cms_WV
Data source: Big Local News · About: big-local-datasette
118 rows where "filedate" is on date 2018-09-01
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5573 | 5573 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 156 | D | 0 | 1 | VNJW11 | Based on review of the facility's reported allegations to proper state authorities, staff interview, record review, resident interview, and review of the care area of liability notices and beneficiary appeal right review, the facility failed to ensure Residents #9 and #47 were informed of the facility's rules regarding safeguarding of personal property prior to alleged allegations of misappropriation of resident property made by both residents. This was true for two (2) of eight (8) reported allegations to proper state authorities reviewed. The facility also failed to ensure Resident #181 received notice of the decision to terminate Medicare covered services two (2) days before the proposed end of services. This was true for one (1) of three (3) residents reviewed for the care area of liability notices and beneficiary appeal right review. Resident identifiers: #9, #47 and #181. Facility census: 154. Findings include: a) Resident #9 Review of the facility's immediate fax reporting of allegations to the nursing home program, on 12/02/14, found the resident reported $70.00 was missing from her purse. The incident was reported to the Office of Health Facilities Licensure and Certification (OHFLAC) on 11/04/14. The five (5) day follow up report, completed on 11/10/14, found the corrective action by the facility was, Has resident trust available and access to that money at all times. Has a locked drawer she can keep her valuables in. In an interview with the administrator and the social services director, at 8:48 a.m. on 12/04/14, the administrator stated residents could get a lock on their night stand drawer and a key if they wished to lock up valuables. The administrator verified the facility's admission agreement did not contain this information, but residents were informed of a locking drawer by the activity director during competition of a recreational assessment. At 10:45 a.m. on 12/04/14, the administrator provided a copy of the recreation assessment and stated the activity staff ask resident's the question, How… | 2018-09-01 |
| 5574 | 5574 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 157 | D | 0 | 1 | VNJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure the physician was notified of changes which required physician directives for two (2) residents identified through random opportunities for discovery. The physician was not notified when Resident #222 had [MEDICAL CONDITION] (a resting heart rate under 60 beats per minute). In addition, the physician was not notified when there was a need to alter Resident #1's order for enteral feedings. Resident identifiers: #222 and #1. Facility census: 154. Findings include: a) Resident #222 Review of the medical record revealed no evidence the physician or nurse practitioner was notified of Resident #222's [MEDICAL CONDITION] (a resting heart rate under 60 beats per minute). According to the MAR indicated [REDACTED]. The electronic medical record (EMR) contained documentation of a pulse of 56 bpm at 12:37 p.m. on 11/11/14 and 42 bpm at 6:00 p.m. In addition, the EMR indicated the resident's pulse was 43 bpm on 11/12/14 at 1:20 a.m. There was no evidence the physician or nurse practitioner was notified the resident was experiencing [MEDICAL CONDITION] until 11/13/14, when the resident's pulse was 48 bpm at 9:50 a.m. On 11/13/14 new orders were received from the nurse practitioner to (typed as written), D/C [MEDICATION NAME], (due to) decrease (indicated by a downward pointing arrow) HR (heart rate) and BP (blood pressure). Decrease (indicated by a downward pointing arrow) [MEDICATION NAME] to 50 mg po daily hold SBP (systolic blood pressure) Interview with DON, at 8:25 a.m. on 12/08/14, confirmed the physician/nurse practitioner was not notified of the Resident #222's [MEDICAL CONDITION] until 11/13/14 when new orders were given by the nurse practitioner. b) Resident #1 Observation of the resident, at 10:16 a.m. on 12/02/14, with licensed practical nurse (LPN), Employee #154 found a bag of [MEDICATION NAME] 1.5 infusing. The [MEDICATION NAME] 1.5 was dated 11/30/14 at … | 2018-09-01 |
| 5575 | 5575 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 166 | D | 0 | 1 | VNJW11 | Based on review of the facility's grievance/complaint forms, staff interview, policy and procedure review, and resident interview, the facility failed to ensure prompts efforts were made to resolve grievance/complaints. In addition, the facility failed to keep the resident apprised of its progress toward resolution. This was true for three (3) of thirty-five (35) complaints/grievances reviewed. Resident identifiers: #63, #143 and #43. Facility census: 154. Findings include: a) Resident #63 On 12/04/14, review of the facility's grievance/complaint reports found on 10/13/14, Resident #63 reported, she was unable to get up for Saturday activities because a lift pad could not be found. Employee #52, the social services director, completed the complaint form. On 10/13/14 the compliant was assigned to the second floor unit manager, the administrator, and the director of nursing. The complaint was to be resolved by 10/18/14. Review of the facility's policy entitled, Grievance/Concern, revised on 06/10/13 found, . Center leadership will investigate, document, and follow up on all formal concerns and grievances registered by any patient or patient representative, Social Services personnel will serve as patient advocates in the grievance/concern process . Section 5.4, Notify the person filing the grievance of resolution within 72 hours. The resolution for the grievance/complaint filed on 10/13/14 was: New lift pads to be ordered and an area made in each shower room to keep the lift pads. The documentation was not completed by the social services director until 11/24/14 and not within 72 hours as required by the facility policy. In addition, the form contained no evidence the information was communicated to the resident who made the complaint. At the bottom of the form was an area to indicate how and when the resident received the facility's resolution. This portion of the form contained no documentation. Employee #52 was interviewed, at 12:05 p.m. on 12/04/14. She was asked why the resolution of the grievance was not discu… | 2018-09-01 |
| 5576 | 5576 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 225 | E | 0 | 1 | VNJW11 | Based on review of the facility's reported allegations to proper state authorities, staff interview, review of grievance complaint forms, and resident interview, the facility failed to ensure all alleged violations involving neglect and misappropriation of resident property were reported to the proper state authorities and/or failed to ensure each allegation was thoroughly investigated for seven (7) of eight (8) allegations of alleged abuse, neglect and misappropriation of resident property. In addition, allegations of neglect were not reported for two (2) of two (2) allegations of neglect discovered during a review of thirty-four (34) grievance / complaint forms reviewed. For Resident #9, the facility failed to immediately report two (2) allegations of misappropriation of property. For Resident's #193 and #170, the facility failed to immediately report alleged allegations of neglect. For Residents #47, #211 and #76, the facility failed to report allegations of misappropriation of personal property to local law enforcement agency. For Residents #9, #4, #217 and #220, the facility failed to conduct a thorough investigation allegedly providing the statements. Resident identifiers: #9, #47. #4, # 193, #211, #76, #217, #220 and #170. Facility census: 154. Findings include: a) Resident #9 On 11/05/14, the nursing home reported, to the nursing home program (on OHFLAC form 225), Resident states she is missing $70.00 from her purse. Attached to the report was a statement from Employee #128 (nursing assistant) and Employee #95 (registered nurse). These statements were signed and dated 11/01/14, indicating the misappropriation of personal property was not immediately reported. According to Employee #128's statement, he was the employee who found the resident's purse on the bathroom floor. He helped the resident look through her purse when she discovered the money was missing. Employee #95's statement acknowledged she was aware the resident had reported $70.00 missing from her purse. There were six (6) additional witness st… | 2018-09-01 |
| 5577 | 5577 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 241 | E | 0 | 1 | VNJW11 | Based on observation, staff interview, and resident interview, the facility failed to provide an environment and promote care to maintain or enhance the dignity and respect for nineteen (19) of nineteen (19) residents. During Stage 2 of the Quality Indicator Survey (QIS), during dining, the third floor dining room was very noisy and crowded. In addition, due to the crowded environment, Resident #24 was not able to remove herself from the dining room when she finished eating. Resident identifiers: #78, #52, #59, #182, #18, #131, #60, #71, #29, #50, #136, #17, #140, #27, #49, #45, #24, #134, and #77. Facility census: 154. Findings include: a) Observation of the third floor dining room on 12/02/14 1. Observation of the third floor dining room began at 11:37 a.m. on 12/02/14. The dining room was furnished with two (2) four (4) person tables pushed against each other, two 1/2 circle tables positioned in a circle, and two (2) four (4) person round tables. This furniture was appropriate for the space; however, the room was crowded because staff did not use approximately one-third of the available floor space. 2. At 11:50 a.m., Residents #78, #52, #59, #182, #18, #131, #60, #71, #29, #50, #136, #17, #140, and #27, a total of fourteen (14) residents, were observed being served in the dining room. Also in the dining room, a portion of the time or during the entire meal, were Employees #190, #189, # 204, #197, #35, #54, #78, #7, #1, and #78, a total of ten (10) employees. In addition to residents and employees, there was serving equipment in the dining room. There were three (3) three (3) shelf serving carts, two (2) large warming carts, and one (1) tall cold food cart. During the dining experience, staff who were serving residents had to turn sideways to get between the residents and the equipment. After serving the fourteen (14) residents in the dining room, dietary staff began portioning food onto meal trays for the residents on third floor who ate in their rooms. This started at 11:50 a.m. and continued until 12:22 p.m.… | 2018-09-01 |
| 5578 | 5578 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 242 | D | 0 | 1 | VNJW11 | Based on a random opportunity for observation and resident interview, the facility failed to honor a resident's desire/preference to exit the dining room after finishing her meal. This is true for one (1) of fifteen (15) residents eating in the third floor dining room. Resident identifier: #24. Facility census: 154. Findings Include: a) Resident # 24 On 12/03/14 at 12:05 p.m., Resident #24 stated loud enough for staff to hear I am finished eating. She then removed her clothing protector, pushed herself away from the table and turned her wheelchair toward the entrance/exit door. She then sat quietly until dietary staff removed all the equipment which blocked the entrance/exit door of the third floor dining room. At 12:25 p.m., Resident #24 then propelled her wheelchair out of the dining room. An interview was then conducted with Resident #24. She stated she liked to leave the dining room as soon as she completed her meal, but she often had to wait until dietary equipment blocking the entrance/exit door was moved from the dining room. | 2018-09-01 |
| 5579 | 5579 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 246 | D | 0 | 1 | VNJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of grievance/complaint forms, resident interview and staff interview, the facility failed to ensure Resident #63 was provided reasonable accommodations based on individual needs. A physician's orders [REDACTED]. A lift pad was not available when the resident wanted to get out of bed to attend an activity. This was true for one (1) resident during a random observation. Resident identifier: #63. Facility census: 154. Findings include: a) Resident #63 On 12/04/14, review of the facility's grievance/complaint reports found on 10/13/14, Resident #63 reported she was unable to get up for Saturday activities because a lift pad could not be found. Review of the most recent minimum data set (MDS), a quarterly MDS, with an assessment reference date (ARD) of 09/21/14, found a score of 14 on the brief interview for mental status (BIMS), indication the resident was cognitively intact. The resolution for the grievance/complaint filed on 10/13/14 was: New lift pads to be ordered and an area made in each shower room to keep the lift pads. This was documented by the social services director on 11/24/14. Review of the care plan, initiated on 11/01/08, and the current physician's orders [REDACTED]. The social services director and the administrator were interviewed on 12/04/14 at 12:05 p.m. They were asked how long the resident had to wait for a lift pad to be available. The administrator answered the question by replying, It was just the one (1) time. | 2018-09-01 |
| 5580 | 5580 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 252 | E | 0 | 1 | VNJW11 | Based on observation, and staff interview, the facility failed to ensure a clean, comfortable and homelike environment in the third floor dining room. The area was soiled, overcrowded and noisy while serving meals. This has the potential to affect all residents who eat in the third floor dining room. Facility census: 154. Findings include: a) Observation of the third floor dining room on 12/02/14 1. Observation of the third floor dining room began at 11:37 a.m. on 12/02/14. The dining room was furnished with two (2) four (4) person tables pushed against each other, two 1/2 circle tables positioned in a circle, and two (2) four (4) person round tables. This furniture was appropriate for the space; however, the room was crowded because staff did not use approximately one-third of the available floor space. 2. At 11:50 a.m., Residents #78, #52, #59, #182, #18, #131, #60, #71, #29, #50, #136, #17, #140, and #27, a total of fourteen (14) residents, were observed being served in the dining room. Also in the dining room, a portion of the time or during the entire meal, were Employees #190, #189, # 204, #197, #35, #54, #78, #7, #1, and #78, a total of ten (10) employees. In addition to residents and employees, there was serving equipment in the dining room. There were three (3) three (3) shelf serving carts, two (2) large warming carts, and one (1) tall cold food cart. During the dining experience, staff who were serving residents had to turn sideways to get between the residents and the equipment. After serving the fourteen (14) residents in the dining room, dietary staff began portioning food onto meal trays for the residents on third floor who ate in their rooms. This started at 11:50 a.m. and continued until 12:22 p.m., at which time staff had prepared all the meal trays, cleaned the steam table, and removed the serving equipment. Although the dietary staff were quiet during this time, the act of portioning the food and handling equipment was very noisy. 3. Observation revealed a three (3) shelf cart from which drink… | 2018-09-01 |
| 5581 | 5581 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 272 | D | 0 | 1 | VNJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to accurately assess two (2) of twenty-six (26) resident minimum data sets (MDS) reviewed during Stage 2 of the Quality Indicator Survey (QIS). The MDS was incorrectly coded for Resident #210, who did not have documentation by the physician to indicate the resident had six months or less to live. The MDS for Resident #103 omitted the [DIAGNOSES REDACTED]. Resident identifiers: #210 and #103. Facility census: 154. Findings include: a) Resident #210 Review of the resident's medical record on 12/02/14 at 1:30 p.m., found Section J entitled, Health Conditions, of the most recent significant change MDS, with an assessment reference date (ARD) of 10/29/14, was coded as the resident had a condition or chronic disease that may result in a life expectancy of less than 6 (six) months (requires physician documentation).Further review of the medical record on 12/09/14 at 11:00 a.m., found no documentation by the physician to indicate the resident had a life expectancy of 6 months or less.On 12/09/14 at 11:50 a.m., Employee #85, the registered nurse - MDS coordinator, verified the resident's MDS, Section L was incorrectly coded. b) Resident #103 On 12/03/14 at 3:35 p.m., review of Resident #103's medical record found on 09/08/14, Physician #208 documented on the history and physical the resident had end stage [MEDICAL CONDITIONS]. The resident was receiving [MEDICAL TREATMENT]. Review of the minimum data set (MDS) assessment on 12/03/14 at 3:38 p.m., revealed Resident #103 was admitted on [DATE]. The admission MDS with an assessment reference date (ARD) of 09/12/14, in Section I, under [MEDICAL CONDITION], I1500 [MEDICAL CONDITIONS], or [MEDICAL CONDITIONS] was not coded as an active disease. In an interview on 12/04/14 at 09:05 a.m., Registered Nurse (RN) #172 was asked whether the resident's admission MDS should be coded for [MEDICAL CONDITION]. She reviewed Resident #103's admissio… | 2018-09-01 |
| 5582 | 5582 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 279 | E | 0 | 1 | VNJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview and observation the facility interdisciplinary team failed to develop a comprehensive care plan, and describe the services needed for residents to maintain a safe environment. The facility failed to address discharge planning, activities of daily living care needs, and extremity bruising care needs. Resident identifiers: #217, #1, and #103. Facility census: 154. Findings include: a) Resident #217 Review of the Social Services Assessment and Recreation Assessment both dated 10/28/14 for Resident #217 revealed the resident planned to return home after a short-term stay. Review of the Care Plan dated and initiated on 11/11/14 revealed no evidence of a problem, goal or interventions concerning discharge planning. On 12/11/14 at 10:14 a.m., social worker, Employee #52 agreed discharge planning had not taken place since Resident #217 was admitted . b) Resident #1 At 2:35 p.m. on 12/04/14, the resident was observed with Employee #79, a registered nurse, who was providing treatments, and assigned nursing assistant (NA), Employee # 9. A strong odor was detected at the entrance to the resident's room. Further observation found both of the resident's hands were severely contracted. As Employee #79 was cleaning the resident's hands, a strong, putrid odor permeated the room. Employee #79 stated the resident's hands definitely need cleaned. She began cleaning the resident's hands with a washcloth. Light brown colored substances and a thick puss like substance was removed from the palms of the resident's hands. She then dried the hands by using a pillowcase. Review of the resident's annual minimum data set (MDS), with an assessment reference date (ARD) of 08/16/14, found section (S) coded the resident as having contractures of the hips, hands, legs, knees, ankles, shoulders, elbows, and wrists. Review of the resident's care plan found two (2) focus problems entitled contractures. The specific locat… | 2018-09-01 |
| 5583 | 5583 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 280 | D | 0 | 1 | VNJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to revise the care plan for two (2) of twenty-six (26) resident care plans reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #91's care plan was not revised to reflect when her physical therapy services were discontinued. Additionally, Resident #103's care plan was not revised to reflect her [DIAGNOSES REDACTED]. Resident Identifiers: #91 and #103. Facility Census: 154 . Findings Include: a) Resident #91 A review at 9:21 a.m. on 12/10/14 of Resident #91's medical record revealed the resident was discharged from physical therapy services on 10/29/14 and had a fall on 11/01/14. Further review of the medical record, revealed a progress note dated 11/03/14 which reads as follows (typed as written): IDT (interdisciplinary team) discussed fall with no injury that occurred on 11/01/14. (Name of Resident) had ambulated across the hallway to the nurses desk and as she turned to wall (walk) back to her chair she lost her balance and fell against eh (the) nurses desk and slid down the wall onto her buttocks. (Name of Resident) did not hit her head. No c/o (complaints of) pain or discomfort. All parties notified of fall. She was just discharged from therapy services on 10-29-14 to RNS (restorative nursing services). Care plan reviewed and remains appropriate at this time. Review of Resident #91's care plan pertaining to her risk of falls revealed the following intervention (typed as written): Continue with PT (physical therapy) for ambulation. An interview at 1:23 p.m. on 12/10/14 with the Director of Nursing confirmed the care plan was not revised to reflect the resident had been discharged from physical therapy. b) Resident #103 A review of Resident #103's care plan on 12/03/14 at 3:17 p.m., revealed a care plan related to Resident exhibits or is at risk for fluid excess as evidenced by [MEDICAL TREATMENT] related to acute kidney injury. In addition there was a care pl… | 2018-09-01 |
| 5584 | 5584 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 282 | D | 0 | 1 | VNJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to implement and/or arrange services in accordance with the resident's written plan of care for two (2) of twenty-six (26) resident care plans reviewed in Stage 2 of the Quality Indicator Survey (QIS). Resident #25's care plan was not implemented in regards to use of a wheelchair for mobility. Resident #1's care plan was not implemented in regards to the specialty mattress checks. Resident identifiers: #25 and #1. Facility census: 154. Findings include: a) Resident #25 A review of Resident #25's medical record on 12/10/14 at 1:15 p.m., revealed a significant change (decline) minimum data set (MDS) with an assessment reference date of 10/01/14. Under Section G, entitled Mobility Devices indicated none of the above devices used (cane/crutch, walker, wheelchair manual or electric, and limb prosthesis). Further review of the resident's medical record, on 12/10/14 at 2:00 p.m., revealed Resident #25 was care planned on 10/17/14 with a goal as follows: (Resident #1 name) will continue to be able to use her wheelchair independently or with limited assist on the unit over next 90 (ninety) days. Interventions included: 1. Dycem to wheelchair. (Resident's name) can use her wheelchair independently most of the time, 2. PT (Physical Therapy) to screen prn (as needed) for decline in functional mobility. Resident #25 had a documented incident on 10/20/14 at 2:00 p.m. as follows: Resident was in her Geri-chair outside of her room (staff had taken her and were going to change her) resident was leaning over arm of chair reaching for hand rail on wall when she fell out of her chair hitting her head on the floor, resident has a cut above right eye with bruising noted, resident was left in floor and monitored until EMS (emergency medical squad) arrived and transported resident to (Name of local hospital). Medical record review found no progress notes to indicate why the resident was placed i… | 2018-09-01 |
| 5585 | 5585 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 309 | G | 0 | 1 | VNJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident observation and policy review, the facility failed to provide the necessary care and services, in accordance with the comprehensive assessment, to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (one) of 3 (three) residents reviewed for the care area of death during Stage 2 of the Quality Indicator Survey (QIS), and for 2 (two) residents identified during random opportunities for discovery. Resident #222 was admitted to the facility on [DATE] and was unresponsive with no pulse or respirations at the facility on 11/17/14. During this thirteen (13) day stay, the facility failed to administer Resident #222's [MEDICATION NAME] in dosage prescribed by the physician, failed to hold his [MEDICATION NAME] when Resident #222's pulse fell outside the physician established parameters, and the attending physician failed to accurately assess the resident's medication regimen prior to making medication changes (regarding [MEDICATION NAME]) on 11/10/14. The facility also failed to notify Resident #222's attending physician/nurse practitioner when the resident was suffering from [MEDICAL CONDITION] (very slow heart beat) with pulses of 56, 42, and 43 over a two (2) day period. It was determined these issues resulted in actual harm to this resident. Resident #1's enteral feedings and dressing changes to his percutaneous endoscopic gastronomy (PEG) tube site were not provided as ordered by the physician. Additionally, the facility failed to provide Resident #131's pain medication as ordered by the physician. Resident Identifiers: #222, #1, and #131. Facility Census: 154. Findings Include: a) Resident #222 1. A review of Resident #222's medical record, completed at 12:56 p.m. on 12/04/14, revealed Resident #222 was a patient at a local hospital from 11/01/14 until 11/04/14, at which time he was transferred to this facility. The local hospital's referral for Resident … | 2018-09-01 |
| 5586 | 5586 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 312 | E | 0 | 1 | VNJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review and staff interview, the facility failed to ensure dependent residents received the proper care and necessary services to maintain good grooming and personal hygiene. Residents clothing were observed to have bleach stains, a resident was found to have a foul odor to bilateral hands and a female resident was observed to have unshaven facial hair. This is true for four (4) of five (5) residents reviewed for activities of daily living, during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #42, #62, #1, and #178. Facility census: 154. Findings Include: a) Resident #42 During Stage 1 of the QIS, Resident #42 was observed to be wearing a shirt with visible bleach stains. b) Resident #62 During Stage 1 of the QIS, Resident #62 stated she had a new two piece outfit sent to the facility laundry and returned with bleach stains. During the Stage 2 investigation, Resident #62 stated she had received a new two piece outfit from a family member. She wore the outfit one time and sent it to the facility laundry. The outfit was then returned and placed in her closet. When she decided to wear it for the second time she found it to have numerous large bleach stains on it. She stated the shirt was teal with black trim. On observation the shirt was light gray, with brown trim and had numerous large bleach stains. On 12/04/14 at 10:18 a.m., laundry employee #100 was interviewed concerning how the laundry is washed. She explained the washer automatically dispenses detergent, bleach and fabric softener according to how it is set. The washer has a setting to wash clothing without hot water and bleach. The setting on the washer has to be manually set by the laundry staff in order to prevent bleach and extremely hot water from being used. c) Resident #1 Review of the resident's most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 11/16/14, found section (G) refl… | 2018-09-01 |
| 5587 | 5587 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 323 | G | 0 | 1 | VNJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide an environment that was free from accident hazards, over which the facility had control, for one (1) of four (4) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The resident had a history of [REDACTED]. Resident #25 had experienced an injury on 03/31/14. The facility had not ensured interventions were implemented to prevent additional falls from occurring. The facility also failed to lock a storage cabinet in the Unit 1 shower room. The cabinet contained items that were potentially hazardous when inhaled, ingested or came into contact with skin or eyes. This had the potential to affect more than a limited number of residents on Unit 1. Resident identifier: #25. Facility census: 154. Findings include: a) Resident #25 Review of the medical record, on 12/10/14 at 10:00 a.m., revealed the resident had an order, dated 10/20/14, to Transfer to hospital for evaluation and treatment related to fall. An incident detail, dated 12/20/14 at 2:00 p.m., was reviewed on 12/10/14. It noted the resident was in her geri- chair outside of her room and the resident was leaning over ar of chair reaching for the hand rail on the wall and she fell out of the chair and hit her head on the floor. The report also indicated staff observed a laceration above the right eye with bruising. The MDS with an assessment reference date (ARD) of 10/01/14, was reviewed on 12/10/14 at 11:00 a.m. The MDS revealed a brief interview for mental status (BIMS) score of 00, which indicated severe impairment. Section (G) noted transfers required extensive assist (non-weight bearing) of two (2). The MDS also noted the resident's balance was unsteady. Review of comprehensive care plan with a completed review date of 10/17/14, revealed the following : Focus, Resident is at risk for falls: impaired mobility, impaired cognition and incontinence and resident will continue to be able to us… | 2018-09-01 |
| 5588 | 5588 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 329 | D | 0 | 1 | VNJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to make sure the residents drug regimen was as free from unnecessary medications as possible for two (2) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident #222 was administered an anti-hypertensive medication on three (3) consecutive days when his pulse fell below the physician established parameter of 60 beats per minute. Also, Resident #222 was not administered the correct dosage of [MEDICATION NAME] on 11/10/14 and 11/11/14. Additionally, Resident #201 had a pharmacy recommendation dated 08/06/14 which recommended her dose of [MEDICATION NAME] (a medication used to treat depression) be decreased to 20 milligrams a day from 40 milligrams per day. The physician accepted this recommendation, but the facility failed to implement the physician order. Resident Identifiers: #222 and #201. Facility Census: 154. Findings Include: a) Resident #222 1. A review of Resident #222's medical record at 12:56 p.m. on 12/04/14, revealed a physician order [REDACTED]. The heart rhythm is fast and irregular in this condition) . Review of the MAR for 11/10/14 and 11/11/14 revealed Resident #222's previous dose of [MEDICATION NAME] 2 mg was not removed from the MAR until after he received that dose on 11/11/14. The new dosage of 2.5 mg was added to the MAR indicated [REDACTED]. An interview with the Director of Nursing (DON) at 2:00 p.m. on 12/04/14, confirmed the facility administered the wrong dose of [MEDICATION NAME] on 11/10/14 and 11/11/14. 2. Review of Resident #222's MAR for 11/14/14 through 11/16/14 revealed the following medication, [MEDICATION NAME] 50 mg po qd (one time a day) dx (diagnosis)[MEDICAL CONDITION](hypertension) hold SBP The DON, at 2:00 p.m. on 12/04/14, confirmed facility staff administered the [MEDICATION NAME] 50 mg on 11/14/14, 11/15/14 and 11/16/14, when the resident ' s pulse was belo… | 2018-09-01 |
| 5589 | 5589 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 371 | F | 0 | 1 | VNJW11 | Based on observation, policy review, and staff interview, the facility failed to store, distribute, and serve food in a manner which reduced the potential of contamination and/or the development of foodborne illness. Cereal was stored in plastic bins unlabeled and undated in the kitchen and in the nutritional pantry on the second (2) unit. Food items stored and available for use in the refrigerator and freezer were opened, unlabeled, undated. Floor tile was missing in two (2) places in the kitchen. Two (2) metal carts for resident's water pitchers and tray covers, and one dishwasher were found to be unsanitary. Drinks were found in the second (2) unit nutritional pantry refrigerator unlabeled and undated. During a lunch meal on the third (3) unit, a dietary staff member failed to change her gloves after serving residents at the table, before returning to the hot table serving area. There were soiled equipment: one square table with a board game printed on top had the varnish worn down to the particle board on all four (4) corners of the table. The varnish on another square table was worn down to the particle board and the edges of the table was chipped and worn. There were three (3) round tables and the front of a serving cabinet was soiled. A geri-chair had Styrofoam wrapped around the arms of the chair and was held in place with black tape. The air conditioners in the dining room was found to be soiled with dirt in the vents. These findings had the potential to affect all residents residing in the facility. Facility census: 154. Findings include: a) Kitchen and nutritional pantry on second (2) unit. An initial tour of the kitchen with Food Service Director (FSD) #110 on 12/01/14 at 11:45 a.m. found: 1. One (1) carton of lactose fat free milk was opened, undated, and unlabeled in the refrigerator. 2. Eight (8) rolls in a clear plastic bag was opened, undated and unlabeled in the freezer. 3. Four (4) clear plastic container with rice kripsies, raisin bran, cheerios, and cornflakes were unlabeled and undated. 4. F… | 2018-09-01 |
| 5590 | 5590 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 386 | D | 0 | 1 | VNJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the physician took an active role in supervising the care for Resident #222. There was no evidence of an accurate evaluation and review of the resident's condition to make informed decisions about the continued appropriateness of the resident's current medical regimen. The physician's progress note for Resident #222, written on 11/10/14, did not accurately reflect the residents medication regimen. This was true for one (1) of three (3) residents reviewed for the care area of death during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifer: #222. Facility Census: 154. Findings Include: a) Resident #222 Review of Resident #222's medical record revealed he was admitted to the facility on [DATE] with the following physician's orders, Aspirin 81 mg(milligrams) po (by mouth) daily for [MEDICAL CONDITION], [MEDICATION NAME] 100 mg po daily for hypertension, [MEDICATION NAME] 25 mg po daily for hypertension, [MEDICATION NAME] 10 mg po daily for hypertension, [MEDICATION NAME] 2 mg po daily for [MEDICAL CONDITION], [MEDICATION NAME] 40 mg po daily for [MEDICAL CONDITION], [MEDICATION NAME] 150 mg po daily for [MEDICAL CONDITION] reflux disease, donepezil 10 mg po at bedtime for dementia, [MEDICATION NAME] sodium 100 mg po twice a day for constipation. The medical record indicated Resident #222 was seen by his attending physician on 11/10/14. The physician progress notes [REDACTED]. Under the heading symptoms the following was noted (typed as written), Pt (patient) states his bp gets this way all his life. Never had dizziness or chest pains. 88/41 on [MEDICATION NAME], HCTZ ([MEDICATION NAME]), [MEDICATION NAME]. BS (blood sugar) all good. The pulse documented on the progress note was 46 beats per minute and the blood pressure documented was 108/63. Under the section titled assessment/plan the following was documented by the physician (typed as written), [ME… | 2018-09-01 |
| 5591 | 5591 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 428 | D | 0 | 1 | VNJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to act upon a consultant pharamacist recommendation for two (2) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). The consultant pharmacist made a recommendation to decrease Resident #201's Celexa from 20 milligrams twice daily to 20 milligrams one time a day. The attending physician accepted the pharmacist recommendation on 08/18/14, but the facility failed to implement the medication change. For Resident #72 the facility failed to address the pharmacist recommendations related to an as needed anti-anxiety medication. Resident Identifiers: #201 and #72. Facility Census: 154. Findings Include: a) Resident #201 A review of Resident #201's medical record at 1:42 p.m. on 12/10/14 revealed a current physician's orders [REDACTED]. The medical record also contained a consultation report from the consultant pharmacist dated 08/06/14 which contained the following text (typed as written): Recommendation: Please consider decreasing citalopram (celexa) to 20 mg orally daily. Following any gradual dose reduction attempt, residents should be closely monitored for re-emergence of target symptoms and/or withdrawal symptoms. If symptoms emerge, alternative or adjunctive therapy may be warranted. Rationale for recommendation: An FDA (food drug administration) safety alert released (MONTH) 28, 2012, states that the maximum dose of citalopram for patients greater than [AGE] years of age is 20 mg daily due to the potential risk of abnormal heart rhythms with higher doses . Resident #201's attending physician reviewed and accepted this recommendation as written on 08/18/14. The physician indicated the recommendation should have been implemented as written. The consultation report was signed by the director of nursing (DON) on 08/19/14. Review of Resident #201's physician orders [REDACTED]. The resident has continued to rece… | 2018-09-01 |
| 5592 | 5592 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 441 | E | 0 | 1 | VNJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to maintain an infection control program to ensure a safe and sanitary environment necessary to help prevent the potential development and transmission of disease and infection. The facility failed to keep resident care equipment clean or in a condition in which it could be cleaned, and failed to ensure proper handwashing/glove changing was completed following pressure ulcer care. This practice has the potential to effect more than a limited number. Resident identifiers: #1, #136. Facility census: 154. Findings Include: -- During Stage I of the Quality Indicator Survey (QIS) on 12/01/14 at 4:18 p.m., a geri-chair sitting on the third floor, near room [ROOM NUMBER] was observed to have a large reddish brown soiled area on the inside on the right arm of the chair. Nursing assistant, Employee #34 was asked to clean the area. The area was cleaned and the soiled area was removed. -- During Stage 1 of the QIS on 12/01/14 at 12:20 p.m., a treatment cart sitting on the third floor was observed to have two round brown circles, approximately three inches wide, on the top of the cart. Nursing assistant, Employee #3 was asked to clean the top of the treatment cart. The brown soiled area was removed. -- At 12:30 p.m., on 12/01/14 and at 11:37 a.m., on 12/02/14 Resident #136 was observed sitting in a geri-chair, in the dining room. The geri-chair was observed to have dark gray Styrofoam wrapped around both arms of the chair with black tape holding the Styrofoam in place. -- On 12/09/14 at 2:22 p.m. registered nurse, Employee #79 was observed completing pressure ulcer care on Resident #1. Upon completing the care Employee #79 left the same gloves used during the pressure ulcer care, on her hands and adjusted the bed with a remote control and readjusted the enterel tube feeding for the resident. Upon completion of the care Employee #79 was made aware of break in infection control and agreed she had… | 2018-09-01 |
| 5593 | 5593 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 463 | D | 0 | 1 | VNJW11 | Based on observation, staff interview and policy review, the facility failed to provide Resident #165 with a a call light. This has the potential to affect a limit number of residents. Resident identifier #165. Facility census 154. Findings include: a) Resident #165. Observation during Stage I on 12/01/14 at 1:33 p.m., revealed Resident #165 did not have a call light cord. There is a white plug covering where the call light cord comes out from the wall. During another observation, the call light cord on Resident #165 side of the room. On 12/02/14 at 9:45 a.m., during a staff interview with licensed practical nurse #84, she confirmed Resident #165 did not have a call light cord. She stated she did not know why the call light cord was not in place. She then revealed the call light cord may have been taken out of the room because another resident needed a call light cord. She stated the resident cannot us the call light anyway. In an interview with the director of nursing #166 on 12/02/14 at 9:58 a.m., when she was asked why Resident #165 did not have a call light cord. She stated every room should have a call light cord, whether a resident can turn the light on or not. The DON stated the resident did not have an alternative communication device within her reach when unattended. On 12/02/14 at 11:00 a.m. the director of nursing stated she observed the room and the room did not have a call light cord so she placed a call light cord on Resident #165's side of the room. Review of the facility's policy related to call lights on 12/02/14 at 1:00 p.m., all Genesis HealthCare patients will have a call light or alternative communication device within their reach at all times when unattended. Observation of Resident #165's side of the room on 12/02/14 at 2:00 p.m. revealed the staff has placed a call light cord on her side of the room. | 2018-09-01 |
| 5594 | 5594 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 490 | F | 0 | 1 | VNJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, policy review, and observation the facility was not adminsitered in a manner that enabled it to use its resources effectively and effeciently to attain or maintain the highest practicable physical, mental, and psychosocial well being of each resident. The facility had a system failure in regards to Resident #222 which resulted in actual harm. Resident #222 was admitted to the facility on [DATE] and was unreponsive with no pulse of respirations at the facility on 11/17/14. During this thirteen (13) day stay, the facility failed to administer Resident #222's [MEDICATION NAME] in dosage prescribed by the physician, failed to hold his [MEDICATION NAME] when Resident #222's pulse fell outside the physician established parameters, and the attending physician failed to accurately assess the resident's medication regimen prior to making medication changes (regarding [MEDICATION NAME]) on 11/10/14. The facility also failed to notify Resident #222's attending physician/nurse practicioner when the resident was suffering from [MEDICAL CONDITION] (very slow heart beat) with pulses of 56, 42, and 43 over a two (2) day period. The facility had no system which ensured greivances voiced by residents were acted upon and responded to promptly. This affected Resident #63, #143, and #43. The facility had no system in place which ensured all allegations involving mistreatment, neglect, abuse, and misppropriation of resident property were reported to the proper state authorities in accordance with state law and were thoroughly invesitgated by facility staff. This affected Resident #9, #47, #4, #193, #211, #76, #217, #220 and #170. There was no system in place to ensure residents were given a dignified dining experience. The third floor dining room was very loud and crowded during the dining experience. A resident was not able to independently remove herself from the dining room after completing the meal, … | 2018-09-01 |
| 5595 | 5595 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 514 | E | 0 | 1 | VNJW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain an accurate and complete medical record for five (5) of twenty-six (26) residents reviewed during Stage 2 of the Quality Indicator Survey. One (1) resident had the [DIAGNOSES REDACTED]. Two (2) residents were receiving medication without a medical [DIAGNOSES REDACTED]. One (1) resident's advanced directive did not correlate with the physician orders [REDACTED]. This has the potential to affect more than a limited number of residents. Resident identifiers: #103, #99, #66, #126, #69. Facility census 154. a) Resident #103 1. Resident #103 and Weight Loss A review of Resident #103's record on 12/09/14 at 9:18 a.m., revealed a nutritional assessment with the date of 11/12/14 and the weight status question #3 has loss of five (5) percent or more in the last month or loss of ten (10) percent or more in the last six (6) month is marked as yes, on a prescribed weight loss regimen. Review of Resident #103's physician order [REDACTED]. In an interview on 12/10/14 at 9:15 a.m., when the dietician #209 was asked whether the nutritional assessment with the date of 11/12/14 was accurate related to resident being on a prescribed weight loss regimen. The dietician reviewed the record and she stated, I inaccurately marked this wrong. I should have marked yes, for the weight loss, but not on a planned weight loss regimen. 2. Resident #103 and [DIAGNOSES REDACTED].>Record review of Resident #103's history and physical on 12/04/14 at 9:50 a.m., in which was completed by physician #208, indicated the resident has a [DIAGNOSES REDACTED]. Review of Resident's #103's [DIAGNOSES REDACTED]. In an interview on 12/04/14 at 10:15 a.m. with #85 registered nurse (RN) was asked to review the [DIAGNOSES REDACTED]. b) Resident #99 Review of medical records on 12/08/14 at 3:00 p.m., revealed Resident #99 to have two incomplete physician orders [REDACTED]. Medications include, [MEDICATION NAME] extended … | 2018-09-01 |
| 5596 | 5596 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2014-12-12 | 520 | F | 0 | 1 | VNJW11 | Based on record review, staff interview, resident interview, policy review, and observation 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 systems failure to ensure prompt resolutions of resident grievances. This affected Resident #63, #143, and #43. The QAA committee failed to identify and/or develop a plan of action to correct systems failure to ensure all alleged 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. This affected Resident #9, #47, #4, #193, #211, #76, #217, #220 and #170. The QAA committee failed to identify and/or develop a plan of action to correct systems failure to ensure residents were given a dignified dining experience. The third floor dining room was very loud and crowded during the dining experience. A resident was not able to independently remove herself from the dining room after completing the meal, the dining room and the dining equipment in the room were in need of cleaning and appeared soiled. This affected Resident #78, #52, #59, #182, #18, #131, #60, #71, #29, #50, #136, #17, #140, #27, #49, #45, #24, #134, and #77. Affected residents included Resident #222, #63, #143, #43, #211, #9, #47, #4, #193, #76, #217, #220, #170, #78, #52, #59, #182, #18, #131, #60, #71, #29, #50, #136, #17, #140, #27, #49, #45, #24, #134, and #77; however, these systemic problems had the potential to affe… | 2018-09-01 |
| 5597 | 5597 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2015-04-10 | 253 | E | 0 | 1 | QSV111 | Based on observation and staff interview, the facility failed to provide effective housekeeping and maintenance services for four (4) of thirty-five (35) resident rooms observed during Stage I of the Quality Indicator Survey (QIS). The bathroom doors were scuffed and the bathroom door frames had chipped paint, exposing the metal frame. In addition, a wall in a resident's room had missing paint. This affected more than an isolated number of residents. Facility census: 78. Findings include: a) Bathroom doors and framing: -- Room 107 - The bathroom door was scuffed. -- Room 110 - The bathroom door was scuffed and the paint was chipped exposing the metal door frame. -- Room 161 - The bathroom door had a deep scrape exposing the wood. The bathroom door frame had chipped paint, exposing the metal door frame. b) Room 114 had a large area where the wall was unpainted. On 04/10/15 at 1:15 p.m., the Plant Operations Manager #55 verified Rooms 107, 110, 161, and 114 needed repaired and repainted. | 2018-09-01 |
| 5598 | 5598 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2015-04-10 | 272 | D | 0 | 1 | QSV111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately assess three (3) of twenty-four (24) residents reviewed in Stage 2 of the Quality Indicator Survey (QIS). The comprehensive Minimum Data Set (MDS) for Resident #15 did not accurately reflect the resident's active [DIAGNOSES REDACTED].#48 did not correctly reflect [MEDICAL TREATMENT] as a treatment, and the MDS for Resident #21 did not accurately reflect a [DIAGNOSES REDACTED].#15, #48, and #21. Facility census: 78. Findings include: a) Resident #15 A review of the medical record for Resident #15, on 04/07/15 at 4:30 p.m., revealed this resident had an active [DIAGNOSES REDACTED]. A review of the Significant Change MDS, with an Assessment Reference Date (ARD) of 06/05/14, revealed Item I5400 for [MEDICAL CONDITION] disorder was not marked as an active diagnosis. An interview on 04/08/15 at 11:25 a.m., with MDS Coordinator #54, verified the Significant Change MDS with the ARD of 06/05/14, Section I5400 for [MEDICAL CONDITION] disorder was not marked as a [DIAGNOSES REDACTED]. b) Resident #48 A review of the medical record for Resident #48, on 04/09/15 at 9:05 a.m., revealed this resident had end stage [MEDICAL CONDITIONS] and received [MEDICAL TREATMENT] on Monday, Wednesday, and Friday at 12:30 p.m. A review of the annual MDS, with an ARD of 03/13/15, revealed Item O0100. Special Treatments, Procedures, and Programs did not indicate the resident received [MEDICAL TREATMENT]. An interview, on 04/09/15 at 1:30 p.m., with the MDS Coordinator, verified the annual MDS with an ARD of 03/13/15 under O0100, Special Treatments, Procedures, and Programs was not marked to indicate this resident received [MEDICAL TREATMENT] as a treatment for [REDACTED]. c) Resident #21 On 04/09/15 at 9:10 a.m., during a review of the physician's orders [REDACTED]. At 9:35 a.m. on 04/09/15, Section I, the Active [DIAGNOSES REDACTED]. The Annual MDS, with an ARD of 03/03/15, also reviewed on 04/0… | 2018-09-01 |
| 5599 | 5599 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2015-04-10 | 279 | E | 0 | 1 | QSV111 | **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 for four (4) of twenty-four (24) Stage 2 residents. A care plan was not developed to address current problems for Resident #24, who developed a pressure ulcer and required rehabilitation services. Resident #95's care plan was not developed for six (6) areas for which the Care Area Assessment (CAA) indicated care plans would be developed. The care plan for Resident #107 did not address nutritional needs. Resident #48 received [MEDICAL TREATMENT] services and required fluid restrictions which were not addressed in the care plan. Resident identifiers: #24, #95, #107, and #48. Facility census: 78. Findings include: a) Resident #24 During a closed record review related to pressure ulcers and rehabilitation services, on 04/07/15 at 11:38 a.m., the medical record revealed Resident #24 developed an unstageable area measuring six centimeters (cm) by eight centimeters (6 cm x 8 cm) on his coccyx. The date of identification was noted as 11/27/14. Additionally, the resident required rehabilitation services related to a decline in condition. Further review of the medical record, on 04/09/15 at 12:05 p.m., revealed the residents's previous comprehensive care plan was resolved and/or discontinued on 09/16/14. A new comprehensive care plan was not developed after the resident was readmitted to the facility on [DATE]. Review of the care plan, with the director of nursing (DON), on 04/09/15 at 12:30 p.m., confirmed the resident did not have a comprehensive care plan and had resided in the facility greater than twenty-one (21) days. Additionally, she confirmed a care plan was not developed to address the pressure ulcer when it developed. b) Resident #95 On 04/09/15 at 4:00 p.m., review of the Admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 11/11/14, found Section I, the Active [DIAGNOSES REDACTED]. Section V, the Care Area As… | 2018-09-01 |
| 5600 | 5600 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2015-04-10 | 280 | D | 0 | 1 | QSV111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview, the facility failed to revise care plans for two (2) of twenty-four (24) Stage 2 residents whose care plans were reviewed. A care plan was not revised for Resident #121 related to incontinence management, and for Resident #27, who no longer received liquid medication. Resident identifiers: #121 and #27. Facility census: 78. Findings include: a) Resident #121 During a resident interview, on 04/08/15 at 4:30 p.m., Resident #121 related she experienced urinary incontinence because she was unable to toilet herself. She related she had to wait on staff to assist her to the bathroom and she sometimes voided before she could get to the toilet. She said she rang the call bell to request assistance, but staff did not offer to toilet her. Review of the medical record revealed the resident walked with restorative therapy. An interview with Restorative Nursing Assistant (RNA) #58, on 04/09/15 at 3:30 p.m., revealed the resident walked twice daily with minimal assistance. The resident's admission nursing assessment, dated 10/15/14, indicated the resident was continent. Her [DIAGNOSES REDACTED]. Review of the current care plan revealed an intervention for staff to toilet the resident as needed. An interview with the director of nursing (DON), on 04/09/15 at 11:00 a.m., confirmed staff had not reviewed and revised the care plan to promote continence as the resident's condition improved. . b) Resident #27 During the afternoon of 04/09/15, a review of the care plan for this resident, dated 01/21/15, revealed the identification of a problem with [MEDICAL CONDITION]. An intervention for this condition was to send foods high in iron and vitamin C. The care plan also indicated staff would be educated to give liquid iron with fruit juice as vitamin C, because the iron was absorbed better in an acidic environment. A discussion with the director of nursing, on 04/09/15 at 2:56 p.m.… | 2018-09-01 |
| 5601 | 5601 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2015-04-10 | 314 | D | 0 | 1 | QSV111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide care and services to promote healing and prevent infection for one (1) of three (3) residents reviewed for pressure ulcers. The resident had an infected pressure ulcer which was not identified, assessed, or addressed before the area became infected. Resident identifier: #24. Facility census: 78. Findings include: a) Resident #24 A closed record review, on 04/07/15 at 11:38 a.m., revealed a wound assessment note, dated 11/27/14, which indicated the facility identified an unstageable pressure ulcer on the resident's coccyx on 11/24/14. The area measured six centimeters by eight centimeters (6 cm x 8 cm) and was one hundred percent (100%) slough. The wound was initially identified as moisture associated skin [MEDICAL CONDITION] (MASD), and had developed an infection. The skilled nursing note, dated 11/23/14, noted MASD, as did a note dated 11/26/14. Further review of the medical record, on 04/09/15 at 12:04 p.m., revealed the weekly wound evaluation, completed on 11/27/14 by the wound nurse, indicated the area was believed to be an abscess, but opened up with slough in the wound bed, and had moderate drainage with odor. The physician ordered a wound culture, which was obtained on 11/26/14. The results of the culture indicated the wound was infected with three (3) different organisms: Proteus mirabilis, [DIAGNOSES REDACTED] pneumoniae, and [MEDICAL CONDITION]. Prior to the order for the wound culture, the medical record contained no evidence Resident #24 had a deteriorating wound. Skilled nursing notes, dated 11/23/14 and 11/26/14 noted, MASD and was marked, no pressure ulcers. Additionally, the nursing admission assessment, completed on 10/28/14, noted two (2) moles just below a decubitus ulcer. It did not indicate the location of the ulcer, nor provide a description of the area. Subsequent skilled nursing progress notes indicated the resident did not have a press… | 2018-09-01 |
| 5602 | 5602 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2015-04-10 | 315 | D | 0 | 1 | QSV111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, medical record review, policy review, and staff interview, the facility failed to provide care and services to promote urinary continence and/or to prevent infection for two (2) of three (3) residents reviewed for urinary incontinence. A nurse aide (NA) did not provide incontinence care in a manner to prevent infection for Resident #84. In addition, although the resident was assessed as a candidate for a toileting program, the resident was not on an individualized toileting program. Resident #121 was not re-evaluated for an individualized continence management program after the resident had an improvement in overall physical status. Resident identifiers: #84 and #121. Facility census: 78. Findings include: a) Resident #84 1. A Stage 1 observation, on 04/06/15 at 3:01 p.m., revealed the resident had a strong odor of urine and feces. Another observation, on 04/08/15 at 1:32 p.m., revealed a strong body odor of urine. An interview with Nurse Aide (NA) #20, on 04/08/15 at 11:36 a.m., revealed the resident had a leaky bladder At 1:40 p.m. on 04/08/15, NA #20 provided incontinence/perineal (peri) care for the resident. Upon entry to the room, observation revealed a wash basin in the bathroom sink, filled with clear water and washcloths. A pair of gloves, observed on the side of sink, had no barrier beneath them to prevent contamination. The NA assisted the resident into the bathroom, then donned the gloves from the sink. From this point, until the end of the observation, the NA wore the same gloves which first became contaminated from contact with the sink. The NA performed several tasks which further contaminated the gloves and provided peri-care while wearing the gloves. The NA assisted the resident to a standing position in front of the commode, pulled down the resident's urine soaked pants and brief, and assisted Resident #84 to a seated position on the commode. Observation revealed the wheelchair cush… | 2018-09-01 |
| 5603 | 5603 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2015-04-10 | 334 | E | 0 | 1 | QSV111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure each resident was offered and/or received the influenza or pneumococcal immunization for three (3) of five (5) residents reviewed for immunizations. Additionally, the facility failed to ensure their policy for a body temperature check was completed prior to administering the vaccine. The facility's policy for tracking influenza and pneumococcal immunizations was also not implemented. This practice affected (3) of five (5) residents reviewed, but had the potential to affect more than an isolated number of residents. Resident identifiers: #22, #2, and #9. Facility census: 78. Findings include: a) Influenza vaccine Review of the influenza (Flu) vaccination policy, on 04/06/15 at 4:30 p.m., revealed the facility would offer all current and newly admitted residents the influenza vaccine from (MONTH) of each year through the end of (MONTH) the following year. It noted informed consent in the form of a discussion regarding risks and benefits would occur prior to the vaccination and refusals would be documented by the facility. Additionally, the policy indicated the facility would check the resident's body temperature before giving the vaccine, to ensure anyone who was febrile (feverish) would not receive the vaccine until he/she recovered. The policy required staff document the administration of the vaccine, including injection site. 1. Residents # 22 and #9 Review of these resident's medical records, on 04/07/14 at 4:30 p.m., revealed each resident received the flu vaccine on 11/17/14. There was no evidence the residents' temperatures were taken prior to administration of the vaccine. A medical record review and interview with the director of nursing (DON), on 04/09/15 at 3:00 p.m., confirmed there was no evidence body temperatures were obtained prior to administration of the vaccine for either resident. 2. Resident #2 Review of Resident #2's medical r… | 2018-09-01 |
| 5604 | 5604 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2015-04-10 | 364 | E | 0 | 1 | QSV111 | Based on observation and staff interview, the facility failed to ensure foods were prepared in a manner which maintained the intended nutritive value and palatability as planned in the approved recipe. Dietary staff did not use the facility approved recipe when preparing egg salad. This had the potential to affect more than an isolated number of residents who were served the egg salad. Facility census: 78. Findings include: a) On 04/06/15 at lunch time, Dietary Staff #80 was observed preparing egg salad for the evening meal. He was observed chopping the eggs in a large pan. The other ingredients were sitting on the table ready to add to the mixture. The recipe called for mayonnaise. The employee poured mayonnaise from a large jar into the pan with the eggs. He used the same procedure to add the other ingredients to the eggs. None of the ingredients were measured prior to adding them. This process did not ensure the planned nutritive value of the food was maintained. In addition, food prepared in this manner had the potential to affect the palatability of the product. The dietary manager was present at the time and was asked about the use of recipes. She stated staff were supposed to follow the recipes. A copy of the recipe for egg salad was provided on 04/09/15 at 12:24 p.m. The recipe had specific amounts for each ingredient, in accordance with the number of servings needed. The recipe was not followed in the preparation of the egg salad. | 2018-09-01 |
| 5605 | 5605 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2015-04-10 | 428 | D | 0 | 1 | QSV111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a licensed pharmacist reviewed each resident's medication regimen at least monthly, and the pharmacist failed to identify and report a medication irregularity to the attending physician and the Director of Nursing. An allergy to a prescribed medication was not identified and/or addressed by the pharmacist. In addition, a monthly medication regimen review was not conducted for a resident in (MONTH) 2014. These practices affected one (1) of three (3) residents reviewed for the care area of unnecessary medications. Resident identifier: #21. Facility census: 78. Findings include: a) Resident #21 On 04/09/15 at 9:10 a.m., during a review of the physician's orders [REDACTED]. Xanax, a Benzodiazepine medication used to treat Anxiety disorder, was identified as a current medication for the resident. The resident was admitted to the facility on [DATE], and had received Xanax 0.25 mg, one (1) tablet by mouth three (3) times a day since 12/03/13. At 9:20 a.m. on 04/09/15, review of the medical record found no evidence the pharmacist identified and/or addressed the irregularity regarding the resident's allergy to Benzodiazepines, yet the resident was receiving a Benzodiazepine. On 04/09/15 at 2:40 p.m., the Administrator and the Director of Nursing (DON) were made aware of the findings regarding the resident's listed allergy to Benzodiazepines, when receiving a Benzodiazepine as part of her medication regimen. The administrator and the DON were asked to provide evidence the pharmacist identified the irregularity regarding the allergy and the prescribed medication. No evidence was provided by the completion of the Quality Indicator Survey (QIS). In addition, review of the medical record, at 10:35 a.m. on 04/09/15, identified no evidence of a medication regimen review by the pharmacist, for Resident #21, for the month of (MONTH) 2014. At 11:00 a.m. on 04/09/15, the Administrator and … | 2018-09-01 |
| 5606 | 5606 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2015-04-10 | 431 | E | 0 | 1 | QSV111 | Based on observation, review of the Centers for Medicare and Medicaid's (CMS) guidance for this regulation, and staff interview, the facility failed to ensure the labeling of medications dispensed by the pharmacy were consistent with applicable federal and state requirements and currently accepted pharmaceutical principles and practices. An ordered Potassium medication, packaged in individual packets, did not identify the strength/dosage on each of the individual pill packets. This practice affected seven (7) of nine (9) residents who received the medication, Potassium Chloride Extended Release tablets, with the strength/dosage of ten 10 milliequivalents (mEq). Resident identifiers: #70, #31, #21, #3, #111, #53, and #100. Facility census: 78. Findings include: a) Resident #70 On 04/08/15 at 8:55 a.m., during a medication administration observation on the C hall, Licensed Practical Nurse (LPN) #85 identified the pill packet for the resident's ordered Potassium Chloride (CL) Extended Release (ER) was not labeled with the dosage/strength. LPN #85 reviewed the box from which the pill packet was retrieved. The box indicated the dosage/strength was 10 mEq. b) Resident #31 On 04/08/15 at 9:00 a.m., during an observation of the medications in the medication cart, LPN #85 identified the Potassium CL ER 10 mEq, ordered for Resident #31, did not have the dosage labeled on the individual pill packets. c) Resident #21 On 04/08/15 at 9:10 a.m., during an observation of the medications in the medication cart on D hall, LPN #25 identified the Potassium CL ER 10 mEq, ordered for Resident #21, did not have the dosage labeled on the individual pill packets. The box from which the pill packet had been retrieved indicated the dosage/strength was 10 mEq d) Resident #3 On 04/08/15 at 9:12 a.m., LPN #25 identified the Potassium CL ER 10 mEq ordered for Resident #3 did not have the dosage labeled on the individual pill packets. The box, in which the pill packet had been retrieved, indicated the dosage/strength was 10 mEq. e) Resident #11… | 2018-09-01 |
| 5607 | 5607 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2015-04-10 | 441 | F | 0 | 1 | QSV111 | Based on observation, staff interview, policy review, and review of the guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to maintain an effective infection control program to prevent the development and transmission of disease and infection, to the extent possible. Staff failed to utilize proper hand sanitizing techniques for two (2) residents identified through random opportunities for discovery. The facility also failed to fully investigate and implement infection control measures related to an outbreak of a gastrointestinal virus. Residents #84 and #121 were affected; however, these practices had the potential to affect more than a limited number of residents. Facility census: 78. Findings include: a) Hand hygiene 1. Resident #84 An observation, on 04/08/15 at 1:50 p.m., revealed Nurse Aide (NA) #20 wore the same pair of gloves from initiation of incontinence care through completion. She cleaned a urine soaked wheelchair cushion, touched wheelchair arms, a bedside stand in the resident's room, the resident's soiled brief and soiled clothing, and the resident's shoes. The NA did not change her gloves and/or wash her hands after touching these potentially contaminated items. She then provided incontinence care for Resident #84, wearing the contaminated gloves. After performing the resident's care, the NA washed her hands. The entire process, including applying soap and rinsing her hands, lasted for a count of five (5) seconds. 2. Resident #121 An observation, on 04/09/15 at 3:30 p.m., revealed NA #21 washed her hands after providing care to Resident #121. The nursing assistant washed her hands for a count of seven (7) seconds. 3. Review of the facility's hand hygiene policy, on 04/09/15 at 12:30 p.m., revealed staff should wash hands for a minimum of fifteen (15) seconds. 4. According to CDC guidelines, hands should be scrubbed for at least twenty (20) seconds. b) Gastrointestinal symptoms Review of the tracking and trending line listing, on 04/09/15 at 4:50 p.m., reveale… | 2018-09-01 |
| 5608 | 5608 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2015-04-10 | 465 | E | 0 | 1 | QSV111 | Based on observation and staff interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment in five (5) of thirty-five (35) resident rooms observed during the Quality Indicator Survey (QIS). The caulking around commodes was brown and cracked. The resident bathrooms also had loose handrails and towel bars. This had the potential to affect more than an isolated number of residents. Facility census: 78. Findings include: a) On 04/10/15 at 1:15 p.m., an observation of resident bathrooms was made with Plant Operations Manager #55. The identified areas of concern included: 1. Caulking around commodes: Rooms 110, 121, and 123 had caulking around the commodes which was brown and cracked. 2. Loose towel bars and handrails: -- Room 159 had a loose handrail and a loose towel bar. -- Room 160 had a loose towel bar. Employee #55 verified the caulking around the commodes needed replaced and the handrails and towel bars were loose and needed tightened. | 2018-09-01 |
| 5609 | 5609 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2015-03-04 | 161 | E | 0 | 1 | KF9N11 | Based on a review of the facility's surety bond, review of resident trust fund bank statements, and interview with the director of nursing, the facility failed to ensure its surety bond was sufficient to safeguard all personal funds residents had deposited with the facility. This had the potential to affect ten (10) of ten (10) residents for whom the facility handled funds. Facility census: 38. Findings include: a) Review of the resident trust fund bank statements for October, November, and (MONTH) 2014, on 03/03/15 at 10:15 a.m., revealed the highest daily balance for the most recent completed quarter was $18,505.67 on 12/02/14. The bond held by the facility to cover the trust fund account was for $10,000.00. This amount did not ensure sufficient coverage of the highest daily balance in the account. In an interview with the director of nursing (DON), on 03/04/15 at 12:45 p.m., the DON verified $10,000.00 was the correct amount of the surety bond. | 2018-09-01 |
| 5610 | 5610 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2015-03-04 | 225 | C | 0 | 1 | KF9N11 | Based on personnel record review and staff interview, the facility failed to ensure it did not employ individuals who found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility did not make reasonable efforts to uncover information about any past criminal prosecutions by use of fingerprinting, which is a required procedure to ensure a statewide criminal background check in West Virginia. This was true for one (1) of ten (10) employees reviewed. This had the potential to affect more than an isolated number of residents. Employee identifier: #51. Facility census: 38. Findings include: a) Criminal Background Checks Review of personnel files on 03/04/15 at 1:30 p.m., found Nurse Aide (NA) #51, originally came to work at the facility in (MONTH) 2008. The facility completed a criminal background check with fingerprints at that time. NA #51 came back to work at the facility in (MONTH) 2011. The facility completed another criminal background check with fingerprints at that time as well. The employee came back to the facility to work for a third time on 12/30/14. The facility did not complete a statewide criminal background check with fingerprints at the time of the individual's rehire. On 03/04/15 at 2:15 p.m., Human Resources Employee #62 verified the facility did not complete a criminal background check with fingerprints when they rehired NA #51 on 12/30/14. | 2018-09-01 |
| 5611 | 5611 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2015-03-04 | 253 | E | 0 | 1 | KF9N11 | Based on observation and staff interview, the facility failed to ensure it maintained an orderly and sanitary environment in resident rooms and in common areas such as the shower room. Resident rooms had issues such as chipped paint, and deep scratches in the walls. The common shower room had torn linoleum. These practices had the potential to affect more than an isolated number of residents. Facility census: 38. Findings include: a) Environmental observations revealed the following: 1. Room 206 On 02/24/15 at 3:04 p.m., Room 206's heating unit had chipped paint on the front surface of the unit. On 03/02/15 at 1:20 p.m., a second observation with the Director of Facility Services #61, verified the heating unit had chipped paint. 2. Room 204 On 03/02/15 at 1:18 p.m., Room 204 had deep scratches in the entrance door. Director of Facility Services #61 verified these deep scratches and said he could repair them. 3. Room 201 On 02/24/15 at 4:20 p.m., Room 201 had an over-bed table with a section broken out. A second observation, on 03/02/15 at 1:15 p.m., found the same issue. Director of Facility Services #61 said he could replace the over-bed table. 4. Room 222 On 02/25/15 at 9:20 a.m., the bathroom in Room 222 had a urine odor. A dirty bedpan hung from the wall. The bedpan did not have a label. There was also brown grime around the sink water faucets. On 03/02/15 at 1:20 p.m., a second observation of the bathroom in Room 222 found a bedpan sitting on the shower floor. The bedpan had Resident #53's name on it. Director of Facility Services #61 agreed the bathroom had a urine odor. On 02/25/15 at 9:20 a.m. the bathroom in Room 222 had a urine odor. Employee #61 said he would contact housekeeping about the dirty bedpan. On 03/02/15 at 5:00 p.m., the Director of Nursing (DON) #54 said the nursing staff should not store bedpans on the floor of the shower and should not leave one soiled. The DON said nursing staff were supposed to clean the bedpans, bag and label them before storing them. 5. Room 219 On 02/24/15 at 2:54 p… | 2018-09-01 |
| 5612 | 5612 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2015-03-04 | 272 | D | 0 | 1 | KF9N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a comprehensive assessment for one (1) of twenty-one (21) Stage 2 sample residents was accurate. Resident #3's admission minimum data set (MDS) did not identify a Stage III pressure ulcer that was present on admission. Resident identifier: #3. Facility census: 38. Findings include: a) Resident #3 Review of the resident's medical record on 02/26/15 at 10:19 a.m., found Resident #3 had a pressure ulcer at the time of admission. The hospital discharge summary, and the Pre-admission screening, dated 09/16/14, indicated Resident #3 was admitted to the facility with a Stage III sacral pressure ulcer. The resident's admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 09/23/14, did not indicate the resident had any healed or unhealed pressure ulcers. During an interview on 03/04/15 at 9:35 a.m., the director of nursing (DON) reviewed the medical record, including the nursing admission assessment, physician's orders [REDACTED].#3's sacral pressure ulcer on the resident's admission MDS. | 2018-09-01 |
| 5613 | 5613 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2015-03-04 | 280 | D | 0 | 1 | KF9N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, family interview, and staff interview, the facility failed to revise care plans to meet the identified needs of residents. The facility did not revise Resident #20 ' s care plan to include new interventions and/or issues related to those interventions. This affected one (1) of twenty-seven (27) residents reviewed for care plan revision. Resident identifier: #20. Facility census: 38. Findings include: a) Resident #20 On 02/24/15 at 3:50 p.m., during an interview, Licensed Practical Nurse (LPN) #43 stated Resident #20 had fallen in his room on 02/20/15. A nursing entry, dated 02/20/15, noted the resident fell in his room on his right side with his feet straight out in front of him. An observation of the resident's room, on 02/24/15 at 4:30 p.m., revealed the resident had fall mats by his bed. On 03/02/15 at 3:22 p.m., during a family interview, Resident #20's wife said the facility placed the fall mats to the side of the resident's bed after the fall he experienced on 02/20/15. On 02/25/15 at 9:00 a.m., medical record review found a progress note, dated 12/31/14, indicating Resident #20 had a sensor pad alarm to his bed. Progress notes dated 01/24/15, 01/27/15, and 02/18/15 referred to the resident dismantling or turning off his bed alarm. The physician's orders [REDACTED]. On 02/26/15 at 1:56 p.m., Director of Nursing (DON) #54 went into the resident's room and confirmed he had a bed and chair alarm. The DON also said the resident had a history of [REDACTED]. A review of the resident's care plan revealed the facility had a care plan for falls, but had not included the interventions of: -- a bed and chair alarm; -- fall mats to the bedside; -- the resident's ability to dismantle and turn off his alarms; or -- the intervention of placing the bed alarm out of his sight in order to prevent him from dismantling or turning it off. | 2018-09-01 |
| 5614 | 5614 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2015-03-04 | 314 | D | 0 | 1 | KF9N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Staff failed to identify and treat a pressure ulcer of a resident on admission to the facility, and failed to properly utilize a specialty mattress, and utilized improper technique during wound dressing changes. Resident identifier: #3 and #5. Facility census: 38. Findings include: a) Resident #3 A closed record review, on 02/26/15 at 10:19 a.m., revealed a hospital discharge summary and pre-admission assessment, each dated 09/16/14, indicating Resident #3 was transferred to the extended care unit with a Stage III sacral pressure ulcer. The nursing admission note, dated 09/16/15, and nursing assessment, dated 09/17/14, did not address a sacral pressure ulcer. The nursing note indicated a dressing was present on Resident #3's sacral area, but did not indicate it was removed for assessment. The director of nursing (DON), interviewed on 03/04/15 at 9:35 a.m., reviewed the medical record and confirmed no evidence was present to indicate staff assessed Resident #3's wounds, and confirmed no evidence was present to indicate the wound dressings were removed to assess the sacral wound on admission to the facility. She acknowledged the facility failed to assess Resident #3's sacral wound until 09/29/14, at which time the facility obtained an order for [REDACTED].>b) Resident #5 1) On 02/26/2015 at 11:09 a.m., Licensed Practical Nurse (LPN) #28, assisted by Nurse Aide (NA) #42, completed a dressing change of Resident #5's sacral pressure ulcer. Resident #5 was lying on his back on an air fluidized bed with two (2) large cloth incontinence pads beneath him. (Note: The incontinence pads inhibit the desired effects of the air fluidized bed.) Nurse Aide (NA) #42 assisted the nurse to position Re… | 2018-09-01 |
| 5615 | 5615 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2015-03-04 | 315 | D | 0 | 1 | KF9N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for use of indwelling (Foley) catheters, received catheter care to prevent urinary tract infections. A nursing assistant attempted to clean a resident's catheter without utilizing soap and water. Resident identifier: #29. Facility census: 38. Findings include: a) Resident #29 A Stage 1 interview, on 02/24/15 at 3:53 p.m., revealed Resident #29 had an indwelling Foley catheter. Review of the medical record, on 03/03/15 at 9:02 a.m., revealed Resident #29 was treated for [REDACTED]. coli). An observation of Foley catheter/perineal care, with Nurse Aide (NA) #62, on 03/03/15 at 10:05 a.m., revealed the NA did not utilize soap and did not perform perineal care. Additionally, the NA attempted to scrub feces from the catheter tubing, using only a wet washcloth. An interview with Licensed Practical Nurse (LPN) #35, on 03/03/2015 at 10:19 a.m., revealed the facility practice for Foley catheter care included peri care using soap and water. On 03/03/15 at 10:30 a.m., an interview with the Director of Nursing (DON) revealed the protocol for Foley catheter care included providing perineal care and catheter care with the utilization of soap and water. During another interview with the DON, on 03/03/15 at 4:30 p.m., she reviewed the peri care procedure and the Foley catheter procedure in the nursing manual utilized by the facility. The DON confirmed the procedure indicated prior to providing Foley catheter care, peri care should be performed. The DON confirmed the NA should have cleansed Resident #29 with soap and water. | 2018-09-01 |
| 5616 | 5616 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2015-03-04 | 431 | E | 0 | 1 | KF9N11 | Based on observation, staff interview, and, review of the Centers for Disease Control and Prevention (CDC) safe practice guidelines, and manufacturer package inserts, the facility failed to label a multi-dose vial of medication in accordance with currently accepted professional principles. A multidose vial of purified protein derivative (PPD) did not have a date to identify when it was opened. This practice had the potential to affect more than a limited number of residents. Facility census: 38. Findings include: a) Medication storage During an observation of one (1) of one (1) medication rooms, on 02/24/15 at 3:45 p.m., the refrigerator contained a multidose vial of purified protein derivative (PPD), which was opened and not dated. Employee #33, a licensed practical nurse (LPN), interviewed during the observation on 02/24/15, related the vial should have been labeled when opened. He verified staff were unable to determine when the medication when the vial was opened. CDC safe practice guidelines include, If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. The package insert from the manufacturers of PPD includes Vials in use for more than 30 days should be discarded. | 2018-09-01 |
| 5617 | 5617 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2015-03-04 | 441 | F | 0 | 1 | KF9N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policy, the facility failed to maintain an infection control program to provide a safe, sanitary and comfortable environment. Staff failed to maintain aseptic technique during a pressure ulcer wound dressing change, utilized improper hand washing technique, failed to maintain aseptic technique with medication storage, failed to store residents' personal hygiene supplies properly, failed to utilize standard precautions with garbage disposal, and failed to ensure the floor tile in the common shower room could be effectively cleaned. These practices had the potential to affect more than a limited number of residents. Resident identifier: #5. Facility census: 38. Findings include: a) Resident #5 1) On 02/26/2015 at 11:09 a.m., Employee #28, a Licensed Practical Nurse (LPN) , assisted by Employee #42 (NA) completed a dressing change of Resident #5 ' s sacral pressure ulcer. Resident #5 was lying on his back with two (2) large cloth incontinence pads beneath him. Nurse Aide (NA) #42 assisted the nurse to position Resident #5 on his right side. The LPN removed a dressing from Resident #5's right buttock and a dressing from the left buttock while wearing the same gloves. Neither dressing covered a visible wound. While wearing the same gloves used to remove the two (2) dressings from the resident's buttocks, which rendered the gloves contaminated, the nurse cleaned around the top and outer aspects of an open wound on the resident's coccyx/sacral area. She then wiped through the wound bed, from the coccyx toward the anus, with the same gauze used to clean around the top and outer wound bed. This created a potential for spreading microorganisms from the dressings on the buttocks as well as the periphery of the open wound. Upon completion of the wound treatment, the nurse placed a small coccyx/sacral dressing, which did not completely cover the bottom of the wound bed. 2) During a second obser… | 2018-09-01 |
| 5618 | 5618 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2015-03-04 | 514 | D | 0 | 1 | KF9N11 | Based on medical record review and staff interview, the facility failed to ensure one (1) of twenty-seven (27) residents had an accurate and complete medical record. The facility failed to complete neurological check documentation for a resident after he sustained a fall. Resident identifier: #20. Facility census: 38. Findings include: a) Resident #20 On 02/24/15 at 3:50 p.m. during an interview, Licensed Practical Nurse (LPN) #43 said Resident #20 had a fall in his room on 02/20/15. A nursing note dated 02/20/15 at 9:16 p.m., stated, CNA (certified nurse aide) called for nurse in 206. This nurse and DON (name) entered the room to find resident lying in the floor on his right side with feet straight out on front of him. Resident had shoes on and glasses on. When asked what happened resident laughed and said nothing I just decided to lay in the floor. Resident moved all extremities w/o (without) difficulty and denied any pain or discomfort. When asked if resident wanted to go to ER (emergency room ) and be evaluated resident declined. Will begin neuro checks and monitor. The director of nursing (Employee #54) provided a copy of the neurological assessment flow sheet for Resident #20. The nursing staff began neurological checks on the resident on 02/20/15 at 9:30 p.m. They continued until 02/21/15 at 12:15 p.m. and started again on 02/22/15. On 02/22/15 they marked the entry as day but did not give the exact time they had completed the assessment. The director of nursing had no other information to provide regarding why the nursing staff did not complete the neurological assessment after 12:15 p.m. on 02/21/15. | 2018-09-01 |
| 5619 | 5619 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2015-03-04 | 520 | E | 0 | 1 | KF9N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview and policy review, the facility failed to maintain an effective Quality Assessment and Assurance (QAA) Committee. The QAA committee failed to identify and act upon quality deficiencies in the daily operation of the facility in which it did have, or should have had, knowledge. During the survey process, deficits in infection control practices and surety bond coverage were identified. Each had the potential to affect more than an isolated number of residents. There was no evidence these observable quality deficits were identified by the QAA Committee. Facility census: 38. Findings include: a) Surety Bond On 03/03/15 at 10:15 a.m., review of the current surety bond, which protects the monies held in the resident trust fund account, revealed the bond was for $10,000.00. The bank statements for the trust fund account for the most recent completed quarter ending in (MONTH) 2014 revealed the highest daily amount contained in the account was $18,505.67. The surety bond was not of a sufficient amount to cover the highest balance held in the account. During an interview on 03/04/15 at 1:30 p.m., the director of nursing and the administrator verified the amount of the surety bond had not been reviewed during the quality assurance committee meeting which was held in (MONTH) 2014. The bank statements reviewed were for October, November, and (MONTH) 2014. The timeframe in which these daily averages were higher than the bond amount should have been addressed by the QA committee. The QA committee should have addressed the need to increase the amount of coverage and implemented an action plan. b) Infection control 1) On 02/26/2015 at 11:09 a.m., Employee #28, a Licensed Practical Nurse (LPN), assisted by Employee #42 (NA) completed a dressing change of Resident #5's sacral pressure ulcer. Resident #5 was lying on his back with two (2) large cloth incontinence pads beneath him. Nurse Aide (NA) #42 assisted … | 2018-09-01 |
| 5620 | 5620 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2015-06-08 | 241 | D | 0 | 1 | X2G511 | Based on observation, staff interview, and facility policy and procedure review, the facility failed to maintain resident dignity for one (1) of two (2) residents reviewed for urinary catheter use during Stage 2 of the survey process. The resident's Foley catheter bag was not covered, and was in view of anyone at the resident's bedside. Resident identifier: #3. Facility census: 85 Findings include: a) Resident #3 On 06/04/15 at 9:28 a.m., observation revealed Resident #3 sitting on the side of her bed. The resident's Foley catheter bag was uncovered. Immediately after the observation, Nurse Aide (NA) #112 was asked about the uncovered catheter bag. She confirmed the catheter bag was uncovered, but stated she was unclear whether or not it should be covered when the resident was in bed. A copy of the facility's policy and procedure regarding Foley catheters was requested from the director of nursing (DON) on 06/04/15 at 10:00 a.m. Review of the facility's policy and procedure titled Closed Urinary Drainage System, with the director of nursing (DON) on 06/04/15 at 10:22 a.m., revealed the following (typed as written): 10. Ensure that closed urinary drainage systems bags are covered with a drainage bag. The DON confirmed this was the facility's policy and procedure, and it was not followed for Resident #3. | 2018-09-01 |
| 5621 | 5621 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2015-06-08 | 323 | E | 0 | 1 | X2G511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible. Simultaneous activation of the resident call system revealed the bedside call light (nurse call) canceled the resident bathroom call light (emergency/urgent call) when a resident needed assistance in the bathroom. This had the potential to affect all residents residing in semi-private rooms on East Wing #1 and East Wing #2. Room identifiers: #119, #120, #122, #123, #128, #130, #220, #221, #222, #224, #228, #229, #230, #232, and #233. Facility Census: 85. Findings include: a) On 06/03/15 at 9:09 a.m., activation of the call light in Room #220, revealed when the bathroom call light (emergency/urgent) was activated, and then the bedside call light (nurse call) was activated, the bathroom call light was inactivated. The only staff notification of the need for assistance was at the bedside and not the bathroom. Activation of the call light in Room #222, at 9:11 a.m. on 06/03/15, revealed the same issue with both the bedside call light and the bathroom call light in this room. b) An interview with the Maintenance Director, on 06/03/15 at 12:15 a.m., revealed he had worked at the facility for [AGE] years and to his knowledge, the call light system was wired according to the manufacturer's specifications. He stated he would check all call light systems. On 06/04/15 at 11:47 a.m., the maintenance director reported all semi-private rooms on East Wing #1 and East Wing #2 were affected. The bathroom light would not light or sound if the bedside call light was activated by another resident. The rooms were identified as Rooms #119, #120, #122, #123, #128, #130, #220, #221, #222, #224, #228, #229, #230, #232 and #233. The maintenance director agreed the call light system was not correct, and the bedside call light should not override the bathroom call light. In addition, the maintenance director stated he had fou… | 2018-09-01 |
| 5622 | 5622 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2015-06-08 | 425 | D | 0 | 1 | X2G511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of guidance provided by the facility's pharmacy, and Center for Disease Control and Prevention (CDC) recommendations, the facility, in collaboration with the pharmacist, failed to ensure the safe and effective use of medications. One (1) of four (4) medication storage room refrigerators contained a partially used multi-dose vial of Purified Protein Derivative (PPD), a medication injected beneath the skin to aid in the detection of exposure to [DIAGNOSES REDACTED], which was open for use for greater than the number of days directed by the manufacturer. This practice had the potential to affect an isolated number of residents. Facility census: 85. Findings include: a) Observation of the first floor West hall medication room refrigerator, on 06/03/15 at 9:37 a.m., revealed an opened and partially used one (1) milliliter (ml) ten (10) test vial of Purified Protein Derivative (PPD). Nursing staff inscribed the date of 04/17/15 on the vial and its box, indicating the date it was originally opened. Licensed Practical Nurse (LPN) #80 said this vial of PPD should have been discarded on 05/17/15, but was not. She estimated there was enough medication remaining to administer two (2) or three (3) more injections. She discarded the vial at that time. The Center for Disease Control and Prevention (CDC) guidelines for multi-dose vials included, . the United States Pharmacopoeia (USP) General Chapter 797 recommends the following for multi-dose vials of sterile pharmaceuticals: If a multi-dose vial has been opened or accessed (e.g. needle-punctured) the vial should be dated and discarded within twenty-eight (28) days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. During an interview with the director of nursing (DON), on 06/03/15 at 11:45 a.m., she said according to the manufacturer's guidelines, an opened vial of PPD serum must be thrown away after thirty (30) days, e… | 2018-09-01 |
| 5623 | 5623 | SUNDALE NURSING HOME | 515083 | 800 J D ANDERSON DRIVE | MORGANTOWN | WV | 26505 | 2015-06-08 | 441 | D | 0 | 1 | X2G511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of the facility's policy and procedure, the facility failed to maintain an effective infection control program to prevent, to the extent possible, the onset and spread of infections. A resident's Foley catheter bag was observed on the floor. This was true for one (1) of two (2) residents reviewed during Stage 2 for urinary catheter use. Resident identifier: #3. Facility census: 85. Findings include: a) Resident #3 A review of the medical record, on 06/04/15 at 9:15 a.m., revealed this [AGE] year old resident was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. On 06/04/15 at 9:28 a.m., an observation of Resident #3 revealed the Foley catheter bag was lying on the floor. In an interview with the assigned Nursing Assistant (NA) #12, she agreed the catheter bag was to be off the floor and was not. NA #12 removed the Foley catheter bag from the floor. A review of the facility policy and procedure, with the director of nursing (DON), titled Closed Urinary Drainage System, on 06/04/15 at 10:22 a.m., revealed the following: 3. Attach drainage bag to bed frame, below level of resident's bladder-not touching floor. The DON agreed this was the facility policy and procedure, and the facility did not follow the policy and procedure for Resident #3. | 2018-09-01 |
| 5624 | 5624 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2015-08-28 | 272 | D | 0 | 1 | ZQ4I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed accurately assess to ensure the accuracy of the information in the comprehensive assessment recorded on the MDS (minimum data set) in regards to the presence of and the number of pressure ulcers present on two (2) of seventeen (17) residents whose MDS's were reviewed. Resident identifiers: #57 and #239. Facility census: 25. Findings include: a) Resident #57 The closed medical record completed, on 08/27/15 at 8:20 a.m., revealed a nursing admission history assessment completed by Registered Nurse # 30 on 05/29/15. The nursing admission history assessment indicated the resident had 2+ [MEDICAL CONDITION] and a Stage I pressure ulcer, which was on her coccyx area and described as red. Treatment was started and a care plan addressed the area. The closed medical record revealed area was re-assessed on 06/06/15, and was then described as Stage II, measuring 0.5 X 0.5 X 0.1 cm and was then red peeling skin. On 06/13/15, the area was described as healing Stage II with red peeling / denuded skin. The Admission MDS on 06/05/15, indicated in Section M0210: The resident did NOT have one or more unhealed pressure ulcers at Stage 1 or higher. The 14-day MDS completed on 06/12/15, indicated in Section M0100: The resident had a stage 1 or greater pressure ulcer and in Section M0210 indicated the presence of one (1) unhealed pressure ulcer. Section M0300 indicated the pressure ulcer had originated on 06/06/15. During an interview with RN #63, (MDS Nurse) at 4:00 p.m. on 08/26/15, the closed medical record, including the wound care records, were reviewed and resulted in RN #63 acknowledging the information on the Admission MDS had been in error and the onset of the pressure ulcer should have been the admission date of [DATE], as stated on the admission assessment. b) Resident #239 A review of the closed medical record, on 08/26/15 at 8:30 a.m., revealed Resident #239 was a [AGE] year-old female adm… | 2018-09-01 |
| 5625 | 5625 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2015-08-28 | 356 | C | 0 | 1 | ZQ4I11 | Based on observation and staff interview the facility failed to post nurse staffing data in a clear and readable format in a prominent place readily accessible to residents and visitors. This has the potential to affect all residents. Facility census: 25. Findings include: a) During the initial tour, at 10:45 a.m. on 08/24/15, an observation of the daily staff posting of the direct care staff was made. The posting form was located at the nurses' station behind the charge nurse, approximately five (5) feet off of the floor. The information occupied an eight (8) by fourteen (14) inch sheet of paper and was a typed form filled in with hand-written figures. The daily posting form could not be easily read by the residents or visitors and could not be read by anyone in a wheel chair. This was acknowledged by the Director of Nursing (DON) on 08/26/15 at 2:10 p.m. The DON reported this was the only staff posting for the facility. | 2018-09-01 |
| 5626 | 5626 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2015-08-28 | 441 | E | 0 | 1 | ZQ4I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure they maintained an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. The facility did not ensure the proper cleaning of reusable items when removed from an isolation room. This had the potential to affect more than an isolated number of residents. Facility census: 25. Findings include: a) Resident #254 During observation of the medication pass administration, at 8:20 a.m. on 08/26/15, Registered Nurse (RN) #9 entered the room of Resident #254 who was in Contact Isolation due to the presence of Methicillin-resistant Staphylococcus aureus) MRSA in a knee wound. RN #9 took an [MEDICATION NAME] inhaler out of a drawer on the medication cart and handed it to Resident #254. After Resident #254 had self-administered the medication, RN #9 retrieved the inhaler and placed it back on the medication cart. RN #9 did not wipe off the inhaler. When this was brought to RN #9's attention she stated, I never thought about it. | 2018-09-01 |
| 5627 | 5627 | COLUMBIA ST. FRANCIS HOSPITAL | 515110 | 333 LAIDLEY STREET | CHARLESTON | WV | 25322 | 2015-08-20 | 253 | E | 0 | 1 | GJTV11 | Based on staff interview and observations of the facility environment failed to provide a sanitary, orderly environment for residents. Resident rooms had cosmetic imperfections such as: paint peeling from the doorframes, gouges in the wall and metal showing where plaster had been broken away from the wall. It was evident for six (6) of eight (8) rooms reviewed for residents in the Stage 1 sample. Room identifier numbers: #535, #536, #537, #541, #551 and #553. (The imperfections had been found in stage I of the QIS survey and confirmed in stage II when environment mandatory task triggered out for further investigation.) Facility census: 16. Findings include: Observation in Room #535, at approximately 1:41 p.m. on 08/17/15, revealed a toilet seat has brown substance on back of it,peeling paint on the door to bathroom, and black scuff mark noted on wall. Observation in Room #536, at approximately 1:23 p.m. on 08/17/15, revealed scratched area of paint on wall,door facing going into bathroom had paint off, and plaster missing off edge of wall where two walls join. Observation in Room #537 at approximately 1:13 p.m. on 08/17/15, revealed the wall behind head of bed had gouges and metal was showing where plaster was missing on the edge of where two walls join. Observation in Room #541, at approximately 9:15 a.m. on 08/18/15, revealed the outside of bathroom door had bare metal showing and plaster missing. Observation in Room #551, at approximately 1:26 p.m. on 08/17/15, revealed scratches and gouges above head of bed where a trapeze device had hit the wall, and metal was showing where plaster was missing from edge of where two walls join together. Observation in Room #553, at approximately 1:21 p.m. on 08/17/15, revealed the wall outside of the bathroom door had a piece of wall with plaster gouged out, paint was peeling inside bathroom door and there was a copper color stain behind the toilet. Interview with Maintenance Employee #42, on 08/19/15 at 1:30 p.m., verified all of the observed environmental issues noted. He … | 2018-09-01 |
| 5628 | 5628 | COLUMBIA ST. FRANCIS HOSPITAL | 515110 | 333 LAIDLEY STREET | CHARLESTON | WV | 25322 | 2015-08-20 | 325 | E | 0 | 1 | GJTV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident medical record information and staff interview, the facility failed to maintain adequate parameters of nutritional status for one (1) of one (1) residents reviewed for nutritional concerns. Resident #50 experienced a 6.5% weight loss in less than one month. Thisindicated a significant weight change based on guidelines which state a significant weight loss is 5% in one month. Resident identifier: #50. Facility census: 16. Findings include: a) Resident #50 Review, on 08/19/20 at 3:30 p.m., of the 14 day Minimum Data Set (MDS) assessment with an assessment reference date of 07/14/15 identified in section K a weight loss of 5% or greater. Registered Dietitian (RD) notes dated 07/13/15 showed the resident had a 6.5% weight loss in one week. At that time, no further interventions noted to address the weight loss. The resident weighed 123 pounds on 07/06/15 and then 115 pounds on 07/13/15. According to the RD care plan dated 07/01/15, the resident has slight weight gain, no restriction on diet, may ordering with room service, and likes vanilla Ensure and agreeable to drinking twice a day. Review of weight records show a 7 pound weight loss which equals is a 6.5% weight loss. The resident went from 123 pounds to 115 pounds between 07/06/15 to 07/13/15. Discussion with Employee #40, the RN supervisor, at 9:15 a.m. on 08/19/15, revealed residents weights are taken daily when a weight loss is identified. Resident #50 did not have her weight taken daily upon the noted weight loss. At 10:45 a.m on 08/19/15 Employee #40 informed surveyors the RD had completed an assessment which showed she identified a 6.5% weight loss. However, there was no further communication to nursing by the RD to ensure interventions implemented to prevent further weight loss Employee #40 stated she agreed the RD should have brought it to their attention. If she had, they would have decided on daily weights, the need for supplements, etc and developed a p… | 2018-09-01 |
| 5629 | 5629 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2014-11-19 | 279 | D | 0 | 1 | 149811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record reviews, review of facility policies, and observations, the facility failed to develop comprehensive care plans for pressure ulcers for two (2) residents of nineteen (19) residents whose care plans were reviewed. Resident #135 was admitted with a Stage IV pressure ulcer on the coccyx with a physician's orders [REDACTED]. The care plan for Resident #135 did not address the order for the use of [REDACTED]. Resident #128 was admitted with an unhealed Stage II pressure ulcer to the left heel, and an unstageable area to his coccyx/sacrum. The care plan did not address the need for pressure reduction devices to his bed or chair. Resident identifiers: #135 and #128. Facility census: 112. Findings include: a) Resident #135 Resident #135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with an unstageable pressure ulcer to the left foot and left heel and a Stage IV pressure ulcer on the coccyx. The resident's pressure ulcers were assessed and an air mattress was ordered for the resident. The current physician's orders [REDACTED]. The most recent care plan, dated 10/29/14, indicated the resident had a pressure ulcer and the potential for pressure ulcer development related to decreased mobility, incontinence, poor nutrition with protein level in hospital of one (1), admitted with Stage IV pressure ulcer to the coccyx and two (2) unstageable ulcers to the left inner foot resolved as of 10/29/14. The goals included the resident would have no further skin breakdown and the resident would have the current ulcers and the unstageable areas show signs of healing as evidenced by decrease in size and severity. The interventions included: Sacral wound: -- Clean sacral wound with normal saline solution. -- Pat dry. -- Apply skin prep to wound edges. -- Cover with calcium alginate and [MEDICATION NAME] every day and as needed. Unstageable pressure ulcer and preventative care: -- Clean unst… | 2018-09-01 |
| 5630 | 5630 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2014-11-19 | 282 | D | 0 | 1 | 149811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and observations, the facility failed to implement care plans for three (3) residents of nineteen (19) residents whose care plans were reviewed. Resident #101 had a care plan to address falls and the interventions identified on the care plan were not implemented. Specifically, the bed and chair alarms were not in place for this resident. Resident #135 had a care plan to address falls and the interventions identified on the care plan were not implemented. Specifically, the bed alarm and fall mats were not in place for this resident. Resident #72 had a nutrition care plan with interventions to provide and serve diet as ordered. The current physician order, following swallowing tests, included, mechanical soft diet with thin liquids via small cup sips only, no straws. Resident #72 was observed eating lunch with 3 drinks with straws on her bedside table. Resident identifiers: #101, #135, and #72. Facility census: 112. Findings include: a) Resident #101 Resident #101 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), dated [DATE], found it documented Resident #101 with a functional status as being totally dependent on two (2) staff members for bed mobility and transfers from the bed and she was noted to have had one (1) fall during the assessment window. Review of the current fall care plan revealed Resident #101 was at high risk for falls with a history of falls, involuntary body movements due to [MEDICAL CONDITION]'s chorea, and she moved around in her bed. Her care plan goal documented the resident would be free of injury related to falls. Further review of the fall care plan revealed interventions included, staff were to give her medication for abnormal movement/tremors and anxiety as ordered, keep the wheelie bars on back of wheelchair to keep her wheelchair from flipping over, mattress with built up sides on bed, non-skid socks or shoe… | 2018-09-01 |
| 5631 | 5631 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2014-11-19 | 314 | G | 0 | 1 | 149811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, resident interview, and review of facility policies, the facility failed to provide pressure relieving devices to promote the healing of an unstageable sacral wound for one (1) of three (3)residents reviewed for pressure ulcers. The facility failed to provide a pressure relieving/reduction cushion to Resident #128's wheelchair and an appropriate pressure relieving mattress to his bed to promote the healing of an unstageable pressure ulcer to his sacral area. The wound had increased in size from 5 cm x 6 cm x 2 cm on admission to 6 cm x 6.5 cm x .2 cm on 11/19/14. Resident identifier: #128. Facility census: 112. Findings include: a) Resident #128 This resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The admission nurse's notes, dated 09/24/14, documented a body audit revealed a suspected deep tissue wound measured at 3 centimeter (cm) x 3 cm on the residents left heel, a small red non-opened area to his right heel, a surgical scar to the mid back for a laminectomy with a small amount of light red drainage noted to the dressing, and an unstageable pressure ulcer to his sacrum the measured at 5 cm x 6 cm with 50% red granulation tissue and 50% dark yellow slough and a moderate amount of serosanguinous drainage noted. Review of the 5-day Minimum Data Set (MDS), dated [DATE], found it documented Resident #128 required the extensive assistance of two (2) staff for bed mobility and was dependent on the assistance of two (2) staff for all transfers. He was documented to have an indwelling Foley catheter and was frequently incontinent of bowel. This MDS documented Resident #128 was at risk for skin breakdown and was admitted with an unhealed Stage II pressure ulcers on his left heel, and his coccyx was documented as being an unstageable area of pressure. This MDS documented pressure reduction was applied to his bed upon admission, but there was no documentation indicatin… | 2018-09-01 |
| 5632 | 5632 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2014-11-19 | 323 | D | 0 | 1 | 149811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure that one (1) resident of three (3) residents reviewed for accidents received assistive devices to prevent accidents. Resident #101 was admitted to the facility with a history of falls and a [DIAGNOSES REDACTED]. The facility failed to ensure bed and chair alarms ordered by the physician and identified on the care plan were in use to prevent accidents for Resident #101. Resident identifier: #101. Facility census: 112. Findings include: a) Resident #101 Resident #101 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #101's most recent Minimum Data Set (MDS), dated [DATE], found it documented her functional status as being totally dependent on two (2) staff members for bed mobility and transfers from the bed and was noted to have one (1) fall during the assessment period. Review of the current fall care plan revealed Resident #101 was at high risk for falls, had a history of [REDACTED]. Her care plan goal documented the resident would be free of injury related to falls. Further review of the fall care plan revealed interventions to include staff are to give her medication for abnormal movement/tremors and anxiety as ordered, keep the wheelie bars on back of wheelchair to keep wheelchair from flipping over, mattress with built up sides to her bed, non skid socks or shoes at all times, alarm to bed when in bed, and safety mats to bilateral sides of bed. The physician orders, dated 04/24/14, revealed an order for [REDACTED].#101's bed at all times for safety measures and safety mats to both sides of her bed. Review of a care plan meeting note dated 11/18/14, revealed Resident #101 was alert and had unclear speech, rarely understood by others, rarely understands others, short and long term memory problems noted, lacks capacity to make medical decisions, requires total assistance with care, moves around in her bed, has involunt… | 2018-09-01 |
| 5633 | 5633 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2014-11-19 | 520 | D | 0 | 1 | 149811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and observations, the facility failed to maintain an effective Quality Assessment and Assurance committee that identified quality concerns and implemented corrective actions. The facility failed to ensure an effective system was in place for residents with pressure ulcers to receive the appropriate pressure reduction devices in their beds and chairs. As the facility failed to identify this quality deficiency, they had no plans of action to address the concern through their Quality Assessment and Assurance activities. Resident identifier: #128. Facility census: 112. Findings include: a) Resident #128 This resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The admission nurse's notes, dated 09/24/14, documented a body audit that revealed a suspected deep tissue wound measuring 3 centimeter (cm) x 3 cm on the residents left heel, a very small red non-opened area to his right heel, a surgical scar to mid back from laminectomy with a small amount of light red drainage noted to dressing, an unstageable pressure ulcer to his sacrum 5 cm x 6 cm with 50% red granulation tissue and 50% dark yellow slough with moderate amount of serosanguinous drainage noted. On 11/18/14 at 8:50 a.m. Resident #128 was observed to be seated in his wheelchair in his room and was noted be sitting on some type of cushion. He was also noted to have some type of pressure reduction mattress to his bed. The surveyor was unable to determine the the type of cushion or mattress that were being used during this observation. Director of Nursing (DON) #19 provided the manufacturer's recommendations for the mattress Resident #128 was currently using. There was no information indicating if the mattress was an appropriate mattress for a resident with an unstageable pressure area to the sacrum area. The surveyor researched and found information on the SPAN America website, which was the mattress manufacturer for the resid… | 2018-09-01 |
| 5634 | 5634 | MEADOWVIEW MANOR | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2015-04-16 | 160 | E | 0 | 1 | CDOG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's accounting records and staff interview, the facility failed to ensure resident funds were conveyed to the individual or probate jurisdiction administering the resident's estate according to State law. The deceased resident funds were distributed to individuals without appropriate authorization of individual or probate jurisdiction to administer the residents' estate for five (5) of five (5) residents reviewed for whom the facility managed funds. Resident identifiers: #2, #12, #81, #82, #83. Facility census: 55. Findings include: a) During resident fund review, Bookkeeper #21 reported five (5) residents whose funds were distributed after the death of the resident from (MONTH) of 2014 through (MONTH) of (YEAR). 1. Resident #2 had $31.50, which was distributed by check to an individual known by the resident. 2. Resident #12 had $5.00, which was distributed in cash to an individual known by the resident. 3. Resident #81 had $732.60, which was distributed by check to the resident's spouse. 4. Resident #82 had $20.00, which was distributed by check to an individual known by the resident. 5. Resident #83 had $113.56, which was distributed by check to an individual known by the resident. On [DATE] at 3:35 p.m., Bookkeeper #21 stated she was not aware regulations required deceased resident funds be distributed to an appropriate authorized individual or the probate jurisdiction administering the residents' estate. | 2018-09-01 |
| 5635 | 5635 | MEADOWVIEW MANOR | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2015-04-16 | 253 | E | 0 | 1 | CDOG11 | Based on observation and staff interview, the facility failed to provide housekeeping and/or maintenance services to maintain an orderly interior for seven (7) of thirty-three (33) resident rooms. Curtains were observed with unattached hooks, which caused the curtain to hang out of place. Resident rooms: #102, #10, #106, #112, #205, #209, and #212. Findings include: a) Observations during Stage 1 of the Quality Indicator Survey (QIS) found resident room curtains were unhooked and hanging out of place. During Stage 2 of the QIS, on 04/14/15 at 3:00 p.m., observation of all (33) resident rooms found the hooks were unatactched causing the curtains to hang out of place in the following rooms. -- Room #102 had two (2) hooks unattached. -- Room #104 had one (1) hook unattached. -- Room #106 had (1) hook unattached. -- Room #112 had (2) hooks unattached. -- Room #205 had (1) hook unattached. -- Room #209 had (1) hook unattached. -- Room #212 had three (3) hooks unattached. On 04/14/2015 3:49 p.m., the maintenance supervisor stated he would go through the facility that day and fix the curtains. | 2018-09-01 |
| 5636 | 5636 | MEADOWVIEW MANOR | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2015-04-16 | 279 | D | 0 | 1 | CDOG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a care plan based on the comprehensive assessment for one (1) of seventeen (17) sampled residents. A resident with [DIAGNOSES REDACTED]. Resident identifier: #42. Facility census: 55. Findings include: a) Resident #42 Review of the medical record, on 04/14/15 at 9:00 a.m., revealed this seventy-five (75) year-old resident came to the facility on [DATE]. The resident's admission [DIAGNOSES REDACTED]. Myelodysplasti[DIAGNOSES REDACTED] represents a group of myeloid (bone marrow) stem cell disorders that gradually affect the ability of a person's bone marrow to produce red blood cells, white blood cells, and platelets. This is associated with shortness of breath, feeling tired or weak, bruising or bleeding easily, etc. The admission minimum data set (MDS), with an assessment reference date (ARD) of 02/27/15, identified diagnoses, which included [MEDICAL CONDITIONS], and chronic [MEDICAL CONDITION]. During an interview with MDS Registered Nurse (RN) #37, on 04/14/15 at 11:30 a.m., she said the resident was not care planned for respiratory issues and the blood disorder, but that it should have been done. On 04/16/15 at 11:00 a.m., during an interview with the director of nursing (DON), the lack of care planning for respiratory issues and the blood disorder was discussed. The DON provided no further information prior to exit. | 2018-09-01 |
| 5637 | 5637 | MEADOWVIEW MANOR | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2015-04-16 | 282 | D | 0 | 1 | CDOG11 | Based on record review, staff interview, resident interview, and observation, the facility failed to provide services in accordance with a resident's care plan for one (1) of seventeen (17) residents whose care plans were reviewed during Stage 2 of the survey. The facility did not implement the pressure ulcer care plan interventions for a right elbow protector and bilateral heel protectors for a high-risk resident with a current in-house acquired pressure ulcer. Resident identifier: #36. Facility census: 55. Findings include: a) Resident #36 An observation of Resident #36, on 04/16/15 at 10:00 a.m., with Nurse Aide (NA) #48, found the resident had a suspected deep tissue injury (SDTI) on her right heel. Interventions in place included an air mattress and a device to prevent the heels from touching the bed, called heels off cushion. A review of the care plan, on 04/16/15 at 10:30 a.m., found interventions for both nurse and nurse aides to implement. These interventions included bilateral heel protectors, right elbow protector At 10:40 a.m. on 04/16/15, Licensed Practical Nurse (LPN) #2 identified herself as the nurse in charge of Resident #36 for that shift. Both LPN #2 and Registered Nurse (RN) #28, the charge nurse, stated they were unaware Resident #36 had the need for these preventative devices, and would have to check the medical record. At 10:50 a.m. on 04/16/15, NA #48 was asked if she knew the resident was supposed to wear an elbow protector and heel protectors. She stated, Not until (LPN #2) just told me. The form titled Guidelines for Daily Care, an individualized care plan based reference sheet taped in each resident's closet, was reviewed at 11:10 a.m. on 04/16/15. It stated, HIGH RISK FOR SKIN BREAKDOWN. It also had interventions under the skin care section for bilateral heel protectors and a right elbow protector. In an interview on 04/16/15 at 1:00 p.m., when asked about her elbow and heel protectors, Resident #36 stated she did not know where they were. When asked why she did not wear them, she sai… | 2018-09-01 |
| 5638 | 5638 | MEADOWVIEW MANOR | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2015-04-16 | 314 | D | 0 | 1 | CDOG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, and record review, the facility failed to provide care and services to prevent the development of new pressure ulcers for one (1) of three (3) Stage 2 residents reviewed for pressure ulcers. The resident, with a history of development of pressure ulcers, did not have physician ordered interventions in place. Resident identifier: #36. Facility censuses: 55. Findings include: a) Resident #36 Observation of Resident #36, on 04/16/15 at 10:00 a.m., with Nurse Aide (NA) #48, found the resident had a suspected deep tissue injury (SDTI) on her right heel. Interventions in place included an air mattress and a device to prevent the heels from touching the bed, called a heels off cushion. A review of the physician's orders [REDACTED]. At 10:40 a.m. on 04/16/15, an interview was conducted with Licensed Practical Nurse (LPN) #2, who identified herself as the nurse in charge of Resident #36 for that shift, and Registered Nurse (RN) charge nurse #28. When asked about the heel protectors and the right elbow protector, they stated they were unaware Resident #36 needed these preventative devices. They said they would have to check the medical record. At 10:50 a.m. on 04/16/15, NA #48 was asked if she knew the resident was supposed to wear an elbow protector and heel protectors. She stated, Not until (LPN #2) just told me. | 2018-09-01 |
| 5639 | 5639 | MEADOWVIEW MANOR | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2015-04-16 | 371 | E | 0 | 1 | CDOG11 | Based on observation and staff interview, the facility failed to store, prepare, and serve food in a sanitary manner. A dietary aide touched non-food items and then food items while wearing contaminated gloves. In addition, a plastic crate full of individual sized milk cartons was on the floor under the bottom shelf of the walk-in refrigerator. These practices had the potential to affect more than an isolated number of residents who received nourishment from the kitchen. Facility Census: 55. Findings Include: a) During the initial observations of the kitchen, on 04/09/15 at 11:12 a.m., Dietary Aide (DA) #51 did not use hygienic practices while preparing cookie plates for the noon meal. The DA touched non-food items and then food items, while wearing the same pair of gloves, five (5) consecutive times. DA #51 picked up cookies off a cookie sheet with her gloved hands, placed a cookie on a plate, wrapped the cookie plate with plastic wrap, and then placed the wrapped cookie plate on a serving cart. When she placed the plates on the cart, she grabbed and touched the handle and the side of the serving cart. DA #51 repeated this process five (5) times while wearing the same contaminated gloves. When made aware of this observation, Dietary Supervisor Assistant (DSA) #33 gave DA #51 a spatula and instructions to use the spatula to lift the cookies off the baking pan and transfer them to the plates. DSA #33 agreed the DA was handling the cookies while wearing contaminated gloves. An interview with Dietary Supervisor (DS) #1, on 04/16/15 at 4:20 p.m., verified DA #51 should have washed her hands and changed gloves between contact with non-food and food items. b) Observations at 11:15 a.m. on 04/09/15, during the initial tour of the kitchen, found a plastic crate full of individual sized milk cartons resting on the floor under the bottom shelf of the walk-in refrigerator. An interview with DS #1, on 04/16/15 at 4:20 p.m., revealed nothing was to be stored directly on the floor of the walk-in refrigerator. She stated, . whe… | 2018-09-01 |
| 5640 | 5640 | MEADOWVIEW MANOR | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2015-04-16 | 431 | E | 0 | 1 | CDOG11 | Based on observation and staff interview, the facility failed to ensure all medications and biologicals were stored properly. The medication room refrigerator was found unlocked. Controlled medications inside the refrigerator were not stored in a separately locked, permanently affixed location. Instead, the controlled medications were stored in taped and/or locked boxes which could be picked up and removed from the refrigerator. This had to the potential to affect more than a limited number of residents. Facility census: 55. Findings include: a) On 04/09/15 at 11:00 a.m., the facility's medication room was observed, accompanied by licensed nurse Employee #49. When initially attempting to inspect the medication room refrigerator, it was found unlocked. Inside the refrigerator was a small, clear, see-through plastic box which resembled one used for leftover food storage. Strips of bright pink tape secured the lid to the box. The box was not permanently secured to the refrigerator. This box contained Resident #37's hospice emergency medications, called a comfort care pack. It contained fifteen (15) milliliters (ml.) of liquid Morphine twenty (20) milligrams (mg.) per ml. and ten (10) Ativan one (1) mg. tablets. The former is a narcotic analgesic used to control pain, and the latter is a medication used to treat anxiety. Both are Schedule II narcotics. Substances in this schedule have a high potential for abuse. Next, a small metal box approximately ten (10) inches long by six (6) inches wide by three (3) to four (4) inches deep had its own lock and key, but was not permanently affixed to the refrigerator. The box could easily be picked up and removed from the refrigerator. Inside the box were three (3) unopened vials of two (2) milligram (mg.) per one (1) milliliter (ml.) vials of Ativan, and three (3) opened and partially used vials of two (2) mg. per ml. vials of Ativan, which belonged to Resident #26. The facility's emergency narcotic box was attached to a vinyl-coated shelf in the refrigerator. This box had its … | 2018-09-01 |
| 5641 | 5641 | MEADOWVIEW MANOR | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2015-04-16 | 441 | E | 0 | 1 | CDOG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy and procedure review, the facility failed to maintain an infection control program to prevent, to the extent possible, the transmission of infection. Random opportunities for observation revealed four (4) nursing assistants, and a registered nurse provided resident care and services while wearing contaminated gloves and/or with contaminated hands. Contaminated gloves were worn while providing catheter care for one (1) of 3 residents reviewed for catheter care during Stage 2 of the survey. Three (3) additional nursing assistants contaminated their hands while washing their hands, and then served meals to residents. Resident identifier: #6. Facility census: 55. Findings include: a) Resident #6 On 04/14/15 at 4:45 p.m., while observing perineal and catheter care for Resident #6, nursing assistant (NA) #84 donned gloves to provide the resident's care. The resident had a bowel movement (BM). He next touched the privacy curtains, clean wash clothes, the bathroom door knob, the bathroom cabinet door, the side rails, resident bed linens and resident clothing. Wearing the same gloves, NA #84 cleaned up the BM from the resident. The NA did not change the contaminated gloves before touching items in this resident's room and bed. In addition, when NA#84 removed the contaminated gloves, hand hygiene was not completed prior to donning clean gloves. At 4:55 p.m. on 04/14/15, Registered Nurse (RN) #38, entered Resident #6's room and began assisting NA #84 to complete the perineal and catheter care for this resident. After cleaning the BM from around the catheter, RN #38 was observed touching the bed control, side rail, over-the-bed table, bed linens, privacy curtains, and Resident #6's clothing before removing the contaminated gloves. In an interview with NA #84 and RN #38, on 04/14/15 at 5:10 p.m., both employees agreed they did not remove their contaminated gloves prior to touching multiple items in Residen… | 2018-09-01 |
| 5642 | 5642 | MEADOWVIEW MANOR | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2015-04-16 | 502 | D | 0 | 1 | CDOG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure timely laboratory (lab) services for one (1) of seventeen (17) sample residents. The facility had no evidence they had completed a two (2) physician's orders [REDACTED].#3. Resident Identifier: #3. Facility census: 55 Findings include: a) Resident #3 The medical record was reviewed on 04/15/15 at 10:00 a.m. The annual minimum data set (MDS), with assessment reference date (ARD) of 01/18/15, contained diagnoses, which included [MEDICAL CONDITION], hypertension, and [MEDICAL CONDITION] disorder. Recapitulation of physician's orders [REDACTED]. The physician ordered Chemistry eight (8) blood studies every six (6) months beginning 08/05/14, and TSH ([MEDICAL CONDITION] stimulating hormone) blood study annually from 02/19/13. There was no evidence that either of these two (2) lab tests were completed when due in (MONTH) (YEAR). Review of the medical record found the most recent results for the Chemistry 8 were on 08/05/15. The date of the most recent TSH result was 02/14/14. The physician prescribed the daily administration of [MEDICATION NAME] twenty-five (25) micrograms for [MEDICAL CONDITION]. The initial order date for the [MEDICATION NAME] was 12/02/13. Upon inquiry, on 04/15/15 at 11:55 a.m., the director of nursing (DON) said she was unable to locate the results for the Chem eight (8) or the TSH that were ordered by the physician for (MONTH) (YEAR). She produced the tickler file for (MONTH) that showed the resident was on the lab draw request on 02/05/15 for both the Chem eight (8) and the TSH. She said she would contact the lab and check for the results. During an interview with the DON, on 04/15/15 at 3:00 p.m., she said the Chem eight (8) and the TSH, which were ordered by the physician and scheduled for 02/05/15, were not done. | 2018-09-01 |
| 5643 | 5643 | MEADOWVIEW MANOR | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2015-04-16 | 514 | D | 0 | 1 | CDOG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure accurate and complete documentation for one (1) of three (3) residents reviewed for pressure ulcers, out of seventeen (17) Stage 2 sampled residents. There were incorrect assessment scores for a resident with multiple pressure ulcers. Resident identifier: #79. Facility census: 55. Findings include: a) Resident #79 Review of the medical record for a deceased resident, on [DATE] at 4:30 p.m., found Resident #79 had multiple pressure ulcers when admitted to the facility. The wound nurses used the Pressure Ulcer Scale for Healing (PUSH) Tool to score the level and type of pressure ulcers. A comparison of total scores measured over time provides an indication of the improvement or deterioration in pressure ulcer healing. The most recent pressure ulcer measurements for Resident #79 occurred on [DATE]: - Left heel PUSH score was fourteen (14) - Right heel PUSH score was twenty-four (24) - Right buttocks PUSH score was thirty-four (34) - Sacrum PUSH score was forty-four (44) At 9:45 a.m. on [DATE], after review of the PUSH scores for this resident, Registered Nurse (RN) #38, the staff development educator, said the [DATE] PUSH scores were computer errors. She said that instead of giving PUSH scores for each individual pressure ulcer, the computer erroneously added the scores together. She was not previously aware these PUSH scores were incorrect. After she reviewed the [DATE] measurements of the pressure ulcers for Resident #79, RN #38 said the PUSH scores should have been as follows: - Left heel PUSH score ten (10), rather than fourteen (14) - Right heel PUSH score ten (10), rather than twenty-four (24) - Right buttocks PUSH score ten (10), rather than thirty-four (34) - Sacrum PUSH score ten (10), rather than forty-four (44) Employee #38 said the [DATE] PUSH score for the left heel was fifteen (15), but should have been ten (10) instead. During an interview with the d… | 2018-09-01 |
| 5644 | 5644 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 154 | D | 0 | 1 | DSPZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, family interview, and staff interview, the facility failed to ensure the responsible party of a resident with a severe decline in health status was given information about the resident's reasonable available alternatives; including the option of palliative care. Resident identifier: 98. Facility census: 99. Findings include: a) Resident #98 A review of the clinical record revealed Resident #98 was a [AGE] year-old male initially admitted to the facility on [DATE]. He was determined by his physician to lack the capacity to make health care decisions and his brother was his medical power of attorney (MPOA). Resident #98 was designated to be a Full Code, meaning he was to be resuscitated should he stop breathing or his heart stop. His present [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED].#217 at 10:15 a.m. on 07/22/15. The resident had multiple hospitalization s in (YEAR). When discharged to the hospital on [DATE], his skin was clear with no pressure ulcers. On readmission on 04/02/15, his admission physical indicated [MEDICAL CONDITION] of his lower extremities, but no evidence of pressure ulcers. A Significant Change comprehensive assessment was completed on 04/09/15. An entry in the clinical record by NP #217 on 05/21/15, indicated the resident had multiple unstageable pressure wounds. His last readmission was 07/08/15 and although there was no terminal [DIAGNOSES REDACTED]. The record on readmission indicated Resident #98 was a Full Code. The record indicated Resident #98 now had 1 unstageable and 11 deep tissue injuries (DTIs) and the treatment goal stated by the NP/Physician was, Expectation is for non-healing with goal to prevent worsening of wounds. The care plan meeting notes from 07/19/15, indicated he was a full code; had recent cognitive changes and scored 0/15 on his brief interview for mental status (BIMS); and was refusing oral intake. There was no evidence of any … | 2018-09-01 |
| 5645 | 5645 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 155 | D | 0 | 1 | DSPZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to ensure the responsible party of a resident with a severe decline in health status was given information about the resident's rights regarding cardiopulmonary resuscitation and the facility's policies regarding exercising these rights. Resident identifier: #98. Facility census: 99. Findings include: a) Resident #98 A review of the clinical record revealed that Resident #98 was a [AGE] year old male initially admitted to the facility on [DATE]. He had been determined by his physician to lack the capacity to make health care decisions and his brother was indicated as his MPOA (Medical Power of Attorney). He was designated to be a Full Code. His present [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED].#217 at 10:15 a.m. on 07/22/15. The resident had multiple hospitalization s in (YEAR). When discharged to the hospital on [DATE], his skin was clear with no pressure ulcers and on readmission on 04/02/15, his admission physical indicated [MEDICAL CONDITION] of his lower extremities, but no evidence of pressure ulcers. A Significant Change comprehensive assessment was completed on 04/09/15. An entry in the clinical record by NP #217 on 05/21/15, indicated the resident had multiple unstageable pressure wounds. His last readmission was 07/08/15 and although there was no terminal [DIAGNOSES REDACTED]. The record on readmission indicated Resident #98 was a Full Code. The record indicated Resident #98 now had 1 unstageable pressure ulcer and 11 DTI's (deep tissue injury) and the treatment goal stated by the NP/Physician stated, Expectation is for non-healing with goal to prevent worsening of wounds. The care plan meeting notes from 07/19/15, indicated he was a Full Code; had recent cognitive changes and scored 0/15 on his BIMS (brief interview for mental status); and was refusing oral intake. There was no evidence of any discussion of the resident's status with the MPOA.… | 2018-09-01 |
| 5646 | 5646 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 166 | D | 0 | 1 | DSPZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, and family interview, the facility failed to make prompt efforts to resolve grievances a resident and/or representative may have. A family member reported she voiced multiple complaints and concerns regarding her family member's care and said, Nothing gets done. A resident reported he had voiced complaints about another resident for the past two and a half (2.5) years and said, It falls on deaf ears and, No one does anything. Resident identifiers: #90 and #18. Facility census: 99. Findings include: a) Resident #90 A medical record review on 07/27/15 at 10:55 a.m., found this resident was admitted to the facility 07/01/11 with [DIAGNOSES REDACTED]. A physician's progress note dated 07/06/15 stated, She is no longer verbal with the exception of a few occasional words, and, She has fallen due to her trying to get in or out of bed/chair without assistance but is unable to call or ask for assistance. The most recent recreation assessment completed on 07/15/15 asked, What are the most important parts of your typical daily routine at home? for which the response by the resident representative was, lay down and take naps after her meals. The current care plan stated Resident is to be offered to be laid down after breakfast and dinner, if she says no, offer again a little later. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/15 coded resident under Section G, Item G0110, as being totally dependent for transfers and needing two (2) staff members for assistance. During an interview with the resident's responsible party, on 07/23/15 at 10:30 a.m., she voiced concern regarding staff not following the care plan she agreed to in the care plan meeting. The staff at the meeting agreed her mother would be out of bed at certain times, and returned to bed at certain times. She said staff were not doing that. She also said she came in frequently and found her fam… | 2018-09-01 |
| 5647 | 5647 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 225 | G | 0 | 1 | DSPZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon resident interview, family interview, staff interview, record review, and review of facility documents, the facility failed to ensure residents were free from abuse and neglect, resulting in actual harm to Resident #120. The facility failed to immediately report all allegations as required by law, failed to consistently conduct thorough, complete investigations, failed to consistently follow its past practice for the protection of residents during investigations, and failed to identify an allegation of neglect. This was found for four (4) of twenty-two (22) allegations of abuse/neglect reviewed. Resident identifiers: #120, #183, #14, and #90. Facility census: 99. Findings include: a) Resident #120 Abuse/neglect reports submitted by the facility were reviewed on 07/22/15 at 1:00 p.m. There were three (3) reports of alleged abuse/neglect perpetrated against resident #120 between 02/01/15 and 07/06/15. Another allegation initially took place on 07/23/14. Resident #120's Brief Interview for Mental Status (BIMS) score, as assessed on 09/27/13 was 15. This indicated he was cognitively intact. He was determined by a physician to possess the capacity to make informed medical decisions and act as his own responsible party. His [DIAGNOSES REDACTED]. He was partially paralyzed and ambulated in a motorized wheelchair. He was being followed by a consultant psychiatrist for his anxiety, depression, and post-traumatic stress disorder ([MEDICAL CONDITION]). The review of reportable allegations found Resident #120 made allegations of verbal and emotional abuse by a physician and a nurse practitioner. Resident #120 was initially interviewed on 07/20/15 at 2:00 p.m. During this interview, he voiced both those allegations documented in the facility's abuse investigation files and had several other complaints as well. Two (2) of the reported allegations were reviewed and are described separately: 1. Allegation #1: The facility's report of alleged abuse… | 2018-09-01 |
| 5648 | 5648 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 241 | E | 0 | 1 | DSPZ11 | Based upon observation, resident interview, and staff interview, the facility failed to maintain and/or enhance residents' dignity and respect. Staff repeatedly opened the door to a resident's room and walked in without knocking first or asking permission to enter. Staff was not interacting with residents in the restorative dining room except when residents moved away from the tables or tried to leave the area. This was found for more than an isolated number of residents. Resident identifiers: #120, #15, and #93. Facility census: 99. Findings include: a) Resident #120 Resident #120 was reviewed, in part due to a complaint being investigated during the annual survey. Several different resident interviews were conducted with Resident #120 in his room as part of the investigation. An interview in Resident #120's room, on 07/20/15 at 2:00 p.m., revealed staff walked in the resident's room without knocking. The interview with Resident #120 lasted approximately one half (1/2) hour. During this time, the staff opened the door without saying anything. When the staff noticed the interview was taking place, they turned and left, quickly shutting the door behind them. An interview on 07/22/15 at 1:30 p.m., in Resident #120's room, with the door closed, revealed three (3) times facility staff opened the door to the room without knocking and walked in without saying anything. The interview lasted approximately one (1) hour. When the facility staff saw the interview taking place, they turned and quickly left, shutting the door behind them. An interview was conducted on 07/23/15 at 1:20 p.m., in Resident #120's room, with the door closed. The interview lasted approximately one half (1/2) hour. One (1) time, facility staff opened the door to the room without knocking and walked in without saying anything. When the staff member saw the interview in progress, the individual turned and left quickly, shutting the door behind him/her. No attempt was made to identify the staff members due to the priority of completing necessary interv… | 2018-09-01 |
| 5649 | 5649 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 248 | G | 0 | 1 | DSPZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, medical record review and staff interview, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. Resident #159 tearfully stated she was bored and had nothing to do except walk the hall or lie in bed and watch television (TV). This resulted in actual harm to Resident #159. In addition, the fourteen (14) residents eating in the restorative dining room were not provided activities prior to the meal service. This practice hae the potential to affect more than a limited number of residents. Resident identifiers: #159, #13, #17, #135, #93, #86, #32, #124, #24, #63, #112, #15, #125, #90, and #30. Facility census: 99. Findings include: a) Resident #159 Resident #159 was interviewed on 07/21/15 at 10:55 a.m. after she requested to speak with a surveyor. She was intermittently tearful during this interview and reported she normally has a very active social life, but since being admitted to the facility she was extremely bored and had nothing to do except lay on the bed and watch television or walk in the halls. Random observations on 07/20/15 and 07/21/15 found Resident #159 crying in the hall of the facility adjacent to the nurses' station. On both occasions, she was observed being escorted back to her room and heard saying she was bored and wanted to go home. Review of the medical record on 07/21/15 at 2:30 p.m., revealed Resident #159 was admitted to the facility on [DATE], she was transferred to acute care on 05/13/15 and returned to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 05/12/15, identified her activity preferences as having something to read such as books, paper and magazines, news and animals as somewhat important and music as very important. Resident #159's current care plan, marked as revi… | 2018-09-01 |
| 5650 | 5650 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 250 | D | 0 | 1 | DSPZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to ensure the responsible party of a resident with a severe decline in health status received appropriate medically-related social services prior to decision-making about the health care of the resident. Resident identifier: #98. Facility census: 99. Findings include: a) Resident #98 A review of the clinical record revealed that Resident #98 was a [AGE] year-old male initially admitted to the facility on [DATE]. The resident ' s physician determined the resident lacked the capacity to form health care decisions, and his brother was his Medical Power of Attorney (MPOA). He was designated to be a Full Code. His present [DIAGNOSES REDACTED]. On 05/21/15, after a physical examination by the attending physician, these [DIAGNOSES REDACTED]. They were also verified in a staff interview with Nurse Practitioner (NP) #217 at 10:15 a.m. on 07/22/15. The resident has had multiple hospitalization s in (YEAR). When discharged to the hospital on [DATE], his skin was clear with no pressure ulcers. On readmission to the facility on [DATE], his admission physical indicated edema of his lower extremities, but no evidence of pressure ulcers. A Significant Change comprehensive assessment was completed on 04/09/15. An entry in the clinical record by NP #217 on 05/21/15, indicated the resident had multiple unstageable pressure wounds. His last readmission was 07/08/15, and although there was no terminal diagnosis, the physician had indicated the resident's Rehab (rehabilitation) potential is poor. The record on readmission indicated Resident #98 was a Full Code. The record indicated Resident #98 now had 1 unstageable and 11 deep tissue injuries (DTIs) and the treatment goal stated by the NP/Physician stated, Expectation is for non healing with goal to prevent worsening of wounds. The care plan meeting notes from 07/19/15 indicated he was a Full Code; had recent cognitive changes and … | 2018-09-01 |
| 5651 | 5651 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 253 | E | 0 | 1 | DSPZ11 | Based on observation and staff interview the facility failed to provide effective housekeeping and maintenance services to prevent the persistent unpleasant odor of urine in a bathroom on a hallway located between the main lobby and the entry to the Assisted Living unit. The area was readily accessible to all residents, visitors, and/or staff. Additionally, doors of the Vintage dining room and the Resident lounge/activities room were marred and in need of repair. Facility census: 99. Findings include: a) At 10:30 a.m. on 07/20/15, Guest Services Director #213, who was located at the reception desk in the main lobby, was asked for the location of a bathroom. She advised against the one closest to her desk on the hallway leading to the Assisted Living unit. She said, It smells very bad An observation of the bathroom revealed it did smell badly of stale urine, although the room appeared clean with no stains and the exhaust fan was running. A second observation of the bathroom at 2:00 p.m. on 07/21/15, also found the same strong urine odor. The third observation, accompanied by Maintenance Supervisor #202 at 12:45 p.m. on 0722/15, revealed the same odor. He said the room was cleaned often, but several male residents who hung out in the lobby area used the bathroom during the day. The smell was attributed to this. There was no type of odor dispeller in use. There were several male residents seen daily during the survey in the lobby area. During an interview with the Administrator, at 4:00 p.m. on 07/23/15, the observation was relayed to her, and she stated they were, Working on it. b) During the initial tour of the facility on 07/20/15 at 10:30 a.m., the exterior of the doors to the Vintage dining room and the Resident lounge/activities room were observed with chipped and marred areas near the hinge jamb. During an interview on 07/22/15 at 12:15 p.m., the Administrator said there must have been a strip on that part of the door at one time. On 07/22/15 at 1:30 p.m., these finding were discussed with Maintenance Directo… | 2018-09-01 |
| 5652 | 5652 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 258 | E | 0 | 1 | DSPZ11 | . Based on observation, resident interview, and staff interview, the facility failed to ensure maintenance of comfortable sound levels for three (3) Stage 2 sample residents who were reviewed for the environment facility task. The three (3) door alarms on the 300 hall (the exterior glass doors used by staff as entrance and exit doors) were not maintained at an acceptable noise level for residents. This practice had the potential to affect more than an isolated number of residents residing on the 300 hallway. Resident identifiers: #117, #3, and #21. Facility census: 99 Findings include: a) On 07/20/15 at 11:40 a.m., observations revealed several staff repeatedly exiting door #11 (exterior glass door located between rooms #311 and #312), causing the door alarm to sound. The door alarm sound was very loud, shrill, and deafening. Licensed Practical Nurse (LPN) #203 and Nurse Aide (NA) #127 were present at the nurses' station and witnessed this observation. They both agreed the door alarm was, Way too loud. LPN #203 notified maintenance to try to turn down the sound on the alarms, so it would not be so loud. At 11:00 a.m. on 07/21/15, a resident set off the door alarm to door #11 and Speech Therapist (ST) #61 redirected the resident. Neither ST #61, nor a nearby housekeeper were aware of the code to turn off the door alarm. The door alarm continued to sound for five (5) minutes before a staff member responded and used a code (numbered keypad located by the door) to turn off the alarm. b) Resident #117 During an interview with Resident #117 on 07/21/15 at 8:30 a.m., he stated there were many door alarms going off, because of the staff exiting the doors a lot and setting off the alarms. Resident #117 stated, It is bad enough in the day because it really hurts your ears, but it is worse at night and affects me trying to sleep. c) Resident #3 On 07/22/15 at 1:15 p.m., in an interview with Resident #3, she stated, Yes the door alarms are loud and it scares me. They are so loud and no one is sure what is going on when they … | 2018-09-01 |
| 5653 | 5653 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 272 | E | 0 | 1 | DSPZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview, the facility failed to conduct an accurate comprehensive assessment for residents related to having anticoagulation therapy (Resident #124), urinary incontinence (Resident #101), dentures (Resident #61), and [MEDICAL TREATMENT] treatments (Resident #72). This practice was found during a review of the minimum data set (MDS) assessments for four (4) of twenty-six (26) sample residents during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #124, #101, #61, and #74. Facility census: 99 Findings include: a) Resident #124 On 07/22/15 at 11:00 a.m., medical record review for Resident #124 revealed an admission date of [DATE] and a re-admission date of [DATE]. His [DIAGNOSES REDACTED]. As a treatment for [REDACTED]. On 06/05/15, he was changed to Xarelto (an anticoagulant medication) 15 mg po daily ordered and a dosage change on 06/19/15 for Xarelto 20 mg po daily. At 1:00 p.m. on 07/22/15 a review of the significant change MDS with an assessment referenced date (ARD) date of 06/11/15, revealed Section N, Item (N0410) Anticoagulant was coded as 0 days. This meant the resident had not recieved an anticoagulant in the past seven (7) days. During an interview with Clinical Record Consultant (CRC-RN) #209 on 07/22/15 at 4:00 p.m., after reviewing the MDSs, she agreed and verified the 06/11/15 MDS was inaccurate. She stated she did not think of the medication as being an anticoagulant medication and it should be coded as such on the MDS. b) Resident #101 On 07/23/15 at 8:20 a.m., Nurse Aide (NA) #182 was observed providing incontinence care per facility policy, infection control standards and standards of care. A medical record review conducted for Resident #101 on 07/23/15 at 9:15 a.m., revealed her admitting [DIAGNOSES REDACTED]. The activities of daily living (ADL) forms reveal documentation by the NAs describing Resident #101, as always incontine… | 2018-09-01 |
| 5654 | 5654 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 279 | D | 0 | 1 | DSPZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to develop and/or revise a comprehensive care plan based on a resident's current health condition/status that included measurable objectives and timetables to meet a resident's medical, nursing and psychosocial needs. Two (2) of twenty-six (26) Stage 2 sample residents whose care plans were reviewed during the Quality Indicator Survey (QIS) were affected. Resident #124's care plan did not address anticoagulation therapy. Resident #159's care plan did not address activities. Resident identifiers: #124 and #159. Facility census: 99. Findings include: a) Resident #124 On 07/22/15 at 11:00 a.m., a medical record review conducted for Resident #124, revealed an admission date of [DATE] and a re-admission date of [DATE]. His [DIAGNOSES REDACTED]. As a treatment for [REDACTED]. He was changed to Xarelto 15 mg po daily ordered on [DATE] and a dosage change on 06/19/15 for Xarelto 20 mg po daily. At 1:30 p.m. on 07/22/15, a review of the care plan dated 06/22/15 for Resident #124, revealed an absence of a focus, goal and interventions related to his anticoagulation therapy. During an interview with Clinical Record Consultant (CRC) #209 on 07/22/15 at 4:00 p.m., after reviewing the care plan for Resident #124, she agreed and verified the care plan did not contain any plan related to anticoagulation therapy. She stated she had not thought of the medication as being an anticoagulation medication and he should have been care planned for anticoagulant therapy, with goals and interventions. A copy of the care plan for Resident #124 was provided by CRC #209 on 07/28/15 at 10:55 a.m. She commented the care plan was corrected after the interview on 07/22/15 to reflect focus, goals and interventions related to anticoagulation therapy. b) Resident #159 Resident #159 was interviewed on 07/21/15 at 10:55 a.m. after she requested to speak with a surveyor. She was intermitten… | 2018-09-01 |
| 5655 | 5655 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 280 | D | 0 | 1 | DSPZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to revise the care plan as the resident's health status changed as evidenced by the failure to address the onset of urinary incontinence in a resident who was formerly always continent and/or the development of a deep tissue injury requiring treatment ordered by the physician for one (1) of 26 residents in the sample. Resident identifier: #132. Facility census: 99. Findings include: a) Resident #132 Review of the clinical record for Resident #132, at 3:00 p.m. on 07/27/15, revealed him to be a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He had no skin breakdown on admission. A review of the skin integrity report written on 06/25/15, revealed the development of a deep tissue injury wound to the dorsal area of the right thigh measuring 2 cm (centimeters) X 2 cm with no drainage. The physician ordered [MEDICATION NAME] to R (right) Dorsal thigh qs (every shift) X 14d (days) then re-eval (re-evaluate). The wound was re-evaluated on 07/02/15, and had increased to 2.5cm X 2.5cm with serosanguinous drainage present. The physician then changed the treatment orders to: Cleanse back of R (right) thigh DTI (deep tissue injury) with wound cleanser. Apply Hydrogel + Border DSG (dressing) daily + PRN (as needed). The care plan had not been revised to indicate the presence of an active wound; there was no measurable goal for healing; and no interventions planned. The active care plan initiated on 03/03/15 indicated only the need for prevention and monitoring. The care plan also failed to address the resident's occasional urinary incontinence which developed after admission. A review of the Significant Change MDS (minimum data set) of 04/22/15, revealed in Section V that the resident had triggered for urinary incontinence and indicated a decision had been made to care plan the problem; but that had not been done. There had been a care plan meeting o… | 2018-09-01 |
| 5656 | 5656 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 282 | D | 0 | 1 | DSPZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview, the facility failed to provide services by qualified persons in accordance with each resident's written plan of care. A responsible party reported a resident's care plan was not implemented and a complaint was filed. Resident identifier: #90. Facility census: 99. Findings include: a) Resident #90 Medical record review on 07/27/15 at 10:55 a.m. found this resident was admitted to the facility 07/01/11 with [DIAGNOSES REDACTED]. A physician's progress note dated 07/06/15 stated, She is no longer verbal with the exception of a few occasional words, and, She has fallen due to her trying to get in or out of bed/chair without assistance but is unable to call or ask for assistance. The most recent recreation assessment completed on 07/15/15 asked, What are the most important parts of your typical daily routine at home? for which the response by the resident's representative was, Lay down and take naps after her meals. The current care plan stated, Resident is to be offered to be laid down after breakfast and dinner, if she says no, offer again a little later. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 04/23/15, coded the resident under Section G as being totally dependent and requiring two (2) staff members for transfers. During an interview with the resident's responsible party on 07/23/15 at 10:30 a.m., she voiced concern regarding staff not following the care plan she agreed to in the care plan meeting. She said the staff at the meeting agreed her mother would be out of bed at certain times, and returned to bed at certain times. She said staff were not doing this. She said she had always reported concerns and there should be records of them. During an interview with the Administrator on 07/28/15 at 10:00 a.m., she provided a copy of a complaint made to her by the responsible party dated 07/01/15. The complaint described two (2) occasions of Resident… | 2018-09-01 |
| 5657 | 5657 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 328 | D | 0 | 1 | DSPZ11 | Based on resident interview, observation, medical record review, and staff interview, the facility failed to ensure a resident received needed foot care and treatment. Resident #159's toenails were long, thick, protruding upward, and causing the resident discomfort. The resident was not seen by the visiting podiatrist on multiple occasions although she was present in the facility at the time of his visits. This was found for one (1) resident who requested an interview. Resident identifier: #159. Facility census: 99. Findings include: a) Resident #159 Resident #159 was interviewed on 07/21/15 at 10:55 a.m., after she requested to speak with a surveyor. She reported she had requested to see the podiatrist during his visits to the facility on multiple occasions and each time was told she was not on the list. She pulled off her sock to display her long, thick, and upward protruding nails that were causing discomfort. Review of the medical record, on 07/21/15 at 11:15 a.m., revealed Resident #159 was initially admitted to the facility on the A wing for therapy on 05/05/15. She was transferred to acute care on 05/13/15 and returned to the A wing on 05/20/15 for further therapy. On 07/07/15, she was transferred to the B wing for long term care. Her physician orders did not include a consult with the visiting podiatrist. Licensed Practical Nurse (LPN) #208 reviewed the medical record during an interview on 07/21/15 at 11:30 a.m. She confirmed there were no orders in Resident #159's medical record for a consult with the visiting podiatrist. LPN #208 examined the resident's feet and agreed she needed to have nail care by the podiatrist. The Director of Nursing (DON) and LPN #203 were interviewed on 07/21/15 at 12:40 p.m. They were unaware of the resident's long thick toenails or that the resident has not seen the podiatrist since her admission. During a follow up interview with the DON on 07/21/15 at 5:00 p.m., he reported the podiatrist visited monthly and examined residents on either the A wing or the B wing. He was on t… | 2018-09-01 |
| 5658 | 5658 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 329 | D | 0 | 1 | DSPZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the physician responded to a pharmacy recommendation for reduction of an antipsychotic medication in a timely manner. This practice was found for one (1) of five (5) Stage 2 sample residents reviewed for unnecessary medications. Resident identifier: #33. Facility census: 99. Findings include: a) Resident #33 On 07/28/15 at 8:30 a.m., a medical record review revealed Resident #33 was admitted on [DATE] and readmitted after a hospitalization on [DATE] with [DIAGNOSES REDACTED]. She was currently receiving the medication [MEDICATION NAME] 0.25 milligrams (mg) by mouth daily in the morning and 5 mg by mouth at bedtime for the [DIAGNOSES REDACTED]. A pharmacy consultation report dated 01/06/15, revealed the resident was receiving [MEDICATION NAME] 0.5 mg twice a day (BID) and recommended reducing the dose to 0.25 mg am (morning) and 0.5 mg hs (bedtime). The report was signed by the physician with an illegible date and signed by the Director of Nursing with the date of 03/07/15. A physician order, dated 03/08/15, was (typed as written) D/C [MEDICATION NAME] 0.5 mg bid (twice a day). Start [MEDICATION NAME] 0.25 mg po Qam (every morning) and 5 mg po QHS (every bedtime) for delusions. The report also contained a comment (typed as written); REPEATED RECOMMENDATION from 11/4/2014: Please respond promptly to assure facility compliance with Federal regulations. After reviewing the Pharmacy consultation report on 07/28/15 at 10:15 a.m., the DON stated, I am not sure what happened, it was a delay on our part to respond to the recommendation. I will try and locate the (MONTH) recommendation report since it is not in the chart. On 07/28/15 at 10:40 a.m., a telephone interview was conducted with Consulting Pharmacist #220 with the DON present. The pharmacist verified she did send a recommendation to the facility and attending physician in (MONTH) 2014. It was not acted upon, so … | 2018-09-01 |
| 5659 | 5659 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 371 | F | 0 | 1 | DSPZ11 | Based on observation and staff interview, the facility failed to maintain proper maintenance and sanitation in the kitchen by failing to maintain the cleanliness of a ceiling vent and a proper hand-washing sink. This had the potential to affect all residents. Facility census: 99. Findings include: a) During an observation of the kitchen at 7:45 a.m. on 07/22/15, accompanied by Dietary Managers #116 and #149, the ceiling vent in the dish-room was noticed to exhibit surface rust, which was advanced to the degree it could fall onto the surfaces below where clean dishes and utensils were stored. Dietary Manager #149 stated he would contact maintenance immediately to have it refinished. The metal sink used for handwashing was in disrepair. The faucet leaked continually and, due to the extremely small size of the sink, resulted in the floor beneath and around the sink being wet. In addition, the caulking around the metal sink was missing in places causing gaps that could harbor debris, microorganisms, and moisture. Dietary Manager #149 stated he would contact maintenance to have it repaired. | 2018-09-01 |
| 5660 | 5660 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 425 | D | 0 | 1 | DSPZ11 | Based on observation, staff interview, and review of recommendations from the Centers for Disease Control and Prevention (CDC), the facility, in coordination with the licensed pharmacist, failed to ensure medications were stored and labeled in a manner that ensured the potency and safety of the medications. Multi-dose vials of insulin were dated when opened on one (1) of four (4) halls where medication carts were observed. This practice had the potential to affect two (2) residents who received insulin from the 300-hall medication cart. Resident identifiers: #132 and #62. Facility census: 99. Findings include: a) Resident #132 Inspection of the 330-medication cart on 07/22/15 at 1:15 p.m., revealed an opened, partially full bottle of Novolog for Resident #132 with the date 05/28/15 written on one side of the box. On a different side of the box, the date 05/29/15 was written. Licensed Practical Nurse (LPN) #164, who was present for the inspection, said the facility practice was to discard opened insulin vials within a month after opening. Although it was unclear on which date the vial was opened because of the two (2) different dates on the box, LPN #164 agreed that over a month had passed since the open date and the vial should be discarded. b) Resident #62 The inspection of the 330-medication cart on 07/22/15 at 1:15 p.m. also revealed an opened vial of Lantus insulin for Resident #62. Neither the vial or the box it was packaged in had a date to indicate when staff had opened it. LPN #164 who was present during the inspection agreed there was no way of knowing when the vial was opened and stated it should be discarded and replaced. c) During an interview with the Director of Nursing (DON) on 07/22/15 at 2:30 p.m., he said the policy was for the nurse to check the throw away date prior to administering insulin, discard it after 28 days, and then order a new vial. He provided a policy used by the facility on Injectable Medications, last revised 03/31/15. On the subject of Insulin Vials, it stated, All vials should… | 2018-09-01 |
| 5661 | 5661 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 465 | E | 0 | 1 | DSPZ11 | Based on observation and staff interview, the facility failed to provide a safe and sanitary environment for staff. Two (2) of two (2) portable computers used by nursing staff for documentation were found to be extremely dirty. One of these was used only by the wound care nurse. This had the potential to affect more than a limited number of staff and residents. Facility census: 99. Findings include: a) A portable computer on wheels labeled Awing #1 was presented to the surveyors on 07/20/15 for use during the annual survey. The computer was noted to have food crumbs and dust on the keyboard and mouse pad and the top shelf was full of debris, including a broken Christmas ornament covered in dust and hair, candy wrappers, lollipop stick, dust balls and a saline syringe. On 07/20/15 at 3:20 p.m., Registered Nurse (RN) #169 confirmed the Awing #1 computer was used daily by the staff for charting. During an interview on 07/21/15 at 12:30 p.m., Licensed Practical Nurse (LPN) #203 provided a second computer on wheels that was used daily by the wound care nurse. This computer was found to be covered in dirt, dust and tiny particles of debris throughout the keyboard. LPN #203 confirmed the wound care nurse's computer needed cleaned. | 2018-09-01 |
| 5662 | 5662 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 514 | D | 0 | 1 | DSPZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview, the facility failed to maintain accessible, accurate and/or complete medical records for three (3) of twenty-six (26) residents whose medical records were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #124 had an incomplete Medication Administration Record [REDACTED]. Resident #132 had an inaccurate medical record pertaining to his current health status. Resident identifiers: #124, #33, and #132. Facility census: 99. Findings include: a) Resident #124 On 07/22/15 at 11:00 a.m., medical record review for Resident #124 revealed an admitting [DIAGNOSES REDACTED]. ) 400, along with an injection of 10 units of Humalog insulin before meals and at bedtime (HS). Documentation on the MAR for (MONTH) (YEAR), on 06/05/15 at 1700 (5:00 p.m.), identified a fingerstick blood sugar of 221. This was within the prescribed parameters, but lacking documentation for the insulin injection. There was an absence of documentation for both the fingerstick and the injection of insulin on 06/11/15 at 2100 (9:00 p.m.), 06/14/15 at 1700 (5:00 p.m.) and 06/14/15 at 1100 (11:00 a.m.). After reviewing the (MONTH) (YEAR) MAR for Resident #124 on 07/22/15 at 3:00 p.m., Licensed Practical Nurse (LPN) #203, verified there were blank areas on the noted dates. She stated, I cannot truly say if the blood sugars were done or if the insulin was given. They are to be charted always. b) Resident #33 On 07/28/15 at 8:30 a.m., a medical record review revealed Resident #33 was admitted on [DATE] and readmitted after a hospitalization on [DATE]. Resident #33 was currently receiving [MEDICATION NAME] 0.25 milligrams (mg) by mouth daily in the morning and 5 mg by mouth at bedtime for the [DIAGNOSES REDACTED]. A pharmacy consultation report dated 01/06/15, revealed the resident was receiving [MEDICATION NAME] 0.5 mg twice a day (BID) and the pharmacist recommended reducing the dose… | 2018-09-01 |
| 5663 | 5663 | WAYNE NURSING AND REHABILITATION CENTER | 515168 | 6999 ROUTE 152 | WAYNE | WV | 25570 | 2015-01-13 | 278 | D | 0 | 1 | Z71511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Section N of Resident #11's minimum data set assessment accurately reflected the use of a hypnotic medication during the assessment reference period. This was evident for one (1) of eighteen (18) current residents in the Stage 2 sample. Resident identifier: #11. Facility census: 59. Findings include: a) Resident #11 During review of the medical record, on 01/13/15 at 11:00 a.m., it was discovered the current care plan and physician orders [REDACTED]. According to the Medication Administration Record [REDACTED]. The quarterly MDS assessment, with an assessment reference date of 12/02/14, did not identify in Section N, related to medications, the resident had received any hypnotic medications during the required seven (7) day look back period. When this was reviewed with Director of Nursing #81, on 01/13/15 at 11:15 a.m., she verified according the Medication Administration Record [REDACTED]. | 2018-09-01 |
| 5664 | 5664 | WAYNE NURSING AND REHABILITATION CENTER | 515168 | 6999 ROUTE 152 | WAYNE | WV | 25570 | 2015-01-13 | 279 | D | 0 | 1 | Z71511 | **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 for a resident experiencing pain that included measurable goals and described the services to be provided. This was found for one (1) of eighteen (18) Stage 2 sample residents. Resident identifier: #50. Facility census: 59. Finding include: a) Resident #50 On 01/12/15, a review of the medical record revealed on 09/20/14 the physician had ordered [MEDICATION NAME] solution 0.25 milligrams (mg) to be given every three (3) hours as needed for pain. The Medication Administration Record [REDACTED]. Review of the resident's care plan found it did not include measurable goals and did not provide non-pharmacologic and/or pharmacologic interventions for pain management. In an interview, on 10/12/15 at 1:45 p.m., with the director of nursing (DON), she verified the care plan did not address pain management or any interventions for pain management for this resident. | 2018-09-01 |
| 5665 | 5665 | PINE VIEW NURSING AND REHABILITATION CENTER | 515184 | 400 MCKINLEY AVENUE | HARRISVILLE | WV | 26362 | 2015-01-21 | 225 | F | 0 | 1 | XRGM11 | Based on employee personnel file review, review of Chapter 514.4.1 of the Medicaid manual and certification memorandum from the Bureau for Medical Services (BMS) regarding the requirements for criminal background checks to meet the requirements of the Affordable Care Act, staff interview, and review of facility policy, the facility failed to ensure criminal background investigations were completed for all employees prior to hire and every three (3) years thereafter throughout the remainder of employment. Eight (8) of fifteen (15) employees reviewed were found to not have required criminal background checks. The facility failed to complete criminal background investigations for two (2) employees (#10 and #42) at the time of hire. The facility also failed to incorporate in its policy a requirement for criminal background checks every three (3) years throughout the remainder of an individual's employment as required by BMS to meet the requirements of the Affordable Care Act. Six (6) employees (#46, #62, #68, #26, #69 and #13) who had worked in the facility for more than three (3) years, were found to not have had a criminal background check repeated by (MONTH) 1, 2014 as directed by BMS. This practice had the potential to affect all residents. Employee identifiers: #46, #62, #10, #42, #68, #26, #69, and #13. Findings include: a) On 01/20/15 at 11:00 a.m., a review of personnel files for new and tenured employees with Bookkeeper #20, identified the following: 1. Nurse Aide (NA) #46 A review of the personnel file for Nurse Aide (NA) #46, hired on 12/06/09, revealed a background check dated 11/14/10. The 11/14/10 background check was not timely, and no repeat background check had been conducted by (MONTH) 1, 2014 as required by BMS to meet the requirements of the ACA. 2. Activities Director #62 Review of the personnel file for Activities Director #62, hired 01/27/97, revealed no evidence of a statewide criminal background check completed since her date of hire. 3. Housekeeper #10 A review of the personnel file of House… | 2018-09-01 |
| 5666 | 5666 | PINE VIEW NURSING AND REHABILITATION CENTER | 515184 | 400 MCKINLEY AVENUE | HARRISVILLE | WV | 26362 | 2015-01-21 | 226 | F | 0 | 1 | XRGM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on employee personnel file review, staff interview, policy review, and review of Chapter 514.4.1 of the Medicaid manual and certification memorandum from the Bureau for Medical Services (BMS) regarding the requirements for criminal background checks to meet the requirements of the Affordable Care Act (ACA), the facility failed to develop and implement written policies and procedures to screen current and/or potential employees for a history of abuse, neglect, or mistreatment of [REDACTED]. The facility failed to complete criminal background investigations for two (2) employees (#10 and #42) at the time of hire. The facility also failed to incorporate in its policy a requirement for criminal background checks every three (3) years throughout the remainder of an individual's employment as required by BMS to meet the requirements of the Affordable Care Act. Six (6) employees (#46, #62, #68, #26, #69 and #13) who had worked in the facility for more than three (3) years, were found to not have had a criminal background check repeated by (MONTH) 1, 2014 as directed by BMS. This practice had the potential to affect all residents. Employee identifiers: #46, #62, #10, #42, #68, #26, #69 and #13. Findings include: a) On 01/20/15 at 11:00 a.m., a review of personnel files for new and tenured employees with Bookkeeper #20 identified four (4) employees with either no statewide criminal background checks or no background checks for more than three (3) years. 1. Nurse Aide (NA) #46 A review of the personnel file for Nurse Aide (NA) #46, hired on 12/06/09, revealed a background check dated 11/14/10. The 11/14/10 background check was not timely, and no repeat background check had been conducted by (MONTH) 1, 2014 as required by BMS to meet the requirements of the ACA. 2. Activities Director #62 Review of the personnel file for Activities Director #62, hired 01/27/97, revealed no evidence of a statewide criminal background check completed since her date … | 2018-09-01 |
| 5667 | 5667 | PINE VIEW NURSING AND REHABILITATION CENTER | 515184 | 400 MCKINLEY AVENUE | HARRISVILLE | WV | 26362 | 2015-01-21 | 323 | E | 0 | 1 | XRGM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards, over which it had control, as possible. The door to the soiled utility room, located between both orange and blue halls, was observed unlocked. The soiled utility room contained potentially hazardous items such as chemicals and contaminated items. This had the potential to affect all residents within the facility who were ambulatory or mobile in wheelchairs. Facility census: 53 Findings include: a) On 01/19/15 at 11:15 a.m., the soiled utility room located between both orange and blue halls was found unlocked with tuberculocidal (able to kill Mycobacterum [DIAGNOSES REDACTED]) disinfectant spray under the sink, a large trash barrel containing refuse, soiled linen, and a hopper. There was no lock to allow the soiled utility room to be secured/locked. 1. The disinfectant spray bottle included the following labeling: -- Keep out of reach of children -- Note to physician---probable mucosal damage may contraindicate the use of gastric lavage. -- Caution---if swallowed call the poison control center. 2. The refuse, soiled linen, and hopper (where bedpans and urinals were cleaned), had the potential to transmit pathogenic microorganisms to residents should they access the area. c) At 11:25 a.m., Medical Secretary #51 said the room had never been locked and there was no way to lock the room. All staff used the soiled utility room to clean equipment and to dispose of trash and soiled linen d) At 11:35 a.m., Assistant Director of Nursing (ADON) #69 was asked about the soiled utility door not being locked. She stated she had been there for four (4) years and the door had never been locked, in fact there was no lock on the door. She agreed it was a resident safety safety issue after being shown the bottle of tuberculocidal disinfectant spray located under the sink in the unlocked soiled utility room. She immediately remov… | 2018-09-01 |
| 5668 | 5668 | PINE VIEW NURSING AND REHABILITATION CENTER | 515184 | 400 MCKINLEY AVENUE | HARRISVILLE | WV | 26362 | 2015-01-21 | 356 | C | 0 | 1 | XRGM11 | Based on observation and staff interview, the facility failed to post the nurse staffing data in a clear and readable format in a prominent place readily accessible to residents and visitors. This had the potential to affect all residents. Facility census: 53. Findings include: a) During the initial tour of the facility, at 11:30 a.m. on 01/19/15, an observation of the daily staff posting of the direct care staff found the posting form was located in the secured area behind the nurses' station. This was approximately four (4) feet from access by a resident or the general public. The information occupied the top half of an 8 inch X 11 inch sheet of paper and was a typed form filled in by handwritten figures. Residents and/or visitors could not easily read the form. This was acknowledged by the Director of Nurses at 3:20 p.m. on 01/20/15. She also acknowledged it was the only posting in the facility. | 2018-09-01 |
| 5669 | 5669 | PINE VIEW NURSING AND REHABILITATION CENTER | 515184 | 400 MCKINLEY AVENUE | HARRISVILLE | WV | 26362 | 2015-01-21 | 441 | E | 0 | 1 | XRGM11 | Based on observation, staff interview, and facility policy review, the facility failed to provide an environment to help prevent the development and transmission of disease and infection. There was a failure to ensure staff members adhered to posted isolation signage precautions. A staff member failed to wear the personal protective equipment (PPE) identified on the posted sign before entering a resident's isolation room. This practice had the potential to affect more than a limited number of residents. Resident identifier: #69. Facility census: 53. Findings include: a) Resident #69 The initial tour of the facility, on 01/19/15 at 11:00 a.m., noted an orange contact precaution isolation sign attached to the door facing of Resident #69's room. There was also an over-the-door isolation container containing PPE. The isolation signage included, 3. Wear gown to enter the room. Discard gown in the room. Do not re-use. 4. Wear gloves when entering room. Change after contact with infective material. In an interview at 11:05 a.m., with Licensed Practical Nurse (LPN) #50, she stated Resident #69 was in isolation due to Methicillin-resistant Staphylococcus Aureus (MRSA) in her urine. She was in a private room and wore a brief because she was incontinent of urine. On 01/19/15 at 1:07 p.m., a staff member entered Resident #69's room wearing only gloves. When she exited the room, she introduced herself (as Employee #14) and said her job title was Hospitality Aide. Upon asking if she was supposed to wear a gown, she stated, No I was just picking up her lunch tray. When she reviewed the isolation signage, she stated, Yes, I should have worn a gown to go into the room, my bad. At 1:15 p.m. on 01/19/15, during an interview with LPN #45, she commented she was the nurse on the orange hall, but did not have Resident #69's room. During the interview she stated, Yes, everyone knows to wear a gown upon entering the room because she is in contact isolation and the only resident in the facility in isolation. A review of the copy of the in… | 2018-09-01 |
| 5670 | 5670 | PINE VIEW NURSING AND REHABILITATION CENTER | 515184 | 400 MCKINLEY AVENUE | HARRISVILLE | WV | 26362 | 2015-01-21 | 490 | F | 0 | 1 | XRGM11 | Based on review of facility personal files, staff interview, and facility policy review, 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. There was a failure to comply with Federal and State regulations, codes, and guidelines and/or facility policy. Procedures to fully meet the mandated deadline for West Virginia statewide criminal background checks were not effectively implemented. This had the potential to affect all residents. Facility census: 53 Findings include: a) A memorandum from the West Virginia Bureau for Medical Services (BMS) was sent to all West Virginia long term care providers on 2/15/13. The memorandum stated in part: At a minimum, a fingerprint-based, state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout West Virginia, the Bureau for Medical Services will allow the nursing facilities until (MONTH) 1, 2014 to have all current employees up to date with criminal investigation background checks. Once the current employee has completed the background check, this will start the employees on their three year rotation for fingerprint based checks. b) A citation was recommended by the survey team for failure to comply with statewide criminal background checks. This was recommended under at a level of scope and severity having the potential to affect all residents living in the facility. Review of facility policy for abuse prohibition found the facility pledged to adhere to all local, state, and federal laws and directives in an effort to protect all residents under their care. Interviews with administrative staff were conducted in the formulation of those findings and showed admin… | 2018-09-01 |
| 5671 | 5671 | PINE VIEW NURSING AND REHABILITATION CENTER | 515184 | 400 MCKINLEY AVENUE | HARRISVILLE | WV | 26362 | 2015-01-21 | 500 | D | 0 | 1 | XRGM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, review of Appendix PP of the Centers for Medicaid and Medicare Services State Operations Manual, and facility record review, the facility failed to ensure an agreement was in place with the entity providing [MEDICAL TREATMENT] services that met professional standards and principles that apply to professionals providing service and the timeliness of the services. This affected one (1) of one (1) resident reviewed for [MEDICAL TREATMENT] services in Stage 2 of the Quality Indicator Survey. Resident identifier: #70. Facility census: 53. Findings include: a) Resident #70 Clinical record review for Resident #70 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission physician orders [REDACTED]. The clinical record revealed the resident had gone to [MEDICAL TREATMENT] on 01/12/15, 01/14/15, 01/16/15, and 01/19/15. On 01/20/15 at 11:42 a.m., upon inquiry, Office Manager #63 stated, I don't know if we have a [MEDICAL TREATMENT] contract. (Resident #70's name) was setup for [MEDICAL TREATMENT] prior to admission. On 01/20/15 at 11:47 a.m., Assistant Administrator #91 stated, I don't think we have a [MEDICAL TREATMENT] contract. We just continued treatment with the same place that he (Resident #70) had prior to admission. Residents can choose several different locations for [MEDICAL TREATMENT]. On 01/20/15 at 1:33 p.m., the Administrator stated, I didn't know until a few minutes ago that (resident's name) was going to an independent contract [MEDICAL TREATMENT] center. We do not have a contract with them. I have placed a call to the [MEDICAL TREATMENT] center to obtain one. b) The expectations, outlined in the interpretive guidelines for 483.25 of the Centers for Medicaid and Medicare Services, Appendix PP of the State Operations Manual include, When [MEDICAL TREATMENT] is provided in the facility by an outside entity, or the resident leaves the facility to obtain [M… | 2018-09-01 |
| 5672 | 5672 | NELLA'S NURSING HOME | 5.1e+35 | 200 WHITMAN AVENUE, CRYSTAL SPRINGS | ELKINS | WV | 26241 | 2015-02-19 | 225 | D | 0 | 1 | VV3811 | Based on record review and staff interview, the facility failed to complete thorough investigations into the past histories for two (2) of five (5) employees whose personnel files were reviewed. Background checks through the Nurse Aide Registry program were not completed upon hire. This practice had the potential to affect more than an isolated number of residents. Employee identifiers: #52 and #55. Facility census: 68. Findings include: a) The personnel file of Employee #52, maintenance employee, was reviewed on 02/18/15 at 4:00 p.m. Employee #52 was hired on 10/30/13. There was no evidence a Nurse Aide Registry search was performed. b) The personnel file of Employee #55, laundry employee, was reviewed on 02/18/15 at 4:00 p.m. Employee #55 was hired on 06/04/13. There was no evidence a Nurse Aide Registry search was performed. c) This matter was discussed with Employee #20, secretary, on 02/19/15 at 1:00 p.m. She stated she could not find evidence of a Nurse Aide Registry search on either employee. | 2018-09-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );