeth. During an interview on 10/13/14 at 2:45 p.m., NA #6… | 2018-05-01 |
| 5922 | 5922 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2015-06-11 | 252 | D | 1 | 0 | P4O811 | Based on observation and staff interview, the facility failed to provide a clean homelike environment which de-emphasized the institutional character of the setting, to the extent possible, in two (2) bathrooms, each shared by two (2) rooms. Residents' personal use items were stored between the grab bar and the bathroom wall and/or on the bathroom floor. This practice affected three (3) residents, but had the potential to affect all residents who resided in the four (4) rooms which shared the two (2) bathrooms. Resident identifiers: #60, #111, and #65. Facility census: 138. Findings include: a) Resident #111 and Resident #65 Observation on 06/10/15 at 9:15 a.m., found a pink wash basin, a Texas hat (a device placed on a commode to collect urine or stool specimens), and a gray bed pan stacked atop each other on the floor in a bathroom shared by Resident #111 and Resident #65. The items were not bagged, and were not labeled with anyone's name. These items were still there when the bathroom was observed again at 2:15 p.m. on 06/10/15. This bathroom was also shared by the residents who resided in the room next door. b) Resident #60 Observation on 06/10/15 at 10:50 a.m., found a pink fracture bed pan (smaller bed pan that goes under the resident from the front) in the bathroom that Resident #60 shared with residents in the adjoining room. The fracture pan was stored between the grab bar and the bathroom wall. It was not labeled with a person's name, and it was not contained in a bag. It was still there when the bathroom was again observed at 2:15 p.m. on 06/10/15. c) During an interview with Licensed Practical Nurse (LPN) #1, on 06/10/15 at 2:30 p.m., she said personal items such as bed pans were stored in clean trash bags in the residents' bottom dresser drawers. LPN #1 said those items were also labeled with a sticker which contained the name of the resident to whom the items belong. She was then shown the items found in the two (2) bathrooms. LPN #1 agreed they were not labeled, bagged, and/or otherwise properly st… | 2018-05-01 |
| 5923 | 5923 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2015-06-11 | 280 | D | 1 | 0 | P4O811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interviews, the facility failed to accurately revise the comprehensive care plan for two (2) of seven (7) residents whose care plans were reviewed. The care plan for Resident #80 was incorrectly revised when the assistance needed for transfers changed. The care plan for Resident #37 was not revised for [MEDICAL CONDITIONS] transmission precautions. Resident identifiers: #80, and #37. Facility census: 138. Findings include: a) Resident #80 Resident #80 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 05/15/15, the physician signed and dated the Resident Capacity to Make Medical Decisions form, stating the resident demonstrated the capacity to make medical decisions. On 06/09/15 at 10:15 a.m., a review of the care plan for Resident #80 revealed a focus area related to functional deficits. The focus stated the resident was not steady during transfers and ambulation. The goal of the focus area was for Resident #80 to maintain the current level of functioning without decline. Interventions included assistance of one (1) staff member and a gait belt for transfers and ambulation, with a revision date of 04/10/15. A review of the physician's orders [REDACTED]. The previous order, written upon admission in July 2014, was to transfer with the assistance of two (2) and a gait belt. During an interview with Resident #80, on 06/10/15 at 9:25 a.m., the resident was asked how much assistance she received when transferring from the bed to the wheelchair, or the wheelchair to the toilet and back. She said sometimes she received assistance from one (1) staff member and sometimes she received assistance from two (2) staff members. When asked if the staff members used a gait belt to assist with transfers, Resident #80 replied, No, they just help me move from place to place. On 06/10/15 at 2:45 p.m., the care plan and physician orders [REDACTED]. The DON verified the care plan… | 2018-05-01 |
| 5924 | 5924 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2015-06-11 | 282 | D | 1 | 0 | P4O811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interviews, the facility failed to implement care plan interventions for three (3) of seven (7) residents whose care plans were reviewed. The care plan interventions for the amount of required assistance and/or the use of assistive devices for transfers were not implemented for these residents. Resident identifiers: #95, #139, and #37. Facility census: 138. Findings include: a) Resident #95 Resident #95 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/20/15, the physician signed and dated the Resident Capacity to Make Medical Decisions form, stating the resident demonstrated the capacity to make medical decisions. On 06/10/15 at 10:15 a.m., upon inquiry, Resident #95 said she had been a resident in the facility for almost eight (8) years. When asked how much assistance she received when transferring from the bed to the wheelchair, or the wheelchair to the toilet and back, she said sometimes she was transferred with the assistance of one (1) and sometimes she was assisted by two (2) staff members. She said it just depended on how many nurse aides (NAs) were working on the hall. When asked if the NAs used a gait belt when assisting with transfers, she said, The aides never use a gait belt when they help me move, and I do not need one. At 1:50 p.m. on 06/10/15, a review of the physician's orders recapitulation for June 2015, signed by the physician on 05/28/15, identified the mobility order was to transfer the resident with the assistance of one (1) staff member and a gait belt. On 06/10/15 at 3:25 p.m., a review of the care plan for Resident #95 revealed a focus area related to functional deficits, related to weakness and [MEDICAL CONDITION]. The focus stated the resident was not steady during transfers and ambulation. The goal of the focus area was that Resident #95 would not decline in current functional performance. Interventions, last revised on 09/16/… | 2018-05-01 |
| 5925 | 5925 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2015-06-11 | 309 | D | 1 | 0 | P4O811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure two (2) of seven (7) residents reviewed were provided care and services to maintain their highest practicable well-being. The residents were not provided the amount of staff assistance for transfers as ordered by the physician and/or as indicated in their care plans. Resident identifiers: #37 and #139. Facility census: 138. Findings include: a) Resident #37 Review of the medical record, on 06/10/15 at 9:50 a.m., found physician's orders [REDACTED]. Interview on 06/10/15 at 11:00 a.m., with Nursing Assistant (NA) #46, found staff walked Resident #37 to the toilet and helped her with transfers with a one (1) person assist. The NA provided her copy of the aides' worksheet she used for provision of care. It indicated, under the heading entitled Daily Activities, the resident was a one (1) person assist. NA #46 said the aide worksheets, individualized for each resident, were hand-written by the nurse in charge, and were kept in a blue folder at the nurses' desk. She said the aides got a copy of these for their use. An interview was conducted on 06/10/15 at 11:00 a.m., with Licensed Practical Nurse (LPN) #1. Upon inquiry as to how many staff persons should help Resident #37 with transfers or to take her to the toilet, she said, in her opinion, it should be two (2). The LPN checked the physician's orders [REDACTED].#37 required a two (2) person assist for transfers. She then changed the aide worksheets from a one (1) person assist to a two (2) person assist. During an interview with the director of nursing (DON), on 06/10/15 at 1:00 p.m., she said she would expect if the physician's orders [REDACTED]. The DON was informed the physician ordered a two (2) person assist for transfers for Resident #37, but the aides' worksheets directed the resident was only a one (1) person assist. Upon inquiry of another nursing assistant (NA #82), on 06/10/15 at 6:00 p.m., she said Resi… | 2018-05-01 |
| 5926 | 5926 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2015-06-11 | 441 | E | 1 | 0 | P4O811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and facility policy review, the facility failed to maintain an Infection Control Program to prevent, to the extent possible, the onset and spread of infections for one (1) of three (3) residents during an observation of medication administration. In addition, one (1) of four (4) isolation rooms did not have a sign posted which indicated the need to use Personal Protective Equipment (PPE) and/or to see a nurse prior to entering the room. These practices had the potential to affect more than a limited number of residents. Resident identifier: #91. Facility census: 138 Findings include: a) Resident #91 On 06/09/15 at 8:15 a.m., during observation of medication administration, Licensed Practical Nurse (LPN) #6 inadvertently tipped the medication cup, which contained the resident's medications, onto its side. Some of the medications spilled onto the surface of the medication cart. One medication, a multi-vitamin, fell to the floor. LPN #6 used his ungloved hand to push the spilled medications back into the cup from the surface of the medication cart. He placed a new multi-vitamin into the medication cup, and continued preparing the remainder of the resident's medication for administration. The LPN next picked up the multi-vitamin from the floor, disposed of it, and without washing or otherwise sanitizing his hands, picked up the medication cup and administered the medications to Resident #91. This created a potential for transferring microorganisms from the floor to the cart and the resident. It was verified the nurse did not wash his hands after retrieving the pill from the floor. At 8:35 a.m. on 06/09/15, when asked what he should have done differently when the pills spilled onto the surface of the medication cart, LPN #6 said, I should not have touched them. Upon further inquiry, he confirmed touching the medication with his ungloved hand and using medications which had come into contact with the medicat… | 2018-05-01 |
| 5927 | 5927 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2015-06-11 | 502 | D | 1 | 0 | P4O811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to ensure a physician ordered laboratory test was obtained for one (1) of seven (7) sample residents, so assessment and treatment could be maximized. Resident identifier: #139. Facility census: 138 Findings include: a) Resident #139 A review of the medical record for Resident #139, on 06/09/15 at 4:00 p.m., revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 06/09/15 at 4:15 p.m., a review of the resident's physician's orders [REDACTED]. These were ordered for 05/18/15, 05/22/15, 05/26/15, and 05/30/15. At 5:15 p.m. on 06/09/15, the results of the ordered laboratory specimens were reviewed. The normal laboratory values for Ammonia Levels range from nine (9) to thirty (30). The resident's Ammonia levels increased from 56 on 05/13/15 to 86 on 05/18/15. The record contained no results for an Ammonia Level on 05/22/15, as ordered for the resident on 05/18/15. There was, however, a laboratory specimen drawn for a comprehensive metabolic panel (CMP) on 05/22/15, and these results were in the resident's medical record. The Ammonia Level was obtained on 05/26/15. It indicated a slightly decreased level of 82. The Ammonia Level obtained on 05/30/15 was even lower, at 69. On 06/10/15 at 2:15 p.m., when asked to provide the results for the Ammonia Level ordered for 05/22/15, Nurse Manager (NM) #167 said on 05/18/15, the Nurse Practitioner (NP) told her it was not necessary to obtain the level on 05/22/15 since the resident had poor intravenous access, and it was difficult to obtain a specimen. When asked if the order was discontinued or if a clarification was made regarding the order, NM #167 said, No, it probably should have been. At 9:55 a.m. on 06/11/15, an interview was conducted with the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and the NP, regarding the order to obtain an Ammonia Level for the resident on 05/22… | 2018-05-01 |
| 5928 | 5928 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2015-06-11 | 514 | D | 1 | 0 | P4O811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to maintain accurate, and complete clinical information for one (1) of seven (7) residents whose clinical records were reviewed. The medical record did not contain evidence of administration of some of the resident's medications. In addition, when medication clearly was not administered, the medical record did not always indicate why it was not administered as ordered. Resident identifier: #139. Facility census: 138. Findings include: a) Resident #139 On 06/11/15 at 9:45 a.m., the Medication Administration Record (MAR), and the progress notes for Resident #139 were reviewed with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). Discussed were the 8:00 p.m. ordered medications, of 05/11/15, the date of the resident's admission. The MAR was handwritten, and blocked to indicate when the resident was to receive the first dose of each of the ordered medications. The MAR indicated Resident #139 was to receive [MEDICATION NAME] HCL, [MEDICATION NAME], and [MEDICATION NAME] at 8:00 p.m., beginning on 05/11/15. All the boxes to be initialed when the medications were administered were blank for 05/11/15. There was no evidence the medications were administered, and/or no explanation if they were not administered. The DON and the ADON both verified they were not able to determine if the resident had or had not received the ordered medications. A review of the progress notes for Resident #139 also found no evidence to indicate whether the medications were administered. Further review of the MAR for Resident #139 identified on 05/12/15, the 2:00 p.m. ordered dose of [MEDICATION NAME] was blank. No explanation regarding why the medication administration boxes were left blank was found on the MAR, or in the nurses' progress notes. On five (5) days, 05/18/15, 05/19/15, 05/27/15, 05/28/15, and 05/29/15, the ordered [MEDICATION NAME] was circled, indicating it wa… | 2018-05-01 |
| 5929 | 5929 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-01-16 | 253 | E | 0 | 1 | 947511 | Based on observations and staff interviews the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior for six (6) of eighteen (18) resident bathrooms. The vents in six (6) resident bathrooms on the second floor were not clean as evidenced by dust covering the exterior of the vent. Room identifiers: 200-A, 201, 202, 204-A, 204-B, and 205. Facility census: 38. Findings include: a) 200-A An observation of Room 200-A, at 8:46 a.m. on 01/14/15, revealed the overhead bathroom vent was not clean as evidenced by a covering of dust on the exterior of the vent. b) Room 201 An observation of Room 201, at 9:00 a.m. on 01/14/15, revealed the overhead bathroom vent was not clean as evidenced by a covering of dust on the exterior of the vent. c) Room 202 An observation of Room 202, at 9:47 a.m. on 01/14/15, revealed the overhead bathroom vent was not clean as evidenced by a covering of dust on the exterior of the vent. d) Room 204 A An observation of Room 204-A, at 12:04 p.m. on 01/14/15, revealed the overhead bathroom vent was not clean as evidenced by a covering of dust on the exterior of the vent. e) Room 204-B An observation of Room 204-B, at 9:21 a.m. on 01/14/15, revealed the overhead bathroom vent was not clean as evidenced by a covering of dust on the exterior of the vent. f) Room 205 An observation of Room 205-A, at 11:49 a.m. on 01/14/15, revealed the overhead bathroom vent was not clean as evidenced by a covering of dust on the exterior of the vent. g) Tour with the Director of Nursing A tour with the director of nursing, from 3:31 p.m. to 3:44 p.m. on 01/14/15, confirmed the overhead bathroom vents mentioned above were not clean. | 2018-05-01 |
| 5930 | 5930 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-01-16 | 272 | D | 0 | 1 | 947511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to conduct an accurate comprehensive assessment for one (1) of five (5) residents reviewed for unnecessary medications. The anticoagulant, [MEDICATION NAME], was not identified as having been administered. Resident identifier: #39. Facility census: 38. Findings include: a) Resident #39 On 01/15/15 at 10:00 a.m., a review of the physician's orders [REDACTED]. This order was written upon the resident's admission to the facility. At 01/15/15 at 12:45 p.m., the admission minimum data set (MDS) assessment, with the assessment reference date (ARD) of 11/26/14, was reviewed. Section N0410, (medications received) referred to medications received during the last seven (7) days or since admission/entry or reentry if less than 7 days. The facility marked the medication category of anticoagulant as 0 for Resident #39. On 01/15/15 at 12:50 p.m., upon inquiry, the director of nursing (DON) said she was responsible for completing the MDS assessments. The DON then reviewed the admission MDS for Resident #39. She verified the administration of the anticoagulant, had not been indicated in the assessment, as it should have been. | 2018-05-01 |
| 5931 | 5931 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-01-16 | 323 | E | 0 | 1 | 947511 | Based on resident room observation and staff interview, the facility failed to ensure the resident environment in which it had control over was as free from accident hazards as possible. The grab bars near the toilets were not tightly secured to the wall. This affected two (2) of eighteen (18) bathrooms observed during Stage 1 of the Quality Indicator Survey (QIS). Additionally, the hard plastic guards on the wall mounted heaters were broken leaving the metal beneath the guards exposed. The exposed metal was sharp in places and also had the potential to become hot when the heater was producing heat. This was true for three (3) of eighteen (18) resident heaters observed during Stage 1 of the QIS. This had the potential effect any resident who was able to reach out and touch the exposed metal of the heating unit. Room identifiers: 200-A, 201, and 204-B. Facility census: 38. Findings include: a) Room 200-A An observation of Room 200-A, at 8:46 a.m. on 01/14/15, revealed the hard plastic guard on the wall mounted heater was broken leaving the metal beneath the guard exposed. The exposed metal was sharp in places and had the potential to become hot when the heater was producing heat. b) Room 201 An observation of Room 201, at 9:00 a.m. on 01/14/15, revealed the hard plastic guard on the wall mounted heater was broken leaving the bare metal part of the heating unit exposed. The exposed metal was sharp in places and also had the potential to become hot when the heater was producing heat. c) Room 204-B An observation of Room 204-B, at 9:21 a.m. on 01/14/15, revealed the hard plastic guard on the wall mounted heater was broken leaving the bare metal part of the heating unit exposed. The exposed metal was sharp in places and also had the potential to become hot when the heater was producing heat. Additionally, the assist grab bar behind the toilet was loose and moved up and down when pulled on. d) Tour with the Director of Nursing A tour with the director of nursing from 3:31 p.m. to 3:44 p.m. on 01/14/15, confirmed the af… | 2018-05-01 |
| 5932 | 5932 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-01-16 | 356 | B | 0 | 1 | 947511 | Based on observation and staff interview the facility failed to post nurse staffing data that reflected the current date and the facility's census. The facility staff posting on 01/13/15, the first day of the Quality Indicator Survey was for the week of 12/07/14 through 12/13/14. Additionally, when the facility provided the accurate posting for the week of 01/11/15 through 01/17/15 the census for 01/11/15 and 01/12/15 was not contained on the form. This had the potential to affect more than an isolated of residents currently residing in the facility. Facility census: 38 Findings include: The staff posting was observed, at 2:30 p.m. on 01/13/15, during the initial tour of the second floor. The posting was for the week of 12/07/14 through 12/13/14. It did not contain the census for any of the seven (7) days during that week. An interview with the director of nursing (DON), at 3:58 p.m. on 01/13/15, confirmed the staff posting is always there and accurate. She stated she would have to try to find out where it was and why it was not posted. She confirmed the staff posting, which was posted, was for the week of 12/07/14 through 12/13/14. At 4:15 p.m., on 01/13/15, the human resources director presented the staff posting for the week of 01/11/15 to 01/17/15. The dates of 01/11/15, 01/12/15 and for the 7-3 shift of 01/13/15 was completed on the form, but the census was not filled out for those dates. When asked why it was not posted in a prominent place at the time of the initial tour she stated, I came and got it to make sure it was updated and forgot to put it back up. When asked if the census was included on the staff posting she stated, It's not on these, should it be? | 2018-05-01 |
| 5933 | 5933 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-01-16 | 502 | D | 0 | 1 | 947511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure laboratory services were obtained to meet the needs of one (1) of five (5) residents reviewed for the care area of unnecessary medications. The facility had not received the results of a prothombin time and international normalized ratio (PT/INR) test for one (1) resident. Resident identifier: #39. Facility census: 38. Findings include: a) Resident #39 On 01/15/14 at 10:00 a.m., a review of the physician's orders [REDACTED]. The order, written on 11/14/14, indicated the facility would obtain a PT/INR every two (2) weeks. At 10:45 a.m. on 01/15/15, a review of the treatment administration record (TAR) revealed laboratory specimens were obtained on 12/04/14, 12/18/14, and 01/01/15. The results for the specimens obtained on 12/04/14 and 12/18/14 were located in the resident's medical record. The medical record did not contain evidence of the results for the specimen obtained on 01/01/15. At this time, the director of nursing (DON) was asked to locate and provide the results for the specimen obtained on 01/01/15. On 01/15/15 at 11:05 a.m., during an interview with both the DON and Employee #5 (administrator), both employees verified there were no results obtained for the PT/INR obtained on 01/01/15. Upon inquiry as to the reason, the administrator said the facility never received the results. The administrator said she telephoned the laboratory on 01/05/15, in order to receive the results. She said the laboratory had no record at that time of receiving the specimen. The administrator said on 01/09/15, the laboratory notified the facility of the fact that the specimen obtained on 01/01/15 had not been a sufficient specimen. Upon inquiry as to what the facility should have done when the results were not available in a timely manner, the DON said, the lab should have been drawn again, and resubmitted. A review of the PT/INR results with both employees revealed the last … | 2018-05-01 |
| 5934 | 5934 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-01-16 | 514 | D | 0 | 1 | 947511 | **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 16 medical records reviewed was accurate and complete. Resident #21's current nursing assessment reflected she did not have dentures. The resident was admitted to the facility with dentures. The medical record did not reflect what happened to the resident's dentures. Resident identifier: #21. Facility census: 38. Findings include: a) Resident #21 Resident #21 triggered for dental status in Stage 1 of the Quality Indicator Survey (QIS). An observation of Resident #21 in the dining room, on [DATE] at 11:45 a.m., revealed the resident had some missing teeth in the bottom of her mouth. A review of the medical record, on [DATE] at 12:00 p.m., revealed the resident was admitted to the facility on [DATE]. An admission nursing assessment dated [DATE] revealed the resident had full upper dentures. An admission nursing assessment dated [DATE] indicated the resident still had a full upper denture. An admission nursing evaluation dated [DATE], said the resident did not have an upper plate of dentures. An interview with Employee #29 (nurse aide) who was assigned to care for Resident #21 revealed she did not know how long the resident had not worn her upper dentures. She said she was not sure what happened to them. During an interview with the director of nursing (DON), Employee #16, on [DATE] at 12:30 p.m., she said she did not know what happened to the resident's dentures. On [DATE] at 12:45 p.m., Employee #21 (medical records) attempted to locate information regarding what happened to the resident's dentures. She was unable to locate any evidence regarding what happened to the resident's dentures. At 1:00 p.m. on [DATE], the DON called the resident's daughter who verified the resident did not have the dentures and said she had not had them for a long time. The DON said the resident's daughter told her the dentures were missing since her previous roommate expired.… | 2018-05-01 |
| 5935 | 5935 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2015-01-07 | 225 | E | 0 | 1 | RDRC11 | Based on resident interview, record review, staff interview, review of resident council meeting minutes, and policy review, the facility failed to report and investigate allegations of verbal abuse for two (2) of two (2) residents identified during a review of resident council meeting minutes. Resident identifier: #21 and #37. Facility census: 104. Findings include: a) Resident #21 On 12/30/14 at 3:40 p.m., a review of resident council minutes dated 10/20/14, revealed Resident #21 was one (1) of two (2) residents who alleged some of the night shift nurses were very rude and sassy with the residents. A departmental response form from the nursing department, dated 11/17/14 and stamped second notice given 11/10/14, indicated two (2) residents stated the night nurses were very rude and sassy with us. No specific names were given at the meeting. The response actions taken to resolve the issue identified was, Complaint will be reviewed with nursing staff at scheduled meeting 12/2/14. There was no indication this allegation of abuse was reported or investigated. A review of the reportable abuse/neglect records, on 12/31/14 at 8:40 a.m., revealed no evidence that allegations of nursing staff verbally abusing Resident #21 were reported or investigated. On 12/31/14 at 11:43 a.m., review of Resident #21's minimum data set (MDS) with the assessment reference date (ARD) of 10/29/14, revealed resident scored 14 on the brief interview for mental status (BIMS). A score from 13 -15 on the BIMS indicated a person was cognitively intact. An interview with Resident #21 on 12/31/14 at 11:55 a.m., revealed .some of the night nurses can be a little rough speaking and rude .I am not sure of their names. I try not to deal with them when I can. It's not as bad now as it was since someone talked to them. Resident #21 requested to end the interview due to not feeling well. On 12/31/14 at 10:12 a.m., an interview was conducted with Employee #124 (resident council liaison) concerning the issue of resident council members stating some of the n… | 2018-05-01 |
| 5936 | 5936 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2015-01-07 | 226 | D | 0 | 1 | RDRC11 | Based on resident interview, record review, review of resident council meeting minutes, staff interview, and policy review, the facility failed to operationalize their abuse prohibition policy related to reporting and investigating allegations of abuse for two (2) of two (2) residents reviewed for abuse. Resident identifiers: #21 and #37. Facility census: 104. Findings include: a) Resident #21 On 12/30/2014, at 3:40 p.m., a review of resident council minutes, dated 10/20/14, revealed Resident #21 was one (1) of two (2) residents who alleged some of the night shift nurses were very rude and sassy with the residents. A departmental response form from the nursing department, dated 11/17/14 and stamped second notice given 11/10/14, indicated two (2) residents stated the night nurses were very rude and sassy with us. No specific names were given at the meeting. The response actions taken to resolve the issue identified was, Complaint will be reviewed with nursing staff at scheduled meeting 12/2/14. There was no indication this allegation of abuse was reported or investigated. A review of the reportable abuse/neglect records, on 12/31/14 at 8:40 a.m., revealed no evidence that allegations of nursing staff verbally abusing Resident #21 were reported or investigated. On 12/31/14 at 11:43 a.m., review of Resident #21's minimum data set (MDS) with the assessment reference date (ARD) of 10/29/14, revealed the resident scored 14 on the brief interview for mental status (BIMS). A score from 13 -15 on the BIMS indicates a person is cognitively intact. An interview with Resident #21, on 12/31/14 at 11:55 a.m., revealed .some of the night nurses can be a little rough speaking and rude .I am not sure of their names. I try not to deal with them when I can. It's not as bad now as it was since someone talked to them. Resident #21 requested to end the interview due to not feeling well. On 12/31/14 at 10:12 a.m., an interview was conducted with Employee #124 (resident council liaison) concerning the issue of resident council members s… | 2018-05-01 |
| 5937 | 5937 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2015-01-07 | 242 | D | 0 | 1 | RDRC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and medical record review, the facility failed to ensure a treatment schedule significant to a resident was honored for one (1) of one (1) residents reviewed for choices. The facility failed to offer Resident #20 her bone stimulator on the time schedule requested by the resident. Resident identifier: #20. Facility census: 104. Findings include: a) Resident #20 During a Stage 1 interview on 12/30/14 at 11:14 a.m., Resident #20 related she had fractured her left arm and was receiving rehabilitation services. physician's orders [REDACTED]. It was scheduled for 7:30 p.m. Review of electronic Medication Administration Record [REDACTED]. On 09/13/14 at 3:16 a.m., the bone stimulator was offered. This note related the resident told staff she wanted it at 8:00 p.m. A Stage 2 interview was conducted with the resident on 12/31/14 at 11:14 a.m. Upon inquiry, the resident said she had complained and complained about the times the treatment was offered, but staff did not listen to her. Although the resident informed staff she wanted the treatment at 8:00 p.m., and the order was for 7:30 p.m., staff continued to offer the treatment at times which were not satisfactory to the resident: -- 10/01/14 at 3:19 a.m. -- 10/02/14 at 11:25 p.m. -- 10/11/14 at 10:57 p.m. -- 10/13/14 at 10:46 p.m. -- 10/2514 at 11:16 p.m. -- The e-mars dated 11/02/14, 11/21/14, 11/22/14, 11/27/14, 11/28/14, and 11/31/14 noted the treatment was not administered because the resident was sleeping. -- On 12/08/14 at 22:45 p.m., the e-mar note indicated the resident said, If not done before 9:00 p.m., it couldn't be done. Although the resident informed staff she would not accept the treatment if it was not done before 9:00 p.m., staff continued to offer the treatment at times which the resident said were too late: -- 12/10/14 at 9:58 p.m. -- 12/11/04 at 9:45 p.m. -- 12/13/04 at 10:21 p.m. -- 12/16/04 at 11:30 p.m. -- 12/18/04 at 10:29 p.m. -- 1… | 2018-05-01 |
| 5938 | 5938 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2015-01-07 | 244 | E | 0 | 1 | RDRC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, review of resident council meeting minutes, and policy review, the facility failed to act upon and/or communicate decisions made about the issues identified in resident council meetings. Residents who attended the council meetings had issues with the food they were being served and medication administration times. In addition, the residents voiced a concern over the way they were treated by the nursing staff who worked during the night shift. These practices had the potential to affect more than an isolated number of residents. Facility census: 104. Findings include: a) On 12/30/2014 at 3:40 p.m., the resident council minutes were reviewed. The review revealed the following: 1. The meeting minutes from 08/18/14 revealed the residents wanted buckwheat cakes on some mornings. They also said they would like to have a swing and a few lawn chairs for the courtyard. The activity director was interviewed on 12/30/14 at 3:40 p.m. She indicated she did not know if the residents had received the buckwheat cakes. The facility had no evidence to show they had communicated this request to the dietary department. They also had no evidence they had communicated back to the council members about their request for buckwheat cakes. On 12/30/14 at 4:25 p.m., during an interview with the certified activity director (Employee #124), she said the facility had decided, due to the construction that was going on in the courtyard area, to wait until spring to purchase the lawn chairs and swing. She was asked if the resident council members had been informed of the facility's decision to wait until spring to make the purchases. She said, No, as far as I know they have not. 2. On 09/15/14, the council met. The residents complained their vegetables were cooked to death. The response/actions on the attached dietary departmental response form showed that some residents liked their vegetables cooked soft so they c… | 2018-05-01 |
| 5939 | 5939 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2015-01-07 | 253 | E | 0 | 1 | RDRC11 | Based on observation and staff interview, the facility failed to provide effective housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for nine (9) of sixty-four (64) rooms. The rooms contained heaters in disrepair, cracked and peeling paint, and/or bathroom tile and base molding covered with a brown/black substance. Room #123, #126, #140, #143, #147, #204, #135, #142, and #223. Facility census: 104. Findings include: a) Stage 1 observations, on 12/29/14 and 12/30/14, revealed wall heaters, paint, and floor tile in disrepair and/ or dirty. Observations revealed the following: -- In Room 140, the heater which was rusted along the lower base and was slightly pulled away from the wall -- In Room 223, the heating unit was ajar in two (2) parts. Also, the bottom metal wrap was not attached -- Room 135 had four (4) holes in the wall on the right side of the paper towel rack, and three (3) holes on the left side of the paper towel holder. Blue paint was also noted peeling from the wall along the sink. -- In Room 147, the wall had been patched in fifteen (15) areas on the lower half of the bathroom wall. The patched areas were not painted. Also, the heater was warped and separated from the wall, caulking in the back of the heater was broken and in disrepair, and the base plate was missing from the right lower back of the heater. -- Room 126 had paint peeling in the corner of the wall at the entrance to the bathroom. -- Room 142 had caulking at the back upper part of the heater in disrepair. The heater was also warped, separated from the wall, and the plate was missing from the right bottom of the heater at back near the wall. -- Room 143 had a heater in disrepair. It was rusted, sat diagonally, and had sharp corners -- In Room 123, there were four (4) holes on the left side of the wall and three (3) holes on the right side near the paper towel holder in the bathroom. The paint was cracked and peeling on the wall near the sink. The cove molding along the walls, the flo… | 2018-05-01 |
| 5940 | 5940 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2015-01-07 | 280 | E | 0 | 1 | RDRC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and record review, the facility failed to revise the care plan for two (2) of eighteen (18) Stage 2 residents. The care plan was not revised to include choices significant to Resident #20 or the change in [MEDICAL CONDITION] medications for Resident #67. Resident identifiers: #20 and #67. Facility census: 104. Findings include: a) Resident #20 Review of the resident's care plan revealed it did not contain anything relative to this resident's choice to have a bone stimulator treatment at times of the day deemed satisfactory by the resident. physician's orders [REDACTED]. It was scheduled for 7:30 p.m. Review of electronic Medication Administration Record [REDACTED]. On 09/13/14 at 3:16 a.m., the bone stimulator was offered. This note note related the resident told staff she wanted it at 8:00 p.m. Review of medication administration records indicated Resident #20 refused the bone stimulator on multiple occasions: 09/09/14, 09/13/14, 10/01/14, 10/02/14, 10/11/14, 10/13/14, 10/25/14,11/02/14, 11/21/14, 11/22/14, 11/27/14, 11/28/14, and 11/30/14. On 12/08/14 at 10:45 p.m., the resident said, If not done before 9:00 p.m., it couldn't be done. The care plan, reviewed on 12/31/14 at 12:45 p.m., revealed the care plan was not revised to reflect the resident's choice regarding the time for her bone stimulator treatment. The last care plan revision was 08/25/14; however, on 09/13/14, the resident stated she wanted the treatment at 8:00 p.m. and on 12/08/14, the resident said she would not accept the bone stimulator treatment after 9:00 p.m. b) Resident #67 physician's orders [REDACTED].#67 received [MEDICATION NAME] 0.25 milligrams (mg) by mouth daily at bedtime. The order was initiated on 10/04/14. The [DIAGNOSES REDACTED]. The care plan, reviewed on 01/06/2015 12:31 p.m., revealed the care plan did not address the use of [MEDICATION NAME]. It indicated the resident received [MEDICATION NAME]. Further revie… | 2018-05-01 |
| 5941 | 5941 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2015-01-07 | 282 | D | 0 | 1 | RDRC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure services were provide in accordance with the written plan of care for one (1) of five (5) residents reviewed for unnecessary medications. The facility failed to obtain a hemoglobin A1c (HgbA1c) as ordered. Resident identifier: #53. Facility census: 104. Findings include: a) Resident #53 Review of unnecessary medications, on 01/06/15 at 1:37 p.m., revealed a physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Review of the resident's laboratory (lab) reports and progress notes found no indication the HgbA1c was obtained in February, March, April, May, or June of 2014. Employee #130, a licensed practical nurse (LPN), was interviewed on 01/06/15 at 2:49 p.m. Upon review of the medical record, the LPN confirmed no evidence was present to indicate the labs were obtained as ordered. During an interview with Employee #135, a registered nurse (RN), on 01/06/14 at 3:19 p.m., she said the order had been discontinued. Further review of physician's orders [REDACTED]. Another interview with Employee #135, at 6:00 p.m. on 01/06/14, revealed she had contacted the laboratory and confirmed no evidence was present to indicate the lab work had been completed as ordered. | 2018-05-01 |
| 5942 | 5942 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2015-01-07 | 309 | G | 0 | 1 | RDRC11 | Based on observation, medical record review, staff interview, and policy review, the facility failed to provide the necessary care and services to attain the highest practicable physical, mental and psychosocial well-being in accordance with the resident's plan of care for one (1) of three (3) Stage 2 residents reviewed for pressure ulcers. The facility failed to provide pain medication to a resident who expressed pain either verbally or nonverbally during activities of daily living (ADL) care and/or wound treatment. Resident identifier: #142. Facility census: 64. Findings include: a) Resident #142 During a Stage 1 interview on 12/29/14 at 1:10 p.m., Employee #62, a licensed practical nurse (LPN), related Resident #142 had pressure ulcers on her heels. Review of the medical record, on 12/29/14 at 5:09 p.m., revealed a pressure ulcer assessment, which indicated the resident had an unstageable pressure ulcer (PU) on her right heel and an unstageable pressure ulcer on her left heel. In an interview with Employee #141, a nursing assistant (NA), on 01/06/15 at 2:46 p.m., she related she observed indications of pain when providing ADL care with Resident #142. She indicated the resident expressed pain when staff provided incontinence care. The NA said she wiped around the areas on the resident's buttocks, because they were sore. Employee #53, a NA, interviewed on 01/06/15 at 2:50 p.m., also indicated Resident #142 had pain with ADL care related to skin issues. A wound dressing change was observed on 01/06/15 at 9:45 a.m. Employee #127, a registered nurse (RN) prepared to change the resident's pressure ulcer dressings with the assistance of Employee #34 (NA). The NA said, I don't think she likes this, and the RN replied, I do think she has some pain with this. When Employee #127 cleansed the resident's right heel, the resident furrowed her eyebrows, but did not verbalize pain. After completing the heel dressings, the RN provided treatment to the open areas on the resident's buttocks, which were identified as skin acquire… | 2018-05-01 |
| 5943 | 5943 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2015-01-07 | 329 | D | 0 | 1 | RDRC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure three (3) of five (5) residents who triggered the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS) were free from unnecessary medications. The facility failed to provide non-pharmacological interventions and/or monitoring for side effects, behaviors, and/or efficacy in the use of [MEDICAL CONDITION] medications. Resident identifiers: #74, #10, and #67. Facility census: 104. Findings include: a) Resident #74 Medical record review, on 01/06/15 at 1:50 p.m., found the resident was ordered [MEDICATION NAME] 0.5 milligram (mg) every twelve (12) hours as needed for mild anxiety as evidenced by feeling shaky and/or asking repetitive questions. On 01/06/15, review of a pharmacist's consultant report for this resident revealed a recommendation made on 04/14/14. It indicated Resident #74 was given [MEDICATION NAME] as needed (PRN) nine (9) times in the month of April. On five (5) occasions, there was no documentation of behaviors which resulted in the use of the medication. The pharmacist also noted the facility needed to remind nursing that non-pharmacological interventions must be documented before giving PRN [MEDICATION NAME]. A response, handwritten on the consultation report from the director of nursing was, To be discussed at nurses meeting scheduled for 05/01/14. A review of the 05/01/14 monthly nursing meeting minutes revealed the nurses were instructed to attempt non-pharmacological interventions prior to the use of PRN [MEDICAL CONDITION]. The minutes included: 18. Documentation of non-pharmacological interventions: make sure you are documenting interventions BEFORE you give PRN [MEDICAL CONDITION]. Review of the medication administration records (MARs), on 01/06/15 at 2:00 p.m., found the nurses administered [MEDICATION NAME] 0.5 mg eleven (11) times in November 2014 and thirteen (13) times in December 2014. There was no evidenc… | 2018-05-01 |
| 5944 | 5944 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2015-01-07 | 371 | E | 0 | 1 | RDRC11 | Based on observation and staff interview, the facility failed to store, prepare, and serve food in a sanitary manner. The nourishment pantry refrigerators on both units contained food items without dates and labels. In addition, on the Mountain Village unit, a sticky pink/red liquid was pooled in the bottom of the refrigerator. These practices had the potential to affect more than an isolated number of residents. Facility Census: 104. Findings Include: a) Woodland Village unit On 12/29/14 at 10:35 a.m., the refrigerator on the Woodland Village unit was observed with an unlabeled and undated plastic grocery bag containing bananas and grapes. Also observed in the refrigerator, was a half full beverage from McDonalds, and a container of Chinese take-out food. Neither was labeled or dated. Employee #101, a licensed practical nurse (LPN), verified the items should have been labeled and dated. b) Mountain Village unit At 10:45 a.m. on Monday 12/29/14, food items were observed unlabeled and undated, in the refrigerator and freezer, on the Mountain Village unit. Observed in the freezer was an unlabeled and undated open box of Hot Pockets. The box contained one (1) of two (2) individually wrapped Hot Pocket sandwiches. Observed in the refrigerator without labels and dates were two (2) pies, two (2) opened single serving milk containers, a Ziploc container containing food, and two (2) covered bowls containing food from the kitchen. Also observed in the bottom of the refrigerator, was a pooled sticky pink/red liquid of unknown origin. Employee #127, a registered nurse (RN), verified the items should have been labeled and dated. Upon inquiry as to the cleaning schedule of the refrigerator, she said it was to be cleaned every Sunday, on night shift. She further verified the sticky pink/red substance pooled in the bottom of the refrigerator would not have been there, if the refrigerator had been cleaned Sunday night. | 2018-05-01 |
| 5945 | 5945 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2015-01-07 | 428 | D | 0 | 1 | RDRC11 | Based on record review and staff interview, the facility failed to act upon a consultant pharmacist's recommendation for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Surveyor (QIS). Resident identifier: #10. Facility census: 104. Findings include: a) Resident #10 Review of the 07/11/14 pharmacy consultation report, on 01/07/15 at 8:50 a.m., revealed the consultant pharmacist made an annual recommendation to the physician to review Resident #10 for a gradual dose reduction (GDR) for the anti-depressant medication Prozac. If the physician did not think a GDR was in the best interest of the resident, the pharmacist asked the physician to provide a rationale which described why the GDR was clinically contraindicated. On the pharmacist's consultation report, the physician marked the section, I decline the recommendation(s) above because GDR is CLINICALLY CONTRAINDICATED for this individual. Continued use is in accordance with the current standard of practice and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder as documented below. The physician did not document anything in the section where he should have provided a rationale which described why the GDR was clinically contraindicated. In an interview, on 01/07/15 at 9:00 a.m., with the director of staff development and dementia program (DSD-DP) #135, she was asked to review the 07/11/14 pharmacist's consultation report which recommended the physician review the anti-depressant, Prozac, for a GDR for Resident #10. She was asked if the physician had documented a rationale for continuing the medication. The DSD-DP stated she had to review the record and then she would know. A little while later, the DSD-DP stated she could not find any evidence the physician had provided a rationale for not attempting a GDR. | 2018-05-01 |
| 5946 | 5946 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2015-01-07 | 431 | D | 0 | 1 | RDRC11 | Based on observation, staff interview, policy review, review of manufacturer's instructions, and review of recommendations from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure safety in the use of multi-dose vials of insulin. Vials of insulin were not discarded after being opened for longer than identified by the facility's pharmacy, the insulin manufacturer, and the CDC. This affected three (3) residents with diabetes, whose insulin vials were stored in the Mountain Village unit's refrigerator for use for one (1) of two (2) medication carts. Resident identifiers: #16, #107, and #67. Facility census: 104. Findings include: a) Mountain Village Unit Medication Room refrigerator On 12/31/14 at 11:15 a.m., observation of the Mountain Village unit medication room refrigerator found it contained vials of insulin assigned to specific residents. Four (4) vials of insulin had been open for use for a greater period of time than considered safe/usable: 1. Resident #16 On 12/31/14, a vial of Novolog insulin and a vial of Lantus insulin belonging to Resident #16 were observed in the medication room refrigerator for medication cart two (2). Both vials were initially opened on 11/18/14. Each of these vials should have been discarded twenty-eight (28) days later, on 12/16/14. The date to discard,12/16/14, was written on the outside of both vials. 2. Resident #107 On 12/31/14, a vial of Novolog insulin belonging to this resident was observed in the medication room refrigerator for medication cart two (2). This vial was initially opened on 12/01/14. The vial should have been discarded twenty-eight days later, on 12/29/14. The date to discard,12/29/14, was written on the outside of the vial. 3. Resident #67 On 12/13/14 a vial of Lantus insulin belonging to Resident #67 was observed in the medication room refrigerator for medication cart two (2). This vial was initially opened on 11/19/14. The vial should have been discarded twenty-eight (28) days after it was opened, on 12/17/14. The date to disc… | 2018-05-01 |
| 5947 | 5947 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2015-01-07 | 441 | E | 0 | 1 | RDRC11 | **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 maintain an infection control program to prevent the development and transmission of disease and infection. Staff failed to transport linens in a manner to prevent the spread of infection, failed to wash hands by methods which were consistent with accepted standards of practice, and used improper technique when cleaning wounds for Resident #142. In addition, a nurse touched medication with bare hands during medication pass for Residents #78 and #160 and Resident #102's oxygen concentrator contained an expired humidifier bottle. These practices specifically affected four (4) residents, and had the potential to affect more than a limited number of residents. Resident identifier: #Facility census: 104. Findings include: a) Linen handling During a random observation, on [DATE] 12:11 p.m., Employee #140, a nursing assistant (NA) carried soiled linens from room [ROOM NUMBER], Resident #66, down the hallway past the nurses station, turned left onto the next hallway, and disposed of the linens in the soiled utility room. The NA, interviewed immediately after exiting the soiled utility, related the facility policy indicated only soiled briefs had to be contained. She related items such as soiled bed linens, towels, washcloths, and clothing only required the use of gloves and holding the items away from the uniform. Employee #62, a licensed practical nurse (LPN), interviewed on [DATE] at 3:05 p.m., related linen handling required the use of one glove to transport linens. She related they did not have to be contained unless very soiled. The linen handling policy, reviewed on [DATE] at 3:51 p.m., indicated linens be contained in a bag or container at the location used, prior to transporting them. The director of nursing, (DON), interviewed on [DATE] at 4:00 p.m., confirmed staff handled linen in a manner which created a potential to transmit infection … | 2018-05-01 |
| 5948 | 5948 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2015-01-07 | 490 | E | 0 | 1 | RDRC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident council meeting minutes, policy review, resident interview, and staff interview, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility had no system in place which ensured all allegations involving mistreatment, neglect, abuse, and misappropriation of resident property were reported to the proper State authorities in accordance with State law and were thoroughly investigated by facility staff. In addition, the facility failed to act upon and/or communicate decisions made about the issues identified in resident council meetings. Affected residents included Residents #21 and #37; however, these systemic problems had the potential to affect more than a limited number of residents. Facility census: 104. Findings include: a) Allegations of Verbal Abuse 1. Resident #21 On 12/30/14 at 3:40 p.m., a review of resident council minutes, dated 10/20/14, revealed Resident #21 was one (1) of two (2) residents who alleged some of the night shift nurses were very rude and sassy with the residents. A departmental response form from the nursing department, dated 11/17/14 and stamped second notice given 11/10/14, indicated two (2) residents stated the night nurses were very rude and sassy with us. No specific names were given at the meeting. The response actions taken to resolve the issue identified was, Complaint will be reviewed with nursing staff at scheduled meeting 12/2/14. There was no indication this allegation of abuse was reported or investigated. A review of the reportable abuse/neglect records, on 12/31/14 at 8:40 a.m., revealed no evidence that allegations of nursing staff verbally abusing Resident #21 were reported or investigated. On 12/31/14 at 11:43 a.m., review of Resident #21's minimum data set (MDS) with the assessment reference date … | 2018-05-01 |
| 5949 | 5949 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2015-01-07 | 520 | E | 0 | 1 | RDRC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident council meeting minutes, policy review, and resident and staff interviews, the facility did not have a functional and effective quality assurance (QA&A) program which identified and acted upon quality deficiencies within the facility's operations of which it did have (or should have had) knowledge. The facility had systemic deficits, which the QA&A committee failed to identify and/or implement plans of action to correct the quality deficiencies, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. The QA&A committee failed to identify the facility had no system in place which ensured all allegations involving mistreatment, neglect, abuse, and misappropriation of resident property were reported to the proper state authorities in accordance with state law and were thoroughly investigated by facility staff. In addition, the facility QA&A committee failed to identify the concerns of the resident council were not always acted upon and/or the decisions made about the issues identified were not communicated to the resident council . Affected residents included Residents #21 and #37; however, these systemic problems had the potential to affect more than a limited number of residents. Facility census: 104. a) Allegations of Verbal Abuse 1. Resident #21 On 12/30/14 at 3:40 p.m., a review of resident council minutes, dated 10/20/14, revealed Resident #21 was one (1) of two (2) residents who alleged some of the night shift nurses were very rude and sassy with the residents. A departmental response form from the nursing department, dated 11/17/14 and stamped second notice given 11/10/14, indicated two (2) residents stated the night nurses were very rude and sassy with us. No specific names were given at the meeting. The response actions taken to resolve the issue identified was, Complaint will be reviewed with nursing staff at scheduled me… | 2018-05-01 |
| 5950 | 5950 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 241 | E | 0 | 1 | GK2611 | Based on observation and staff interview, the facility failed to ensure four (4) randomly observed residents were cared for in a manner and in an environment that maintained or enhanced each resident's dignity and respect. During meal service in the Atrium, Residents #91, #73, and #76 were not served meals at the same time as all other residents seated at their table. Resident #40 who was eating in her room, was not served at the same time as her roommate. Resident identifiers: #91, #73, #76, and #40. Facility census: 64. Findings Include: a) Residents #91, #73, and #76 Observations at 11:50 a.m. on 07/28/14, in the Atrium dining room, revealed Residents #78, #91, #73, and #76 were seated at Table #1 waiting for the lunch meal. At 11:55 a.m., Resident #78 was served his meal. Residents #91, #73, and #76 were sitting at the same table as Resident #78, and did not receive their meals at the same time. Residents #91, #73, and #76 were not served their meal until five (5) other residents sitting at three (3) different tables were served their meals. At 12:08 p.m., Resident #73 was served his meal. An interview with the Assisted Living Coordinator (ALC) Registered Nurse (RN) #133, on 07/28/14 at 12:00 p.m., confirmed Residents #91, #73 and #76 were not served their meal at the same time as others seated at their table. He indicated that all residents sitting at the same table should have been served their meals at the same time. . b) Residents #84 and #40 Observation of meal delivery on Goodall Hall, on 07/28/14, found Residents #84 and #40 were waiting for their lunch. At 11:45 a.m., Resident #84 received her meal. Nursing staff served residents in Rooms #18, #22, and #21 before returning to serve Resident #40 her meal at 12:02 p.m. Nurse aide (NA) #67 was interviewed at 12:15 p.m. on 07/28/14. She stated she did not serve Resident #84, and did not know why both residents did not receive their meals at the same time. NA #67 said, This should not have happened because both trays were on the same cart. At 11:21 a.m. on… | 2018-05-01 |
| 5951 | 5951 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 246 | D | 0 | 1 | GK2611 | Based on observation and staff interview, the facility failed to ensure one (1) of five (5) residents observed during the lunch meal on 07/28/14 received services in the facility with reasonable accommodations of their individual needs. The table at which Resident #21 was seated was too high. Resident identifier: #21. Facility census: 64. Findings include: a) Resident #21 An observation at 12:05 p.m. on 07/28/14 revealed Resident #21 sitting in the Atrium at a table that was too high for her. The tabletop was eye level with Resident #21 and was not conducive to a pleasurable dining experience. An interview with the director of quality improvement/registered nurse (RN) #96, at 12:10 p.m. on 07/28/14, confirmed the table top was eye level with Resident #21. When asked if Resident #21 would be able to see her food sitting on the table, she replied, She is blind so she could not see it anyway. She further stated she thought those tables were adjustable and she was not sure why it was so high. According to the resident's quarterly minimum data set assessment, with an assessment reference date of 07/08/14, reviewed on 08/04/14 at 6:53 p.m., the resident required limited assistance with eating. The assessment also identified the resident had severely impaired vision. Therefore, the height of the table was an important factor in allowing this resident to maintain her highest practicable level of independence in her ability to feed herself. | 2018-05-01 |
| 5952 | 5952 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 253 | D | 0 | 1 | GK2611 | Based on observation and staff interview, the facility failed to ensure effective housekeeping services for one (1) of thirty-five (35) census sample residents. The resident had a stand up fan in her room. The plastic outer casing of the fan was covered in black dust and debris. Resident identifier: #11. Facility census: 64. Findings include: a) Resident #11 On 07/29/14 at 2:11 p.m., an observation in Resident #11's room revealed the resident had a stand up fan. The white plastic casing of the fan was covered in black dust and debris. At 2:15 p.m. on 07/29/14, Employee #38 (housekeeping) went into the resident's room, looked at the fan, and agreed it needed cleaned. | 2018-05-01 |
| 5953 | 5953 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 272 | D | 0 | 1 | GK2611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to accurately complete comprehensive minimum data set (MDS) assessments for two (2) of seventeen (17) residents whose MDSs were reviewed. The MDS in the areas of pressure ulcers was not accurate for Resident #89. The MDS for dental status was not accurate for Resident #91. Resident identifiers: #89 and #91. Facility census: 64. Findings include: a) Resident #89 The review of the wound assessment, on 07/31/14 at 9:00 a.m., revealed Resident #89 had a Stage II pressure ulcer on the top of his left foot. It also revealed the resident had a Stage II pressure ulcer on the left lateral leg that developed on 07/15/14. A review of the physician's orders [REDACTED]. The order also stated to apply triple antibiotic ointment to the top of the left foot and cover with border foam dressing daily until healed. The treatment for [REDACTED]. Observation of Resident #89's wounds, with licensed practical nurse (LPN) #12, on 07/31/14 at 9:50 a.m., revealed the resident had a Stage II pressure ulcer on top of the left foot, and a Stage II pressure ulcer on the left lateral leg. In an interview with LPN #12, on 07/31/14 at 9:55 a.m., she confirmed Resident #89 had a Stage II pressure ulcer on top of the left foot, and a Stage II on the left lower lateral leg. On 07/31/14 at 9:53 a.m., a review of Resident #89's MDS assessments revealed a significant change in status assessment with an assessment reference date (ARD) of 07/17/14. Item M0300 (current number of unhealed pressure ulcers at each stage) reflected the resident did not have any unhealed pressure ulcers. An interview with the registered nurse/charge nurse (RN-CN) #101, on 07/31/14 at 11:15 a.m., revealed the area started out as a skin tear. The staff applied a round donut to protect the integrity of the skin. Employee #101 indicated the donut had rubbed the left outer leg and the top of the resident's foot. Employee #101 said … | 2018-05-01 |
| 5954 | 5954 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 279 | D | 0 | 1 | GK2611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan to describe the provision of services needed to meet the needs of three (3) of seventeen (17) residents whose care plans were reviewed. Resident #19 did not have a care plan addressing an eighteen (18) pound weight loss occurring within eleven (11) days after admission to the facility. Resident #89 did not have a care plan addressing hospice services. Resident #46 did not have a care plan addressing behaviors which required the use of an antipsychotic medication. Resident identifiers: #19, #89, and #46. Facility census: 64. Findings include: a) Resident #19 Review of the medical record found the resident was admitted to the facility on [DATE]. A nursing admission assessment, completed on 05/21/14, recorded the resident's admission weight as 151.03 pounds and height as 58 inches. Further review of the resident's weights noted the first weight recorded in the computer was 133 pounds on 06/01/14. The resident did not trigger the facility to address the weight loss because the facility failed to accurately record the admission weight of 151.03 pounds in the computer. Review of the current care plan on 07/29/14 found the facility did not address the resident's weight loss. The registered dietitian, Employee #32, was interviewed at 2:30 p.m. on 07/29/14. She stated she did not address the resident's weight loss when the facility knew, or should have known, the resident experienced an 18 pound weight loss in just 11 days. She said she did not know the resident had lost weight until 06/10/14. The registered dietitian said, The nursing staff has to tell me and they didn't. When I noticed a weight loss on 06/10/14 I had her re-weighed and her weight was 133 pounds. She agreed the care plan failed to address an actual weight loss. b) Resident #89 A review of Resident #89's medical record on 07/31/14 at 9:02 a.m., revealed a physician order [REDAC… | 2018-05-01 |
| 5955 | 5955 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 280 | D | 0 | 1 | GK2611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise the care plans for two (2) of seventeen (17) residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey. The care plans did not reflect current problems, and interventions were not applicable to the residents. Resident #19's care plan was not revised when therapy services were discontinued. Resident #5's care plan was not revised after antipsychotic and hypnotic medications were no longer used. Resident identifiers: #19 and #5. Facility census: 64. Findings include: a) Resident #19 On 07/29/14, review of the resident's current care plan found a problem, Resident has alteration in ADL (activities of daily living) status related to recent hospitalization for pneumonia which is complicated by depression, [MEDICAL CONDITION], muscle weakness, difficulty walking and other multiple medical problems. The goal associated with the problem was, Attempt to improve ADL status AEB (as evidenced by) Resident will work with therapy as ordered toward reaching goals and minimum potential based on her specific abilities daily. The approaches included physical and occupational therapy as ordered. On 07/30/14 at 2:07 p.m., an interview with the physical therapy assistant, Employee #130, found the resident was discharged from occupational therapy on 07/17/14 and from physical therapy on 07/25/14. Review of the current care plan again, on 08/04/14, found the care plan had not been revised to reflect the discontinuation of physical and occupational therapy services. Employee #90, the vice president of health services confirmed, at 5:25 p.m. on 08/04/14, the care plan had not been updated. An interview with Employee #103, the registered nurse minimum data set (MDS) coordinator, at 6:17 p.m. on 08/04/14, found she failed to update the care plan after the therapy services were discontinued. b) Resident #5 A review of Resident #5's medical record at 9:52 a.m. … | 2018-05-01 |
| 5956 | 5956 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 309 | D | 0 | 1 | GK2611 | Based on observation, resident interviews, staff interviews, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (1) of two (2) residents reviewed for positioning. The facility failed to provide services to maintain good body alignment and comfortable positioning for a resident while the resident was sitting up in her chair. Resident Identifier: #40. Facility census: 64. Findings include: a) Resident #40 Observation of Resident #40, on 07/29/14 at 2:55 p.m., revealed she was sitting in her recliner chair, leaning to her left at approximately a 40 degree angle. The chair was in an upright position. The resident's feet were resting on the floor. An interview was conducted,on 07/29/14 at 3:00 p.m., with Employee #280, a nursing assistant (NA), in the hall outside the resident's room. During the interview, the resident continued to lean over to her left side at approximately 40 degrees. The NA looked inside the resident's room and stated, She always sits like that. We prop her up when we see she is leaned over. She sits in her chair all the time and she leans to one side, sometimes worse than that. Employee # 280 then demonstrated how the resident leaned over on her left side at approximately 80 degrees, implying the resident sometimes leaned over that far in her chair. The NA straightened back up and said, We always prop her up with a pillow. On 07/29/14 at 3:25 p.m., Employee # 280 walked by and said, She already has a pillow propping her up. The NA then walked on down the hall. On 07/29/14 at 3:35 p.m., observation revealed Resident #40 was slumped over on her left side at approximately 50 degrees. A small pink pillow was noted behind her back. The pillow was not effectively supporting the resident. Observation of Resident #40, on 07/30/14 at 10:05 a.m., revealed the resident was sleeping in her chair. She was lying across the left arm of her recliner chair at 90 degrees, with her feet r… | 2018-05-01 |
| 5957 | 5957 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 311 | D | 0 | 1 | GK2611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide a restorative program, to maintain or improve the current level of functioning, for one (1) of three (3) residents reviewed for the care area of rehabilitation. A restorative program, after completion of therapy services and as outlined in the physical therapy discharge summary and in the physician's orders [REDACTED].#19. Facility census: 64. Findings include: a) Resident #19 An interview with the physical therapy (PT) assistant, Employee #130, at 2:07 p.m. on 07/30/14, found the resident was discharged from all therapy services on 07/25/14. Occupational therapy (OT) was discontinued on 07/17/14, and PT was discontinued on 07/25/14. On 08/04/14 at 3:02 p.m., OT assistant, Employee #132, stated the resident did not go to a restorative program. She said she did not know why she was not placed in a restorative program. A registered nurse, Employee #101, was interviewed at 3:09 p.m. on 08/04/14. She stated the resident should be on a restorative program. She said she did not know why this had not happened. Employee #101 provided a physician's orders [REDACTED]. Review of the PT discharge summary, dated 07/28/14 at 7:02 p.m., confirmed the discharge disposition was for restorative nursing. There was a goal for training tor take the brace on and off as well as daily gait training. At 3:16 p.m. on 08/04/14, the vice president of health services stated he did not know why the resident was not in a restorative program, but he would find some answers. On 08/04/14 at 4:28 p.m. the physical therapist, Employee #136, stated the discharge summary, which he completed, was incorrect. He stated he should have completed a new summary as the resident was not appropriate for restorative therapy. Employee #136 was unable to provide evidence he had conveyed this information to nursing staff before surveyor intervention. He stated the plans changed when the resident would not wear h… | 2018-05-01 |
| 5958 | 5958 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 314 | G | 0 | 1 | GK2611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, review of information from the National Pressure Ulcer Advisory Panel, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure two (2) of four (4) residents reviewed for pressure ulcers did not develop avoidable pressure ulcers and/or received services to promote healing of existing pressure ulcers. Resident #23 was assessed at high risk for the development of pressure ulcers. The resident had two (2) Stage II pressure ulcers which had not been identified, assessed, or addressed by the facility, resulting in a determination of actual harm to the resident. Resident #19 had bilateral Stage I pressure ulcers to her heels upon admission which were not treated or monitored until after identification during the survey. In addition, the resident expressed pain, associated with the pressure ulcers on her heels, which was not addressed by the facility. Resident Identifiers: #23 and #19. Facility Census: 64. Findings Include: a) Resident #23 In an interview with Registered Nurse (RN) #101, on 07/29/14 at 11:30 a.m., the nurse reported Resident #23 did not have any pressure ulcers. A review of Resident #23's medical record, at 11:00 a.m. on 07/30/14, revealed Resident #23 was readmitted to the facility on [DATE] after a hospitalization due to a fractured femur. The admission nursing assessment indicated Resident #23 had no skin breakdown and/or pressure ulcers upon readmission to the facility. The resident had a Braden Scale for Pressure Sore Risk assessment, completed on 07/08/14, which indicated the resident was at high risk for development of pressure ulcers. A nurse surveyor observed incontinence care for the resident, provided by Nurse Aide (NA) #113, on 07/30/14 at 2:20 p.m. Resident #23 was observed with a pressure ulcer on the left buttock and another on the right buttock. NA #113 stated when she worked with the resident a week ago the resident had only a … | 2018-05-01 |
| 5959 | 5959 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 323 | K | 0 | 1 | GK2611 | Based on observation, water temperature measurements, staff interviews, review of facility procedures, and resident interview, the facility failed to ensure the resident's environment, over which the facility had control, was as free from accident hazards as possible for 34 of 64 facility residents. On 07/28/14, water temperatures obtained in resident areas on all hallways exceeded 110 degrees Fahrenheit (F). Three (3) resident rooms had water temperatures at sinks which exceeded 120 degrees F. The maintenance department became aware the facility's water temperatures exceeded 120 degrees F at 9:00 a.m. on 07/28/14. Maintenance did not promptly alert staff and enact a plan to ensure resident safety while they were adjusting the water temperatures. Interviews revealed nursing staff and administrative staff were not notified of any concerns regarding excessive hot water temperatures until 4:00 p.m. on 07/28/14. Staff interviews also confirmed that from 9:00 a.m., when the problem was identified, until 4:00 p.m., residents were provided showers as scheduled on the day shift, and showers continued to be provided into the evening shift until 4:00 p.m. At 4:00 p.m. on 07/28/14, a resident, who was receiving a shower, complained to staff the water temperatures were too hot. At that time all staff were advised to discontinue the showering of residents. Residents #20, #39, #36, #85, #52, #18, #31, #5, #13, #81, #50, #95, #15, #97, #49, #70, and #3 were all provided showers on 07/28/14 between 9:00 a.m. and 4:00 p.m. Between the hours of 9:00 a.m. and 4:00 p.m., all hand sinks were accessible to each resident who was able to independently wash his/her hands. Residents #53, #47, #19, #69, #46, #12, #37 , #32, #67, #78, #61, #58, #81, #90, #95, #7, #6, #11, #76, #49, #70, and #3 were all identified by facility staff as residents who were independently able to wash his/her own hands. A determination was made that an immediate jeopardy existed. The immediate jeopardy began at 9:00 a.m. on 07/28/14, when the maintenance departme… | 2018-05-01 |
| 5960 | 5960 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 325 | D | 0 | 1 | GK2611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, observation, and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for the care area of nutrition was provided care and services to maintain acceptable parameters of nutritional status. The facility failed to address the resident's expressed dissatisfaction with her meals. In addition, the facility failed to immediately recognize, evaluate, and address an eighteen (18) pound (13.5%) weight loss which, according to medical records, occurred in eleven (11) days. Resident identifier: #19. Facility census: 64. Findings include: a) Resident #19 During an interview with Resident #19 in Stage 1 of the Quality Indicator Survey (QIS), at 8:34 a.m. on 07/29/14, the resident said she had lost weight because she could not eat the food at the facility. She said the food was not good and it was usually cold. She added, The lady in the kitchen had came and talked with me about the food, but it did not do any good. Review of the medical record found the resident was admitted to the facility on [DATE]. A nursing admission assessment, completed on 05/21/14, recorded the resident's admission weight as 151.03 pounds and height as 58 inches. The resident's weights, which were recorded in the computer under vital signs, noted the resident weighed 133 pounds on 06/01/14. The resident's 05/21/14 admission weight, which was 151 pounds, was not noted in the vital signs section in the computer. There was no evidence the resident's eighteen (18) pound (13.5%) weight loss in eleven (11) days was identified or addressed by the facility. The registered dietitian, Employee #32, was interviewed at 2:30 p.m. on 07/29/14. When asked if she addressed the resident's weight loss, she stated she did not address the resident's weight loss because she did not know the resident had lost weight until 06/10/14. She stated, The nursing staff has to tell me and they didn't. When I noticed a weight loss on 06/… | 2018-05-01 |
| 5961 | 5961 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 329 | D | 0 | 1 | GK2611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure three (3) of five (5) residents reviewed for the care area of unnecessary medications, during Stage 2 of the Quality Indicator Survey (QIS), were free of unnecessary medications. Resident #23 had not been considered for a gradual dose reduction of an antipsychotic medication. The facility failed to adequately monitor Resident #5's use of a medication which required a pulse be taken prior to administration. Behavioral symptoms and side effects regarding the use of an antipsychotic medication were not monitored for Resident #46. Resident Identifiers: #23, #5, and #46. Facility Census: 64. Findings include: a) Resident #23 A medical record review, at 4:32 p.m. on 07/29/14, revealed the resident had a physician's orders [REDACTED]. This dose of [MEDICATION NAME] was originally ordered on [DATE], and Resident #23 continued to receive this daily dosage of [MEDICATION NAME]. Further review revealed the resident had been receiving [MEDICATION NAME] oral capsule 40 mg from 05/15/10 until 08/08/11, at which time the [MEDICATION NAME] was reduced to 20 mg a day. Review of the drug regimen reviews, completed by the pharmacist on a monthly basis, revealed the last gradual dose reduction (GDR) of Resident #23's [MEDICATION NAME] was recommended by the pharmacist on 10/09/12. The physician responded to this recommendation by saying, The resident has had a good response to treatment and requires this dose for condition stability. Dose reduction at this time would be contraindicated because benefits outweigh the risks for this patient and reduction is likely to impair the resident function and or cause psychiatric instability. As of 07/29/14, there was no evidence a GDR of [MEDICATION NAME] was recommended, attempted, and/or addressed as clinically contraindicated since 10/09/12. An interview with Registered Nurse (RN) #101, at 9:30 a.m. on 07/30/14, confirmed Resident #23 had not had a… | 2018-05-01 |
| 5962 | 5962 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 356 | C | 0 | 1 | GK2611 | Based on observation and staff interview, the facility failed to ensure the daily staff posting was posted in a place that was visible to residents and visitors. This had the potential to affect all residents and/or their responsible parties. Facility census: 64. Findings include: a) On 08/04/14 at 3:00 p.m., an observation of the nurse staffing posting revealed it was not located in place that was visible and accessible to residents/visitors. The nurse staffing posting was in a clear plastic holder on the wall. The paper the posting was typed on was sitting sideways in the plastic holder. You could not read the posting without taking it out of the plastic holder. The plastic holder was not within reach of a resident who was in a wheelchair. b) At 3:15 p.m. on 08/04/14, the administrator said he would change the location of the daily staff posting. | 2018-05-01 |
| 5963 | 5963 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 364 | E | 0 | 1 | GK2611 | Based on resident interview, review of grievance concern forms, observation, and food temperature measurements, the facility failed to ensure food was palatable, attractive, and served at temperatures which were acceptable to the residents. Hot foods were not served according to current professional standards and customary practice, which requires hot foods to be no less than 120 degrees Fahrenheit (F) at the time of receipt by the resident. This practice had the potential to affect more than a limited number of residents. Facility census: 64. Findings include: a) Resident interviews During Stage 1 of the Quality Indicator Survey (QIS), nine (9) of fifteen (15) interviewable residents complained of food temperatures and/or food taste. 1) Resident #68 said the food was not always served at proper temperatures, hot foods were not hot and cold foods were not always cold. 2) Resident #19 said the food was cold 3) Resident #91 said the food was barely warm 4) Resident #12 said only once in a while do they get a good meal 5) Resident #31 said the casseroles were horrible 6) Resident #96 said the food was not palatable 7) Resident #5 said cold foods were too warm 8) Resident #3 said the food did not look good 9) Resident #9 said she orders out from town because the food tastes bad. b) Resident complaints Review of grievance / concern forms found eight (8) documented concerns regarding the food since 03/13/14. Complaints included concerns about the menus, uncooked meats, the appearance of the meals, undercooked vegetables, portion sizes, and timely meal delivery. c) Food temperatures on Goodall Hall Observation of the noon meal delivery, on 07/30/14, found the meal cart arrived at 11:55 a.m. At 12:30 p.m., the registered dietitian and the dietary manager were asked to take the temperatures of the foods (with their thermometer) on the last tray on the food cart. The temperatures were: fried zucchini - 110 degrees F baked beans - 115 degrees F beef brisket - 112 degrees F d) Atrium Food Temperature Measurements At 12:16 p.… | 2018-05-01 |
| 5964 | 5964 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 366 | E | 0 | 1 | GK2611 | Based on observation and staff interview, the facility failed to ensure seven (7) of seven (7) residents who disliked zucchini were offered a substitute of similar nutritive value. Each of the residents had a previously identified dislike of zucchini. During the lunch meal on 07/30/14, these residents were not provided or offered another vegetable in place of the zucchini. Resident identifiers: #19, #64, #68, #3, #60, #23, and #42. Facility census: 64. Findings Include: a) Resident #19 Observation of the lunch meal, on 07/30/14 at 12:30 p.m., found the resident was served a BBQ brisket, a potato wedge, a slice of bread, milk and coffee. The resident said the meat was terrible and she was unable to eat it. She said, I can eat the potato and the slice of light bread. When advised the other residents had zucchini and baked beans she said, I don't like zucchini but I would like to have some baked beans. When nursing staff were alerted the resident would like to have baked beans, the dietary manager delivered a bowl of baked beans. The resident ate the baked beans and said were very good. The resident was never offered a substitute for the brisket that she left uneaten. Review of Resident #19's dislikes with the vice president (VP) of dining services, at 4:30 p.m. on 07/29/14, found zucchini was listed as a dislike, but the baked beans were not. The dietary manager was asked what vegetable the resident should have received in place of the zucchini. She said she had forgotten to put on an alternate vegetable. Upon inquiry, she confirmed any resident who had a dislike of zucchini would not have received an alternate vegetable for the noon meal on 07/30/14. b) Residents #64, #68, #3, #60, #23, and #42 The VP of dining services was asked how many residents did not receive a substitution for the zucchini at noon on 07/30/14. In addition to Resident #19, she provided the names of Residents #64, #68, #3, #60, #23, and #42. She indicated all seven (7) residents had voiced a dislike of zucchini and should have been offered an … | 2018-05-01 |
| 5965 | 5965 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 371 | F | 0 | 1 | GK2611 | Based on observations, record review, and staff interview, the facility failed to store foods under sanitary conditions. During the initial tour of the kitchen, multiple food items were observed opened with no date to indicate when they were opened or when they should be discarded. As well, the dry food storage area contained opened food items which required refrigeration after opening. Additionally, during the initial tour of the nutrition pantry on the nursing unit, multiple food items were found unlabeled and undated. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility Census: 64. Findings Include: a) During the initial tour of the kitchen, at 11:30 a.m. on 07/28/14, the following food items were observed stored in the walk-in cooler, the reach-in cooler and/or the dry goods storage area. Each of the food items was opened and partially used; however, they were not dated as to when they were opened or when they should be discarded. -- In the walk-in cooler was: egg salad, ham salad, chicken salad, mozzarella cheese, parmesan cheese, Swiss cheese, bologna, ham, cheddar cheese cubes, light mayonnaise, balsamic vinaigrette, shredded lettuce, and shredded carrots. -- In the reach-in cooler was: a bottle of apple juice and grape juice. -- In the dry goods storage area was: a bag of coco mix and a bag of muffin mix. b) While touring the dry goods storage area, two (2) opened, partially used bottles of mustard were observed. The dates they were opened were 05/20/14 and 05/23/14. c) The Vice President of Dining Services was interviewed at 11:45 a.m. on 07/28/14. She stated all opened items were to have an open date so staff would be able to determine when the items should be discarded and no longer used. She stated the shelf life of the items, once opened, depended on what type of item it was. She indicated the meat, cheese, fresh vegetables, and juice should be discarded in seven (7) days. The mayonnaise and Balsamic vinaigrette would be discarded in 3… | 2018-05-01 |
| 5966 | 5966 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 425 | E | 0 | 1 | GK2611 | Based on a random opportunity for observation and staff interview, the facility failed to ensure the safe storage of medications for residents temporarily residing in the long term care section, who would be returning to the assisted living section of the facility. This practice had the potential to affect any resident who was temporarily admitted to long term care from the assisted living section. Facility Census: 64. Findings include: a) Observation of the medication room, on 07/30/14 at 11:30 a.m., found a clear plastic trash bag which contained multiple medications. The bag contained Cephalexin capsules, Meclizine tablets, Doxycline capsules, Ventolin inhaler, CeraVe lotion, Aquaphor ointment, Cetaphil cream, Levothyroxine tablets, Humlin N insulin, Biotene mouthwash, Aspirin 81 milligram (mg) tablets, and Citracel Calcium Citrate tablets. The medications in the bag belonged to multiple residents. Each medication had been opened and used. Two (2) registered nurses (RNs), Employee #96 and Employee #133, were present during the observation. They stated the medications belonged to residents from the assisted living section of the facility who were currently residents in the long term care section of the facility. The nurses explained the medications were going to be used when the residents returned to the assisted living floor. Upon inquiry, the RNs confirmed some of the medications from the trash bag were currently being used for those residents. They agreed the medications for the multiple residents should not be commingled, should be stored separately for each resident, and should not be stored in a trash bag. The nurses immediately destroyed the medications. | 2018-05-01 |
| 5967 | 5967 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 428 | D | 0 | 1 | GK2611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the licensed pharmacist failed to identify and report irregularities for two (2) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). The pharmacist did not identify and report Resident #23 had not had a gradual dose reduction (GDR) of an antipsychotic medication annually. In addition, the pharmacist did not identify and report Resident #5 was administered medication on multiple occasions without first obtaining a pulse as ordered. Resident Identifiers: #23 and #5. Facility Census: 64. Findings include: a) Resident #23 A medical record review, at 4:32 p.m. on 07/29/14, revealed the resident had a physician's orders [REDACTED]. This dose of Geodon was originally ordered on [DATE], and Resident #23 continued to receive this daily dosage of Geodon. Further review revealed the resident had been receiving Geodon oral capsule 40 mg from 05/15/10 until 08/08/11, at which time the Geodon was reduced to 20 mg a day. Review of the drug regimen reviews, completed by the pharmacist on a monthly basis, revealed the last gradual dose reduction (GDR) of Resident #23's Geodon was recommended by the pharmacist on 10/09/12. The physician responded to this recommendation by saying, The resident has had a good response to treatment and requires this dose for condition stability. Dose reduction at this time would be contraindicated because benefits outweigh the risks for this patient and reduction is likely to impair the resident function and or cause psychiatric instability. As of 07/29/14, there was no evidence the pharmacist recommended a GDR of Geodon since 10/09/12. In an interview with the consultant pharmacist, at 3:20 p.m. on 08/04/14, he stated a GDR of an antipsychotic medication should be made annually if the resident had been on the medication for longer than one (1) year. He stated even if the physician previously indicated a GDR w… | 2018-05-01 |
| 5968 | 5968 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 431 | E | 0 | 1 | GK2611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility, in coordination with the licensed pharmacist, failed to establish a system of medication records that enabled periodic accurate reconciliation, accounting for, and disposition of all controlled medications. The facility had no formal mechanisms in place to safely handle controlled medications, and to maintain accurate and timely medication records. The facility, in coordination with the pharmacist, failed to establish a means to ensure security and safeguarding of controlled medications. There was no system to account for the receipt, usage, disposition, and reconciliation of all controlled medications. The facility was not conducting periodic reconciliations of records of receipt, disposition, and inventory for controlled medications to prevent or identify loss or diversion of these medications. There was no evidence the pharmacist evaluated the facility's systems regarding controlled medications to ensure the facility maintained an accurate accounting of all controlled medications and completed periodic reconciliations. This practice had the potential to affect more than an isolated number of residents. Facility census: 64. Findings include: a) Observation of the medication room, on [DATE] at 11:30 a.m., found a large amount of controlled medications (those which are known to be frequently misused/abused) in a double locked cabinet. Two (2) registered nurses (RNs), Employee #96 and Employee #133, were present during the observation. They stated they were not aware the controlled medications were being stored in the cabinet. Upon inquiry, the RNs said all nurses had access to the cabinet. No logs, indicating who had received these medications and in what dose, were observed in the cabinet. RNs #96 and #133 confirmed the absence of logs related to the medications in the cabinet. The facility had no method of accounting for any of the medications and no method to monitor for and/or reco… | 2018-05-01 |
| 5969 | 5969 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 490 | F | 0 | 1 | GK2611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, resident interview, observation, review of the Resident Assessment Instrument (RAI), staff interview, water temperature measurement, and food temperature measurement, 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, mental and psychosocial well being of its residents. The facility was not administered in accordance with Federal Regulations. Systems to provide optimum quality of care, dietary services, and pharmacy services were not established and / or implemented. - The facility failed to identify, assess and/or provide treatments for Residents #23 and #19, who had pressure ulcers. - The facility failed to ensure the environment was as free as possible from accident hazards over which it had control. - The facility failed to ensure food was palatable, served at temperatures acceptable to the residents, and failed to offered food substitutions. - The facility, in coordination with the licensed pharmacist, failed to ensure safe and secure storage of controlled medications. There was no formal system for periodic reconciliation and accounting of controlled medications to identify loss or diversion of these medications. These practices had the potential to affect all residents. Facility census: 64. Findings include: a) Quality of Care/Pressures ulcers The facility failed to ensure two (2) of four (4) residents reviewed for pressure ulcers did not develop avoidable pressure ulcers and/or received services to promote healing of existing pressure ulcers. Resident #23 was assessed at high risk for the development of pressure ulcers. The resident had two (2) Stage II pressure ulcers which had not been identified, assessed, or addressed by the facility, resulting in a determination of actual harm to the resident. Resident #19 had bilateral Stage I pressure ulcers to her heels upon admission which were not … | 2018-05-01 |
| 5970 | 5970 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 514 | D | 0 | 1 | GK2611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain clinical records that were complete and accurately documented for three (3) of seventeen (17) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #89's physician order was incorrectly documented as a skin tear instead of a Stage II pressure ulcer. There was also a physician's order for wound treatment that did not indicate the location of the wound. In addition, the treatment was discontinued on 07/02/14 and was never removed from the physician's orders. Resident #46 had incorrect documentation on the wound assessment. It indicated the resident had a pressure ulcer, but the resident actually had a venous/arterial ulcer. Resident #40 refused to elevate her legs when she was up in the recliner. Staff failed to document this information in the resident's medical record. Resident identifiers: #89, #40, and #46. Facility census: 64. Findings include: a) Resident #89 1. A review of Resident #89's physician's orders, on 08/04/14 at 5:00 p.m., revealed an order dated 05/19/14 for [MEDICATION NAME] ointment (an antibiotic ointment). It was to be applied to a skin tear on the resident's right lower leg. The area was to be covered with [MEDICATION NAME] (a non-adhesive wound dressing) and Kling (used to secure the dressing in place) daily. On 08/04/14 at 5:05 p.m., review of Resident #89's nurse's progress note, dated 07/22/14, revealed the resident had a Stage II pressure ulcer on the right lower leg, not a skin tear. In an interview with registered nurse/charge nurse (RN-CN) #101, on 08/04/14 at 5:07 p.m., she was asked whether Resident #89 had a pressure ulcer or a skin tear. Employee #101 stated, . the right lower leg started out as a skin tear, but now the area is a Stage II pressure ulcer. She was asked to review the physician's order. After the review, she stated, . the physician order should have been updated to reflect the area is now a Sta… | 2018-05-01 |
| 5971 | 5971 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 520 | F | 0 | 1 | GK2611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to maintain an effective quality assurance (QA) program. The QA committee failed to act upon quality deficiencies during the daily operation of the facility in which it did have or should have had knowledge. Systemic problems were identified in the care areas of pressure ulcers, nutrition, and pharmacy. -- The QA committee failed to ensure the facility identified, assessed and/or provided treatments for Residents #23 and #19, who had pressure ulcers. -- The QA committee failed to ensure the facility provided food which was palatable and served at temperatures deemed acceptable by the residents. The QA committee also failed to ensure the facility provided nutritionally equivalent substitutions for residents' known food dislikes. -- The QA committee failed to ensure the facility, in coordination with the licensed pharmacist, maintained safe and secure storage of medications. The facility did not have a system for periodic accurate reconciliation and accounting of controlled medications. In addition, the facility did not have a system to identify loss or diversion of controlled medication. These practices had the potential to affect all residents. Facility census: 64. Findings include: a) Pressures Ulcers The facility failed to ensure two (2) of four (4) residents reviewed for pressure ulcers did not develop avoidable pressure ulcers and/or received services to promote healing of existing pressure ulcers. Resident #23 was assessed at high risk for the development of pressure ulcers. The resident had two (2) Stage II pressure ulcers which had not been identified, assessed, or addressed by the facility, resulting in a determination of actual harm to the resident. Resident #19 had bilateral Stage I pressure ulcers to her heels upon admission which were not treated or monitored until after identification during the survey. In addition, the resident expressed pain, associ… | 2018-05-01 |
| 5972 | 5972 | GOOD SHEPHERD NURSING HOME | 515038 | 159 EDGINGTON LANE | WHEELING | WV | 26003 | 2014-07-10 | 371 | E | 0 | 1 | E8CB11 | Based on observation, staff interview, and policy review, the facility failed to ensure food was stored in a safe and sanitary manner. Unlabeled and undated food and beverages were stored in the nutrition refrigerators on Three ( 3 ) South, Two ( 2 ) Center, and Two (2) South. This had the potential to affect more than an isolated number of residents. Facility Census: 186. Findings include: a) Observation during the initial tour of the facility, on 07/07/14 at 11:55 a.m., found the Two (2) Center nursing station had a refrigerator containing residents' nourishments and snacks. There was one (1) container with watermelon and an opened bottle of Mountain Dew soft drink. Neither the Mountain Dew, nor the watermelon container were labeled with a date or a resident's name. These items were removed by Employee #118, registered nurse, at 11:56 a.m. She confirmed these items were not to be stored in the refrigerator without labels. b) Observation of the unit refrigerator on Three (3) South, at 12:25 p.m. on 07/07/14, found an open container of ginger ale that was unlabeled and undated. This was also removed by Employee #118. c) The policy for food storage was reviewed and discussed with the Director of Nursing (Employee #163) at 2:55 p.m. on 07/09/14. She said the facility's policy was to date and label food prior to it being put in the refrigerator. | 2018-05-01 |
| 5973 | 5973 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2014-10-15 | 224 | D | 0 | 1 | GZSS11 | Based on resident interview, review of the facility's abuse policy, and staff interview, the facility failed to investigate an allegation of misappropriation of resident property for one (1) of two (2) residents who were reviewed for the care area of abuse during Stage 2 of the survey. The facility did not implement their written policies and procedures that prohibited misappropriation of resident property. Resident identifier: #15. Facility census: 59. Findings include: a) Resident #15 Interview with Resident #15, on 10/07/14 at 2:43 p.m., revealed a nursing assistant (NA), Employee #25, came into her room and the resident caught the NA going through her dresser drawers. Resident #15 said she had a red cup, part of a set that was a gift from her son. The resident said the NA started to take the red cup. The resident said she told the NA not to take the cup. Resident #15 said a few days later the cup showed up missing. She said the next time she saw the NA, she asked her (the NA) if she got the cup. The resident said at first the NA denied getting the cup, but then admitted she had taken it because she did not have anything to drink out of that day. The resident said she was very upset and told the NA to go get the director of nursing (DON). The resident said she got her cup back after that. On 10/13/14 at 4:15 p.m., review of the facility's Abuse Policy, initiation date July 1973 and latest revision September 2008, revealed misappropriation of resident property was to be reported immediately. Their policy stated At no time does staff have a right to a resident's personal property. It also stated, All allegations of abuse involving mistreatment, neglect, or misappropriation of resident property will be reported per facility policy and in accordance to state and federal law. Their policy instructed an initial / immediate investigation to include question resident, staff, and any other witnesses. Initial reporting to the appropriate agencies included in their policy were reporting all allegations to the West Virgin… | 2018-05-01 |
| 5974 | 5974 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2014-10-15 | 225 | F | 0 | 1 | GZSS11 | Based on personnel file review, facility abuse/neglect policy and procedure review, medical record review, review of the requirements for criminal background checks in West Virginia, review of the Bureau for Medical Services manual and memorandum (memo), and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. This was true for five (5) of ten (10) employees whose files were reviewed. In addition, the facility failed to report and investigate an allegation of misappropriation of resident property. A nursing assistant (NA) removed Resident #15's personal beverage cup from the resident's room, even though the resident asked the NA not to take the cup. Employee identifiers: Employee #8, #9, #29, #45 and #11. Resident identifier: #15. This practice had the potential to affect all residents. Facility census: 59. Findings include: a) Criminal Background Checks for Employee #8, #9, #29, #45 and #11 On 10/08/14 at 10:00 a.m., a review of ten (10) personnel files revealed five (5) of ten (10) employees, who were employed by the facility between 06/10/08 and 04/03/12, had no fingerprints or criminal background checks based on fingerprinting in their files. On 10/08/14 at 3:20 p.m., the Human Resource Director stated employee criminal background checks had not been conducted for Employees #8, #9, #29, #45 or #11. The employees with no evidence of the requisite fingerprinting, as required for a statewide criminal background check in West Virginia were: - Employee #8, nursing assistant (NA) hired on 04/28/10; - Employee #9, NA hired on 06/22/10; - Employee #29, licensed practical nurse (LPN) hired on 06/10/08; - Employee #45, LPN hired on 06/20/11, and. - Employee #11, NA rehired on 04/03/12. In a discussion with the administrator (NHA), on 10/06/14 at 4:00 p.m., the NHA denied knowledge of any regulations requiring criminal background checks on all facility employees. She denied any knowledge of the memo issu… | 2018-05-01 |
| 5975 | 5975 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2014-10-15 | 226 | F | 0 | 1 | GZSS11 | Based on staff interview, resident interview, review of the facility's abuse policy, review of the requirements for criminal background checks in West, Virginia, and review of the Bureau for Medical Services manual and memorandum, the facility failed to revise and implement written abuse policies and procedures, for screening employees, to include the requisite criminal investigation background checks by fingerprinting for all tenured employees every three (3) years. This practice had the potential to affect all residents. In addition, the facility failed to operationalize its policy for identifying, reporting, and investigating misappropriation of resident property for one (1) of two (2) residents who were reviewed for the care area of abuse during Stage 2 of the survey. Resident identifier: #15. Facility census: 59. Findings include: a) Facility abuse policy On 10/09/14 at 3:00 p.m., the facility's policy on abuse, with a revision date of 09/20/11, was reviewed. This review revealed the facility failed to update its policy to include the requirement to complete criminal background checks by fingerprinting all employees every three (3) years. The Bureau for Medical Services (BMS) manual was reviewed, and included the following: 514.4.1 Employment Restrictions Criminal Investigation Background (CIB) check results which may place a member at risk of personal health and safety or have evidence of a history for Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three (3) years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five (5) years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memor… | 2018-05-01 |
| 5976 | 5976 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2014-10-15 | 241 | D | 0 | 1 | GZSS11 | Based on resident and staff interviews, the facility failed to ensure interactions between staff and residents promoted dignity and respect for one (1) of two (2) residents who were reviewed for the care area of dignity during Stage 2 of the survey. The resident expressed feelings of being treated with disrespect by a nurse aide (NA). Resident identifier: #15. Facility census: 59. Findings include: a) Resident #15 Interview with Resident #15, on 10/07/14 at 2:43 p.m., revealed the resident did not think she was treated with respect and dignity by all the staff. Resident #15 said a nursing assistant (NA), Employee #25, came into her room and the resident caught the NA going through her dresser drawers. When the resident asked the NA what she was looking for, the resident said the NA .was smart alecky and said she was just looking in the drawers to see if I have as much junk in my drawers as she (NA) has in her drawers. She really got me upset. The resident said the NA started to take her (the resident's) red cup. The resident said she told her not to take the cup because it belonged to a set of cups the resident's son had given her as a gift. A few days later the resident said the cup showed up missing. The next time she saw the NA, the resident said she asked her if she got the cup. The resident said at first, the NA denied getting the cup. The resident said .then when I got really angry and showed myself, the aide admitted getting the cup. The aide said she got it because she said she didn't have anything to drink out of that day. After the aide finally admitted she got it, it was reported to the nurse and others and I got my cup back. Interview with the director of nursing (DON), on 10/14/14 at 2:06 p.m., confirmed Employee #25 took the resident's cup without the resident's permission. | 2018-05-01 |
| 5977 | 5977 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2014-10-15 | 272 | D | 0 | 1 | GZSS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to conduct comprehensive assessments that accurately identified the health status for two (2) of seventeen (17) residents reviewed during Stage 2 of the survey. The minimum data set (MDS) comprehensive assessment for Resident #65 was inaccurately coded that the resident acquired suspected deep tissue injury (DTI) while at an acute care facility. The DTI was actually acquired at the nursing facility. The MDS also noted a pressure relieving device (air mattress) was in place on the resident's bed, but it was not. In addition, Resident #15 was inaccurately assessed for dental status. The annual MDS failed to indicate the resident did not have lower dentures. Resident identifiers: Resident #65 and #15. Facility census: 59. Findings include: a) Resident #65 On 10/09/14 at 11:04 a.m., a medical record review revealed Resident #65 was readmitted , from an acute care hospital, to the facility on [DATE] with a pressure ulcer on the coccyx. According to the medical record, on 08/07/14 the resident developed an in-house acquired avoidable suspected DTI to the left heel. The significant change MDS, with an assessment reference date (ARD) of 08/25/14, was reviewed. Section M, G-2 was coded that a suspected DTI was present on readmission to the facility. This MDS also was coded, in section M1200, that a pressure reducing device was on the resident's bed. The information, in both sections, was carried forward on the MDS with an ARD of 09/16/14, 09/23/14 and 10/01/14. An observation, on 10/14/2014 at 8:15 a.m., revealed no air mattress was on the bed of Resident #65. On 10/14/14 at 10:34 a.m., in an interview with the director of nursing (DON), she confirmed the suspected DTI was not present on readmission and had developed in the facility. In addition, the DON agreed the MDS was coded incorrectly and no pressure relieving device (air mattress) had ever been used on Resident #65's … | 2018-05-01 |
| 5978 | 5978 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2014-10-15 | 279 | E | 0 | 1 | GZSS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to use the results of the assessment to develop comprehensive care plans based on identified individual resident status and needs for five (5) of seventeen (17) Stage 2 sample residents. The care plans for Residents #73, #62, and #63 did not contain goals and interventions for non-pharmacological interventions for behaviors. Resident #63's care plan did not contain goals and interventions related to [MEDICAL TREATMENT] care and services or for prevention of pressure ulcers. The care plan related to incontinence for Residents #20 did not have goals and interventions which were individualized for the resident's needs. Resident identifiers: #73, #62, #65, and #63. Facility census: 59. Findings include: a) Resident #73 A record review,on 10/09/14 at 10:30 a.m., found current [MEDICAL CONDITION] MEDICATION ORDERS FOR [REDACTED]. Target behaviors identified in the medical record under the Staff Communication tab include (typed as written): Crying, freq reassurance, attempts to leav. Review of the resident's care plan revealed no non-pharmacological interventions related to the use of [MEDICAL CONDITION] medications. This was discussed with the director of nursing (DON), on 10/09/14 at 11:00 a.m. She stated she was unaware non- pharmacological interventions were necessary after a resident had been stable on a scheduled [MEDICAL CONDITION] medication long term and was no longer appropriate for gradual dose reduction (GDR). b) Resident #62 Resident #62 was admitted on [DATE], from another long term care facility. Medical [DIAGNOSES REDACTED]. A review of the medical record, on 10/13/14 at 1:10 p.m., revealed Resident #62 was prescribed [MEDICATION NAME] 25 mg at bedtime for depression, [MEDICATION NAME] 60 mg daily for depression, Trazadone 200 mg at bedtime for depression, and [MEDICATION NAME] 20 mg twice daily for [MEDICAL CONDITION] disorder. On 10/13/14 at 2:02 p.m., review of the ca… | 2018-05-01 |
| 5979 | 5979 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2014-10-15 | 280 | D | 0 | 1 | GZSS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise care plans as necessary for two (2) of seventeen (17) Stage 2 sample residents. Resident #17 had a medication change which was not revised in the care plan. Resident #28 had an inaccurate weight measurement. Upon discovery of the inaccuracy, the care plan was not revised. Resident identifiers: #17 and #28. Facility census: 59. Findings include: a) Resident #17 A medical record review was performed on 10/09/14 at 9:30 a.m. Resident #17 had been on [MEDICATION NAME] in the past, but it was discontinued on 05/17/14. No current orders for [MEDICATION NAME] existed. The current care plan had a focus problem stating: Resident has the potential for drug related discomfort related to daily . [MEDICATION NAME] use. This matter was discussed and reviewed with the director of nursing at 10/14/14 at 3:00 p.m. She agreed the care plan had not been revised when the resident's use of [MEDICATION NAME] was discontinued. b) Resident #28 The closed record for Resident #28 was reviewed on 10/08/14 at 12:00 p.m. The minimum data set (MDS), with an assessment reference date (ARD) of 07/03/14, revealed the resident sustained [REDACTED]. This amounted to a 6.4% weight loss in fifteen (15) days. The resident was care planned for a focus on weight loss. Review of the weight log for resident revealed this resident had four (4) weights recorded between 06/23/14 and 08/04/14: - 06/23/14, 361.0 pounds (A hand-written note by the weight stated not right.) - 07/03/14, 337.6 pounds - 07/09/14, 240.0 pounds - 08/04/14, 341.9 pounds An interview was conducted with a MDS nurse, Employee #29, at 1:40 p.m. on 10/08/14. She said the admission weight on 06/23/14 was in error. According to Employee #29, the director of nursing (DON) did monthly audits on resident weights. The DON allegedly made the hand-written notation on the weight record which indicated the 361 pound weight recorded on 06/23/14 was not rig… | 2018-05-01 |
| 5980 | 5980 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2014-10-15 | 282 | D | 0 | 1 | GZSS12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the [MEDICAL TREATMENT] communication records, and staff interview, the facility failed to follow the care plan for post [MEDICAL TREATMENT] care for one (1) of one (1) sample residents. The facility failed to assess the resident, as indicated in the care plan, upon return to the facility from the [MEDICAL TREATMENT] unit. Resident identifier: #65. Facility census: 58. Findings include: a) Resident #65 A review of the care plan for Resident #65, on 12/16/14 at 10:43 a.m., revealed the following interventions, dated 11/20/14: Upon arriving to facility from [MEDICAL TREATMENT] check that dressing to access site dry and intact, check for presence of thrill and bruit, check for presence of a pulse in the affected arm, present of [MEDICAL CONDITION] of the hand, and capillary refill of fingers, check vital signs and weight. On 12/16/14 at 10:57 a.m., a review of the nurses' notes, typed as written, revealed the following: - 11/28/14 at 16:30 (4:30 p.m.) Returned to the facility safely at 16:30 Pm.No N/V (nausea and vomiting). BP (blood pressure) 142/70 mmHg (millimeters of mercury), Temp (temperature) 98.4, P (pulse) 70 and R (respirations) 20. And Post-WT (weight) [MEDICAL TREATMENT] was 110.6 lbs (pounds), and 1.9 lbs withdrawn.Dsg (dressing) to [MEDICAL TREATMENT] site to L)UA (left upper arm) patent, dry and no s/s (signs/symptoms) of infection.Bruit and thrill present.No C/O (complaints) pain or discomfort.resting in bed quietly. - 12/01/14 at 16:00 (4:00 p.m.) resident returned safely at this time. VS:BP130/66 mmhg, Temp [MEDICATION NAME] and [MEDICATION NAME] taken at 2pm at [MEDICAL TREATMENT].No N/V. The [MEDICAL TREATMENT] port site to LUA covered w/ (with) pressure dsg (dressing), and patent, dry. No redness or bleeding.Bruit and thrill positive.Resting in bed quietly. Pre WT was 108.7 lbs and post-Wt was 102.8 lbs, 5.7 lbs withdrawn by [MEDICAL TREATMENT]. - 12/03/14 16:30 (4:30 p.m.) Returned … | 2018-05-01 |
| 5981 | 5981 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2014-10-15 | 314 | G | 0 | 1 | GZSS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on minimum data set (MDS) review, medical record review, observation, and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for pressure ulcers during Stage 2 of the survey did not develop an avoidable pressure ulcer. The facility failed to implement interventions in an effort to prevent the development of the pressure ulcer. An in-house acquired suspected deep tissue injury (DTI) was identified on the resident's heel seven (7) days after readmission to the facility. The facility was unable to provide evidence of the implementation of interventions to prevent the development of the pressure ulcer or to assist in the healing of the pressure ulcer once it was identified. Resident identifier: #65. Facility census: 59. Findings include: a) Resident #65 On 10/08/14 at 9:30 a.m., a review of the medical record revealed the resident was readmitted from a local acute care hospital on [DATE]. The medical [DIAGNOSES REDACTED]. At 11:04 a.m. on 10/09/14, a review of the resident's significant change MDS, with an assessment reference date (ARD) of 08/25/14, revealed Section M, G-2 was coded that a suspected DTI was present on readmission to the facility on [DATE]. Section M1200 B and C also noted a pressure reducing device and a turning/repositioning program was in place. This information was carried forward on the MDS's with ARD's of 09/23/14 and 10/01/14. Additional medical record review revealed Resident #65 was not readmitted with a suspected DTI. According to the medical record, on 08/07/14 an in-house acquired suspected DTI to the left heel was identified. Observation, on 10/14/14 at 8:15 a.m., revealed no pressure reducing device was on the bed of Resident #65. The care plan contained two (2) problem statements related to pressure ulcers: -- On 08/12/14, the care plan indicated the resident had a Stage II pressure ulcer on the coccyx related to decreased mobility, related to a fractured pelvis. The care plan… | 2018-05-01 |
| 5982 | 5982 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2014-10-15 | 425 | D | 0 | 1 | GZSS11 | Based on observation, staff interview, review of manufacturer's instructions, and review of guidance provided by the facility's pharmacy, the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. A multi-dose vial of insulin was open for use for greater than the number of days directed by the manufacturer. Another multi-dose vial of insulin was open and had no date inscribed to indicate when the vial was initially opened. Use of medication from a multi-dose vial which was open for a time period greater than that recommended by the manufacturer had the potential to negatively impact the safety and/or potency of the medication. Resident identifier: #65. Facility census: 59. Findings include: a) Resident #65 On 10/09/14 at 9:00 a.m., the medication storage room on the second floor of the Extended Care Facility (ECF) was observed. An opened, partially used, multi-dose vial of Novolin-N insulin for Resident #65 was stored in the medication refrigerator. It was initially opened on 08/23/14. A second vial of Novolin-N insulin for Resident #65 was observed in the medication refrigerator. It was delivered by the pharmacy on 09/08/14. This nearly full vial was opened (needle punctured), but was not dated to indicate when it was first opened. The manufacturer's instructions for Novolog insulin directed an opened vial be thrown away after six (6) weeks (42 days) of use, even if there was insulin left in the vial. At 11:00 a.m. on 10/09/14, licensed practical nurse (LPN) Employee #29 said the facility had no policy related to dating vials when opened, or how long to keep vials after they were initially opened. She produced a copy of insulin storage recommendations that she said the facility's pharmacy provided as a guideline. According to those recommendations, Novolin-N insulin could be kept refrigerated for up to forty-two (42) days after the initial opening. The LPN said the vial of Novolin-N insulin for Resident #65, that had initially been opened on 08/23/14, should h… | 2018-05-01 |
| 5983 | 5983 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2014-10-15 | 465 | E | 0 | 1 | GZSS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to provide a sanitary and comfortable environment for residents, staff, and the public. Cobwebs were present on the outside of numerous windows on the second floor of the facility. An access grate in the ceiling, located in the tunnel between the first floor residents' quarters and the exit door, was rusted. These cosmetic imperfections affected Resident #26, and had the potential to affect more than a limited number of residents. Room identifiers: #202, #203, #304, #205, #206, #207, #208, #209, #210, #211. Facility census: 59. Findings include: a) Resident #26 An interview was conducted with Resident #26, on 10/14/14 at 11:30 a.m. She said she did not like to see spider webs on her window. She said the spider webs had been there for a long time. Observation revealed the presence of numerous cobwebs located on the outside of her window pane. b) Rooms 202, 203, 204, 205, 206, 207, 208, 209, 210, 211 Observations, on 10/14/14 at 11:30 a.m., revealed the presence of cobwebs on the outside window panes in rooms 202, 203, 204, 205, 206, 207, 208, 209, 210, and 211. On 10/14/14 at 11:50 a.m., an interview was conducted with the maintenance supervisor. He said this was the first he had heard of this issue. He said maintenance was in charge of the upstairs outside window washing, and they cleaned those windows about twice a year. Upon inquiry, he said those outside windows were most recently cleaned this spring. He produced a pest control log book to show the facility had a pest control program that also treated for [REDACTED]. c) Observation, on 10/15/14 at 9:30 a.m., found a rusted metal grate in the ceiling located in the tunnel between the first floor residents' living quarters and the exit door. An interview was conducted with the maintenance supervisor on 10/15/14 at 10:30 a.m. He said the metal grate was in the ceiling because sometimes the heat pipes got hot an… | 2018-05-01 |
| 5984 | 5984 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2014-10-15 | 490 | F | 0 | 1 | GZSS11 | Based on review of personnel records, review of the requirements for criminal background checks in West Virginia, review of the Bureau for Medical Services manual and memorandum (memo), policy and procedure review and staff interviews, the facility was not administered in an efficient and effective manner to maintain the highest practicable well-being of each resident. Required fingerprint criminal background investigations were not conducted five (5) of ten (10) employees whose files were reviewed. This practice had the potential to affect all residents. Employee identifiers: #8, #9, #29, #45 and #11. Facility census: 59. Findings include: a) Criminal Background Checks On 10/08/14 at 10:00 a.m., a review of ten (10) personnel files revealed five (5) of ten (10) employees, who were employed by the facility between 06/10/08 and 04/03/12, had no fingerprints or criminal background checks based on fingerprinting in their files. On 10/08/14 at 3:20 p.m., the Human Resource Director stated no employee criminal background checks had been conducted for Employees #8, #9, #29, #45 or #11. The employees with no evidence of the requisite fingerprinting, as required for a statewide criminal background check in West Virginia were: - Employee #8, nursing assistant (NA) hired on 04/28/10; - Employee #9, NA hired on 06/22/10; - Employee #29, licensed practical nurse (LPN) hired on 06/10/08; - Employee #45, LPN hired on 06/20/11, and. - Employee #11, NA rehired on 04/03/12. In a discussion with the administrator (NHA), on 10/06/14 at 4:00 p.m., the NHA denied knowledge of any regulations requiring criminal background checks on all facility employees. She denied any knowledge of the memo issued to all Medicaid participating facilities on February 15, 2013. She stated this may have been received by the previous NHA, but she had no knowledge of the memo. To ensure the facility had not employed an individual who had been found guilty of abusing, neglecting, or mistreating residents by a court of law, West Virginia requires submission… | 2018-05-01 |
| 5985 | 5985 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2014-10-15 | 520 | F | 0 | 1 | GZSS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record reviews, review of personnel records, review of the requirements for criminal background checks in West Virginia, review of the Bureau for Medical Services manual and memorandum (memo), policy and procedure review, and staff interview, the quality assessment and assurance (QA&A) committee failed to identify a quality deficiency of which they were aware or should have been aware. The QA & A committee did not identify and implement a plan of action to ensure the facility did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. Required fingerprint criminal background investigations were not conducted for five (5) of ten (10) employees whose files were reviewed. Employees (#8, #9, #29, #45, and #11). In addition, the QA & A committee failed to identify and implement a plan of action to ensure the results of residents' assessments were used to develop comprehensive care plans based on identified individual resident status and needs for five (5) of seventeen (17) Stage 2 sample residents. The care plans for Residents #73, #62, and #63 did not contain goals and interventions for non-pharmacological interventions for behaviors. Resident #63's care plan did not contain goals and interventions related to [MEDICAL TREATMENT] care and services or for prevention of pressure ulcers. The care plan related to incontinence for Residents #20 did not have goals and interventions which were individualized for the resident's needs. These practices had the potential to affect all residents. Facility census: 59. Findings include: a) Criminal Background Checks On 10/08/14 at 10:00 a.m., a review of ten (10) personnel files revealed five (5) of ten (10) employees, who were employed by the facility between 06/10/08 and 04/03/12, had no fingerprints or criminal background checks based on fingerprinting in their files. On 10/08/14 at 3:20 p.m., the Human Resource Director stated n… | 2018-05-01 |
| 5986 | 5986 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2014-07-24 | 309 | E | 0 | 1 | 1O0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to administer all medications as ordered by the physician for one (1) of twenty (20) Stage 2 sampled residents. Resident #13 only received fifteen (15) of twenty (20) ordered doses for treatment for [REDACTED]. Twenty-five (25) percent of the medication was not given as ordered by the physician. Resident identifier: #13. Facility census: 88. Findings include: a) Resident #13 Review of the medical record on 07/23/14 at 1:00 p.m. revealed Resident #13 had sores inside the oral cavity. On 07/16/14, the physician prescribed [MEDICATION NAME] 100,000 units per milliliter (ml.), 5 cubic centimeters (cc) to swish around the oral cavity, then swallow, 4 times daily for 5 days. The physician diagnosed the resident with oropharyngeal candidiasis. Of twenty (20) doses reserved on the Medication Administration Record [REDACTED]. The resident did not receive any of the four (4) doses as indicated on the MAR indicated [REDACTED]. The reason identified for the omission was that the medication was not available. Once the medication was received and could be started, the nursing staff should have adjusted the schedule for the medication to ensure the entire 20 doses was administered as ordered. During an interview with the director of nursing (DON) on 07/24/14 at 10:30 a.m., she said the medication was not obtained from the pharmacy until 07/17/14. She said they did not have the [MEDICATION NAME] in stock and it was not a STAT (without delay) order. Therefore, the medication should have been written on the MAR indicated [REDACTED]. | 2018-05-01 |
| 5987 | 5987 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2014-07-24 | 431 | E | 0 | 1 | 1O0M11 | Based on observation, staff interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of manufacturer instructions, and policy review, the facility failed to implement appropriate medication storage methods. Drugs were not stored in a locked compartment. A multi-dose vial of insulin was open for greater than 28 days. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #43. Facility census: 88. Findings include: a) Medication Cart At 1:05 p.m. on 07/21/14, a medication cart was observed on the C hall unattended. Upon further inspection, there was a box with vials of insulin bearing the names of residents sitting on top of the cart along with an injectable insulin pen. The cart was observed for five (5) minutes and no nurse returned. The Director of Nursing (DON) was contacted at 1:10 p.m. and made aware of the situation. She immediately intervened. In an interview with licensed practical nurse (LPN) #22, at 8:00 a.m. on 07/21/14, she said the medication cart with the medications left on top of the cart was assigned to her. She said she knew they were not supposed to be there and she usually kept them in a drawer, but this time she did not. She went on to say she had stepped into a room to provide resident care and shut the door leaving the cart unattended. When this matter was discussed with the Administrator on 07/22/14 at 9:00 a.m., she provided a policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles. This policy was last revised 01/01/13. Section 3.3 included, Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. b) Resident #43 The B wing medication cart was observed on 07/23/14 at 5:00 p.m., accompanied by LPN #51. An opened, partially used vial of Novolog insulin for Resident #43 was dated 06/14/14. LPN #51 said 06/14/14 was the da… | 2018-05-01 |
| 5988 | 5988 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 156 | D | 0 | 1 | 7HHJ11 | Based on staff interview, review of the facility's liability and appeal notices, and review of the memorandum from the Centers for Medicare and Medicaid Services (CMS) regarding liability notices and beneficiary appeal rights in nursing homes (issued on 01/09/09), the facility failed to issue the correct notice of Medicare non-coverage form for two (2) of three (3) residents when Medicare services were discontinued by the facility. Both residents were receiving therapy and were discharged from Medicare services with Medicare benefit days remaining. Resident identifiers: #60 and #62. Facility census: 98. Findings include: a) Resident #60 Review of the resident's notice of Medicare non-coverage form with Employee #94, the registered nurse (RN) admissions coordinator, at 1:53 p.m. on 09/17/14, found Resident #60 was discharged from Medicare skilled services on 04/23/14. The reason for the discontinuation was, Resident has met goals established with PT. OT (physical and occupational therapy) and has plateaued. RN #94 verified the resident had benefit days remaining. RN #94 issued form CMS to the resident's responsible party on 04/21/14. b) Resident #62 Review of the resident's Notice of Medicare Non-Coverage form, with RN #94 at 1:53 p.m. on 09/17/14 found the resident's last covered day of Medicare skilled services was 04/02/14. The reason for the denial was, Patient has met all goals with therapy and no longer meets criteria for skilled services. RN #94 verified the resident had benefit days remaining when discontinued from Medicare services. RN #94 issued form CMS to the resident's responsible party on 03/31/14. c) According to the CMS, S&C-09-20 memorandum guidance, dated 01/09/09, Use the Notice of Provider Noncoverage (Form CMS ) also known as the Generic Notice to notify resident of the right to an expedited review by a QIO (Quality Improvement Organization): All covered services are ending for coverage reasons and resident has benefit days remaining. The example provided was, SNF (skilled nursing facility) de… | 2018-05-01 |
| 5989 | 5989 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 166 | D | 0 | 1 | 7HHJ11 | Based on resident interview, staff interview, and record review, the facility failed to actively work toward a resolution of a grievance for one (1) of two (2) sample residents reviewed for the care area of personal property during Stage 2 of the survey. The resident had a missing cell phone which the facility indicated they would replace if the resident's lost cell phone was not located. The facility replaced the cell phone with a cell phone which quit functioning soon after it was provided. The facility took no further action regarding the cell phone. Resident identifier: #90. Facility census: 98. Findings Include: a) Resident #90 In an interview with Resident #90, at 10:09 a.m. on 09/15/14, the resident said someone had stolen his cell phone. He said staff told him they were going to replace it, but they never did. The social worker (SW), at 8:25 a.m. on 09/17/14, confirmed the resident had a missing cell phone some time ago. She stated they searched for the phone and were unable to locate it. The SW said she provided the resident with a phone which had been unclaimed in the facility's lost and found for about six (6) months. A review of this reportable incident was completed at 10:30 a.m. on 09/17/14. The five-day follow up form, dated 05/24/13, was reviewed. The date of incident was noted as 05/22/13. The corrective action by facility was, Family was notified of missing cell phone(NAME)Co. (county) Sheriff's Dept.(department) also was notified of the alleged incident. Also, staff continues to monitor for cell phone. Encouraged resident not to keep things of value in room but in locked safe as well as will monitor when visitors are in room. Will replace cell phone if unable to locate phone. In an additional interview with Resident #90, at 10:45 a.m. on 09/17/14, he again stated he had not had a cell phone since his came up missing. When asked if the facility had given him a new phone he stated, No I don't have one. A follow-up interview with the SW, at 11:33 a.m. on 09/17/14, confirmed the facility gave the r… | 2018-05-01 |
| 5990 | 5990 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 225 | F | 0 | 1 | 7HHJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's abuse/neglect assessment and reporting policy, review of the complaint files, staff interview, and personnel file review, the facility failed to ensure all allegations of neglect and abuse were reported and thoroughly investigated for three (3) of seven (7) grievances/concerns reviewed. In addition, the facility failed to be thorough in their investigations of the past histories of five (5) of five (5) employees they hired. The facility did not check with the abuse registry and /or obtain required criminal background checks, including fingerprinting, for these employees. These practices affected Residents #52, #148, and #156, and had the potential to affect all residents. Facility census: 98. Findings include: a) Resident #52 Review of a grievance/concern form, at 4:00 p.m. on 09/17/14, revealed the resident reported allegations of neglect and verbal abuse on 07/14/14, regarding incidents which occurred on 07/12/14 and 07/13/14: 1. Resident reports Licensed Practical Nurse #19 is very rude and hateful, and she is untimely with medications and she thinks she gave her two [MEDICATION NAME] instead of her pain medication. 2. Staff didn't provide a bed pan in timely manner. A notation on the form, under findings of the investigation, revealed the facility found the employee was perceived by the resident as rude and hateful. The corrective action was: Instructed to be mindful of how she is being perceived by resident when giving care. There was no evidence of a thorough investigation into the complaints. There was nothing which indicated how the facility determined the resident's complaint was only a perception that the employee was rude or hateful. There was no evidence of an thorough investigation regarding the resident's medication concerns or the timely provision of a bedpan. In addition, these allegations of verbal abuse and neglect were not reported to the required state agencies. During an interview with th… | 2018-05-01 |
| 5991 | 5991 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 226 | F | 0 | 1 | 7HHJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's abuse/neglect assessment and reporting policy, review of the complaint files, staff interview, and personnel file review, the facility failed to operationalize its policies related to allegations of neglect and abuse for three (3) of seven (7) residents. The allegations were not reported and investigated as required by their policy titled: Abuse, Neglect, Reporting Forms. In addition, the facility failed to operationalize its policies and procedures for screening employees for protection of residents from abuse, neglect, mistreatment, and misappropriation of property. The facility also failed to operationalize its policy to be thorough in the investigations of the past histories of five (5) of five (5) employees they hired. These practices affected Resident #52, #148, and #156. The practices had the potential to affect all residents. Facility census: 98. Findings include: a) Resident #52 Review of a grievance/concern form, at 4:00 p.m. on 09/17/14, revealed the resident reported allegations of neglect and verbal abuse on 07/14/14, regarding incidents which occurred on 07/12/14 and 07/13/14: 1. Resident reports Licensed Practical Nurse #19 is very rude and hateful, and she is untimely with medications and she thinks she gave her two [MEDICATION NAME] instead of her pain medication. 2. Staff didn't provide a bed pan in timely manner. A notation on the form, under findings of the investigation, revealed the facility found the employee was perceived by the resident as rude and hateful. The corrective action was: Instructed to be mindful of how she is being perceived by resident when giving care. There was no evidence of a thorough investigation into the complaints. There was nothing which indicated how the facility determined the resident's complaint was only a perception that the employee was rude or hateful. There was no evidence of an thorough investigation regarding the resident's medication concerns or the t… | 2018-05-01 |
| 5992 | 5992 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 242 | D | 0 | 1 | 7HHJ11 | Based on resident interview, medical record review, and staff interview the facility failed to allow one (1) of three (3) residents, who triggered the care area of choices, the right to exercise autonomy regarding what this resident considered an important aspect of his life. Resident #57 was not allowed the opportunity to make a choice regarding how many times a week he received a shower. Resident identifier: #57. Facility census: 98 Findings include: a) Resident #57 In an Interview with Resident #57, on 09/15/14 09:58 a.m., he was asked if he could choose how many times a week he took a bath or shower. He replied, We are to receive (2) showers a week, but we do not get two (2) showers a week. Further inquiry revealed he wanted two (2) showers a week. Review of the bathing response form revealed Resident #57 received only two (2) showers the entire month of August 2014. He was not provided two (2) showers a week as he chose. On 09/16/14 at 4:00 p.m., the director of nursing (DON) was asked why Resident #57 only received two (2) showers during the month of August 2014. She stated for three (3) weeks during August 2014, the facility did not have an employee to help with showers. The DON said this was the reason Resident #57 did not receive two (2) showers a week as he desired. | 2018-05-01 |
| 5993 | 5993 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 244 | E | 0 | 1 | 7HHJ11 | Based on the resident council president interview, review of the resident council meeting minutes, and staff interview the facility failed to ensure grievances voiced by the group, which affected resident care and life at the facility, were acted upon. In addition, the facility failed to ensure any decisions regarding the grievances from the resident council were communicated to the group. This had the potential to affect more than an isolated number of residents. Facility census: 98. Findings include: a) Resident council president interview The resident council president, Resident #46, was interviewed at 3:30 p.m. on 09/16/14. When asked if the facility listened to the resident council's views and acted upon any grievances the group has filed, the resident responded, That's a big fat, no. He stated, They just set around and talk about it, or I guess they do, and that's as far as it goes. Resident #46 stated during numerous meetings, he had personally told, people in charge about people who cannot help themselves get back to their rooms after evening activities. He said there are little old ladies who sit in the dining room and cry because no one will help them get back to their rooms. Resident #46 said he had also asked for more games to be played, such as Dominoes and Checkers. He said currently the facility played Bingo, but he would like to see more games included in the activity program. He also stated that other residents in the group meeting complain about their roommates, the food, missing personal items, staffing and other things. b) Resident council minutes from March 2014 through August 2014 Review of the resident council meeting minutes, on 09/17/14, found the following: 1. March 2014 -- Resident #79 complained of a noisy roommate and missing clothing. The facility's answer to the missing clothing was, Spoke with daughter who stated resident has no missing clothing at this time -- Another resident complained about cold food. The facility's response was, Talked with resident and food is not always cold… | 2018-05-01 |
| 5994 | 5994 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 246 | D | 0 | 1 | 7HHJ11 | Based on observation, resident interview, and staff interview, the facility failed to provide reasonable accommodations of individual needs for one (1) resident discovered during a random opportunity for discovery during Stage 2 of the Quality Indicator Survey (QIS). The resident did not have batteries for her hearing aids, which she expressed a desire to wear to to improve her hearing. The resident also had a broken catch on one (1) of the hearing aids. Resident identifier: #47. Facility census: 98. Findings include: a) Resident #47 During an interview with the resident, along with the dietary manager and Employee #110, the registered nurse, (RN) minimum data set (MDS) coordinator, at 8:30 a.m. on 09/17/14, RN #110 used a pen and paper to communicate with Resident #47. The resident was unable to hear verbal conversation. The interview was initially conducted to assess the resident's dental needs. RN #110 was asked if the resident had a hearing aid. The RN stated she did not know, but would ask the resident. RN #110 used the pen and paper to ask the resident if she had a hearing aid. The resident responded by saying she had a hearing aid and pointed to her night stand drawer. The resident said she could not use it because she did not have any batteries. RN #110 then asked the resident if her hearing aid worked. The resident responded, Yes, but why would I wear it if I don't have any batteries? At 9:30 a.m. on 09/17/14, the social worker (SW) said she had called the resident's daughter and asked the daughter to bring batteries to the facility. The SW said the family of Resident #46 told her the resident would not wear her hearing aids. When asked why she asked the family about the hearing aids, when the resident was capable of communicating her needs, the SW had no response. At approximately 10:00 a.m. on 09/18/14, the director of nursing (DON) said the resident was wearing her hearing aid. The DON said she had assisted the resident with placing the batteries in her hearing aid. The DON confirmed the resident had … | 2018-05-01 |
| 5995 | 5995 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 272 | D | 0 | 1 | 7HHJ11 | Based on medical record review and staff interview, the facility failed to ensure the accuracy of the annual comprehensive minimum data set (MDS) assessments for (2) of three (3) residents reviewed for the care area of dental status during Stage 2 of the Quality Indicator Survey (QIS). Neither resident's assessment related to oral/dental status was accurate. Resident identifiers: #47 and #87. Facility census: 98. Findings include: a) Resident #47 Observation of the resident, at 2:37 p.m. on 09/15/14 during Stage 1 of the QIS, found the resident's bottom teeth were broken and discolored On 09/15/14, review of the most recent annual MDS, with an assessment reference date (ARD) of 08/04/14, found Section (L) entitled oral/dental status was coded to reflect the resident had no dental issues. At 4:30 p.m. on 09/16/14, Employee #110, the registered nurse (RN) MDS coordinator, stated the dietary manager was responsible for the completion of Section (AL), oral/dental status, of the MDS. At 8:00 a.m. on 09/17/14, the dietary manager and RN #110 were asked to examine the resident's oral cavity. When RN #110 asked the resident if she could examine her teeth, Resident #47 pointed to her bottom teeth and said, I only have three (3) teeth in the bottom and they aren't good. She pointed to a tooth on the right side of her mouth and said, This one hurts sometimes, it's down to the gum. RN #110 examined the resident's oral cavity and concluded the resident had a tooth that was broken at the gum line, and the resident needed a dental consult because she appeared to have a cavity. The dietary manager was asked how she completed the oral exam of the resident's dental needs when completing Section (AL). She stated, I don't, I ask the nursing assistants. Both employees verified the annual MDS, with an ARD of 08/04/14, was incorrect. They confirmed it should have been coded to reflect an obvious or likely cavity or broken natural teeth. b) Resident #87 Observation of the resident's oral cavity, on 09/16/14 at 9:54 a.m., found the resid… | 2018-05-01 |
| 5996 | 5996 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 278 | D | 0 | 1 | 7HHJ11 | Based on record review and staff interview, the facility failed to ensure the minimum data set (MDS) assessments, for one (1) of five (5) residents whose MDSs were reviewed for unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS), accurately reflected the resident's status. The resident's last two (2) quarterly MDSs did not reflect the resident's rejection of care. Resident identifier: #35. Facility census: 98. Findings include: a) Resident #35 This resident's previous two (2) quarterly MDSs were reviewed. One (1) had an assessment reference date (ARD) of 03/17/14. The other had an ARD of 06/17/14. On each MDS, Section E , Rejection of Care, reflected the resident had not not rejected care in the previous seven (7) days, the specified look back period. Review of the resident's medication administration records (MARs), on 09/17/14 at 11:00 a.m., revealed in March 2014, the resident refused her morning medication on 03/10/14, 03/11/14, 03/12/14, 03/14/14 and 03/16/14. In June 2014, the resident refused her morning medication on 06/13/14 and 06/14/14. These refusals were during the seven (7) day look back periods for both the MDS with an ARD of 03/17/14 and the MDS with an ARD of 06/17/14. These rejections of care, which occurred during the look back period, were not identified on either MDS. The MDS Coordinator/registered nurse (MDSRN) #110, during an interview on 09/17/14 at 11:45 a.m., verified the resident had rejected care during the look back period; therefore, neither MDS was accurate. | 2018-05-01 |
| 5997 | 5997 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 279 | D | 0 | 1 | 7HHJ11 | Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan, based on the results of the minimum data set (MDS) assessment, for one (1) of four (4) residents reviewed who triggered the care area of nutritional status during Stage 2 of the Quality Indicator Survey (QIS). The facility's MDS assessment triggered the care area assessment (CAA) for nutrition. The CAA indicated the facility would proceed with care planning for nutrition; however, a care plan was not developed for the resident regarding the assessed nutritional problem. Resident identifier: #101. Facility census: 98. Findings include: a) Resident #101 Stage 1 survey information revealed this resident was underweight and had a body mass index (BMI) of less than 22. The resident triggered nutrition status, for Stage 2 of the survey, because she was underweight with a BMI of 18.1. The resident's annual MDS assessment, with an assessment reference date (ARD) of 12/22/13, was reviewed. The MDS triggered the CAA for nutrition. The CAA worksheet indicated the problem related to nutrition would be care planned. The care plan considerations were, Will continue to provide super foods at meals to help maintain weight and possible help promote weight gain. Staff to encourage po (by mouth) intake and offer food substitutions as needed. Dietary to provide food preferences as requested. May provide another nutritional supplement if deemed necessary by dietician or nursing. Although the CAA indicated a care plan would be developed and also indicated specific interventions for the care plan, review of the medical record found no care plan for nutrition. At 4:18 p.m. on 09/17/14, the dietary manager confirmed there was no care plan for nutrition. She stated she had not care planned the resident's nutritional status as outlined in the CAA. | 2018-05-01 |
| 5998 | 5998 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 280 | D | 0 | 1 | 7HHJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise the care plans for three (3) of seventeen (17) residents whose care plans were reviewed during Stage 2 of the survey. Each resident had a change in care and/or treatment needs for which a care plan revision was indicated. Resident #105's care plan was not revised after she experienced a fall. Resident #1's care plan was not revised to reflect the use of devices related to skin breakdown. Resident #89's care plan was not revised to reflect her current fluid restriction requirements. Resident identifiers: #105, #1 and #89. Facility census: 98. Findings include: a) Resident #105 Medical record review, on 09/17/14 at 9:00 a.m., revealed nurse's notes dated 09/08/14. This note stated Resident #105 had experienced a fall at 4:20 p.m. in the dining room. Review of the resident's care plan for falls, with a target date of 11/18/14, revealed a problem statement which indicated Resident #105 had .a potential of falls . The care plan was not revised to reflect the resident had an actual fall on 09/08/14. In an interview, on 09/17/14 at 11:15 a.m., the director of nursing (DON) verified the care plan was not revised after the resident experienced a fall. b) Resident #1 Review of the resident's physician's orders [REDACTED]. They were to be worn at night, and off during the day. On 09/16/14, review of the resident's current care plan, which was revised on 06/23/14, found a focus/problem of, Potential for alteration in structural integrity of layers of skin caused by prolonged pressure related to immobility, incontinence (bladder and bowel) and skin desenization (typed as written) from DM (diabetes mellitus). Has paralysis on the right side. The goal associated with this focus/problem was, Will remain free from skin breakdown thru review date. The care plan contained no directives related to the use of the palm protectors to prevent skin breakdown. The current care plan was r… | 2018-05-01 |
| 5999 | 5999 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 282 | D | 0 | 1 | 7HHJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to implement the care plan for one (1) resident identified through a random opportunity for discovery. The resident's care plan related to dsyphagia was not implemented. Resident identifier: #1. Facility census: 98. Findings Include: a) Resident #1 Observations of Resident #1, at 11:50 a.m. on 09/15/14, revealed the resident was being assisted with eating by Nurse Aide (NA) #75. The resident had a cup of fruit punch on his tray. NA #75 placed a straw in the fruit punch and held the cup of fruit punch to Resident #1's mouth so he could drink from the straw. The resident was observed to take four (4) drinks of fruit punch from the straw at different times during the meal. Observation of Resident #1's tray card revealed the resident was to have pudding thickened liquids. An interview with cook #90, at 11:56 a.m. on 09/15/14, confirmed Resident #1 was to have pudding thickened liquids. When she removed the lid from the cup which contained Resident #1's fruit punch, observation revealed the liquids were thinner than pudding consistency. Cook #90 stated she would mix up some more. She returned and stated she followed the directions on the thickener, but the fruit punch was still not thick enough. The speech pathologist (SP) #81, in an interview at 12:05 p.m. on 09/15/14, confirmed the fruit punch Resident #1 was served was not pudding consistency. She stated the fruit punch looked like a honey thickened consistency. The SP was asked if Resident #1 should have been drinking his fruit punch through a straw. She said pudding thickened liquids should be too thick to flow through a straw. The SP further stated, Typically, residents who are on thickened liquids do not have straws because you need to control the amount of fluid that goes into their mouth. A review of Resident #1's care plan, at 1:00 p.m. on 09/16/14, revealed: Focus: Resident has a swallowing problem related to … | 2018-05-01 |
| 6000 | 6000 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 309 | D | 0 | 1 | 7HHJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each resident was provided care and services to attain or maintain his/her highest practicable well-being. One (1) of one (1) residents reviewed for [MEDICAL TREATMENT] services, during Stage 2 of the survey, was not provided fluids in accordance with her established restriction and/or needs. Resident identifier: #89. Facility census: 98 Findings include: a) Resident #89 On 09/16/14 at 2:30 p.m., the resident's annual minimum data set (MDS) assessment, with an assessment reference date (ARD) of 07/02/14, was reviewed. Section I Diagnosis: [REDACTED]. Review of the medical record, on 09/16/14, revealed a physician's orders [REDACTED].#89 had an order for [REDACTED]. The resident was to receive 360 ml of fluid three (3) times daily, at each meal, and an additional 420 ml during the day. This totaled 1500 ml daily. The Medication Administration Record [REDACTED]. There was no documentation on the MAR, or elsewhere, which indicated the amount of fluid nursing provided during medication administration. Review of the nursing assistant (NA) Kiosk, the instructions for the NAs, also revealed no directives regarding the resident's fluid restriction. Review of the resident's care plan revealed the resident had an order for [REDACTED]. The information on the resident's meal ticket was not accurate. It indicated the resident was ordered a 1200 ml fluid restriction. The resident's information and/or dietary plan was not updated when the resident was ordered a 1500 ml fluid restriction on 01/03/14. Review of the fluid intake record for the month of September 2014 revealed documentation on only seven (7) of fifteen (15) days from 09/01/14 through 09/15/14. On the seven (7) days in which there was documentation of fluid intake, the following was recorded: --09/01/14 860 ml --09/05/14 840 ml --09/06/14 960 ml --09/07/14 960 ml --09/11/14 480 ml --09/14/14 720 ml --09/15/14 720 ml In an … | 2018-05-01 |
| 6001 | 6001 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 323 | K | 0 | 1 | 7HHJ11 | Based on water temperature measurements, observations, staff interview, and review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), the facility failed to ensure the resident environment, over which it had control, was as free from accident hazards as possible. At 3:10 p.m. on 09/15/14, a water temperature measurement of the water at the hand sink in Room 402 was obtained by facility staff using facility equipment. The water was 131.8 degrees Fahrenheit (F). According to CMS Guidance to Surveyors, a 3rd degree burn can occur in 15 seconds when the water temperature is 133 degrees F. This discovery was determined an immediate jeopardy (IJ) situation, with the potential to affect more than an isolated number of residents. At 4:18 p.m. on 09/15/14, the Nursing Home Administrator (NHA) was notified of the IJ, and that it was due to the elevated water temperature. The NHA was informed the IJ began at 3:10 p.m. on 09/15/14, when a water temperature of 131.8 degrees F was obtained in resident Room 402. During an interview with the NHA, after notification of the IJ, she stated the maintenance department was making adjustments and the temperatures should already be below 120 degrees F. The water temperature in Room 402 was obtained, at 4:22 p.m. on 09/15/14, by facility staff using the facility's thermometer. The temperature of the water in the hand sink in Room 402 was even higher. It was 135 degrees F. The NHA was notified the temperature was hotter than before and would be included in the determination of the IJ. The facility's plan of correction (P(NAME)) was accepted by the state agency at 5:30 p.m. on 09/15/14. The facility submitted the following plan to remove the immediacy of the deficient practice: (typed as written) 4:20 p.m. All employees working were inserviced to immediately inform the Administrator, DON (Director of Nursing) and/or the maintenance director if water is hot when washing hands. 4:30 (pm) Staff was instructed to d… | 2018-05-01 |
| 6002 | 6002 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 365 | D | 0 | 1 | 7HHJ11 | Based on observation, staff interview, and record review, the facility failed to ensure one (1) resident, identified through a random opportunity for discovery, was provided food in a form to meet his individual needs. Liquids were not provided in the consistency the resident required due to dysphagia. Resident identifier: #1. Facility census: 98. Findings Include: a) Resident #1 Observations of Resident #1, at 11:50 a.m. on 09/15/14, revealed the resident was being assisted with eating by Nurse Aide (NA) #75. The resident had a cup of fruit punch on his tray. NA #75 placed a straw in the fruit punch and held the cup of fruit punch to Resident #1's mouth so he could drink from the straw. The resident was observed to take four (4) drinks of fruit punch from the straw at different times during the meal. Observation of Resident #1's tray card revealed the resident was to have pudding thickened liquids. An interview with cook #90, at 11:56 a.m. on 09/15/14, confirmed Resident #1 was to have pudding thickened liquids. When she removed the lid from the cup which contained Resident #1's fruit punch, observation revealed the liquids were thinner than pudding consistency. Cook #90 stated she would mix up some more. She returned and stated she followed the directions on the thickener, but the fruit punch was still not thick enough. The speech pathologist (SP) #81, in an interview at 12:05 p.m. on 09/15/14, confirmed the fruit punch Resident #1 was served was not pudding consistency. She stated the fruit punch looked like a honey thickened consistency. When asked if Resident #1 should have been drinking his fruit punch through a straw, the SP said pudding thickened liquids should be too thick to flow through a straw. The SP stated she hoped to upgrade the liquids to a thinner consistency; however, for right now, she did not feel comfortable doing so because the resident had some coughing and congestion. She confirmed that pudding thickened liquids best met Resident #1's needs at that time. The Director of Nursing (DON) was … | 2018-05-01 |
| 6003 | 6003 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 371 | F | 0 | 1 | 7HHJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility failed to store food in a manner which reduced the potential of contamination and/or the development of foodborne illnesses. Outdated food items were stored and available for use in the reach in coolers in the kitchen. In the facility Kitchenette, food items were stored in the refrigerator opened, unlabeled, undated, and/or beyond their expiration date. Additionally, the facility was not monitoring the temperature of the freezers in the refrigerators in the Kitchenettes. These practices had the potential to affect all residents residing in the facility. Facility census: 98. Findings Include: a) Kitchen The initial tour of the kitchen, completed at 8:10 a.m. on 09/15/14, revealed two (2) cups of honey thickened water in the reach in cooler. It had a manufacturer's use by date of 07/29/14. Also, in the reach in cooler, was a container of pepperoni and a container of mozzarella cheese. Each container had an open date of 08/05/14. Interview with Lead Cook #90, at 8:15 a.m. on 09/15/14, confirmed the honey thickened liquid. with a manufacturer's use by date of 07/29/14, should not have been available for use and should have been discarded after the expiration date. She stated they used the pepperoni and mozzarella cheese last week, and did not change the date on the container. She stated there was no way it had been in the reach in cooler since 08/05/14; however, she confirmed it should not be used because the discard date could not be determined. . b) Kitchenettes Observations were made of the kitchenettes on the 300 and 400 halls during the initial tour of the facility on 09/15/14 at 8:30 a.m. The following sanitation issues were identified: 1. 300 Hall kitchenette -- One (1) milk shake with Resident #9's name with no date. -- Two (2) blue, one (1) orange, one (1) green, and one (1) red ice pop with a tear in the clear plastic paper, exposing them to potential contamination. … | 2018-05-01 |
| 6004 | 6004 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 412 | D | 0 | 1 | 7HHJ11 | Based on medical record review, resident interview, resident observation, and staff interview, the facility failed to obtain needed dental services for two (2) of two (2) Medicaid residents who triggered dental status in Stage 2 of the Quality Indicator Survey (QIS). Neither resident's need for dental care and services was identified, assessed, and/or addressed by the staff members who should have been aware of each resident's dental status and need for dental services. Resident identifiers: #47 and #87. Facility census: 98. Findings include: a) Resident #47 Observation of the resident, at 2:37 p.m. on 09/15/14, during Stage 1 of the QIS, found the resident's bottom teeth were broken and discolored On 09/15/14, review of the most recent annual MDS, with an assessment reference date (ARD) of 08/04/14, found Section (L) entitled oral/dental status was coded to reflect the resident had no dental issues. At 4:30 p.m. on 09/16/14, Employee #110, the registered nurse (RN) MDS coordinator, stated the dietary manager was responsible for the completion of Section (AL), oral/dental status, of the MDS. At 8:00 a.m. on 09/17/14, the dietary manager and RN #110 were asked to examine the resident's oral cavity. When RN #110 asked the resident if she could examine her teeth, Resident #47 pointed to her bottom teeth and said, I only have three (3) teeth in the bottom and they aren't good. She pointed to a tooth on the right side of her mouth and said, This one hurts sometimes, it's down to the gum. RN #110 examined the resident's oral cavity and concluded the resident had a tooth that was broken at the gum line, and the resident needed a dental consult because she appeared to have a cavity. She said she would make arrangements for a dental consult for the resident. The dietary manager was asked how she completed the oral exam of the resident's dental needs when completing Section (AL). She stated, I don't, I ask the nursing assistants. Both employees verified the annual MDS, with an ARD of 08/04/14, which indicated the resident … | 2018-05-01 |
| 6005 | 6005 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 490 | F | 0 | 1 | 7HHJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's abuse/neglect assessment and reporting policy, review of the complaint files, review of resident council meeting minutes, resident interview, staff interview, personnel file review, water temperature measurements, observations, and review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS) the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Systems related failures were found regarding the implementation of the facility's written Abuse/Neglect/misappropriation of resident property policies and ensuring reporting and the thorough investigation of abuse/neglect for three (3) of seven (7) grievances/complaints reviewed. (Resident identifiers: #52, #148 and #146.) In addition, the facility had no system in place which ensured it did not employ individuals who had been found guilty of abuse, neglect, or mistreatment of [REDACTED]. (Employee identifiers: #15, #22, #63, and #73.) The facility also failed to make reasonable efforts to uncover information about past criminal histories of potential employees by not performing a West Virginia (WV) statewide criminal background investigation for (5) of five (5) employees reviewed who were hired in 2014. (Employees #15, #22, #63 ,#65. and #73. The facility failed had no system which ensured grievances voiced by the resident council group were acted upon and responded to promptly. This affected Residents #46, #79, #13, #46 and other unidentified residents. There was a failure to develop a system which ensured residents who had dental care needs were provided services to assess and address those needs for two (2) of two (2) residents who required the services, Residents #47 and #87. The facility had no system to identify unsafe wat… | 2018-05-01 |
| 6006 | 6006 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 520 | F | 0 | 1 | 7HHJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's abuse/neglect assessment and reporting policy, review of the complaint files, review of resident council meeting minutes, resident interview, staff interview, personnel file review, water temperature measurements, observations, and review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), the facility did not have a functional and effective quality assurance (QAA)program which identified and acted upon quality deficiencies within the facility's operations of which it did have (or should have had) knowledge. The facility had systemic deficits which the QAA committee failed to identify and/or implement plans of action to correct the quality deficiencies, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. The QAA committee failed to identify and/or develop a plan of action to correct a systems failure regarding the implementation of the facility's written Abuse/Neglect/misappropriation of resident property policies and ensuring reporting and the thorough investigation of abuse/neglect for three (3) of seven (7) grievances/complaints reviewed. (Resident identifiers #52,#148 and #146.) The QAA committee failed to identify and/or develop a plan of action to correct a systems failure to ensure it did not employ individuals who had been found guilty of abuse, neglect, or mistreatment of [REDACTED]. (Employee #15, #22, #63, and #73.) The facility also failed to make reasonable efforts to uncover information about past criminal histories of potential employees by not performing a West Virginia (WV) statewide criminal background investigation for (5) of five (5) employees reviewed who were hired in 2014. (Employees #15, #22, #63 ,#65. and #73. The QAA committee failed to identify and/or develop a plan of action to correct a systems failure to ensure grieva… | 2018-05-01 |
| 6007 | 6007 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2015-05-20 | 272 | D | 1 | 0 | 5Z8811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to completely and accurately assess two (2) of six (6) residents reviewed during a complaint survey ending on 05/20/15. The comprehensive minimum data set (MDS) did not accurately reflect the dental status of Resident #109. For Resident #63, the dental status care area assessment (CAA), a part of the comprehensive assessment, was not completed in its entirety. Resident identifiers: #109 and #63. Facility census: 118. Findings include: a) Resident #109 Resident #109's medical record, reviewed at 10:00 a.m. on 05/20/15, revealed the resident was readmitted to the facility on [DATE]. The readmission nursing assessment indicated Resident #109 had natural teeth in fair condition. The resident did not have dentures or partials. An oral assessment, completed on 09/16/14, indicated Resident #109 had pink gums, and decayed and broken natural teeth. The resident did not have dentures. Review of the annual MDS, with an assessment reference date (ARD) of 10/29/14, found in Section (L0200), the resident's assessment indicated no likely cavities or broken natural teeth. At 11:00 a.m. on 05/05/15, the director of nursing (DON) confirmed the annual MDS with an ARD of 10/29/14, was inaccurate. The DON said the resident had natural teeth that were broken and cavities were present. b) Resident #63 At 8:30 a.m. on 05/19/15, a review of the resident's last full MDS, a modified significant change MDS, with an ARD of 07/02/15, found Section (L) entitled oral/dental status, indicated the resident had obvious or likely cavity or broken natural teeth. Further review of the CAA worksheet completed with the MDS, entitled dental care, found the facility failed to complete to complete the section requiring input from the resident and/or family representative regarding the dental care area. The facility also failed to complete the section that said, Will dental care be addressed in the care plan and if so what… | 2018-05-01 |
| 6008 | 6008 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2015-05-20 | 280 | D | 1 | 0 | 5Z8811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure the care plan for (1) of six (6) residents whose care plans were reviewed, was revised to meet the resident's individual needs. The care plan for Resident #61 was not revised related to dental care. Resident identifier: #61. Facility census: 118. Findings include: a) Resident #61 At 9:25 a.m. on 05/19/15, Nurse Aide (NA) #82 was observed providing oral care to Resident #61. The NA stated he was trained to use a Toothette (oral swab), not a toothbrush, to clean the resident's teeth. He stated the resident needed to be approached on her right side when providing oral care. NA #82 demonstrated he was instructed to dip the Toothette in [MEDICATION NAME] (dental hygiene product) before brushing the resident's teeth. He explained the resident had her own personal bottle of [MEDICATION NAME] and the Toothette needed to be discarded after each dipping. Review of the medical record found the resident had a dental consult on 05/04/15. The dentist deep cleaned her teeth and recommended a deep cleaning every three (3) months. Review of the resident's current care plan, revised on 10/16/14, addressed the problem, Resident is at risk for oral health or dental care problems R/T (related to) natural teeth. Interventions for this problem were, Monitor for changes in nutritional/hydration status and monitor for discomfort in mouth. At 11:10 a.m. on 05/20/15, the director of nursing (DON) confirmed the resident's care plan was not revised to include the use of the dental hygiene product, [MEDICATION NAME]. She also confirmed the care plan was not revised to reflect the resident was scheduled for deep cleaning every three (3) months with the dentist. The DON stated the daily brushing of the teeth was included in the care plan addressing activities of daily living (ADLs), but the specific use of the Toothette and the [MEDICATION NAME] was not included in the care plan.… | 2018-05-01 |
| 6009 | 6009 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2015-05-20 | 514 | E | 1 | 0 | 5Z8811 | Based on record review and staff interview, the facility failed to maintain accurate clinical records for five (5) of six (6) residents reviewed for a complaint survey ending on 05/20/15. Each resident had conflicting documentation related to dental status between nursing assessments, facility oral assessments, dental consults, the care plans, and/or the minimum data set (MDS) assessments. Resident identifiers: #50, #79, #109, #61, and #63. Facility census: 118. Findings include: a) Resident #50 Review of Resident #50's medical record, on 05/18/15 at 2:00 p.m., found an admission nursing assessment completed on 05/12/15. The assessment indicated the resident had broken or loosely fitting full or partial dentures. The admission minimum data set (MDS), with an assessment reference date (ARD) of 05/18/15, found Section (L 0200), entitled oral/dental status, indicated the resident had obvious or likely cavities or broken natural teeth. An interview with the director of nursing (DON), on 05/18/15 at 4:00 p.m., confirmed the nursing assessment was incorrect because the resident had her own teeth. The DON verified the resident had no full or partial dentures. She stated the MDS was accurate, but the nursing assessment was not. b) Resident #79 On 05/19/15 at 11:15 a.m., review of the resident's medical record found an admission nursing assessment completed on 05/08/15. The assessment indicated the resident had no dental issues. Review of the admission MDS with an ARD of 05/15/15, Section (L) entitled oral/dental status, indicated the resident had no natural teeth or tooth fragments and was edentulous. At 1:30 p.m. on 05/19/15, the DON verified the nursing assessment was not accurate, as the resident had no natural teeth, dentures, and/or a partial. c) Resident #109 Medical record review, on 05/20/15 at 9:15 a.m., found a care plan initiated on 07/24/14 indicating the resident had natural teeth with cavities. On 09/16/14, an oral assessment indicated the resident had decayed, broken and missing natural teeth. The nursing … | 2018-05-01 |
| 6010 | 6010 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 166 | D | 0 | 1 | K1XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, staff interview, resident interview, and family interview, the facility failed to ensure prompt efforts were made to resolve issues residents had, and also failed to keep resident and family members informed of progress toward resolution. This was found for two (2) of forty-six (46) residents reviewed and one (1) randomly reviewed resident. Resident identifiers: #103, #25, and #105. Facility census: 94. Findings include: a) Resident #103 Record review, beginning on 08/06/14 at 10:14 a.m., found this [AGE] year-old woman was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was sent out to an out of state behavioral health unit on 07/25/14 due to escalating behaviors. During investigation of the facility's care for the maintenance of her nutritional status, it was discovered staff identified she had lost her dentures. The review found an inventory of personal items completed upon admission, 03/21/14, documented Resident #103 had both upper and lower dentures. The registered dietitian's medical nutrition therapy assessment, dated 06/24/14, included the statement, (typed as written): CNA (certified nursing assistant) believes resident does wear upper dentures but her lower dentures are lost. The resident was receiving a regular diet for both nutrients and texture. The nursing assessment completed upon admission (on 03/21/14) documented Resident #103 had both upper and lower dentures. The nursing assessment completed 06/24/14 documented Resident #103 had no dentures. On 08/06/14 at 11:57 a.m., information was requested from the director of nursing (DON), Employee #17, regarding any staff awareness of the missing dentures prior to 06/24/14, and any documented attempts to locate them or inform anyone of the loss. On 08/06/14 at 2:47 p.m., the DON confirmed that the exact date the dentures went missing could not be determined, but was documented as at least as far back as 06/24/14. He presented a Grievance/C… | 2018-05-01 |
| 6011 | 6011 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 225 | F | 0 | 1 | K1XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on employee personnel file review, review of Chapter 514.4.1 of the Medicaid manual and a clarification memorandum from the Bureau for Medical Services (BMS) regarding the requirements for criminal background checks to meet the requirements of the Affordable Care Act, and staff interview, the facility failed to ensure individuals who had been employed more than three (3) years had had another criminal background check to determine whether the individuals had been found guilty of abuse, neglect, or mistreatment of [REDACTED]. This was not completed for seven (7) of fifteen (15) employees whose personnel files were reviewed. This practice had the potential to affect all residents. Employee identifiers: #20, #35, #45, #78, #79, #87, and #104. Additionally, the facility failed to ensure all allegations of mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, were reported immediately to the administrator of the facility and to other officials in accordance with State law. This was found for three (3) of forty-six (46) complaints reviewed, and had the potential to affect more than a limited number of residents. Resident identifiers: #42, #43, and #34. Facility census: 94. Findings include: a) On 08/06/14 at 11:05 a.m., a review of the personnel files for tenured employees was conducted with Employee #38, the payroll/human resources person. This review identified the following: 1. Employee #20 A review of the personnel file for Employee #20, a cook, who was hired on 06/09/11, revealed no evidence of an up to date statewide criminal background check completed since her hire date. 2. Employee #35 Upon a review of the personnel file for Employee #35, a NA, who was hired on 10/24/1994, revealed no evidence of an up to date statewide criminal background check was completed since her hire date. 3. Employee #45 Review of the personnel file for Employee #45, a nurse aide (NA) who was hired on… | 2018-05-01 |
| 6012 | 6012 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 241 | E | 0 | 1 | K1XR11 | , Based on observation and staff interview, the facility failed to ensure the dignity of the residents who required total feeding by staff as exhibited by staff members addressing residents with a label instead of their name in a hallway where others could overhear. Resident #24 was referred to as a Feed. This had the potential to affect more than an isolated number of residents. Resident identifier: #24. Facility census: 94. Findings include: a) Resident #24 During the observation of the medication pass at 8:30 a.m. on 08/06/14, an alert and oriented resident approached Employee #118 (nurse aide) in her wheelchair in the hallway and asked the nurse aide for assistance. In the immediate presence of Resident #24, Employee #42 (nurse administering medications), and the surveyor, the nurse aide answered the resident by saying she would assist her . as soon as I check on the Feeds. She then continued to the tray carts sitting in the hallway. During an interview with the Director of Nursing at 12:15 p.m. on 08/14/14, he was informed of the incident and told similar episodes had been observed during the survey. He stated this was not appropriate and he would address this with staff. | 2018-05-01 |
| 6013 | 6013 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 252 | E | 0 | 1 | K1XR12 | Based on observation and staff interview, the facility failed to ensure a homelike environment which de-emphasized the institutional character of the setting. The facility was not free, to the extent possible, of unpleasant odors. Urine odors from the laundry, odor of urine from a recognized resident source, and the odor of permanents from the beauty shop lingered and/or reoccurred throughout Hilltop unit. The facility had a cover-up deodorizer to use after the odors occurred; however, staff did not always use the deodorizer when needed. There was no evidence the facility attempted a preventative solution to eliminate the known odors. This had the potential to effect all (46) residents residing on Hilltop unit. Facility census: 83. Findings include: a) At 9:30 a.m. on 11/05/14, a strong odor of urine was noticed coming from room #149. It could be smelled beyond the nurses station at the end of the hall. Employee #91, a licensed practical nurse (LPN) stated a resident who resided in that room had become agitated and refused to allow staff to change her brief. She said this happened often and they would try again later. At 11:30 a.m., the strong urine odor was still present and could be detected throughout Hilltop hall, including the Solarium. The odor was present outside the main dining room, which was filling with residents for the noon meal, and became stronger at the entry to Hilltop hall. The Administrator (NHA) was approached in her office, at 11:30 a.m. on 11/05/14. She was told of the odor, and was asked what was done to dispel odors in the facility. The NHA immediately said she thought the odor was coming from the laundry. She added that there were odors into the hall from the laundry at times, and she went to check. The laundry was located between the dining room and Hilltop hall. The NHA returned and acknowledged the odor was from the laundry. She said she did not know know what had been done to dispel it. The NHA stated she would refer the answer to the housekeeping supervisor (Employee #59) when he ret… | 2018-05-01 |
| 6014 | 6014 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 253 | E | 0 | 1 | K1XR11 | Based on observation and staff interview, the facility failed to provide to provide effective housekeeping and maintenance services in eleven (11) of thirty-five (35) rooms observed during Stage 1 and Stage 2 of the survey. Environmental issues included missing and peeling wallpaper, discolored and stained caulking around the toilet base, loose and missing baseboards, missing caulking around the sink counter top, stained and discolored baseboards under the sink, missing bathroom floor thresholds, rusted metal toilet paper holder, scratched door frames, scratched and discolored sink basin, cracked and missing floor tile in bathrooms and resident rooms, cracked and missing plaster near a sink and a gouged and scratched bathroom doors. This practice had the potential to affect more than an isolated number of residents. Room numbers: #101, #105, #106, #110, #136, #138, #143, #144, #145, #146, and #166. Facility census: 94 Findings include: a) On 08/12/14 at 2:30 p.m., accompanied by Employee #105, the Maintenance Director, a tour of the facility was conducted. The tour revealed the following issues: 1. Room #101: The wall plaster was cracked and had missing pieces near the sink located within the resident's room. The caulking located around the base of the toilet in the bathroom was stained and discolored. 2. Room #105: The floor tile in the resident room had multiple cracks. 3. Room #106: The floor tile in the room was stained and had multiple cracks. There was stained and discolored caulking around the base of the toilet in the bathroom. 4. Room #110: The heating/air conditioning unit located in the room under the window had wires visible and protruding from the base of the unit. The floor tile in the room had multiple cracks. The toilet located in the bathroom had stained and discolored caulking around the base. 5. Room #136: The sink counter located in the room had missing laminate measuring 3 inches by 4 inches on the left lower corner revealing the pressed fiberboard. Also the front lower lip of the sink counte… | 2018-05-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );