cms_WV
Data source: Big Local News · About: big-local-datasette
228 rows where "filedate" is on date 2019-01-01
This data as json, copyable, CSV (advanced)
Suggested facets: inspection_date (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5285 | 5285 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2015-05-12 | 225 | C | 0 | 1 | ORJG11 | Based on personnel record review, review of the requirements for criminal background checks in West Virginia, review of the Bureau for Medical Services manual and memorandum, and staff interview; the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. 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 five (5) employee files reviewed. This had the potential to affect more than a limited number of residents. Employee identifier: #42. Facility census: 181.Findings include: a) Employee #42 On 04/27/15 at 4:21 p.m., a review of personnel files found one (1) of five (5) employees hired by the facility had no fingerprints, or criminal background checks based on fingerprinting, in their files. The file contained a criminal background check completed based on Nurse Aide #42's social security number. Employee #42 was hired on 03/16/15. In a discussion with the Administrator and director of nursing at 4:21 p.m. on 04/27/15, the administrator indicated Nurse Aide #42's fingerprinting had been scheduled and then rescheduled. On 05/12/15 at 11:00 a.m., the administrator provided evidence the nurse aide had fingerprints completed on 04/21/15. The facility received the results on 04/27/15. The administrator said Employee #42 had been scheduled to for fingerprinting prior to the hire date of 03/16/15. Employee #42 missed the appointment. The administrator and director of nursing said 04/21/15 was the earliest date the fingerprints could be rescheduled. However, the facility had no evidence that this was the earliest date the fingerprints could be rescheduled. On 05/12/15 at 2:15 p.m., the director of nursing provided timecard information that showed Nurse Aide #42 had worked 29 days from 03/16/15 through 04/26/15 prior to the facil… | 2019-01-01 |
| 5286 | 5286 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2015-05-12 | 314 | D | 0 | 1 | ORJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure that one (1) of three (3) residents reviewed for pressure ulcers resident did not develop pressure sores unless the individual's clinical condition demonstrated they were unavoidable. The facility also failed to ensure one (1) of three (3) residents received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The facility failed to identify, assess, and treat two (2) wounds for Resident #156. The resident had a wound located on the anterior aspect of the right first toe and one on the anterior aspect of the right third toe. Resident #156 also had a Stage 2 pressure ulcer on the buttocks. Resident identifier: #156. Facility census: 181. Findings include: a) Resident #156 A random observation, on 04/28/15 at 10:46 a.m., revealed two (2) black wounds: one (1) located on the anterior aspect of Resident #156's right first toe and one (1) on the anterior aspect of the right third toe. Restorative Aide #86, related he had not reported the areas because staff was aware of their presence. He later reported he was mistaken about the wounds. Licensed Practical Nurse (LPN) #151, Registered nurse (RN) #105 and unit manager entered the room during the observation. Upon inquiry, neither nurse identified the areas, or knew how they were acquired. Medical record review, on 04/21/15 at 10:53 a.m., provided no information related to the wounds. Further review of the medical record, on 04/28/15 at 12:30 p.m., revealed no physician's orders, progress notes, assessments, or nursing notes related to the toes. Additionally, the wound was not identified on the skin assessment dated [DATE]. A physician's progress note, dated 04/28/15 indicated the wounds were acquired due to friction rub resulting in observed abrasions. An interview with LPN #10, the wound care nurse, related he had not been informed of the resid… | 2019-01-01 |
| 5287 | 5287 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2015-05-12 | 323 | E | 0 | 1 | ORJG11 | Based on observation and staff interview the facility failed to provide an environment that was free from accident hazards over which the facility had control. Both elevators had sharp jagged broken edges on the elevator's back panel and a cleaning product containing bleach was used on urine. This practice had the potential to affect more than an isolated number of residents. Facility census: 181. Findings include: a) Random observations during the initial tour of the facility, which started at 11:20 a.m. on 04/20/15, revealed accident hazards on both elevators the residents used to go from their rooms on the third and fourth floors to the dining room on the first floor. Both elevators had broken panels at the back wall of the elevators. The rear panel on both elevators had a chunk of panel missing which left sharp jagged broken edges at the height level of wheel chair foot rests. Maintenance repaired the elevators rear panels after surveyor intervention. b) Random observations during the initial tour and throughout the survey on the third and fourth floors revealed multiple areas where urine odors were noted. The initial tour inspection of resident's bathrooms on the third and fourth floor found even though the bathrooms appeared clean and unsoiled there still remained lingering urine odors of various strengths in different bathrooms. On 04/23/15 at 10:33 a.m. an interview with Housekeeping Staff #186, revealed some residents .have accidents and urine soaks into the tiles around the commode and it is hard to get the smell out. When it is real bad I use tilex. It has bleach in it to help get the odors up . On 04/23/15 at 11:03 a.m. an interview with the Environmental Services Director concerning urine odors in the facility revealed the facility is aware and have discussed it in meetings and have replaced several toilets, removed tile, and re-caulked some of the toilets, and a recent estimate to install a flooring coating has been obtained to try to address the urine odor issue. Invoices, receipts and meeting note… | 2019-01-01 |
| 5288 | 5288 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2015-05-12 | 425 | E | 0 | 1 | ORJG11 | Based on observation and staff interview, the facility failed in collaboration with the pharmacist to ensure a safe and effective use of medications. The facility did not dispose of expired medication and ointments in the medication storage rooms. Expired Heparin (used to treat and prevent blood clots in the veins, arteries, or lungs) and petroleum jelly (skin protectant ointment) was found inside the medication storage rooms. This had the potential to affect more than a limited number of residents. Facility census: 181. Findings include: a) Medication storage room on fourth - floor Observation and tour of the fourth - floor medication storage room on 04/21/15 at 8:30 a.m. with Unit Manager (UM) #22, revealed forty-five (45) packets of five (5) gram (GM) Curad petroleum jelly skin protectant ointment with the expiration date of 03/14. UM #22 stated the night shift nurse was to review the medication storage room nightly and any medication/ointments that were expired were to be discarded. UM #22 confirmed the ointment should have been discarded. b) Medication storage room pulmonary/old building (OB) unit A review and tour of the pulmonary/OB unit's medication storage room with UM #105 on 04/21/15 at 9:12 a.m., found thirty-two (32) individual Heparin lock flush solution five (5) milliliter (ml), one - hundred (100) units/ml with the expiration date of 02/15. UM #105 confirmed the heparin flush had expired and needed discarded. c) In an interview on 04/27/15 at 12:00 p.m., the director of nursing (DON) stated the facility's pharmacist came into the facility and completed a monthly audit of expired medication/ointments that were found inside their medication storage rooms. The DON revealed the pharmacist just did an audit, and the audit revealed there were no expired medication/ointments found within the medication storage room prior to the start of the survey. The DON stated, The pharmacist must have not identified during the audit that staff had not discarded the expired Heparin and petroleum jelly skin protectant … | 2019-01-01 |
| 5289 | 5289 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2015-05-12 | 431 | E | 0 | 1 | ORJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and the facility's guidelines for medication administration, the facility failed to ensure safe medication storage. A medication cart was found to be unlocked, unattended and out of the sight of a nurse. This had the potential to affect more than an isolated number of residents. Facility census: 181. a) Medication cart on the old building (OB) unit. A random observation on 04/28/15 at 4:33 p.m., revealed a medication cart was down the OB hallway at room [ROOM NUMBER]. The medication cart drawer was facing the hallway, and an observation revealed the drawer was not locked. The medication cart was unattended and out of the sight of a nurse. The observation of the unlocked medication cart occurred for two (2) minutes. At 4:35 p.m. on 04/28/15, the Unit coordinator registered nurse (UC-RN) #172 walked down the hall and locked the medication cart. UC-RN #172 stated she was not the nurse administering medications from this cart. She said, The cart needs locked. She said licensed practical nurse (LPN) #29 was passing medication from the cart. On 04/28/15 at 4:39 p.m., LPN #29 came walking down the hall to the medication cart on the OB unit outside of room [ROOM NUMBER]. LPN #29 said she was passing medication from this cart. LPN #29 confirmed she was told by the staff that she had left the medication cart unlocked and out of her sight. She stated, It is my fault. During an interview with the director of nursing (DON) on 04/28/15 at 7:15 p.m.; the DON provided the facility's guidelines on medication administration. The guidelines revealed the medication cart should be locked and positioned to ensure resident safety and privacy. The policy also stated to keep the cart within the line of sight when administering medications. | 2019-01-01 |
| 5290 | 5290 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2015-10-08 | 157 | D | 0 | 1 | NC4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to promptly notify the attending physician and/or the healthcare decision maker of changes in condition for two (2) of two (2) residents reviewed for the care area of notification of change. Resident #7 experienced a significant weight loss and the attending physician and healthcare decision maker was not promptly notified. For Resident #58, the facility failed to immediately inform the resident's physician of blood sugars less than 40 as directed by the physician. Resident Identifiers: #7 and #58. Facility Census: 53. Findings Include: a) Resident #7 A review of Resident #7's medical record at 1:41 p.m. on 10/06/15, found the following weights recorded: -- 08/31/15 - 177.5 pounds, -- 09/01/15 - 177.5 pounds, -- 09/08/15 - 169.0 pounds, -- 09/15/15 - 159.0 pounds, -- 09/21/15 - 158.0 pounds, -- 10/01/15 - 150.0 pounds. From 08/31/15 to 09/01/15, Resident #7 lost 8.5 pounds. She then lost another 10 pounds from 09/08/15 to 09/15/15, and an additional nine (9) pounds from 09/15/15 to 10/01/15. Review of Resident #7's progress notes found a note written by the dietitian, dated 09/22/15, which addressed Resident #7's significant weight loss of 19.5 pounds since her admission to the facility on [DATE]. The dietitian's progress note indicated the weight loss was likely contributed to the [MEDICAL CONDITION] which was present upon admission to the facility. Review of the residents' urine output record since admission found the resident had larger than normal amounts of urine output on an almost daily basis and her [MEDICAL CONDITION], which was present on admission, had subsided. The resident's record indicated she had a [DIAGNOSES REDACTED]. Review of the nursing progress notes and the physician progress notes [REDACTED].#7's attending physician was notified of the resident's significant weight loss. An interview with the Director of Nursing (DON) and the Certified Dietary Manager (CDM… | 2019-01-01 |
| 5291 | 5291 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2015-10-08 | 272 | D | 0 | 1 | NC4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately complete a comprehensive minimum data set (MDS) for two (2) of twenty-three (23) Stage 2 sampled residents. Resident #7's admission MDS did not accurately reflect the amount of assistance she required with eating. Resident #63's annual MDS did not accurately reflect all of her active diagnoses. Resident Identifiers: #7 and #49. Facility Census: 53. Findings Include: a) Resident #7 A review of Resident #7's admission MDS, with an assessment reference date (ARD) of 09/07/15, found for Item G0110H1 - Eating, self-performance was coded with a zero indicating the resident was independent with eating with no help or staff oversight needed. In an interview, at 10:00 a.m. on 10/07/15, Licensed Practical Nurse (LPN) #82 stated the admission MDS was inaccurate at G0110H1. When asked if Resident #7 had a decline in eating since admission to the facility, she stated, No. She indicated that the MDS should have indicated supervision because the resident always ate her meals in the dining room, where staff supervised and cued all the residents during meal time. LPN #82 indicated she made a mistake on Resident #7's admission MDS. b) Resident #49A review of Resident #49's medical record, completed on 10/06/2015 at 2:00 p.m., revealed the resident was admitted to the facility on [DATE]. On 07/24/15, the attending physician completed a History and Physical for Resident #49. The assessment and plan included, [AGE] year old female with progressive [MEDICAL CONDITION] . comfort care and refer to hospice. The medical record contained an admission MDS with an assessment reference date (ARD) of 07/30/15. This MDS, under Item J1400 - Prognosis, reflected Resident #49 did not have a condition or chronic disease that might result in a life expectancy of less than six (6) months. The Centers for Medicare & Medicaid Services Long Term Care Facility Resident Assessment Instrument User's Manual Ve… | 2019-01-01 |
| 5292 | 5292 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2015-10-08 | 278 | D | 0 | 1 | NC4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately assess one (1) of five (5) residents reviewed for the care area of unnecessary medications. Two (2) Quarterly Minimum Data Set (MDS) assessments did not accurately reflect the resident's active [DIAGNOSES REDACTED].#63. Facility census: 53. Findings include: a) Resident #63 Resident #63 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident also had a readmission date of [DATE], following an admission to a behavioral health unit, due to hallucinations and [MEDICAL CONDITION]. On 10/06/15 at 12:45 p.m., a review of the physician's orders [REDACTED]. One (1) order was for [MEDICATION NAME] 1 milligram (mg) by mouth one (1) time a day for [MEDICAL CONDITION]. The other order was for [MEDICATION NAME] 2.5 mg by mouth at bedtime for [MEDICAL CONDITION]. Prior to the orders written on 08/27/15, the resident was receiving [MEDICATION NAME] 1 mg by mouth one (1) time a day for [MEDICAL CONDITION], and 2 mg by mouth at bedtime for [MEDICAL CONDITION]. At 1:00 p.m. on 10/06/15, the previous two (2) Quarterly MDS assessments, with assessment reference dates of 05/19/15 and 08/18/15, were reviewed. Section I (Active Diagnoses), under the Psychiatric/Mood Disorder at I5950 ([MEDICAL CONDITION] (other than [MEDICAL CONDITION])), was unchecked on both assessments. A review of the care plan for Resident #63, on 10/06/15 at 1:15 p.m., found a focus area identified the resident used the antipsychotic medication [MEDICATION NAME]. The care plan indicated its use was related to [MEDICAL CONDITION] with recurrent episodes of psychotic behavior, auditory hallucinations; hears music and voices at night. The [MEDICATION NAME] was increased on 08/27/15. On 10/06/15 at 2:10 p.m., the Quarterly MDS assessments, with ARDs of 05/19/15 and 08/18/15, Section I, were reviewed with MDS Nurse #82. When asked about Section I5950 specifically, she said she missed chec… | 2019-01-01 |
| 5293 | 5293 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2015-10-08 | 309 | E | 0 | 1 | NC4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide the necessary care and services to each resident to maintain and/or attain the resident's highest practicable well-being for one (1) of one (1) resident reviewed for the care area of [MEDICAL TREATMENT], in a sample of twenty-four (24) facility residents. The facility failed to follow physician's orders [REDACTED].#58; failed to hold Resident #58's medications on multiple occasions when the resident's heart rate was below the physician ordered parameters; and failed to notify the physician as directed when Resident #58's blood sugar was below 40. The failure to notify the physician of the episodes of [DIAGNOSES REDACTED] and/or slow heart rate, did not provide the physician the opportunity to determine whether dosage adjustments to the resident's medications were needed. Resident identifier: #58. Facility census: 53. Findings include: a) Resident #58 1. Review of the resident's medical record found physician's orders [REDACTED]. There was another order to administer [MEDICATION NAME] 1 milligram (mg) intramuscularly (IM) STAT (immediately) for blood sugars of 40 or less and to repeat the resident's blood sugars in 15 minutes and until the blood sugar was stable at 100. Staff failed to notify the physician when the resident's blood sugars were less than 40, failed to administer [MEDICATION NAME] immediately, and failed to recheck the resident's blood sugars when the resident's blood sugars were less than 40 on: -- 09/23/15 at 6:30 a.m. blood sugar was 39. -- 09/29/15 at 6:30 a.m. blood sugar was 26. 2. Medical record review found another physician's orders [REDACTED]. Repeat finger stick in fifteen (15) minutes and repeat orange juice if needed every 15 minutes. According to the resident's Medication Administration Record, [REDACTED] -- 09/01/15- blood sugar was 48. -- 09/04/15- blood sugar was 55. -- 09/09/15- blood sugar was 47. -- 09/14/15- blood sugar was 48. -- 09/… | 2019-01-01 |
| 5294 | 5294 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2015-10-08 | 329 | E | 0 | 1 | NC4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of six (6) residents reviewed for unnecessary medications, during Stage 2 of the Quality Indicator Survey (QIS), was free from unnecessary medications. There was no rationale or discussion of the benefits for the use of two (2) medications in the same pharmacological classification. Additionally, Resident #58 was administered [MEDICATION NAME] and [MEDICATION NAME] when his pulse (heart rate) fell outside of the physician established parameters. Resident identifier: #58. Facility census: 53. Findings include: a) Resident #58 On 10/07/15, medical record review at 12:30 p.m. found Resident #58 was admitted to the facility on [DATE].1. Review of the Medication Administration Record [REDACTED]. (milligrams) PO (by mouth) daily for [DIAGNOSES REDACTED]. Review of the consultant pharmacist's Chronological record of drug regimen review, completed on 10/07/15 at 1:15 p.m., revealed the consultant pharmacist had conducted a monthly review of Resident #58's medication regimen monthly since 04/17/14 with NI (no irregularities) and no RM (recommendations made) at any review. Further review of the medical records, on 10/07/15, found no evidence the physician addressed the use of multiple antidepressant medications ([MEDICATION NAME] and [MEDICATION NAME]). Neither the physician, nor the pharmacist addressed risks and/or benefits of the concurrent use of [MEDICATION NAME] and [MEDICATION NAME], both of which have serotonergic activity with the potential to place the resident at risk of serotoni[DIAGNOSES REDACTED] and/or cardiac arrhythmias. 2. Additionally, Resident #58 received [MEDICATION NAME] and [MEDICATION NAME]. The physician's orders [REDACTED]. a. [MEDICATION NAME] tablet 200 mg po (by mouth) daily for treatment of [REDACTED]. On the following dates at 6:00 a.m., the medication ([MEDICATION NAME]) should have been held, but was not. --09/13/15- heart rate was 52. --… | 2019-01-01 |
| 5295 | 5295 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2015-10-08 | 371 | E | 0 | 1 | NC4111 | Based on observation and staff interview, the facility failed to store foods in a manner which ensured sanitary conditions. Food items stored in the nourishment room refrigerator were not labeled to indicate the date of preparation and/or dates they should be discarded. This had the potential to affect more than an isolated number of residents. Facility census: 53. Findings include: a) Nourishment room An observation of the nourishment room refrigerator, at 12:05 p.m. on 10/05/15, with Licensed Practical Nurse (LPN) #20 revealed the following sanitation infractions: -Two (2) sandwiches, with no date of preparation and/or date to discard. - A bag of food from a local restaurant, with no date as to when the food was prepared and no date to discard. LPN #20 stated she believed the sandwiches were from the previous evening's snacks sent from the kitchen. She immediately discarded the food items. At 10:41 a.m., on 10/08/15, these findings were discussed with Dietary Manager (DM) #16. The DM stated kitchen staff were responsible for dating and labeling the food items they prepared and for cleaning the nourishment room refrigerator. | 2019-01-01 |
| 5296 | 5296 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2015-10-08 | 428 | E | 0 | 1 | NC4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility's pharmacist failed to identify and report a medication irregularity for one (1) of six (6) residents reviewed for unnecessary medications. The resident's medication regimen included duplicate antidepressant therapy (Lexapro and Trazodone) for which there was no rationale for use and/or evidence of necessity. Resident identifier: #58. Facility census: 53. Findings include: a) Resident #58 On 10/07/15, medical record review, at 12:30 p.m., found Resident #58 was admitted to the facility on [DATE].Review of the Medication Administration Record [REDACTED]. (milligrams) po (by mouth) daily for [DIAGNOSES REDACTED]. Review of the consultant pharmacist's Chronological record of drug regimen review completed on 10/07/15 at 1:15 p.m., revealed the consultant pharmacist had conducted a monthly review of Resident #58's medication regimen monthly since 04/17/14 with NI (no irregularities) and no RM (recommendations made). The pharmacist failed to identify the concomitant use of Trazodone and Lexapro, both of which have serotonergic activity. This had the potential to place the resident at risk of serotoni[DIAGNOSES REDACTED] and/or cardiac arrhythmias. On 10/07/15 at 2:00 p.m., during an interview with the director of nursing (DON), the medical records were reviewed. The DON confirmed the pharmacist had not identified and reported the use of duplicate antidepressant therapy since Resident #58's admission on 04/03/14. | 2019-01-01 |
| 5297 | 5297 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2015-10-08 | 520 | E | 0 | 1 | NC4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility's Quality Assurance and Assessment (QA&A) Committee failed to identify and address quality deficiencies of which they were aware, or should have been aware, to ensure care practices were consistently implemented and to ensure the facility met or exceeded an expected standard of quality. The committee did not identify the quality deficiencies to develop and implement a plan of action to correct the deficiencies. There was a failure to ensure Resident #58 received care and services related to [DIAGNOSES REDACTED] and hypertension. There was also a failure to ensure Resident #58's physician was notified, to direct the resident's care, when blood glucose levels and heart rates were outside of the established parameters on numerous occasions. In addition, for Resident #7, there was a failure to notify the physician of significant weight losses so appropriate interventions could be established and implemented. Resident identifiers: #58 and #7. Facility census: 53. Findings include: a) In the area of quality of care, the QA&A committee failed to identify and address a failure to provide optimum care in the treatment for [REDACTED]. Resident identifier #58. 1. There was a failure to follow physician's orders [REDACTED].#58. Review of the resident's medical record found physician's orders [REDACTED]. There was another order to administer [MEDICATION NAME] 1 milligram (mg) intramuscularly (IM) STAT (immediately) for blood sugars of 40 or less and to repeat the resident's blood sugars in 15 minutes and until the blood sugar was stable at 100. Staff failed to notify the physician when the resident's blood sugars were less than 40, failed to administer [MEDICATION NAME] immediately, and failed to recheck the resident's blood sugars when the resident's blood sugars were less than 40. This was identified on: -- 09/23/15 at 6:30 a.m. blood sugar was 39. -- 09/29/15 at 6:30 a.m. blood sugar was 26. Medi… | 2019-01-01 |
| 5298 | 5298 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2015-06-24 | 258 | E | 0 | 1 | FGRX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews and staff interviews the facility failed to provide comfortable sounds levels for five (5) of twenty-eight (28) residents on the B Unit. Resident identifiers: #10, #35, #37, #39, and #71. Facility census: 57. Findings include: a) Resident #10 During an interview, on 06/22/15 at 9:17 a.m., Resident #10 revealed it was loud in the facility in the evening. The resident stated some of the residents are loud and yell out in the evening. b) Resident #35 During an interview, on 06/22/15 at 9:48 a.m., Resident #35 stated the televisions were too loud after supper. c) On 06/23/15 at 6:50 p.m., the facility was entered to make observations of the noise levels in the facility. Upon entering the facility, a television on Unit B room [ROOM NUMBER] was playing extremely loud. d) An interview with Licensed Practical Nurse (LPN) #11, on 06/23/15 at 7:00 p.m., revealed the resident always turned the television up very loud every day, and they had to ask him to turn it down. LPN #11 stated the resident liked to listen to music loudly and liked to sing. e) Resident #37 During an interview, on 06/22/15 at 1:00 p.m., Resident #37 indicated it was noisy in the facility in the evenings and stated the televisions were loud. The resident stated she tells the staff, but they do not do anything. f) Resident #39 In an interview, on 06/23/15 at 7:11 p.m., the resident said staff were loud on the B Unit dining room in the evening and some of the resident ' s televisions were loud in the evening. g) Resident #71 During an interview, on 06/22/15 at 7:05 p.m., Resident #71 revealed it was very noisy in the facility in the evening. The resident stated she often heard small children yelling loudly and staff was loud at times. During the interview with Resident #71, children were heard yelling loudly from out in the hall. Upon observation, there were two (2) small children in the main dining room on the B Unit running and yelling loudl… | 2019-01-01 |
| 5299 | 5299 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2015-06-24 | 371 | F | 0 | 1 | FGRX11 | Based on observations and staff interviews, the facility failed to store food under sanitary conditions to prevent, to the extent possible, the outbreak of foodborne illness. This practice had the potential to affect all residents who received nutrition from the kitchen. Facility census: 57. Findings include: a) The initial tour of the facility was conducted on 06/22/15 at 6:50 a.m. The following sanitation infractions were identified and discussed with staff as indicated: 1. The floors around the cove molding in the kitchen had a large build-up of a black substance. 2. The milk cooler did not contain a thermometer. Dietary Employees #8 and #9 verified the milk cooler did not have a thermometer. They stated the milk cooler was new and they were not sure where to locate the thermometer. 3. Observation of the walk-in freezer revealed bags of dough balls and frozen vegetables which were stored in boxes open to the air. Dietary Employee #9 verified this at 7:05 a.m. 4. The walk-in cooler had a cardboard carton of macaroni salad and a box of sausage patties open to air. 5. Observation of the walk-in cooler revealed a box of more than 20 Health Shakes. An interview with Dietary Employee #9, regarding the system to thaw, serve, and dispose of the Health Shakes, revealed the employee was not aware of any policy. Dietary Employee #9 deferred to Dietary Employee #8. Interview with Dietary Employee #8, on 06/22/15 at 7:10 a.m., revealed the Health Shakes were taken out of the walk-in freezer and placed in the walk-in cooler to thaw. He stated the shakes were usually gone within a week or so. Employee #8 said he was unaware of any policy for how long they could be thawed prior to disposal. An interview with Dietary Manager (DM) #32, on 06/22/15 at 1:45 p.m., revealed the shakes placed in the walk-in cooler (from the walk-in freezer) were usually all gone within a week or so. Observation with DM #32, on 06/23/15 at 12:48 p.m., revealed two (2) boxes of Health Shakes in the walk-in cooler. One (1) box had (MONTH) 1st written o… | 2019-01-01 |
| 5300 | 5300 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2015-06-24 | 460 | F | 0 | 1 | FGRX11 | Based on observations and staff interviews, the facility failed to provide full visual privacy in 15 resident rooms observed on the A and B Units. The Stage 2 Sample was 24. Facility census: 57. Findings include: a) Rooms B1, B2, and B3 Observations of these rooms, on 06/22/15 between 2:00 p.m. and 4:00 p.m., revealed each room held two (2) beds. -- The privacy curtain went across the foot of the bed for the bed nearest the door. -- A second curtain was located between the beds from the wall at the head of the bed to about 4 feet from the opposite wall. -- There was no curtain that went across the foot of the bed of the resident nearest the window. -- The common bathroom was at the foot of the bed for the resident nearest the window. There was also a common sink, with a mirror above it, on the wall at which the middle privacy curtain did not reach. With that curtain pulled, residents could see each other on the opposite side of the curtain. b) The facility also had twelve (12) additional rooms with the same floor plan and bed arrangements. The privacy curtains in those rooms also failed to allow for full visual privacy. c) Observation with the facility Administrator and the Maintenance Supervisor, on 06/24/15 at 8:55 a.m., verified the resident in the bed next to the window did not have visual privacy from a roommate or anyone using the sink or common bathroom. The Administrator said, We have extra track and curtains. We will get that fixed. I have never looked at the curtains that way. | 2019-01-01 |
| 5301 | 5301 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2015-06-24 | 469 | F | 0 | 1 | FGRX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interviews, and record reviews, the facility failed to maintain an effective pest control system to ensure the facility was free from pests. The facility was observed with small flying gnat-like insects in resident rooms, hallways, common areas, nurses ' stations, the elevator, dining room, and conference room. This practice had the potential to affect all facility residents. Facility census: 57. Findings include: a) Observations of the facility, from 06/22/15 through 06/24/15, revealed the continual presence of gnat-like insects in the conference room, common areas, hallways, nurse ' s station, elevator, and the dining room. b) Rooms B8, B10, and B12 Observations on the initial tour, on 06/22/15 from 7:00 a.m. to 7:30 a.m., revealed the presence of gnat-like insects in these rooms. During a follow up observation, on 06/23/15 at 3:20 p.m., gnat-like insects were seen again in room B12. Room B10 was having floor work done with the door closed so an observation was not possible. c) Resident #71 Interview with Resident #71, on 06/23/15 at 7:05 p.m., revealed there were a lot of small flying bugs of some kind in her room. She stated she swatted them away, but they always came back. She stated they had been bad for a few weeks, and she wished they would do something about them. d) Resident #39 Interview with Resident #69, on 06/23/15 at 7:09 p.m., revealed there were a lot of small flying insects around the facility. She stated they were in her room and in the dining room. She stated they fly around her food when she is eating and she wished the facility would get rid of them because they have been a problem for over a month. Interview with Resident #39, on 06/23/15 at 7:11 p.m., revealed there were several small flying bugs in her room. The resident indicated they were all over the facility in the halls and the dining room. She stated they got on her food when she ate. During the interview, the re… | 2019-01-01 |
| 5302 | 5302 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | 600 MEDICAL PARK | WHEELING | WV | 26003 | 2015-07-02 | 246 | D | 0 | 1 | 90J611 | Based on observation, resident interview, and staff interview, the facility failed to provide reasonable accommodation of individual needs for two (2) of twenty-two (22) sample residents. The physical environment was not maintained in a manner which allowed for independent functioning, as the residents were unable to turn their over-the-bed lights on and off as desired. Resident identifiers: #158 and #136. Facility census: 100. Findings include: a) Resident #158 On 06/25/15 at 10:09 a.m., during Stage 1 resident interviews, Resident #158 was asked if there were any issues regarding lighting in the room related to his comfort. Resident #158 stated the lighting was fine, if he could turn his over-the-bed light on and off as needed, but there was no way to do that. An observation of the over-the-bed light at that time revealed a three (3) inch chain hanging from the over-the-bed light. There was no cord attached which Resident #158 could reach to turn the light on and off as he desired. b) Resident #136 During Stage 1 resident interviews on 06/25/15 at 11:16 a.m., Resident #136 was asked if there were any issues regarding light in the room related to her comfort. Resident #136 stated No. Observation of the over-the-bed light at that same time revealed a three (3) inch chain with a four (4) inch piece of cord attached. When Resident #136 was asked if she was able to turn her over-the-bed light on and off as she wished, the resident stated she just kept it on all the time. She said if she needed it turned off, she had to put on her call light. c) In an interview with the administrator on 07/01/15 at 4:00 p.m., she stated she was not aware of any issues with the over-the-bed light cords. She said she would inform the maintenance department to check all residents' light cords and replace them as needed. d) On 07/02/15 at 9:15 a.m., the administrator confirmed there were missing over-the-bed light cords in the rooms of Residents #158 and #136, and those were being replaced. In addition, the administrator said all residen… | 2019-01-01 |
| 5303 | 5303 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | 600 MEDICAL PARK | WHEELING | WV | 26003 | 2015-07-02 | 247 | D | 0 | 1 | 90J611 | Based on medical record review, resident interview, facility policy and procedure review, and staff interview, the facility failed to provide a notice before a room change to one (1) of two (2) residents reviewed for admission, transfer and discharge during Stage 2 of the survey. The resident was moved from a room on Hall 2 to Hall 1 without prior notice of the room change. Resident identifier: #19. Facility census: 100. Findings include: a) Resident #19 On 06/25/15 at 9:11 a.m., during Stage 1 of the survey, Resident #19 was asked if she had been moved to a different room or had a roommate change in the last nine (9) months. Resident #19 answered Yes. The resident was asked if she was given notice before the room change or a change in roommate. Resident #19 responded No. She stated, They came in and told me I was moving and threw my things on the bed and moved me down here (first floor). In an interview with the director of nursing (DON), on 07/02/15 at 8:53 a.m., she stated she talked with Resident #19 regarding moving to another room, but she did not have evidence of the conversation. There was also no evidence Resident #19 agreed to the room change. A request was made at that time, for a copy of the facility's policy and procedure regarding in-house resident transfers. The facility's policy and procedure titled, In-house Resident Transfers Between Units, Room to Room, was reviewed on 07/02/15 at 9:27 a.m. The policy included, under the section titled Procedure: 6. Prior to a transfer or room change, the resident is provided with preparation and orientation appropriate to their level of comprehension. 7. Prior to a room/roommate change, the . and documented on the 'Notification Room/Roommate Change' form. No evidence was found by the facility that this form was completed. In addition, a nurse's note, dated 02/27/15 at 1930 (7:30 p.m.), noted the patient was moved from 2__B to 1__B. | 2019-01-01 |
| 5304 | 5304 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | 600 MEDICAL PARK | WHEELING | WV | 26003 | 2015-07-02 | 257 | E | 0 | 1 | 90J611 | Based on observation, resident interviews, family interview, random resident observations, thermostat and room temperature gauges observations, and staff interviews, the facility failed to ensure safe and comfortable ambient temperatures were maintained to minimize residents' susceptibility to loss of body heat and risk of hypothermia. During a family interview and resident interviews during Stage 1 of the survey, Residents #79, #101, #175, #21, and #14 stated the environment was cold. Random observations of ambient room temperatures in the day rooms on the first and second floors and the dining room/activity room revealed temperatures of 66 degrees F (Fahrenheit) to 68 degrees F. This practice had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: #79, #101, #175, #21, and #14. Facility census: 100. Findings include: a) Resident #79 During a family interview on 06/25/15 at 12:29 p.m., the family member stated her mother always complained about the building being cold. A random observation of Resident #79, in the first floor day room on 07/02/15 at 9:14 a.m., revealed the resident sitting in a wheelchair with a bath blanket wrapped around her shoulders. When asked if the room temperature was comfortable, she stated, Of course it is cold, but that is the way it has to be. b) Resident #101 On 06/24/15 at 3:37 p.m., during Stage 1 interviews, Resident #101 was asked do you have any problems with the temperature, lighting, noise or anything else in the building that affects your comfort? Resident #101 responded, Gets cold. c) Resident #175 During observations of the first floor day room on 07/02/15 at 9:14 a.m., when asked if the room temperature was comfortable, Resident #175 stated, It is cold. d) Resident #21 On 07/02/15 at 9:14 a.m., Resident #21 was observed with two (2) bath blankets around her shoulders and a blanket over her legs. When asked if the room temperature was comfortable, she stated, I am cold. This interview was conducted in the first flo… | 2019-01-01 |
| 5305 | 5305 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | 600 MEDICAL PARK | WHEELING | WV | 26003 | 2015-07-02 | 272 | D | 0 | 1 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, minimum data set (MDS) assessment review, review of the Long-Term Care Facility Resident Assessment Instrument User's Manual, and staff interview, the facility failed to conduct a comprehensive assessment as part of an ongoing process for a Resident #31 who had dental caries. During Stage 2 of the survey, one (1) of three (3) residents reviewed for dental status found the annual MDS failed to identify dental caries in Item L0200D. Resident identifier: #31. Facility census: 100. Findings include: a) Resident #31 On 06/24/15 at 3:01 p.m., an observation of Resident #31 revealed dental caries of the back lower left teeth. A review of the medical record on 07/01/15 at 1:20 p.m., revealed Resident #31 was admitted on [DATE] with [DIAGNOSES REDACTED]. The attending physician deemed Resident #31 had capacity to make medical decisions on 08/22/12. The annual MDS with an assessment reference date (ARD) of 11/05/14, identified the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact. A continued review of the medical record revealed an oral assessment completed on 04/09/14 by dental hygienist students, and signed by the supervising dentist, found a traumatized lesion in the left oral mucosa. A dental consult, dated 04/16/14, stated teeth were cleaned and heavy plaque was present. In addition, two (2) teeth were noted to need extraction due to root tip exposure and a large cavity. An additional note by the dentist stated patient 'states' does not want teeth removed. A review of the annual MDS, with an ARD of 11/05/14, revealed for Dental Status, Item L0200G was marked as none of the above were present. Item L0200D, which would identify the resident had obvious or likely cavity or broken natural teeth, was not marked. In an interview on 07/01/15 at 3:23 p.m., the director of nursing (DON) stated the information for coding the MDS was obtained from the… | 2019-01-01 |
| 5306 | 5306 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | 600 MEDICAL PARK | WHEELING | WV | 26003 | 2015-07-02 | 279 | D | 0 | 1 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to develop a comprehensive care plan for one (1) of twenty-one (21) Stage 2 sample residents. A care plan was not developed for a resident with dental caries. Resident identifier: #136. Facility census: 100. Findings include: a) Resident #136 An observation on 06/25/15 at 12:53 p.m., revealed Resident #136 had a broken front tooth with brown discoloration. During an interview with the resident, she related she had tooth problems. The resident said her teeth had broken off, and some of them have come out. The resident further added she had chewing and eating problems related to the broken teeth. An [MEDICAL CONDITION] screening, dated 03/26/15, noted a slightly swollen submandibular node .slightly red under max denture .The mandibules anterior teeth are severely decayed. (Severely decayed was circled in red ink.) . Patient states pain sometimes, but not often. Also, the answer Yes was circled in relation to the statement, This patient needs a follow up dental examination. Another oral assessment, dated 10/25/13, also indicated Resident #136 was missing teeth and had a total of six (6) caries. The exam indicated the teeth were sharp and jagged. An interview with Registered Nurse (RN) #9, on 06/29/15 at 12:52 p.m., revealed all registered nurses (RN) and licensed nurses (LPN) were responsible for updating care plans. The RN confirmed a comprehensive care plan had not been developed related to dental care for this resident. | 2019-01-01 |
| 5307 | 5307 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | 600 MEDICAL PARK | WHEELING | WV | 26003 | 2015-07-02 | 280 | E | 0 | 1 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to revise care plans for four (4) of twenty-one (21) residents reviewed in the Stage 2 sample. Revisions were not initiated in relation to accidents, pressure ulcers, non-pressure related skin conditions, and medication changes. Resident identifiers: #157, #127, #136, and #70. Facility census: 100. Findings include: a) Resident #157 During an interview with Licensed Practical Nurse (LPN) #11 on 06/24/15 at 3:50 p.m., the nurse related Resident #157 fell on [DATE] when climbing out of bed. Incident and accident forms, reviewed on 07/01/15 at 12:32 p.m., revealed the resident had fallen on 01/29/15, 02/01/15, 02/05/15, 02/09/15, 03/23/15, 03/24/15, 05/20/15, 05/25/15, 06/13/15, 06/15/15, and 06/23/15. Each report, with the exception of the one for 02/09/15, indicated the care plan had been updated. An observation on 06/24/15 at 4:21 p.m., noted Resident #157 had a bruise around her left eye. The incident report, dated 06/23/15 indicated the resident obtained a hematoma on the left temple when she fell and was treated for [REDACTED]. The care plan, reviewed on 07/01/15 at 2:30 p.m., revealed a comprehensive care plan with a review date of 05/10/15, and noted the next review date as 08/05/15. During a review of the care plan with Registered Nurse (RN) #9, on 07/01/15 at 3:30 p.m., the RN confirmed the care plan only indicated the resident had a potential for falls, but had not been revised to reflect the interventions for ten (10) of the eleven (11) actual falls. Additionally, the care plan did not address the hematoma, bruising around the left eye, or pain related to the fall. b) Resident #127 1. Licensed Practical Nurse (LPN) #11, interviewed on 06/24/15 at 3:53 p.m., related Resident #127 had a pressure ulcer on his coccyx which was unstageable at the deepest anatomical level. Review of the medical record, on 06/25/15 at 9:40 a.m., revealed the resident was r… | 2019-01-01 |
| 5308 | 5308 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | 600 MEDICAL PARK | WHEELING | WV | 26003 | 2015-07-02 | 282 | E | 0 | 1 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and clinical record review, the facility failed to implement the care plans for two (2) of two (2) residents who had pacemakers, in the Stage 2 sample of twenty-one (21) residents. The interventions for pacemaker checks were not implemented. Resident identifiers: #73 and #162. Facility census: 100. Findings include: a) Resident #73 Resident #73's clinical record was reviewed on 06/29/15 at 4:00 p.m The resident was admitted on [DATE] with cumulative medical [DIAGNOSES REDACTED]. An 08/04/12 admission nursing assessment indicated Resident #73 had a pacemaker located in the left chest area. The current care plan, dated 04/27/15, included the problem: Potential for pacemaker malfunction/failure or altered cardiac output related to implanted pacemaker. The interventions were: Observe/record/report to MD (medical doctor) prn (as needed) signs/symptoms of altered cardiac output or pacemaker malfunction. Monitor for signs/symptoms: [MEDICAL CONDITION], irregular heart rhythm, chest pain, shortness of breath, report to MD. Monitor vital signs as ordered/per facility protocol and record, notify MD of significant abnormalities. Pacemaker checks as ordered and document in chart. Review of the clinical record revealed no evidence of pacemaker checks. During an interview on 06/29/15 at 4:30 p.m., Registered Nurse (RN) #5 confirmed Resident #73's medical record contained no evidence of an assessment of her pacemaker. On 06/30/15 at 11:00 a.m., RN #57 provided documentation from Resident #73's physician which stated the resident had a dual chamber pacemaker implanted on 06/17/08. The last evidence a pacemaker function test was performed was on 03/27/12. b) Resident #162 Resident #162's clinical record was reviewed on 06/30/15 at 12:00 p.m. The resident's [DIAGNOSES REDACTED]. The current care plan, dated 05/17/15, included the problem: Potential for pacemaker malfunction/failure or altered cardiac output related to implanted pacema… | 2019-01-01 |
| 5309 | 5309 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | 600 MEDICAL PARK | WHEELING | WV | 26003 | 2015-07-02 | 309 | E | 0 | 1 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and clinical record review, the facility failed to ensure two (2) of two (2) residents who had pacemakers, in the Stage 2 sample of twenty-one (21 residents, were provided services to maintain the highest practicable well-being. Pacemaker checks were not performed to ensure ongoing function of their cardiac pacemakers. Resident identifiers: #73 and #162. Facility census: 100. Findings include: a) Resident #73 Resident #73's clinical record was reviewed on 06/29/15 at 4:00 p.m The resident was admitted on [DATE] with cumulative medical [DIAGNOSES REDACTED]. An 08/04/12 admission nursing assessment indicated Resident #73 had a pacemaker located on the left chest area. The current care plan, dated 04/27/15, included the problem : Potential for pacemaker malfunction/failure or altered cardiac output related to implanted pacemaker. The interventions were: Observe/record/report to MD (medical doctor) prn (as needed) signs/symptoms of altered cardiac output or pacemaker malfunction. Monitor for signs/symptoms: [MEDICAL CONDITION], irregular heart rhythm, chest pain, shortness of breath, report to MD. Monitor vital signs as ordered/per facility protocol and record, notify MD of significant abnormalities. Pacemaker checks as ordered and document in chart. During an interview, on 06/29/15 at 4:00 p.m., Licensed Practical Nurse (LPN) #56 stated she did not know if Resident #73 had a pacemaker. On 06/29/15 at 4:30 p.m., Registered Nurse (RN) #57 stated the facility relied on the physician to call when a resident was due for a pacemaker check. RN #57 stated the facility provided no telephonic monitoring of pacemaker function. She stated a resident would have to go to a physician's office for assessment of pacemaker function. RN #57 confirmed Resident #73's medical record contained no evidence of an assessment of her pacemaker. At 5:15 p.m. on 06/29/15, RN # 57 provided a [DIAGNOSES REDACTED]. Resident #73 was not included on this… | 2019-01-01 |
| 5310 | 5310 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | 600 MEDICAL PARK | WHEELING | WV | 26003 | 2015-07-02 | 314 | D | 0 | 1 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to provide care and services to promote healing and prevent infection of pressure ulcers. This was true for three (3) of three (3) residents reviewed for pressure ulcers. Resident identifiers: #101, #127, and #136. Facility census: 100. Findings include: a) Resident #101 Resident #101 had two (2) pressure ulcers, a Stage II on his right buttock and a Stage II on his left buttock. There was a physician's orders [REDACTED]. An observation of wound care was performed with Registered Nurse #128 at 8:15 a.m. on 06/30/15. She wore gloves and touched Resident 101's skin around both of the ulcers around his buttocks and two (2) non-pressure open areas on the back of his right thigh. She measured all four (4) areas, removed a paper towel from the dispenser, pulled a pen out of her pocket with her gloved hand and wrote down the measurements. She then put the pen back in her pocket and applied medication to all four (4) areas without cleansing them first. Next, she reapplied the resident's brief. This allowed for transfer of microorganisms from the pen to the nurse's gloved hand, and potentially to the resident's wounds, and from the resident's wounds, to the pen from nurse's gloved hand, to the nurse's pocket, and potentially to other residents.) RN #128 stated the nursing staff would clean the areas and reapply the medication when they gave him his morning care and got him up for the day. This matter was discussed with Licensed Practical Nurse (LPN) #11, at 1:00 p.m. She said she was the nurse responsible for applying medication to Resident #101 when the treatment nurse, RN #128, did not. She said she had not applied medication to Resident #101 that morning because RN #128 applied it already. She said she (LPN #11) would apply the medication at 3:00 p.m. that afternoon when the resident went back to bed. This concern was discussed with RN #128 and the director of nursing (DO… | 2019-01-01 |
| 5311 | 5311 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | 600 MEDICAL PARK | WHEELING | WV | 26003 | 2015-07-02 | 334 | D | 0 | 1 | 90J611 | Based on staff interview, clinical record review, and review of facility policy, the facility failed to provide influenza vaccination education for one (1) of five (5) census sampled residents (Resident #45) prior to administration of the influenza vaccine. Facility census: 100. Findings include: a) Resident #45 Review of Resident #45's clinical record on 06/30/15 at 10:00 a.m., found the 2014-2015 consent to administer the influenza vaccine did not indicate education was provided prior to giving the vaccine on 10/02/14. During an interview, on 06/30/15 at 9:00 a.m., Registered Nurse (RN) #130 could not provide any evidence that Resident #45 had been provided education prior to administration of the influenza vaccine on 10/02/14. On 06/30/15 at 9:00 a.m., a review of facility's policy entitled Immunizations, revised 07/2014, found the policy included, The facility recommends that the influenza vaccine be given annually to all residents. The policy stated, Each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the influenza immunization before the vaccine is offered. . | 2019-01-01 |
| 5312 | 5312 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | 600 MEDICAL PARK | WHEELING | WV | 26003 | 2015-07-02 | 371 | F | 0 | 1 | 90J611 | Based on observation, review of facility policy, and staff interview, the facility failed to store and distribute food under sanitary conditions. Personal food items were stored with resident food products and proper sanitation practices were not utilized when washing dishes. This practice had the potential to affect all residents. Facility census: 100. Findings include: a) Kitchen 1. During an initial tour with the dietary manager, on 06/24/15 at 10:03 a.m., observation revealed a drink in a disposable cup stored on the top shelf of the walk-in refrigerator with containers of residents' food. Shelves below contained boxes of fresh fruit and other items. Another observation on 06/29/15 at 10:30 a.m., again revealed a drink stored on the shelf. 2. An interview with Dietary Aide (DA) #94 on 06/24/15 at 10:15 a.m., revealed the dish wash temperature must reach 150 degrees and 180 degrees rinse. Upon inquiry, the DA related she was unable to find test strips, and related the facility never utilized the manual method for sanitizing dishes. She related, We always use the machine. DA #94 related the machine did not usually reach the proper temperature until three to four (3-4) loads were completed. Observation of the sanitation procedure on 06/24/15 at 10:15 a.m., revealed the temperature only reached a level of 140 degrees Fahrenheit (f). DA #94 washed a tray of plates, a tray of silver-colored bases, a tray of flatware, and a tray of lids. The DA continued to wash dishes. A label on the machine noted a label of ES2000HT and indicated the wash temperature should reach 160 degrees. A discussion with the dietary manager, on 07/01/15 at 10:45 a.m., confirmed the washer was a high temp machine, and according to the manufacturer's notation, the appropriate wash temperature was 160 degrees. Additionally, the dietary aide continued to wash dishes without the machine reaching the appropriate temperature. An alternate method of sanitation was not utilized to ensure proper sanitizing of plates and other items. The DA was also un… | 2019-01-01 |
| 5313 | 5313 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | 600 MEDICAL PARK | WHEELING | WV | 26003 | 2015-07-02 | 431 | E | 0 | 1 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility failed to store drugs in accordance with currently accepted professional principles. Two (2) of six (6) medication carts contained internal medications stored with external medications, staff failed to remove discontinued medications from the medication cart, failed to date vials/bottles of multi-dose containers, a controlled substance was not returned to the pharmacy in a timely manner, and the pharmacist failed to provide oversight of drug storage areas which consisted of two (2) medication rooms and six (6) medication carts. This practice affected six (6) residents, but had the potential to affect all residents. Resident identifiers: Residents #65, #67, #239, #89, #57, and #140. Facility census: 100. Findings include: a) Controlled substances An observation, on [DATE] at 10:30 a.m., with Registered Nurse (RN) #57, revealed discontinued controlled substances stored in a locked drawer in the second floor medication room. The RN related controlled substances were returned to the pharmacy within 72 hours, but indicated the pharmacy picked up medication daily. Review of the medication storage area revealed a card of Hydrocodone for Resident #140, with a discontinuation date of [DATE]. b) North back hall med cart Review of the north back hall medication cart, on [DATE] at 11:05 a.m., with Licensed Practical Nurse (LPN) #54, revealed internal medications stored with external medications. Eye drops and ear drops were stored with each residents internal medications. Additional findings included: -- Resident #239 - undated bottle of Latanoprost eye drops -- Resident #89 - undated bottle of Latanoprost eye drops -- Resident #57 - undated bottle of Latanoprost eye drops with a delivery date of [DATE], and a bottle of Prednisone, discontinued on [DATE], and a bottle of Gentamycin eye drops discontinued on [DATE] The LPN related the resident commonly gets eye infections. -- The medic… | 2019-01-01 |
| 5314 | 5314 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | 600 MEDICAL PARK | WHEELING | WV | 26003 | 2015-07-02 | 441 | F | 0 | 1 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and review of facility policy and procedures, the facility failed to maintain an effective infection control program to help prevent the development and spread of disease and infection. The facility failed to ensure contact precautions were maintained for Residents #32 and #138. The facility failed to ensure staff handled linens properly, used appropriate hand hygiene, and provided wound care using appropriate infection control techniques for Residents #127, #137, and #101. This had the potential to affect all residents in the facility. Resident identifiers: #32, #138, #127, #137, and #101. Facility census: 100. Findings include: a) Resident #32 and #138 - Contact Precautions During a random observation on 06/29/15 at 8:25 a.m., Pastoral Staff #118 was in a room with Resident #32 and Resident #138. Both residents were in contact isolation. Pastoral Staff #118 did not have gloves or a gown on when in the room. The Pastoral Staff #118 exited the room and without washing or sanitizing her hands, entered room [ROOM NUMBER]. A contact precaution sign was posted by the door of Resident #32's and Resident #138's room throughout the survey, starting on 06/24/15. The sign instructed all persons to, Wash hands before entering and leaving patient room, wear gowns when entering the room and wear gloves when entering the room. Licensed Practical Nurse (LPN) #61, on 06/29/15 at 8:30 a.m., confirmed both residents (Residents #32 and #138) were under contact precautions due to active Methicillin Resistant Staphylococcus aureus (MRSA) Infection. Pastoral Staff #118, on 06/29/15 at 8:35 a.m., stated she had not noticed the contact precaution sign by the door of the room. She stated she was not aware Resident #32 and Resident #138 were in isolation. Resident #32's clinical record revealed she was on contact precautions due to an active respiratory MRSA infection. Resident #138's clinical record reve… | 2019-01-01 |
| 5315 | 5315 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | 600 MEDICAL PARK | WHEELING | WV | 26003 | 2015-07-02 | 514 | D | 0 | 1 | 90J611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate and complete medical records. Resident #128 was receiving Hospice services without an order. The pharmacist's medication reviews were not in Resident #70's and #157's medical records. Additionally, MEDICATION ORDERS FOR [REDACTED]. This practice had the potential to affect three (3) of twenty-one (21) Stage 2 residents reviewed. Resident Identifiers: #128, #70, and #157. Facility census: 100. Findings include: a) Resident #128 Resident #128's name was provided by the facility as one of a list of residents receiving Hospice services. In reviewing the medical record, a physician's orders [REDACTED]. On 06/20/15 Hospice services documented in the resident's medical record and began a care plan, however, the was no order for hospice documented in the medical record by the physician. In an interview with Nurse Manager #57 on 07/02/15 at 10:20 a.m., she said the Hospice company came into review the medical record on Saturday 06/20/15 and the resident was out at [MEDICAL TREATMENT]. She said the Hospice company wanted to speak with the resident before putting orders into effect, and the order for Hospice to provide its services was missed. Resident #128 had been receiving Hospice care since 06/20/15. b) Resident #70 Review of the medical record, on 06/25/15 at 11:01 a.m., revealed physician's orders [REDACTED]. Review of pharmacy recommendations revealed no evidence the pharmacist completed a review for (MONTH) (YEAR) or (MONTH) 2014. Behavior flow sheets, related to [MEDICAL CONDITION] medication use, revealed no evidence a behavioral flow sheet, tracking behaviors and side effects of [MEDICAL CONDITION] medications, was completed for the month of (MONTH) (YEAR). An interview with Licensed Practical Nurse (LPN) #14, Registered Nurse (RN) #9, and Medical Records Clerk #104 at 11:15 a.m., confirmed neither the recommendations, nor the flow sheets were in the medical … | 2019-01-01 |
| 5316 | 5316 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2015-06-18 | 272 | D | 0 | 1 | 7M1Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument User's Manual - Version 3.0, and staff interview, the facility failed to conduct an accurate admission comprehensive assessment. Resident #91's initial comprehensive minimum data set (MDS) assessment did not accurately reflect her hydration status. This was found for one (1) of twenty-six (26) Stage 2 sample residents whose assessments were reviewed. Resident identifier: #91. Facility Census: 96. Findings include: a) Resident #91 A review of Resident #91's medical record at 11:00 a.m. on 06/17/15, revealed the Comprehensive Minimum Data Set Assessment (MDS) completed on her readmission (02/08/15) indicated in Item J1550C that she was dehydrated. No evidence was found in the resident's medical record to support coding this item. The instructions for coding J1500 in the Long-Term Care Facility Resident Assessment Instrument User's Manual - Version 3.0 includes: Dehydrated: Check this item if the resident presents with two or more of the following potential indicators for dehydration: 1. Resident takes in less than the recommended 1,500 ml of fluids daily (water or liquids in beverages and water in foods with high fluid content, such as gelatin and soups). Note: The recommended intake level has been changed from 2,500 ml to 1,500 ml to reflect current practice standards. 2. Resident has one or more potential clinical signs (indicators) of dehydration, including but not limited to dry mucous membranes, poor skin turgor, cracked lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, or abnormal laboratory values (e.g., elevated hemoglobin and hematocrit, potassium chloride, sodium, [MEDICATION NAME], blood urea nitrogen, or urine specific gravity). 3. Resident's fluid loss exceeds the amount of fluids he or she takes in (e.g., loss from vomiting, fever, diarrhea that exceeds fluid replacement). During an interview with Employee #70… | 2019-01-01 |
| 5317 | 5317 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2015-06-18 | 278 | D | 0 | 1 | 7M1Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument User's Manual - Version 3.0, and staff interview, the health professional who certified the accuracy of Section J of Resident #91's admission and quarterly minimum data set (MDS) assessments did not accurately code the resident's hydration status. This was found for one (1) of twenty-six (26) Stage 2 sample residents. Resident identifier: #91. Facility Census: 96. Findings include: a) Resident #91 A review of Resident #91's medical record at 11:00 a.m. on 06/17/15, revealed the Comprehensive Minimum Data Set Assessment (MDS) completed on her readmission (02/08/15) indicated in Item J1550C that she was dehydrated. No evidence was found in the resident's medical record to support coding this item. Dehydration was also checked on the Quarterly MDS with an assessment reference date of 05/05/15. Again, there was no evidence found in the resident's medical record to support coding this item. The instructions for coding J1500 in the Long-Term Care Facility Resident Assessment Instrument User's Manual - Version 3.0 includes: Dehydrated: Check this item if the resident presents with two or more of the following potential indicators for dehydration: 1. Resident takes in less than the recommended 1,500 ml of fluids daily (water or liquids in beverages and water in foods with high fluid content, such as gelatin and soups). Note: The recommended intake level has been changed from 2,500 ml to 1,500 ml to reflect current practice standards. 2. Resident has one or more potential clinical signs (indicators) of dehydration, including but not limited to dry mucous membranes, poor skin turgor, cracked lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, or abnormal laboratory values (e.g., elevated hemoglobin and hematocrit, potassium chloride, sodium, [MEDICATION NAME], blood urea nitrogen, or urine specific gravity). 3. Resident's fluid loss … | 2019-01-01 |
| 5318 | 5318 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2015-06-18 | 441 | E | 0 | 1 | 7M1Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain infection control procedures to aid in the prevention and/or spread of infection within the facility. Resident #91's medication containers were placed directly on the bedside table and then returned to the medicine cart and stored among other resident's medications. In addition, a nurse was observed picking up pills off of the floor with her bare hand, and continue with medication pass without washing her hands. This practice had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: #91 and #95. Facility census: 96. Findings include: a) Resident #91 During the observation of the administration of medications, on 06/17/15 at 8:15 a.m. Licensed Practical Nurse (LPN) #131 passed medications to Resident #91. LPN #131 placed an [MEDICATION NAME] diskus and a [MEDICATION NAME] inhaler directly on the resident's bedside table while administering the resident's morning medications. She returned the [MEDICATION NAME] diskus and the [MEDICATION NAME] inhaler into open boxes in the medication cart among other residents' medications without cleaning them. b) Resident #95 During medication pass on 06/17/15 at 8:25 a.m., Resident #95 dropped two (2) pills on the floor. LPN #131 removed the glove from her right hand, retrieved the pills off of the floor with her bare hand, then obtained replacements from the medication cart and administered the replacement pills without washing/sanitizing her hands. c) LPN #131 was interviewed immediately after these observations on 06/17/15 at 8:35 a.m. She agreed placing the [MEDICATION NAME] diskus and [MEDICATION NAME] inhaler directly on the bedside table was a break in aseptic technique and the medication containers should have been wiped off before returning them to the cart. In addition, she acknowledged she had not washed/sanitized her hands after picking the pills up off of the floor,… | 2019-01-01 |
| 5319 | 5319 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2015-06-18 | 514 | D | 0 | 1 | 7M1Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and Hospice policy review, the facility failed to maintain complete, organized and readily accessible clinical records in accordance with accepted professional standards and practices of care. Resident #50 was receiving weekly hospice services, but the medical record lacked accurate and current information of the Hospice nursing visits and care provided. This was found for one (1) of two (2) residents whose medical records were reviewed for Hospice services during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #50. Facility census: 96. Findings include: a) Resident #50 Review of the medical record on 06/17/15 at 1:10 p.m., revealed Resident #50 was admitted to the facility on [DATE] and readmitted on [DATE] after a hospitalization . She was receiving Hospice services for a [DIAGNOSES REDACTED]. The current care plan included twice a week visits by the hospice nurse. The last nursing Hospice visit documented in the medical record was dated 09/02/14. The chart lacked any documentation by the facility staff regarding the Hospice nursing visits or communication between services. Hospice Registered Nurse (RN) #186 reviewed the medical record during an interview on 06/17/15 at 1:40 p.m., and confirmed the last documented visit by the Hospice nurse was 09/02/14. During the interview she stated, I have never done that, I document in the computer and that is where my notes are kept. On 06/17/15 at 1;50 p.m., during an interview, the Administrator commented hospice nurses and aides were in the facility in accordance with the contract and did talk with the nurse regarding the resident's care. After reviewing the chart of Resident #50, she agreed there was no documentation of Hospice visits or communication with the facility staff. Nurse Consultant #188 reviewed the medical record of Resident #50 on 06/17/15 at 2:10 p.m. She commented the facility staff and Hospice staff did communicate regard… | 2019-01-01 |
| 5320 | 5320 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2015-09-17 | 159 | C | 0 | 1 | I3KW11 | Based on resident interview and staff interview, the facility failed to manage resident funds in a manner, which ensured residents had access to their funds seven (7) days per week, rather than just during normal banking hours. This had the potential to affect 19 of 19 residents whose accounts were managed by the facility. Resident identifiers: #5, and #20. Facility census: 25. Findings include: a) Resident #5 During an interview in Stage I of the Quality Indicator Survey (QIS) on 09/15/15 at 9:23 a.m., Resident #5 said residents could not get money from their accounts on weekends. b) Resident #20 During an interview in Stage I of the Quality Indicator Survey (QIS) on 09/15/15 at 4:33 p.m., Resident #20 said residents could not get money from their accounts on weekends. On 09/17/15 at 7:15 a.m., interviews conducted with Licensed Practical Nurse (LPN) #100, and Nurse I #87. Upon inquiry, both said they were unsure how residents would get money out of their accounts on weekends. They said they have no petty cash box in the medication carts or in the locked medication room. LPN #100 said, in the past six (6) years of her employment with the facility, she does not recall any resident requests for money out of their accounts on weekends. During an interview with Accounts Payable Representative #101, on 09/17/15 at 10:43 a.m., she said residents might only access their funds for cash during banking hours, Monday through Friday. She said there is no administrative staff available on weekends to obtain cash from (name of bank) on weekends. She was unsure if the (name of bank) was open on Saturdays. She acknowledged the facility does not keep cash on hand. She said if the residents wanted cash for use on the weekends, they needed to request those funds prior to bank closing on Fridays. She further explained residents must sign a check to obtain cash from his/her bank checking account, and two (2) administrative staff members must sign the check. Someone from the facility then travels to the bank to cash the check for the… | 2019-01-01 |
| 5321 | 5321 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2015-09-17 | 272 | D | 0 | 1 | I3KW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to conduct an accurate comprehensive assessment for one (1) of eleven (11) Stage 2 sample residents. The comprehensive assessment for Resident #22 did not accurately reflect the resident's medical [DIAGNOSES REDACTED]. Resident identifier: #22. Facility census: 25. Findings include: a) Resident #22 A review of the medical record, on 09/17/15 at 9:40 a.m., revealed an admitted for Resident #22 on 02/17/12. Concurrent [DIAGNOSES REDACTED]. A concurrent review of the annual minimum data set (MDS) with an assessment reference date (ARD) of 02/15/15 revealed no [DIAGNOSES REDACTED]. In an interview with the MDS coordinator, on 09/17/15 at 10:19 a.m., she agreed she made a mistake and did not mark Section I1200 that Resident #22 had a [DIAGNOSES REDACTED]. | 2019-01-01 |
| 5322 | 5322 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2015-09-17 | 279 | E | 0 | 1 | I3KW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, and observation, the facility failed to develop care plans with measurable goals in accordance with the residents' assessments. The care plans did not contain information about pertinent diagnoses, which required treatment. This is true for four (4) of eleven (11) Stage 2 sample residents. Resident identifiers: #20, #30, #5, and #21. Facility census: 25. Findings include: a) Resident #20 1) Contracture During an observation and interview with Resident #20, on 09/15/15 at 4:30 p.m., his left arm was much smaller than the right and drawn up tightly against his chest, with elbow and wrist bent sharply. The resident stated it was the result of a birth injury, and had always been this way. During an interview, on 09/15/15 at 4:50 p.m., with the Unit Manager #85 she revealed the Resident had a congenital deformity of the arm. She stated this made it difficult to dress Resident #20 unless his contracted arm was placed in his shirt first, because it was so tight against his body. Review of the medical record, on 09/16/15 at 9:30 a.m., revealed Resident #20 received restorative therapy during (MONTH) (YEAR) for all of his extremities. A 07/17/15 physical therapy evaluation documented the resident as having left upper extremity contractures due to birth with fixed contractures. A significant change minimum data set (MDS) assessment completed 06/04/15 lists contractures of hand, wrist, elbow, and shoulder on the left side in Section S. The current care plan made no mention of Resident #20 having multiple contractures in his left arm, nor are there interventions in place in regards to care associated with these contractures. 2) [MEDICAL CONDITION] A medical record review, on 09/16/15 at 12:30 p.m., noted on the most recent minimum data set (MDS) with an assessment reference date (ARD) of 06/04/15 under Section I (Active Diagnoses) item I5400 [MEDICAL CONDITION] Disorder or [MEDICAL CONDITION] w… | 2019-01-01 |
| 5323 | 5323 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2015-09-17 | 309 | D | 0 | 1 | I3KW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to conduct pain assessments following the administration of Tylenol. This was evident for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #5. Facility census: 25. Findings include: a) Resident #5 Medical record review, on 09/16/15 at 1:00 p.m., revealed the [DIAGNOSES REDACTED]. Review of the medication administration records (MAR) and nurse progress notes from 08/21/15 through 09/16/15, found Tylenol administered by nursing staff prn (as needed) for pain a total of fourteen (14) times. There was no evidence of post-Tylenol pain assessments for thirteen (13) out of those fourteen (14) doses, to see if the pain medication was effective. During an interview with Nurse I #80, on 09/16/15 at 2:00 p.m., she reviewed the MAR and nurse progress notes covering 08/21/15 through 09/16/15. After this review, she verified and agreed there was no evidence of post prn Tylenol pain assessment following the administration of Tylenol for pain. Nurse I #80 said staff used to be better with documentation of the effectiveness of pain medications administered. She noted there was no pop-up on their computer program to remind nurses to go back, assess, and document pain relief following the administration of prn (as needed) pain medications. Rather, with their software program, the nurse has to return to the computer and add another separate entry to document the effectiveness of the prn pain medication. She said in this case, it was not done. | 2019-01-01 |
| 5324 | 5324 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2015-09-17 | 364 | C | 0 | 1 | I3KW11 | Based on observation and staff interview the facility failed to ensure the appearance and palatability of leafy greens prepared for residents receiving pureed diets. They did not present the greens with a consistency that allowed them to maintain a firmness on the plate and not flow into the surrounding foods. This practice affected all residents who received pureed foods. Facility census: 25. Findings include: a) The noon food service, at 12:03 p.m. on 09/16/15, included a menu which consisted of kielbasa, sauerkraut, and mixed leafy greens. When the pureed form of the leafy greens was served from the steam table to the plate or bowl, they were observed to be thin and soup-like in appearance. This was mentioned to Cook/Server #81 (Cook/Server) and to Food Service Supervisor #84 (Food Service Supervisor), who were present during the service. Cook #81 acknowledged the greens would flow into the other items in the present consistency and added thickening to the greens for the remainder of the service. | 2019-01-01 |
| 5325 | 5325 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2015-09-17 | 371 | F | 0 | 1 | I3KW11 | Based on observation and staff interview the facility failed to ensure food items were stored under sanitary conditions. The facility was not able to ensure the freshness of food after the food was opened from the original packaging. This had the potential to affect all residents who received nutrtion from the kitchen. Facility census: 25. Findings include: a) During a follow-up visit to the kitchen at 11:50 a.m. on 09/16/15, the dry storage areas were toured with Food Service Supervisor #84. Three (3) plastic storage containers of dry contents labeled as Biscuit Mix were observed on a shelf in a dry storage room. The label did not include the date when the mix was taken from its original container and placed in the plastic storage container. Food Service Supervisor #84 examined the containers and agreed there should have been a date on the label. She removed the containers from the room and stated they would be discarded. | 2019-01-01 |
| 5326 | 5326 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2015-09-17 | 425 | D | 0 | 1 | I3KW11 | Based on observation, staff interview, and review of manufacturer's instructions, the facility failed, in collaboration with the pharmacist, to assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident. An opened and partially used multi-dose vial of Lantus insulin for Resident #16, was open for use for greater than the number of days directed by the manufacturer. Use of medication from a multi-dose vial which was open for a time greater than that recommended by the manufacturer, had the potential to negatively affect the safety and/or potency of the medication. This had the potential to affect the only insulin-dependent diabetic who resided in the facility. Resident identifier: #16. Facility census: 25. Findings include: a) Resident #16 Observations of the medication carts on 09/16/15 at 12:00 p.m. revealed one (1) opened and partially used vial of Lantus insulin, which belonged to Resident #16. The date inscribed on the vial was 08/04/15. Licensed practical nurse (LPN) #100 said 08/04/15 was the date the vial was initially opened and used. Information typed on the side of the Lantus insulin box directed staff to discard the vial after twenty-eight (28) days of opening. LPN #100 then disposed of the vial of Lantus insulin, and obtained a fresh, unopened vial of Lantus insulin from the medication room refrigerator. She said the evening shift nurse administers the daily insulin, and would date the new vial this evening when she uses it for the first time. Review of the manufacturer's instructions revealed that Lantus insulin may be used for up to twenty-eight (28) days after the date it was initially opened. During an interview with the director of nursing on 09/16/15 at 5:00 p.m., she said nursing staff informed her today about the Lantus insulin being opened for greater than twenty-eight (28) days. No further information was provided. | 2019-01-01 |
| 5327 | 5327 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2015-06-18 | 156 | D | 0 | 1 | 6BSN11 | Based on review of the liability notices and staff interview, the facility failed to provide the correct notice of termination of Medicare services, required by the Centers for Medicare and Medicaid Services (CMS), for one (1) of three (3) residents reviewed for the care area of liability notices and beneficiary appeal. Resident #127 received a notice informing her she could appeal her discharge from a skilled service after she had exhausted her allotted amount of skilled care days. Resident identifier: #127. Facility census: 94. Findings include: a) Resident #94 At 06/18/15 at 9:07 a.m., Clinical Reimbursement Coordinator #78 provided a copy of the notice given to Resident #127 on 01/08/15 regarding the exhaustion of her 100 days benefit period for medically necessary skilled care. The facility had attached to the notice a request for a Medicare Intermediary Review. The resident had indicated on the form that she did not want her bill for the services she continued to need to be submitted to the intermediary for a Medicare decision. According to CMS, the number of skilled care days is set in law and the Medicare Intermediary cannot extend the benefit period. Clinical Reimbursement Coordinator #78 said she did not know the facility could not give residents the right to appeal the exhaustion of the 100-day skilled care period. | 2019-01-01 |
| 5328 | 5328 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2015-06-18 | 160 | D | 0 | 1 | 6BSN11 | Based on record review and staff interview, the facility failed to ensure the funds for one (1) of three (3) residents reviewed for the conveyance of personal funds, were sent to the individual administering the resident's estate or probate jurisdiction after the resident's death. Resident identifier: #80. Facility census: 94. Findings include: a) Resident #80 On 06/17/15 at 11:30 a.m., the facility's closed account summary report revealed Resident #80's account was closed on 03/12/15 with a final balance of $1,007.84. During an interview with Office Manager #77 on 06/17/15 at 11:45 a.m., the office manager stated the facility had sent a check for $1,007.84 on 03/13/15 to Resident #80's husband. She verified the facility had issued the check to the resident's husband without evidence he was the executor of the resident's estate. | 2019-01-01 |
| 5329 | 5329 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2015-06-18 | 225 | D | 0 | 1 | 6BSN11 | Based on policy review, a review of the complaints/grievances, and staff interview, the facility failed to ensure an allegation of neglect was identified and reported to the appropriate State agencies. A grievance/complaint report identified Resident #96 was found with dried fecal matter up her back. The facility failed to identify this as an allegation of neglect, and failed to investigate and report the allegation. This was found for one (1) of nine (9) complaint/grievances that were reviewed. Resident identifier: #96. Facility census: 94. Findings include: a) Resident #96 A review of the grievance/complaints on 06/25/15 at 11:00 a.m., revealed the facility had not identified, investigated and reported one (1) allegation of neglect. The grievances/concerns contained an allegation of neglect dated 01/20/15. The allegation statement involving Resident #96 included, (name) reported to SSW-II (social service worker) that when he came in to visit Resident #96 on 01/17 (January 17, (YEAR)) and 01/18 (January 18, (YEAR)) between the hour of 3:15 pm and 3:30 pm, he found her soiled. He reported on Sunday that it was dried fecal matter up her back. He reported that he loves her care here, but was concerned over it being dried and how long it had been there. The resolution of the grievance/concern stated MPOA (medical power of attorney) is pleased with care overall, and that the appropriated staff who were knew (sic) to his wife's care, were individually educated by the NPE (nurse practice educator) on proper protocol and shift change checks. The grievance/concern contained a staff education form completed on 02/13/15 which stated Nurse Aide #63 (NA) and NA #136 were both educated on the need for resident care rounds to be completed every two (2) hours. The education also stated NAs must perform rounds together to ensure residents were clean. The facility's abuse prohibition policy, revised on 07/16/13, defined neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or menta… | 2019-01-01 |
| 5330 | 5330 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2015-06-18 | 253 | E | 0 | 1 | 6BSN11 | Based on observation, resident interview, and staff interview, the facility failed to provide effective housekeeping and maintenance services for six (6) of thirty (30) resident rooms observed during Stage 1 of the Quality Indicator Survey (QIS). The window blinds were broken, the walls had missing paint, and a bathroom door had wood missing. This affected more than an isolated number of residents. Facility census: 94. Findings include: a) Room 109 Observations of this room on 06/15/15 at 4:11 p.m. noted the window blinds were bent. b) Room 102 Observations on 06/16/15 at 10:18 a.m. found the window blinds were bent and had a broken slat. Resident #61 said the blinds had been that way since she was admitted . She was admitted to the facility in late (MONTH) 2014. c) Room 110 Resident room observations on 06/15/15 at 4:14 p.m., found the window blinds were bent and hanging crookedly. d) Room 302 Observations on 06/16/15 at 2:28 p.m. found the wall beside the sink had an area of unpainted plaster approximately 2 inches in diameter. e) Room 115 On 06/16/15 at 1:14 p.m., observation of the bathroom adjoining this room found two (2) areas over 10 inches where the paper covering the sheet rock was scraped and peeling off the bathroom wall. An additional observation on 06/16/15 at 1:41 p.m. found the slats of the window blinds were bent. f) Room 113 Observations on 06/16/15 at 11:44 a.m., noted an area approximately 2.5 inches by 3 inches by the bathroom door handle where the wood was missing. g) On 06/18/15 at 12:20 p.m., Director of Maintenance #16 verified Rooms 102, 109, and 110 needed window blinds replaced, Rooms 113 and 302 had walls with unpainted areas, and Room 115 had a damaged bathroom door. | 2019-01-01 |
| 5331 | 5331 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2015-06-18 | 280 | D | 0 | 1 | 6BSN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and resident interview, the facility failed to ensure residents had the opportunity to participate in their care plan conference for one (1) of three (3) residents reviewed for the care area of 'Participation in Care Planning' during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #14. Employee identifiers: #16, #18, and #47. Facility census: 94. Findings include: a) Resident #14 Review of the resident's medical records revealed this forty-six (46) year old resident made her own medical/daily decisions. The resident did not have a Medical Power of Attorney (MPOA) in place should she become incapable of making her own decisions. Some noted [DIAGNOSES REDACTED]. Her Brief Interview for Mental Status (BIMS) score was 15. (A score between 13 and 15 indicates a person is cognitively intact.) The resident had assistive devices, read Braille, attended activities, and was active as President of Resident Council. On 06/15/15 at 3:19 p.m., during a resident interview in Stage 1 of the QIS, the resident was asked, Have you been involved in decisions about your daily care? The resident replied, I am supposed to be involved. When asked what she meant by that statement, she replied, I'm supposed to be able to go to my care conference meeting, but they only tell me they're going to have it (care conference meeting) this week, they do not give me a specific date. Then later they tell me they have already had it. There are things I would like to say at those meetings. An interview with Director of Nurses (DON) #16, Assistant Director of Nurses #47, and Social Worker (SW) #18 on 06/17/15 at 2:25 p.m., revealed residents and MPOAs were notified with a corporate facility notification letter when their care planning meetings were scheduled. They said the notification letter gave a resident the option to reschedule for a different time if the resident wished. The social worker (SW) stated all res… | 2019-01-01 |
| 5332 | 5332 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2015-06-18 | 428 | D | 0 | 1 | 6BSN11 | Based on staff interview and review of medical record information, it was determined the facility had not informed the attending physician of the registered pharmacist's recommendations and given him the opportunity to respond. This was evident for one (1) of five (5) residents who were reviewed for unnecessary mediation use. Resident identifier: #58. Facility census: 94. Findings include: a) Resident #58 A review of Resident #58's medical record on 06/17/15 at 2:45 p.m., revealed the resident had a drug regimen review document dated 04/27/15, which stated, See report for irregularities and/or recommendations. At that time, no report could be located which explained what the irregularities or recommendations were. At 4:00 p.m. on 06/17/15, Assistant Director of Nursing #70 provided the consultant pharmacist's report. This report did have the specific recommendations for the 04/27/15 timeframe. These recommendations were: 1) Consider discontinuing the Zoloft and increase the Mirtazapine (Remeron) every 6 weeks, depending on depressive symptoms 2) Consider reducing the Magnesium to once daily with follow-up monitoring in 4 weeks 3) Consider reducing the Metformin to 500 mg (milligrams) once daily. (She is on Lantus, CrCl (creatinine clearance) is only 44 and her fasting glucose was 110.) During the survey, the pharmacist's 04/27/15 recommendations were given to the physician on 06/17/15. At that time, the physician wrote orders to implement the changes recommended by the pharmacist. The Zoloft was discontinued, the Remeron was increased to 30 mg, the Magnesium was ordered once daily, and the the Metformin was reduced to 500 mg daily. At 9:45 a.m. on 06/18/15, the director of nursing confirmed the pharmacist's recommendations had not been provided to the physician until 06/17/15. | 2019-01-01 |
| 5333 | 5333 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2015-06-18 | 431 | E | 0 | 1 | 6BSN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the package insert for Aplisol, and review of recommendations from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure multi-dose vials of Aplisol tuberculin testing serum were stored in a manner to ensure the serum was safe and maintained potency. This practice had the potential to affect any residents who received a tuberculin test from the vials of Aplisol. Facility census: 94 Findings Include: a) The medication storage room located at the South nurses' station was inspected on 06/17/15 at 3:45 p.m. A ten (10) dose vial of Aplisol Purified Derivative (PPD - test for [DIAGNOSES REDACTED]) was opened, partially used, and not dated to indicate when it was initially opened. Registered Nurse (RN) #95 verified the vial should have been dated when opened, and it was not. RN #95 disposed of the vial. b) The medication storage room located at the North nurses' station was inspected on 06/17/15 at 3:50 p.m. A ten (10) dose vial of Aplisol Purified Derivative was opened, partially used, and not dated to indicate when it was initially opened. LPN #87 verified the vial should have been dated when opened, and it was not. LPN #87 disposed of the vial. c) The manufacturer's package insert for Aplisol includes, . Vials in use for more than 30 days should be discarded. d) According to the CDC, once a multi-dose vial has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within twenty-eight (28) days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Without dates to indicate when the vials were first opened, staff members could not know when these vials should be discarded. e) On 06/17/15 at 4:05 p.m., the Director of Nursing (DON) was made aware of the observations regarding the opened PPD vials in the two (2) medication storage rooms. The DON verified the vials should have been dated when opened. | 2019-01-01 |
| 5334 | 5334 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2015-06-18 | 441 | E | 0 | 1 | 6BSN11 | Based on observation, medical record review, and staff interview, the facility failed to maintain an infection control program to help prevent development and spread of infection. During incontinence care, a nurse aide broke infection control protocol by placing soiled items directly on the resident's bed. This practice had the potential to affect all residents on the 100 hall of the facility who receive incontinence perineal care. Resident identifier: #94. Facility census: 94. Findings include: a) Resident #94 Review of the nurse aide Kardex on 06/18/15 at 10:56 a.m., revealed Resident #94 was dependent to extensive assist with toileting, and usually was incontinent of bladder and occasionally incontinent of bowel. An intervention noted on the Kardex corresponded with interventions for incontinence care found during a review of the current care plan. Review of the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 05/04/15 revealed Resident #94 was always incontinent of bladder and bowel. On 06/18/15 at 2:12 p.m., Nurse Aide (NA) #98 was observed providing incontinence care to Resident #94. While providing care, Nurse Aide #98 laid the resident's wet soiled incontinence brief and soiled washcloths directly on the resident's bed without any barrier between the bed linen and the soiled wet items. An interview with Infection Control Nurse #41, on 06/18/15 at 3:01 p.m., concerning the observations made during Resident #94's incontinence care, she confirmed infection control principals had not been followed when Nurse Aide #98 placed dirty wet washcloths and a soiled brief on the resident's bed. | 2019-01-01 |
| 5335 | 5335 | ROANE GENERAL HOSPITAL | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2015-10-21 | 155 | E | 0 | 1 | 4PJF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to accurately and consistently incorporate the resident's choices regarding Advance Directives into the clinical record for seven (7) of fourteen (14) residents reviewed. Resident identifiers: #35, #9, #3, #26, #4, #21, and #29. Facility census: 29. Findings include: a) Resident #35 A review of Resident #35's clinical record, at 1:30 p.m. on 10/20/15, revealed the resident was [AGE] years old and was admitted to the facility on [DATE]. Resident #35 was determined by the physician to lack capacity to form her own health care decisions, and the record indicated Resident #35 had appointed a medical power of attorney (MPOA). The resident admission record front sheet indicated, under a section entitled Advanced Directives, that no advanced directives were selected for Resident #35. Further review of the record revealed a Physician Orders for Scope of Treatment (POST) form signed and completed on 03/06/14. In addition, the admission orders [REDACTED]. These findings were reviewed with Social Worker #37 at 2:20 p.m. on 10/20/15. Social Worker #37 acknowledged the statement on the admission record was an error and provided evidence of discussion of the DNR decision with the MPOA at the time of admission to the facility. She agreed the front sheet of the clinical record should reflect that choice and said she would have this corrected. A review of the facility policy entitled: Documentation of Advance Directives, provided by the Social Worker, indicated the existence of the advanced directive was to be entered into the record by the admissions department. If not present at admission, the policy stated, The unit clerk shall follow-up with the patient within 24 hours to secure a copy of the advance directive and will continue to do so during the admission until patient disposition, and This will be scanned to the record by the unit clerk. b) Resident #9, #3, #26, #4, and #21… | 2019-01-01 |
| 5336 | 5336 | ROANE GENERAL HOSPITAL | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2015-10-21 | 225 | D | 0 | 1 | 4PJF11 | . Based on record review and staff interview, the facility failed to report all allegations of neglect to the appropriate outside agencies in accordance with State law for two (2) of sixteen (16) complaints reviewed. Resident #32 alleged she did not receive her eye drops for several days. An allegation was made regarding Resident #35's bed linens not being changed. Resident identifiers: #32 and #35. Facility census: 29. Findings include: a) Resident #32 Review of a complaint form at 9:00 a.m. on 10/21/15, revealed Resident #32 had complained to Licensed Practical Nurse (LPN) #9 on 12/13/14. Resident #32 said she had not had her eye drops administered at 9:00 p.m. for the last several days. This was documented and investigated by Director of Nurses (DON) #17 and Social Worker #37 on 12/15/14, but the allegation of neglect was not reported to the appropriate State offices. During an interview with Social Worker #37 and DON #17 at 11:00 a.m. on 10/21/15, they acknowledged Resident #32 was alert and oriented and able to make her needs known. After review of the complaint, they agreed it should have been reported. b) Resident #35 Review of a complaint form at 9:00 a.m. on 10/21/15, revealed the MPOA (Medical Power of Attorney) for Resident #35 contacted the Social Worker #37 on 02/19/15, with concerns over the resident's bed linens not being changed. This allegation of neglect was investigated by Social Worker #37 and Registered Nurse #19, but it was not reported to the appropriate State offices. During an interview with Social Worker #37 and DON #17, at 11:00 a.m. on 10/21/15, they acknowledged it should have been reported. c) A review of the facility's policy entitled, Mistreatment, Neglect, or Abuse including Injuries of Unknown Source, and Misappropriation of Resident Property, at 10:45 a.m. on 10/21/15, found it included the following definitions of Neglect: -- c) Lack of attention to physical needs ., and -- d) Failure to provide services that result in harm, such as not turning a bed-fast resident of leaving th… | 2019-01-01 |
| 5337 | 5337 | ROANE GENERAL HOSPITAL | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2015-10-21 | 272 | D | 0 | 1 | 4PJF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to conduct a comprehensive assessment accurately reflecting the status of an individual resident. Resident #20's minimum data set (MDS) assessment did not identify that she was receiving Hospice services. This was found for one (1) of sixteen (16) sample residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #20. Facility census: 29. Findings include: a) Resident #20 On 10/21/15 at 9:40 a.m., a medical record review revealed Resident #20 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #20 was admitted to Hospice services on 09/08/15 with the [DIAGNOSES REDACTED]. The significant (sig) change MDS, with an Assessment Reference Date (ARD) of 09/08/15, was not coded for Hospice services in Section O, Item . After reviewing the MDS on 10/21/15 at 11:25 a.m., MDS Coordinator #19 verified the MDS did not reflect Resident #20's Hospice status. She stated, That was the whole reason for doing the sig (signficant) change, and I forgot to mark it that is my fault. | 2019-01-01 |
| 5338 | 5338 | ROANE GENERAL HOSPITAL | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2015-10-21 | 278 | D | 0 | 1 | 4PJF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the individual completing and certifying the accuracy of the significant change assessment for one (1) of sixteen (16) Stage 2 sample residents coded the assessments accurately. The minimum data set (MDS) did not accurately reflect Resident #20's Hospice status. Resident identifiers: #20. Facility census: 29. Findings include: a) Resident #20 On 10/21/15 at 9:40 a.m., a medical record review revealed Resident #20 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #20 was admitted to Hospice services on 09/08/15 with the [DIAGNOSES REDACTED]. A significant (sig) change MDS, with an Assessment Reference Date (ARD) of 09/08/15, Section O, Item did not identify the resident received Hospice services. After reviewing the MDS on 10/21/15 at 11:25 a.m., MDS Coordinator #19 verified the MDS did not reflect Resident #20's Hospice status. She stated, That was the whole reason for doing the sig change and I forgot to mark it that is my fault. | 2019-01-01 |
| 5339 | 5339 | ROANE GENERAL HOSPITAL | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2015-10-21 | 279 | D | 0 | 1 | 4PJF11 | **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 each resident that included measurable objectives and timetables to meet a resident's medical and nursing needs identified in the comprehensive assessment for two (2) of fourteen (14) Stage 2 sampled residents. Resident #20's care plan did not identify her recent admission to Hospice services for end of life care. Resident #26's care plan did not address the resident's [MEDICAL CONDITION], use of a Unna Boot, or contractures. Resident identifiers: #26, and #20. Facility census: 29. Findings include: a) Resident #20 On 10/21/15 at 9:40 a.m., a medical record review revealed Resident #20 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #20 was admitted to Hospice services on 09/08/15 with the [DIAGNOSES REDACTED]. Review of the resident's care plan revealed the care plan did not contain a focus, goal, or intervention that addressed Hospice services. It did contain a handwritten note (typed as written) Hospice 09/08/15 (initials). After reviewing the care plan on 10/21/15 at 11:10 a.m., Minimum Data Set (MDS) Coordinator #19 verified the care plan did not contain any focus, goals or interventions related to Hospice Services. She stated, I have never dealt with Hospice and just wrote that little blurb in the care plan because Hospice has their own care plan. b) Resident #26 Review of the clinical record at 10:00 a.m. on 10/20/15, revealed Resident #26 was a [AGE] year-old female admitted to the facility on [DATE]. The resident was 60 inches tall, and her current weight was 105 pounds. The record included a physician's orders [REDACTED]. Resident #26 had received a diuretic ([MEDICATION NAME] 20 mg (milligram) daily) for [MEDICAL CONDITION] since 07/18/15. The resident also had a physician's orders [REDACTED]. Every shift; Night, Day, Evenings. 1. A review of Resident #26's care plan revealed there was no evide… | 2019-01-01 |
| 5340 | 5340 | ROANE GENERAL HOSPITAL | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2015-10-21 | 309 | D | 0 | 1 | 4PJF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of fourteen (14) residents in the sample was provided the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to provide measurable and consistent monitoring of [MEDICAL CONDITION], polyuria, and/or nocturia by failing to have evidence of the monitoring in the record. Resident identifier: #26. Facility census: 29. Findings include: a) Resident #26 Review of the clinical record at 10:00 a.m. on 10/20/15, revealed Resident #26 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #26 was 60 inches tall, and her current weight was 105 pounds. She had a physician's orders [REDACTED]. The resident had received the diuretic [MEDICATION NAME], 20 milligrams daily, for [MEDICAL CONDITION] since 07/18/15. The resident also had a physician's orders [REDACTED]. Every shift; Night, Day, Evenings. The ADL (activities of daily living) Flow Sheets reflected daily fluid intake, but there was no evidence of urine output being monitored and no instructions in the care plan of the method for monitoring polyuria/nocturia, as the physician instructed. During an interview with Licensed Practical Nurse (LPN) #8, at 3:15 p.m. on 10/20/15, she stated the resident was monitored for [MEDICAL CONDITION], and they initialed the TAR (treatment administration record) that it was done. She stated if there was any [MEDICAL CONDITION], they would document it in the nurses' notes. She acknowledged, after reviewing the care plan, there were no instructions for this in the care plan. During an interview with Registered Nurse #19, (MDS nurse) and Director of Nursing #17 at 11:30 a.m. on 10/21/15, they acknowledged the absence in the record of the monitoring for polyuria or nocturia. They agreed there was a question about the consistency of the monitoring… | 2019-01-01 |
| 5341 | 5341 | ROANE GENERAL HOSPITAL | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2015-10-21 | 431 | E | 0 | 1 | 4PJF11 | Based on observation and staff interview, the facility, in coordination with the licensed pharmacist, failed to provide safe and secure medication storage to minimize loss or diversion. Controlled Schedule II drugs, and other drugs subject to abuse, were not stored in a safe, secure, and locked area. This had the potential to affect more than an isolated number of residents within the facility. Facility census: 29. Findings include: a) An observation of the narcotic cabinet, located in an open alcove area of the large open nurses' station, on 10/20/15 at 3:45 p.m. in the company of Licensed Practical Nurse (LPN) #4, revealed a cabinet with two (2) side by side locked cabinet doors. The cabinet required the nurse to use one key to unlock the narcotic cabinet. Inside the cabinet was a clear plastic box with sections and secured with zip ties. The box was labeled controlled drug emergency kit. The box contained the following medications: [REDACTED] - Tylenol #3--10 tablets, - Xanax 0.25 milligrams (mg) --5 tablets, - Klonopin 0.5 mg --5 tablets, - Lomotil 2.5 mg --5 tablets, - Fentanyl (Duragesic) 25 micrograms (mcg) patch--2 patches, - Fentanyl 50 mcg patch--2 patches, - Norco 5/325 mg--10 tablets, - Vicodin 5/500--10 tablets, - Dilaudid 2 mg--5 tablets, - Ativan 0.5 mg --5 tablets, - MS Contin 15 mg--5 tablets, - Roxanol 20 mg/ml (milliliters) solution--2 - 30 ml bottles, - Oxycontin SR (sustained release) 10 mg--5 tablets, - Roxicodone IR (immediate release) 5 mg--5 tablets, - Percocet 130 mg/ml 1 bottle of 1 ml solution, - Phenobarbital 30 mg --3 tablets, and - Ambien 5 mg--5 tablets. LPN #4 stated, There has never been two (2) locked doors for narcotics, just one locked door to retrieve the narcotics. He further stated, The procedure to remove narcotics is to clip the zip ties after notifying pharmacy and then filling out a pharmacy form for the resident and medications that were needed. LPN #4 said he would check with the DON, and commented, But I guess if you want to take any drugs, it would be relatively eas… | 2019-01-01 |
| 5342 | 5342 | ROANE GENERAL HOSPITAL | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2015-10-21 | 514 | D | 0 | 1 | 4PJF11 | Based on record review and staff interview, the facility failed to provide staff documentation in a legible format to allow staff to conduct care programs and manage and/or respond to the changing status of the residents for two (2) of fourteen (14) residents reviewed. Resident identifiers: #26 and #29. Facility census: 29. Findings include: a) Resident #26 While reviewing the clinical record for Resident #26 at 3:00 p.m. on 10/20/15, the nurses' progress notes written at 2:40 p.m. on 9/30/15, were not legible. The notes at this facility were handwritten. b) Resident #29 During a review of the clinical record for Resident #29 at 3:30 p.m. on 10/20/15, the nurse's progress notes written at 10:15 a.m. on 10/07/15 could not be read due to their illegibility. c) During an interview at 4:10 p.m. on 10/20/15, with Ward Clerk/Aide #27 and RN #19, they were asked to decipher the notes, but could not. They indicated this was a continuing problem with the author, LPN #9. During an interview with the Director of Nurses at 4:30 p.m. on 10/20/15, she admitted she also could not read the notes. | 2019-01-01 |
| 5343 | 5343 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2015-01-28 | 156 | B | 0 | 1 | 11X211 | Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility census: 64 Findings include: a) On 01/20/15 at 11:45 a.m., during an observation of the facility, observation revealed there was no written information posted in the facility to inform a resident about how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. During an interview on 01/27/15 at 9:30 a.m. the Nursing Home Administer was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits. | 2019-01-01 |
| 5344 | 5344 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2015-01-28 | 167 | B | 0 | 1 | 11X211 | Based on observation and staff interview, the facility failed to post the annual survey results in a prominent and readily available area where residents and families may access without asking for assistance. This practice had the potential to affect more than an isolated number of residents. Facility census: 64 Finding include: a) Observation on 01/20/15 at 3:30 p.m. revealed the results of the past annual survey were located on the wall at the nursing station. They were located high on the wall, behind a tall medication cart. b) An observation and interview with Employee #78, on 01/28/15 at 3:30 p.m., indicated a resident in a wheelchair would not be able to reach the annual survey results without difficulty. Facility personal moved the survey results to a more accessible location for residents. | 2019-01-01 |
| 5345 | 5345 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2015-01-28 | 225 | E | 0 | 1 | 11X211 | . Based on review of allegations reported to the State, resident interview, staff interview, and record review, the facility failed to ensure an allegation of abuse for one (1 ) of two (2) residents reviewed for the area of abuse, during Stage 2 of the Quality Indicator Survey (QIS), was reported and investigated. In addition, the facility failed to ensure an inquiry was made to the State nurse aide abuse registry for one (1) of ten (1) employees whose personnel files were reviewed. This had the potential to affect more than an isolated number of residents. Resident identifier #74 Facility census: 64. Finding include: a) Resident #74 On 01/20/15 at 1:50 p.m., during an interview while conducting Stage 1 of the QIS, Resident # 74 stated a Nurse Aide (NA) had hurt his leg. He said he reported this to the social worker. Review of the facility's reported allegations of abuse, on 01/22/15 at 11:10 a.m., revealed no allegation of abuse regarding Resident #74 was reported to the State agencies. Employee #54, the Licensed Social Worker (LSW), was interviewed on 01/22/15 at 11:31 a.m. She said the resident told her the NA used a monotone voice when talking to him. The LSW confirmed the resident also told her, at that time, NA #20 hurt his leg when she was transferring him from the bed to the chair with the lift. She said the monotone voice was investigated and addressed. Upon further inquiry, the LSW said the allegation regarding the NA hurting the resident's leg was not reported, and There was no formal investigation. She said she thought the situation had occurred in the last few months. The LSW did not have any notes regarding the allegation. An interview with the administrator (NHA) and the director of nursing (DON), on 01/22/15 at 11:35 a.m., revealed neither had investigated the allegation of abuse. Further interview with the DON, LSW and NHA, on 01/22/15 at 12:40 p.m., revealed they did not feel the complaint was about the NA hurting the resident, but was regarding the tone of the NA's voice while providing care. T… | 2019-01-01 |
| 5346 | 5346 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2015-01-28 | 253 | E | 0 | 1 | 11X211 | Based on observations and staff interviews, it was determined the facility failed to provide housekeeping and maintenance services to ensure a sanitary, orderly and comfortable environment. Walls were in disrepair, toilet handrails were loose and easily movable, window curtains were dirty, and caulking around windows and baseboards was in poor repair. This practice was evident in six (6) of thirty-three (33) rooms. Room numbers: 98, 216, 218, 219, 221 and 222. Facility census: 64 Findings include: a) Environmental issues were found during the initial tour of the facility on 01/20/15. These issues were observed and reviewed with the maintenance director on 01/27/15 prior to lunch time. The maintenance director confirmed the observations and concerns. 1. Room 98: toilet handrails around the commode were loose and wobbly. (Maintenance later removed these and replaced them with new sturdy ones.) 2. Room 216: the raised toilet seat was dark brown. In addition, the light in the ceiling light was dark with yellow discoloration 3. Room 218: curtains were soiled with brown and black marks, the heater filter was dirty, the drawer handle had the pull part missing in the resident's bath area, the 1/2 shower wall between the commode and the shower was rusty, and the wall board was separated at the sides and bottom of the shower. 4. Room 219: the wall to right of the heater was cracked. There was a hole in the caulking and one could see outside. The over-the-bed light had many scrapes and the window had a crack in it. 5. Room 221: the filter in the heater unit contained a large amount of dust. cleaning. 6. Room 222: there was a rusty looking dark brown stained area around the sink drain. | 2019-01-01 |
| 5347 | 5347 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2015-01-28 | 272 | D | 0 | 1 | 11X211 | Based on medical record review and staff interview, the facility failed to complete an accurate comprehensive assessment for one (1) of twenty-two (22) Stage 2 sample residents. The assessment related to the resident's pressure ulcers did not correctly describe the resident's skin condition. Resident identifier: #65. Facility census: 64. Findings include: a) Resident #65 During a Stage 1 interview, on 01/20/15 at 2:02 p.m., Employee #39, a licensed practical nurse (LPN), indicated Resident #65 had a Stage III pressure ulcer (PU) on his coccyx. She related it may have developed in house. Review of the medical record, on 01/20/15 at 3:47 p.m., revealed a comprehensive minimum data set (MDS) with an assessment reference date (ARD) of 09/22/14. Section M 0300 indicated Resident #65 had one (1) unhealed Stage III PU, which was present on admission/entry/reentry. Section S indicated the pressure ulcer developed in house. Section M0900 indicated the resident also had one (1) Stage III pressure ulcer, which was present on the prior assessment and had completely closed. Further review of the medical record, on 01/22/15 at 10:21 a.m., revealed no evidence from 12/31/13 through 01/22/14, which indicated Resident #65 had a pressure ulcer other than that on his coccyx. Pressure ulcer record logs, reviewed from 02/01/14 through 01/22/15, indicated the Stage III coccyx wound had never healed during that time frame. The records provided no evidence the resident had another wound. During an interview with the MDS coordinator, on 01/22/15 at 2:54 p.m., she reviewed the MDS with an ARD of 09/22/14. She confirmed section M did not correlate with Section S, but did not know which was correct. She also could not relate whether the information regarding the healed pressure ulcer was correct. An interview with the director of nursing, on 01/22/15 at 3:30 p.m., revealed the coccyx wound had never healed. She said she did not believe the resident had developed another wound. Employee #13, a registered nurse (RN), interviewed on 01/27/15 a… | 2019-01-01 |
| 5348 | 5348 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2015-01-28 | 278 | E | 0 | 1 | 11X211 | Based on medical record review and staff interview, the facility failed to complete an accurate quarterly assessment for (1) of twenty two (22) Stage 2 sample residents. The quarterly assessment for this resident was incorrect related to pressure ulcers. Resident identifier: #65. Facility census: 64. Findings include: a) Resident #65 During a Stage 1 interview, on 01/20/15 at 2:02 p.m., Employee #39, a licensed practical nurse (LPN), indicated Resident #65 had a Stage III pressure ulcer (PU) on his coccyx. She related it may have developed in house. Review of the medical record, on 01/20/15 at 3:47 p.m., revealed a quarterly minimum data set (MDS) with an assessment reference date (ARD) of 12/19/14. Section M 0300 indicated Resident #65 had one (1) unhealed Stage III PU, which was present on admission/entry/reentry. Section S indicated the pressure ulcer developed in house. Section M0900 indicated the resident also had one (1) Stage III pressure ulcer, which was present on the prior assessment and had completely closed. Previous quarterly MDSs with ARDs of 12/31/13, 04/01/14 and 06/24/14 also indicated Resident #65 had a Stage III pressure ulcer which was present upon admission/entry or reentry. Each quarterly MDS indicated the resident had one (1) Stage III pressure ulcer present on the prior assessment which had closed. Section S of the quarterly assessments with ARDs of 12/31/13, 06/24/14, and 12/19/14 indicated the coccyx wound was acquired other than in house. Further review of the medical record, on 01/22/15 at 10:21 a.m., revealed no evidence from 12/31/13 through 01/22/14, which indicated Resident #65 had a pressure ulcer other than on his coccyx. Pressure ulcer record logs, reviewed for the time period of 02/01/14 through 01/22/15, indicated the Stage III coccyx wound had never healed during that time frame. The record provided no indication the resident had another wound. During an interview with the MDS coordinator, on 01/22/15 at 2:54 p.m., she reviewed the quarterly MDS with an ARD of 12/19/14. She c… | 2019-01-01 |
| 5349 | 5349 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2015-01-28 | 280 | D | 0 | 1 | 11X211 | Based on medical record review and staff interview, the facility failed to revise the care plan for one (1) of twenty-two (22) residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey (QIS). The care plan was not updated to accurately reflect the resident's need for assistance to attend activities. Resident identifier: #6. Facility census: 64. Findings include: a) Resident #6 On 01/22/15, a review of the resident's care plan, which was revised on 11/04/14, did not indicate the decline in this resident's mobility status. The care plan indicated the resident was able to self transfer and ambulate without assistance to the activities of her choice. The resident's most recent minimum data set (MDS) with an assessment reference date (ARD) of 10/30/14 was reviewed. Section G-0110 was coded the resident required extensive assistance with transfers and locomotion on and off the unit. During an interview on 01/22/15 at 11:00 a.m., the Activities Director stated staff brought the resident to activities in a wheelchair. She verified the care plan needed to be updated to reflect the resident's need for assistance to attend activities. | 2019-01-01 |
| 5350 | 5350 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2015-01-28 | 312 | D | 0 | 1 | 11X211 | Based on observation and staff interview, the facility failed to ensure one (1) of one (1) residents reviewed for the activities of daily living (ADL) care area, during Stage 2 of the survey, received services to maintain good grooming/hygiene. The resident, who was unable to independently perform ADLs, was not provided nail care. Resident identifier: #6. Facility census: 64. Findings include: a) Resident #6 During a resident observation, on 01/22/15 at 9:45 a.m., this resident was discovered to have dirty finger nails. This resident was unable to carry out her activities of daily living (ADL) and required extensive assistance from staff to maintain good grooming. A staff interview and resident observation on 01/22/14 at 3:45 p.m. with Employee #13, registered nurse (RN), verified this resident's finger nails were dirty and needed to be cleaned. She also confirmed this resident is dependent on staff for her ADLs. | 2019-01-01 |
| 5351 | 5351 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2015-01-28 | 371 | E | 0 | 1 | 11X211 | Based on observation and staff interview, the facility failed to ensure foods were stored in a manner to prevent foodborne illnesses to the extent possible. Inadequately covered and outdated food was stored in the refrigerator in the nourishment pantry. This had the potential to affect more than an isolated number of residents who were provided food from the nourishment pantry refrigerator. Facility census: 64. Findings include: a) During the initial tour of the facility on 01/20/2015 at 11:05 a.m., the nourishment pantry located across from the nursing station was observed. Employee #78, a licensed practical nurse (LPN), unlocked the door of the nutrition pantry. Observation of the contents of the refrigerator with Employee # 78 revealed a pitcher of milk with no discard date, a pitcher of orange juice with a discard date of 01/19/15, and a package of orange popsicles with a date of 08/2011. There was also a squeeze container of applesauce with a medicine cup loosely covering the tip. b) At 11:10 a.m. on 01/20/2015, Employee #78 agreed the foods were not stored in a manner which prevented contamination and/or ensured safety for consumption. She discarded the items at that time. | 2019-01-01 |
| 5352 | 5352 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2015-01-28 | 431 | E | 0 | 1 | 11X211 | Based on observation, staff interview, and policy review, the facility failed to store medications and biologicals with currently accepted professional principles. Staff failed to date an opened multi-dose vial of insulin, and stored oral medications with external medications, medications were store outside the original containers, and medications were unlabeled. This practice affected more than a limited number of residents. Resident identifiers: Resident #95, #17, #13, #107, #1, #40, #9, and #16. Findings include: a) Sunny Drive Medication Cart (Residents #13, #95, #17, #107, and #1) An observation of the Sunny Drive medication cart, on 01/26/15 10:46 a.m., with Employee #30, a licensed practical nurse (LPN), revealed an opened, undated vial of Lantus insulin belonging to Resident #13. Additionally, oral medications were stored with inhaled medications for Residents #95, #17, #107, and #1. The inhalers were also stored outside of the original containers. Upon inquiry, the nurse related she did not know the facility policy related to medication storage. b) Meadow Lane Medication Cart (Residents #40, #9, and #16) An observation of the Meadow Lane medication cart, on 01/26/2015 10:55 a.m., with Employee #37, LPN, revealed Resident #40's oral medications were stored with lumigan and azopt eye drops, and xopenex inhalation therapy. Resident #9's oral medications were stored with liquitears eye drops and anucort suppositories Resident #16's section contained three (3) vials of ipatropium inhalation therapy stored unpackaged. The ipatropium inhalation therapy did not contain the resident's name, route of administration, appropriate instructions and precautions. Upon inquiry, Employee #37 (LPN) related she did not know the facility policy related to medication storage. c) Review of the storage and expiration dating of medications, biologicals, syringes and needles policy required eye, ear and nasal drugs and biologicals be stored apart from oral medications. It also indicated medications and biologicals of each residen… | 2019-01-01 |
| 5353 | 5353 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2015-01-28 | 441 | E | 0 | 1 | 11X211 | Based on observation, staff interview, and policy review, the facility failed to maintain an infection control program to prevent, to the extent possible, the development and transmission of disease and infection for six (6) of six (6) residents identified during a random opportunity for observation. Staff failed to sanitize hands during ice pass, placed the ice scoop inside soiled cups, and stored the ice scoop without a cover. In addition, the facility failed to ensure one (1) of two (2) medication carts was maintained in a sanitary condition. Resident identifiers: #42, #40, #49, #7, #16 and #31. Facility census: 64. Findings include: a) Residents #42, #40, #49, #7, #16, and #31 During a random observation, on 01/26/2015 at 4:00 p.m., Employee #25, a nursing assistant (NA) passed ice to Resident #42. The NA entered the room, picked up the resident's cup, located on the over-the-bed table, removed the lid, and placed it on the table. The NA exited the room with the cup, opened the ice chest, and placed a scoop of ice in the cup, dipping the scoop inside of the cup. The NA returned to room, and placed the lid and straw back on the cup. The NA exited the room without sanitizing her hands. She continued to pass ice in other rooms, utilizing the same procedure. The NA passed ice to Residents # 40, #49, #7, #16 and #31. The NA did not sanitize her hands between any of the residents or any of the rooms. After passing ice to these residents, the NA said she was going to take a break. She left the ice cart in the hallway with the scoop in a cradle attached to the side of the cart. The cradle did not have a cap. Review of the ice pass policy, on 01/26/15 at 5:15 p.m., revealed the bowl area of the ice scoop should be covered when not in use. An interview with the director of nursing (DON) on 01/27/15 at 10:00 a.m., revealed staff should sanitize hands between handling residents' cups. The DON also related the scoop should never be placed inside the cup. She confirmed the procedure created a potential for cross contaminat… | 2019-01-01 |
| 5354 | 5354 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2015-01-28 | 514 | D | 0 | 1 | 11X211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure they maintained an accurate and complete medical record for one (1) of twenty two (22) Stage 2 records. The facility did not maintain an accurate and complete medical record in the area of Hospice care. Resident identifier: #101 Facility census: 64. Findings include: a) Resident #101 On 01/22/15 at 10:00 a.m., the medical record review for Resident #101 revealed the resident had a [DIAGNOSES REDACTED]. The resident's care plan indicated the resident's health care decision maker had requested palliative care due to the resident's condition. A progress note, dated 10/27/14 at 9:41 p.m. stated, Skilled services per Dr. (name) d/t ARF (acute [MEDICAL CONDITION], palliative care and liver and [MEDICAL CONDITION]. Consult with Hospice pending A progress note, dated 10/24/14 at 10:52 a.m., stated, IDT (interdisciplinary team) reviewed. Resident received skilled nursing care for wound treatment to left gluteal. Hospice consulted but unable to admit due to skilled treatment On 01/22/14 at 10:15 a.m., during an interview with the social worker (Employee #54) regarding the progress notes on 10/24/14 and 10/27/14, the social worker said the resident's family wanted to utilize the resident's twenty (20) Medicare days where Medicare would reimburse the facility for the resident's care at 100%. They did not want to pay privately or apply for Medicaid, which would have made the resident eligible for Hospice services. The social worker confirmed the facility did not document this information in the medical record. She agreed the facility did not ensure the complete documentation in the medical record regarding why the resident did not qualify for Hospice services. | 2019-01-01 |
| 5355 | 5355 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26508 | 2015-06-25 | 280 | D | 0 | 1 | FV9G11 | **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 and/or ensure appropriate professional disciplines participated in the care planning for two (2) of twenty-three (23) Stage 2 sampled residents. The care plan for Resident #8 did not address actual falls. Hospice personnel did not participate in care planning for Resident #6. Resident identifiers: #118 and #6. Facility census: 59. Findings include: a) Resident #118 Medical records, reviewed on 06/24/15 at 9:30 a.m., revealed Resident #118 fell on [DATE], causing a skin tear to the right arm. Nursing notes, on this same date, revealed an additional fall on this same date. Review of Resident #118's current care plan revealed a care plan for a risk for falls. It was not updated to reflect actual falls after the resident fell twice on on 05/29/15. When this was brought to the attention of Registered Nurse #19, on 06/24/15 at 11:10 a.m., the nurse confirmed the care plan was not updated. The care plan was updated to reflect actual falls on 06/24/15. b) Resident #6 Review of the medical record, on 06/24/15 at 11:00 a.m., revealed Resident #36 was admitted to Hospice on 02/13/15 for the terminal [DIAGNOSES REDACTED]. The CAR meeting summary, dated 05/14/15, included, Resident became Hospice on 2/13/15 and is a Nutritional risk with dysphagia. The record was silent regarding the participation and/or invitation of Hospice staff in the resident's care plan meeting. During a telephone interview with Hospice Nurse #91, on 06/24/15 at 12:50 p.m., she reported the resident's current Hospice plan of care included two (2) visits a week by the registered nurse, two (2) visits a week by the nurse aide, and a monthly visit by the social worker and the chaplain. The nurse said they sent at least one (1) staff member to every care plan meeting, to participate in the interdisciplinary care planning, when the facility informed them of the meeting. Nurse #91 said she was unaware … | 2019-01-01 |
| 5356 | 5356 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26508 | 2015-06-25 | 323 | E | 0 | 1 | FV9G11 | Based on observation and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible. The doors to the soiled utility room, nourishment room, and clean linen room had push button locks which were broken, allowing access to the rooms without entering a code. Each of the rooms contained items which were potentially hazardous to residents. The affected rooms were located between the 100 and 200 halls. This practice had the potential to affect more than an isolated number of residents. Facility census: 59. Findings include: a) During the initial tour, on 06/22/15 at 11:10 a.m., observation revealed the door to the soiled utility room on the 100 hall had a push button lock which could be opened without pushing in a code. The soiled utility room contained soiled linen, refuse containers that contained refuse from all of the resident rooms, a hopper, and a refrigerator with laboratory specimens from various residents. The unlocked door was verified by Nurse Aide (NA) #68, who stated, The door is supposed to be locked at all times to prevent residents from entering the room. She also stated, All of the doors with the push button locks are to be locked at all times to prevent the residents from entering these rooms, for safety reasons. Also during the tour, the nourishment room and clean linen room doors were easily opened without entering a code. The nourishment room contained numerous food items in the cupboards and refrigerator, a coffee pot, a toaster and a microwave. The clean linen room contained clean linen and numerous toiletries, including shampoo, lotion, mouthwash, shaving creams, and disposable razors. b) On 06/23/15 at 8:10 a.m., the nourishment room door, which had a push button lock, was easily opened without punching in a code. The door was verified accessible without punching in a code by Registered Nurse (RN) #48. She stated, It is supposed to be locked all the time to prevent residents from going in the room. c) At 2:05 p.m. on 06/23/15, the s… | 2019-01-01 |
| 5357 | 5357 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26508 | 2015-06-25 | 371 | F | 0 | 1 | FV9G11 | Based upon observation, staff interview, and review of the FDA Food Code as followed by the Monongalia County Health Department's Environmental Health Services, the facility failed to prepare, distribute and serve food under sanitary conditions. Dietary staff persons were not wearing effective hair restraints (e.g., hairnet, hat, and/or beard restraint) to confine their hair to prevent inadvertent contact with exposed food. This had the potential to affect all residents taking nutrition orally. Facility census: 59. Findings include: a) Observations of the luncheon meal in the kitchen and the adjacent main dining room were made on 06/22/15 and 06/23/15. The observations began with the start of the tray line in the kitchen at 11:47 a.m., and continued through the entire dining period until the last residents were finished eating at 1:20 p.m. During the preparation and tray line service, dietary staff persons were observed in the area of the uncovered steam tables and the uncovered plates and bowls of food being prepared for service. -- Dietary Employee #3 wore a visor. It had no top and left his hair unconfined and uncovered. He had a beard, which was also not confined or covered in any way. -- Dietary Employee #6 wore a visor on 06/22/15 which had no top and left his hair unconfined and uncovered. He wore a cap on 06/23/15. His hair extended around four (4) to five (5) inches below the bottom of both the visor and the cap, and was not confined or covered in any manner. He had a beard, which was also not confined or covered in any way. -- Dietary Employee #8 wore a visor, which had no top and left her hair unconfined and uncovered. -- Dietary Employee #89 wore a visor which was the bill section of a hat held to the head with two (2) arms similar to those used for eyeglasses or sunglasses. Her hair was not confined or covered in any manner. b) The 2005 FDA Food Code as adopted through the WV Legislative Rule for Food Establishments 64-17-1, which is followed by the Monongalia County Health Department's Environmental… | 2019-01-01 |
| 5358 | 5358 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26508 | 2015-06-25 | 441 | D | 0 | 1 | FV9G11 | Based on observation and staff interview, the facility failed to ensure an effective infection control program to prevent, to the extent possible, the development and transmission of disease and infection. This was true for one (1) of two (2) residents reviewed for catheter care during Stage 2 of the Quality Indicator Survey. Resident identifier: #83. Facility census: 59. Findings include: a) Resident #83 On 06/24/15 at 2:30 p.m., Nurse Aide (NA) #92 was observed completing catheter care for Resident #83. NA #92 placed gloves on her hands to begin care. After completing the catheter care, NA #92 continued to wear the same gloves used for catheter care while helping the resident dress and while placing the call bell within reach of the resident. She continued to wear the same gloves while walking to the bathroom and opening the bathroom door. NA #92 then returned to the resident's sink, removed the gloves, and placed them in the garbage. She then washed her hands. Immediately upon completing the remainder of care for Resident #83, the breach in standard infection control practice was discussed with NA #92. She agreed she should have removed the gloves upon completing catheter care, before doing the remainder of her tasks. | 2019-01-01 |
| 5359 | 5359 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26508 | 2015-06-25 | 514 | D | 0 | 1 | FV9G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the completeness and accuracy of the clinical record for two (2) of twenty-four (24) Stage 2 sampled residents. Medication orders were inaccurately transcribed into the computer system and onto the Medication Administration Record [REDACTED]. Resident identifiers: #149 and #6. Facility census: 59. Findings include: a) Resident #149 The resident's medical record was reviewed on 06/24/15 at 10:00 a.m. The admission orders [REDACTED] The order summary report, dated 06/01/15 - 06/30/15, stated: [MEDICATION NAME] Capsule 100 MG (milligrams) ([MEDICATION NAME]) Give 1 capsule by mouth two times a day related to mononeuritis of unspecified site. Licensed Practical Nurse (LPN) #45 reviewed the record during an interview on 06/24/15 at 10:20 a.m. She acknowledged this was a transcription error and stated she would correct the medication order immediately. b) Resident #6 Resident #6's medical record was reviewed on 06/24/15 at 11:00 a.m. The resident's current medication orders incorrectly listed the reason for the administration of the anticoagulant Eliquis. The order stated: Eliquis Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day related to OSTEOARTHROS UNSPEC WHETHER GEN/L[NAME] UNSPEC SITE. (Note: [MEDICAL CONDITION] is a disorder of [DIAGNOSES REDACTED] joints such as the knee and hip. An anticoagulant is a medication used to reduce the ability of blood to clot.) The medical record was reviewed with the assistant director of nursing (ADON) during an interview on 06/24/15 at 3:30 p.m. She compared the current medication orders with the admission orders [REDACTED]. The ADON confirmed the order was transcribed into the computer system incorrectly. Eliquis was initially ordered for [MEDICATION NAME] (preventative treatment). It is not a medication used to treat [MEDICAL CONDITION]. | 2019-01-01 |
| 5360 | 5360 | TEAYS VALLEY CENTER | 515106 | 1390 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2015-09-03 | 253 | D | 0 | 1 | XK8011 | Based on observations and staff interview, the facility failed to provide maintenance and housekeeping services necessary to maintain a comfortable and sanitary interior for three (3) of thirty-six (36) rooms observed during Stage 1 of the Quality Indicator Survey (QIS). Room #411, #500 had missing transitions strips in the doorways, which exposed missing tile and Room #400 had missing caulking around the sink. This had the potential to affect more than an isolated number of residents. Room Identifiers: #411, #500 and #400. Facility census: 114. Findings Include: a) Transition strips -- Observations of Room #411 and #500 on 08/30/15 at 6:20 p.m., revealed missing transition strips in both doorways, which exposed broken and missing tile. b) Caulking -- Observation of Room 400, on 08/31/15 at 9:15 a.m., discovered the caulking was missing behind the sink. c) Tour with the Director of Maintenance A tour with Director of Maintenance #63, beginning at 10:15 a.m. on 09/03/15, confirmed the cosmetic imperfections. He verified the missing transition strips needed replaced and the caulking behind the sink needed repaired. | 2019-01-01 |
| 5361 | 5361 | TEAYS VALLEY CENTER | 515106 | 1390 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2015-09-03 | 272 | D | 0 | 1 | XK8011 | Based on record review and staff interview, the facility failed to conduct accurate comprehensive Minimum Data Set (MDS) assessments for two (2) of 30 residents whose assessments were reviewed. The comprehensive assessment did not accurately reflect Resident #95's functional status and for Resident #109 the comprehensive assessment did not accurately reflect the lack of a wound infection. Resident identifiers: #95 and #109. Facility census: 114. Findings include: a) Resident #95 The annual minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/11/15, reviewed on 09/01/15 at 3:00 p.m. revealed the following information. Section G (Functional Status) G0110 (A) Bed Mobility, (B) Transfer, (E) Locomotion on Unit, (F) Locomotion off Unit, (I) Toilet Use, and (J) Personal Hygiene were coded to indicate the resident required extensive assistance with these activities of daily living (ADLs). A review of Resident #95's care plan and ADL records, on 09/01/2015 3:50 p.m., revealed the resident is dependent on staff for all ADL care. An interview, on 09/01/15 4:31 p.m., with the director of nursing (DON) and Assistant Director of Nursing (ADON) #32, confirmed the MDS with the ARD of 06/11/15 for Section G (Functional Activities) G110 (A), (B), (E), (F), (I), and (J) were inaccurately coded. The DON stated, Resident #95 was dependent on staff for all ADLs. b) Resident #109 A review of the Significant Change MDS with the ARD, of 07/22/15 for Resident #109 on 09/03/2015 9:55 a.m., found this assessment was coded under Section I 2500 to indicate a wound infection (other than feet). A review of Resident #109 medical records revealed the resident did not have a wound infection. An interview with the DON, on 09/03/15 at 10:00 a.m., revealed Resident #109 did not have a wound infection. She confirmed Section I 2500 of the MDS with the ARD of 07/22/15 was inaccurately coded. | 2019-01-01 |
| 5362 | 5362 | TEAYS VALLEY CENTER | 515106 | 1390 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2015-09-03 | 371 | E | 0 | 1 | XK8011 | Based on observation, policy review, and staff interview, the facility failed to ensure foods were stored in a safe and sanitary manner. Food was unlabeled and not dated in the nutritional pantry. Additionally, staff was not checking and recording the refrigerator/freezer temperatures in the nutritional pantry. This had the potential to affect more than a minimal number of residents. Facility census: 114. Findings include: a) Nutritional Pantry/Cherry Blossom Hall The initial tour of the nutritional Pantry with Licensed Practical Nurse (LPN) #67, on 08/30/15 at 6:41 p.m., revealed two (2) bowls of Bran Flakes, one (1) bowl of Rice Krispies, and one (1) bowl of Corn Flakes laying on top of the refrigerator unlabeled and undated. The LPN confirmed the cereal would need to be discarded due to the cereal being not labeled/dated with a use by date. Review of the facility's policy related to labeling and dating food stated that food and nutrition service employees would inventory nursing station pantries at least daily. The policy also said they would stock the pantries with sufficient food. The food would be labeled with a use by date. The policy also stated that all outdated or unlabeled snacks, nourishments, supplements, and foods would be discarded. b) Refrigerator/freezer on Cherry Blossom Hall Observation of the refrigerator/freezer in the nutritional pantry on Cherry Blossom Hall with Licensed Practical Nurse (LPN) #67 on 08/30/15 at 6:42 p.m. revealed a refrigerator/freezer temperature log on the front of the refrigerator in the nutritional pantry. A review of the refrigerator/freezer temperature log revealed the staff had not observed/recorded the refrigerator/freezer temperatures from 08/01/15 through 08/31/15. LPN #67 stated, Looks like no staff here has checked the temperature inside the refrigerator/freezer for the whole month of August. The facility's policy related to refrigerator/freezer temperatures revealed, Food Service Director or designee observes and records the temperature of the refrigerator/fre… | 2019-01-01 |
| 5363 | 5363 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2015-06-11 | 225 | E | 0 | 1 | 2MMX11 | Based on personnel record review, review of West Virginia Code 69 CSR 6-8.1, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents. The facility failed to check for findings entered in the nurse aide abuse/neglect registry for three (3) of ten (10) employees whose files were reviewed. This had the potential to affect more than an isolated number of residents. Employee identifiers: #43, #52, and #53. Facility census: 46. Findings include: a) A review of ten (10) personnel files began on 06/09/15 at 4:15 p.m., and continued the morning of 06/10/15. The review found three (3) of ten (10) employees hired by the facility had no evidence of required nurse aide registry checks. The employees with no evidence of the required nurse aide registry check were: 1. Licensed Practical Nurse #43 2. Dietary Employee #52 3. Registered Nurse #53 b) West Virginia Code 69 CSR 6-8.1 describes the establishment of a statewide nurse aide registry for nurse aides found guilty of abuse, neglect, or misappropriation of property. Placement on the registry is intended to provide a mandatory process to prohibit facilities from employing those individuals. All employees are to be checked against the registry regardless of the individual's current job description. c) Human Resources Director (HRD) #40 was interviewed on 06/10/15 at 9:00 a.m. She said the nurse aide registry checks were to be completed by each department head when they made a hiring decision in their department. HRD #40 said the former director of nurses had routinely checked the employees for all the other department heads, but she was not sure the current director was aware of that. d) Facility Administrator #49 was interviewed on 06/11/15 at 10:16 a.m. She acknowledged the required nurse aide registry checks were not completed. | 2019-01-01 |
| 5364 | 5364 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2015-06-11 | 272 | D | 0 | 1 | 2MMX11 | Based on record review and staff interview, the facility failed to conduct an accurate comprehensive Minimum Data Set (MDS) assessment for one (1) of twenty-five (25) Stage 2 residents. The assessment related to the resident's urinary continence was not accurate. Resident identifier: #9. Facility census: 46. Findings include: a) Resident #9 Resident #9 triggered for a decline in urinary incontinence during the Quality Indicator Survey (QIS). His admission MDS, with an assessment reference date (ARD) of 12/29/14, indicated he was occasionally incontinent under section H0300 Urinary Incontinence. This meant the resident had less than seven (7) incontinent episodes during the look back period. The quarterly MDS, with an ARD of 03/18/15 indicated the resident was now frequently incontinent, which meant he had seven (7) or more incontinent episodes during the look back period, with at least one (1) continent episode. These MDS assessments indicated the resident had a decline in urinary incontinence. On 06/10/15 at 8:45 a.m., MDS Coordinator #67 provided the Nurse Aide (NA)documentation of resident continence during the look back period for the Admission MDS with an ARD of 12/29/14. This was the information she said she used to answer the assessment questions on the 5-day MDS. The information she provided demonstrated the resident was not occasionally incontinent as the admission 5/day assessment indicated. At that time, he was actually always incontinent, with no episodes of continence. The resident did not undergo a decline in continence between the 5/day MDS assessment and the 90/day MDS assessment, but actually had an improvement in urinary continence. Employee #67 agreed, based on the NA documentation of urinary incontinence, the 12/29/14 admission MDS was not accurate for Resident #9. | 2019-01-01 |
| 5365 | 5365 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2015-06-11 | 278 | D | 0 | 1 | 2MMX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of incident and accident reports, medical record review, and staff interview, the facility failed to ensure the quarterly minimum data set (MDS) assessments accurately reflected the status of two (2) of twenty-five (25) residents whose assessments were reviewed in Stage 2 of the survey. Staff completed and certified the accuracy of Section J1800 related to falls for Resident #13 and Section K0300 related to weight loss for Resident #57; however, these assessments were not accurate. Resident Identifiers: #13 and #57. Facility census: 46. Findings include: a) Resident #13 On 06/10/15 at 11:35 a.m., a review of the incident and accident reports revealed Resident #13 had a fall on 03/19/15. A review of the medical record, on 06/10/16, revealed Section J1800 of the quarterly MDS, with an assessment reference date (ARD) of 05/11/15, did not reflect a fall since the resident's last assessment. The fall history for this section did not reflect the fall this resident had on 03/19/15. On 06/11/15 at 9:56 a.m., in an interview with the MDS coordinator, she verified Section J1800 did not accurately reflect the fall for this resident on 03/19/15. . b) Resident #57 Resident #57 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to MDS Coordinator #67, on 06/10/15 at 8:45 a.m., Resident #57 underwent a rapid decline in her condition and a Significant Change in Status MDS was completed due to the decline. On 06/09/15 at 3:00 p.m., review of the resident's quarterly MDS, with an ARD of 05/13/15, revealed section K0300 Swallowing/Nutritional Status indicated the resident had no weight loss. The weight loss for this section is defined as Loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The resident's Weights and Vitals Summary was reviewed on 06/10/15 at 8:50 a.m. The summary indicated on 05/12/15, a six (6) month weight loss of 12.4% and a thirty (30) day weight loss of 5%. This was during the look back… | 2019-01-01 |
| 5366 | 5366 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2015-06-11 | 280 | D | 0 | 1 | 2MMX11 | Based on observation, medical record review, and staff interview, the interdisciplinary team failed to revise the care plan for one (1) of twenty-five (25) residents whose care plans were reviewed in Stage 2 of the Quality Indicator Survey (QIS). The care plan was not revised to reflect a change from the need for incontinence briefs to the need for an indwelling Foley catheter. Resident identifier: #45. Facility census: 46 Findings include: a) Resident #45 Observations of Resident #45, during Stage 1 and Stage 2 of the QIS survey, revealed she had an indwelling Foley catheter. On 06/09/15 at 3:35 p.m., a medical record review revealed she returned to the facility with a Foley catheter on 05/05/15, after a hospitalization for the debridement of a Stage lll pressure ulcer. Resident #45's care plan, dated 05/13/15, did not reflect the change in required incontinence care from the use of incontinence briefs to the use of an indwelling Foley catheter. On 06/10/15 at 1:15 p.m., an interview was conducted with Minimum Data Set (MDS) Coordinator/Wound Care Nurse #67. After reviewing Resident #45's care plan, she verified it did not contain anything related to the indwelling Foley catheter. The nurse stated, I am not going to lie to you, there is nothing there on the care plan about the Foley catheter. It got missed. | 2019-01-01 |
| 5367 | 5367 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2015-06-11 | 441 | D | 0 | 1 | 2MMX11 | Based on observation, staff interview, and procedure review, the facility failed to maintain an infection control program to prevent, to the extent possible, the development and transmission of disease and infection for two (2) of thirty (30) residents whose bathrooms were observed in Stage 1 and Stage 2 of the survey. Bedpans were stored without benefit of a covering during two (2) separate observations of two (2) rooms. Resident identifiers: #68 and #19. Facility census: 46. Findings include: a) Resident #68 On 06/08/15 at 1:30 p.m. observation of the bathroom in this resident's room revealed two (2) uncovered bedpans were on the back of the toilet. A second observation, on 06/10/15 at 12:15 p.m., found one (1) uncovered bedpan on the back of the toilet. b) Resident #19 On 06/08/15 at 1:50 p.m., observation of the bathroom in this resident's room revealed two (2) uncovered bedpans were stored in the bathroom . One (1) was on the back of the toilet and one (1) was on the floor A second observation, on 06/10/15 at 12:15 p.m., revealed two (2) uncovered bedpans stored on top of the cabinet over the toilet. c) During an interview with Nurse Aide (NA) #25, on 06/10/15 at 12:00 p.m., she said staff occasionally took bedpans to the hopper to rinse them, then sprayed them with disinfectant. NA #25 explained this was not done after every use. She said night shift did most of the bedpan sanitation. d) This matter was discussed with the administrator on 06/10/15 at 1:30 p.m. She said she would look for a policy on bedpan storage. On 06/10/15 at 2:00 p.m., Employee #90, the quality assurance coordinator, provided a procedure titled, Bedpan, Urinal and Commode number II.B.6. It was last revised (MONTH) 2013. On page 2, item #16 of the procedure stated, Rinse bedpan and clean thoroughly. Dry with paper towels and store covered in resident's unit area. Keep bedpan separate from other resident items. | 2019-01-01 |
| 5368 | 5368 | MEADOW GARDEN | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2015-06-25 | 156 | E | 0 | 1 | 1EZS11 | Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility census: 57 Findings include: a) On 06/22/15 at 11:15 a.m., during an observation of the facility, no written information to inform a resident about how to apply for and use Medicare and Medicaid benefits was observed in the facility. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. An interview was conducted on 06/23/15 at 10:15 a.m., with the Nursing Home Administrator. He was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits. | 2019-01-01 |
| 5369 | 5369 | MEADOW GARDEN | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2015-06-25 | 167 | B | 0 | 1 | 1EZS11 | Based on observation and staff interview, the facility failed to ensure a notice of the results of the most recent survey and any plans of correction were in a place readily accessible to residents. The survey results book was located on a wall at a height that was not accessible to residents in wheelchairs. This practice had the potential to affect more than an isolated number of residents. Facility census: 57. Findings include: a) An observation on 06/24/15 at 9:00 a.m., revealed the survey results book was located on the wall in front of the nurse's station. The book was placed in a plastic holder that was too high for residents in wheelchairs to reach. On 06/25/15 at 1:33 p.m., a second observation of the survey results book revealed it was still located at a height that was not accessible to residents in wheelchairs. At 1:45 p.m. on 06/25/15, Director of Nursing #68 agreed the survey book was located at a height that was not accessible to residents in wheelchairs. She said she could move the survey book to a lower level which would make it easier to view if someone was in a wheelchair. | 2019-01-01 |
| 5370 | 5370 | MEADOW GARDEN | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2015-06-25 | 241 | D | 0 | 1 | 1EZS11 | Based on observation and staff interview, the facility failed to provide care in a manner which maintained dignity for two (2) of five (5) residents observed during an observation of medication administration. During the medication administration observation, the nurse entered resident rooms three (3) times without first knocking or otherwise asking permission to enter. Resident identifiers: #81 and #4. Facility census: 57. Findings include: a) Resident #81 On 06/24/15 at 9:30 a.m., Licensed Practical Nurse (LPN) #41 was observed entering the room of Resident #81 without first knocking or otherwise asking permission to enter the room. The LPN exited the room, and was observed preparing the resident's medication for administration. After the medications were prepared, LPN #41 again entered the room at 9:35 a.m., without knocking or otherwise asking permission to enter, and administered Resident #81's medications. b) Resident #4 At 9:50 a.m. on 06/24/15, LPN #41 was observed entering Resident #4's room without first knocking or otherwise asking permission to enter. The LPN was observed administering medications to Resident #4. On 06/24/15 at 9:55 a.m., upon inquiry, LPN #41 verified she had not knocked on the doors of Resident #4 or Resident #81 at any time prior to entering the room. She agreed she should have knocked, or asked for permission to enter, instead of just walking into the room. | 2019-01-01 |
| 5371 | 5371 | MEADOW GARDEN | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2015-06-25 | 253 | E | 0 | 1 | 1EZS11 | Based on observation and staff interview, the facility failed to ensure a clean, comfortable, sanitary environment for all residents. Nine (9) of twenty four (24) rooms were found with various maintenance and/or housekeeping issues. Rooms had scrapes of black markings along walls and bathrooms doors. Mirrors above the sinks had the finish worn off. The floor in three (3) rooms had a dirty appearance. In addition, the hallway on both A and B halls had areas in need of repair. Room identifiers: A15, B15, B7, A3, A2, B1, A14, and A10. Facility census: 57. Findings include: a) Observations of the environment were made on 06/23/15, 06/24/15, and 06/25/15. Maintenance Director #83 was present for the tour on 06/24/15. The tours revealed the following housekeeping/maintenance concerns: 1. Room A2 An observation on 06/23/15 at 9:16 a.m. revealed the curtains were hanging too low on one side and blocked the air conditioning flow. A second observation, on 06/24/15 at 9:23 a.m., revealed the curtains were coming off the track in several places. Maintenance Director #83 said his assistant took these curtains down to wash them and put them back up. He said they were not put back up correctly. 2. Room A3 On 06/23/15 at 9:28 a.m., the first observation of Room A3 revealed scuff marks outside the bathroom door. The shear hem on the curtain was also loose and hanging down. At 9:35 a.m. on 06/24/15, a second observation revealed scuff marks were located on the outside of the bathroom door. The curtains in the room had a torn hem and the shear part of the back of the curtain was hanging down from the curtain itself. 3. Room A5 On 06/24/15 at 9:37 a.m., the mirror over the sink had the finish worn off. Scuff marks were also observed on the bathroom door facing. 4. Room 10A The first observation of Room 10A, on 06/23/15 at 9:03 a.m., revealed scuff marks on the bathroom door. In addition, the top side of the bathroom door was sticking, making it hard to close. On 06/24/15 at 9:39 a.m., scuff marks were observed on the bathroom door. … | 2019-01-01 |
| 5372 | 5372 | MEADOW GARDEN | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2015-06-25 | 254 | D | 0 | 1 | 1EZS11 | Based on observation and staff interview, the facility failed to ensure bed linen was in good condition for one (1) of thirty-one (31) residents observed for bed linens. There was a large hole in the resident's bedspread. Resident identifier: #51. Facility census: 57. Findings include: a) Resident #51 On 06/24/15 at 12:38 p.m., an observation in Resident #51's room revealed a pink bedspread that had a large hole on the left side near the footboard of the bed. At 12:45 p.m. on 06/24/15, Housekeeper (HK) #62 said she did not know why this bedspread was on Resident #51's bed. She said the rooms with the green curtains should have had green bedspreads. The HK indicated this bedspread went with the rooms that had pink curtains. She said the bedspreads at the facility were old. She took the bedspread off the bed and said she would put a new one on the bed. 06/25/2015 9:19 a.m., the administrator and social worker #58 were informed about the issue. Social Worker #58 said she would do an audit of all bedspreads in residents' rooms to ensure they were in good condition. | 2019-01-01 |
| 5373 | 5373 | MEADOW GARDEN | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2015-06-25 | 272 | D | 0 | 1 | 1EZS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the accuracy of the comprehensive minimum data set (MDS) for two (2) of five (5) residents reviewed for unnecessary medications in Stage 2 of the Quality Indicator Survey (QIS). The MDS for Residents #18 did not reflect the [DIAGNOSES REDACTED].#50 did not reflect a [DIAGNOSES REDACTED].#18, #50. Facility census: 57. Findings include: a) Resident #18 A review of the medical record, on 06/2415 at 10:30 a.m., revealed this resident had an active [DIAGNOSES REDACTED]. Review of the annual MDS, with an Assessment Reference Date (ARD) of 05/15/15, revealed Section I Metabolic I3400 for [MEDICAL CONDITION] disorders was not marked as an active [DIAGNOSES REDACTED]. An interview, on 06/24/15 at 1:52 p.m., with MDS Coordinator #57, verified the annual MDS with the ARD 05/15/15, Section I3400 for [MEDICAL CONDITION] disorders was not accurate regarding the resident's diagnosis. b) Resident #50 A review of medications for Resident #50, on 06/24/15 at 1:00 p.m. revealed she had a physician's orders [REDACTED]. This was for [MEDICAL CONDITIONS]. The annual MDS, with an ARD of 05/29/15, revealed the assessment was not accurate, as the [DIAGNOSES REDACTED]. A review of Resident #50's care plan revealed she had a care plan for [MEDICAL CONDITION] related to hypertension and [MEDICAL CONDITION]. Registered Nurse (RN) Assessment Coordinator (RNAC) #57 confirmed the MDS related to the [DIAGNOSES REDACTED]. He said he should have included this [DIAGNOSES REDACTED]. | 2019-01-01 |
| 5374 | 5374 | MEADOW GARDEN | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2015-06-25 | 278 | D | 0 | 1 | 1EZS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the quarterly minimum data set (MDS) assessment was accurate for one (1) of five (5) residents reviewed for unnecessary medications in Stage 2 of the Quality Indicator Survey (QIS). Staff certified the accuracy of Section I3400; however, it did not accurately reflect a [DIAGNOSES REDACTED].#49. Facility census: 57. Findings include: a) Resident #49 A review of the medical record for Resident #49, on 06/24/15 at 8:48 a.m., revealed the quarterly MDS assessment, with the assessment reference date (ARD) of 05/07/15, did not accurately reflect an active [DIAGNOSES REDACTED]. Further review revealed the physician's orders [REDACTED]. An interview, on 06/24/15 at 1:58 p.m., with the MDS Coordinator #57, verified Section I Active [DIAGNOSES REDACTED]. | 2019-01-01 |
| 5375 | 5375 | MEADOW GARDEN | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2015-06-25 | 279 | D | 0 | 1 | 1EZS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to ensure the development of a comprehensive care plan for one (1) of three (3) residents reviewed for non-pressure related skin conditions during Stage two (2) of the Quality Indicator Survey. The facility failed to develop a care plan to reflect the resident's transfer ability and assistance required for transfers. Resident identifier: #47. Facility census: 57. Findings include: a) Resident #47 At 8:40 a.m. on 06/25/15, a review of the medical records for Resident #47, identified she had been admitted , discharged and readmitted to the facility several times since her initial admission in 2012. Since her admission on 05/07/15, she had been discharged to the hospital two (2) times. She was readmitted to the facility on [DATE] and 05/25/15. At 9:35 a.m. on 06/25/15, a review of the admission Minimum Data Set (MDS) assessment with the assessment reference date (ARD) of 05/15/15, identified the resident required the extensive assistance of two (2) staff members for transfers. The focus area for activities of daily living (ADLs) deficits, created on 01/27/12 and last revised on 05/26/15, did not identify or address the resident's transfer ability or assistance needs At 10:25 a.m. on 06/25/15, a review of the physician's orders [REDACTED].#47. On 06/25/15 at 10:40 a.m., the transfer of Resident #47, with the assistance of two (2) staff members and a mechanical lift was observed. Nurse Aides (NAs) #66 and #93 transferred the resident from her bed to her geri-chair, with the assistance of a mechanical lift. Resident #47 was instructed to cross her arms tightly across her chest. NA #66 said the resident was always transferred using the mechanical lift. At 10:45 a.m. on 06/25/15, when asked, Resident #47 said the facility always uses two (2) staff members when using the lift to transfer her. Resident said the facility has used the lift to transfer her si… | 2019-01-01 |
| 5376 | 5376 | MEADOW GARDEN | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2015-06-25 | 431 | D | 0 | 1 | 1EZS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and recommendations from the Centers for Disease Control and Prevention (CDC), the facility, in coordination with the consultant pharmacist, failed to ensure safe and secure storage of medications. An opened multi-dose vial of tuberculin testing serum was not dated to indicate when it was initially opened. In addition, the narcotics lock box, located in the refrigerator in the medication storage room, was not permanently affixed. These practices had the potential to affect more than an isolated number of residents. Facility census: 57 Findings include: a) An observation of the medication storage room at the Nurses' Station, on 06/22/15 at 11:00 a.m., revealed a ten (10) dose vial of Aplisol Purified Derivative (PPD - test for [DIAGNOSES REDACTED]) which was opened and partially used. The vial was not dated to indicate when it was initially opened. Licensed Practical Nurse (LPN) #47 verified the vial should have been dated when it was opened. She said facility protocol was to date both the vial and the labeled box. LPN #47 disposed of the vial. According to CDC, once 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. Without a date to indicate when the vial was first opened, staff members could not know when this vial should be discarded. b) On 06/22/15 at 11:15 a.m., a locked narcotics box was observed inside of the refrigerator in the medication storage room. The narcotics box was secured to a removable shelf inside the refrigerator; however, the shelf could be easily removed from the refrigerator. c) On 06/23/15 at 8:40 a.m., the Director of Nursing (DON) was made aware of the opened, undated PPD vial and the unsecured narcotics lock box in the refrigerator. She indicated the facility permanently secured the box to the insi… | 2019-01-01 |
| 5377 | 5377 | MEADOW GARDEN | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2015-06-25 | 441 | D | 0 | 1 | 1EZS11 | Based on observation and staff interview, the facility failed to maintain an effective infection control program to prevent, to the extent possible, the development and transmission of disease and infection for two (2) of five (5) residents observed during the observation of medication administration. A nurse prepared and administered medications without washing or otherwise sanitizing her hands. Resident identifiers: #81 and #4. Facility census: 57. Findings include: a) Resident #81 On 06/24/15 at 9:30 a.m., Licensed Practical Nurse (LPN) #41 was observed exiting the room of Resident #81. The LPN then prepared Resident #81's medications for administration without first washing or otherwise sanitizing her hands. Once the medications were prepared, the LPN entered the resident's room and administered the medications to the resident. After administering the medications, the LPN left the resident's room without washing or otherwise sanitizing her hands. She did not wash or sanitize her hands after returning to the medication cart. b) Resident #4 At 9:50 a.m. on 06/24/15, LPN #41 was observed preparing Resident #4's medications for administration. The LPN prepared the medications without first washing or sanitizing her hands. LPN #41 then entered Resident #4's room and administered the medications to the resident. After administering the medications, the LPN left the resident's room without washing or otherwise sanitizing her hands. The LPN did not wash or sanitize her hands after returning to the medication cart. c) On 06/24/15 at 9:55 a.m., upon inquiry, LPN #41 agreed she had not washed or otherwise sanitized her hands at any point during the observation, while preparing and administering medications for two (2) residents. LPN #41 agreed she should have washed or sanitized her hands. The LPN said she would start carrying hand sanitizer with her to ensure she could sanitize her hands if she could not wash them before leaving a resident's room. | 2019-01-01 |
| 5378 | 5378 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2015-05-22 | 242 | D | 0 | 1 | LSP711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interviews, and staff interviews, the facility failed to honor the choices of two (2) of three (3) residents reviewed for choices, from a total resident sample of 15. The residents were not afforded the opportunity to bathe as often as they chose. Resident identifiers: #14 and #55. Facility census: 88. Findings include: a) Resident #55 During an interview with Resident #55, on 05/18/15 at 02:54 p.m., the resident conveyed she did not have a choice about how many times a week she could have a bath or shower. She stated, They tell me when they can do it. The resident said she usually only got one (1) bath a week, but would like to have one twice a week. She also stated that she would prefer to have a tub bath On 05/21/15 at 9:04 a.m. Nurse Aide (NA) #56 conveyed, We have a bath list and they can have so many a week. The nurse aide voiced she knew how many baths each resident was scheduled for each week by looking at the bath sheets. The NA provided a copy of the resident's bath sheet for the week, which indicated Resident #55 had had only one bath for the week, which was on 05/19/15 (Tuesday). She stated the resident had a bath on Tuesday given by NA #52. (NA #52 was not present or available for an interview.) Review of the bath sheets revealed Resident #55 was only assigned to receive a bath one (1) day a week. Her designated day was Tuesday. The bath sheets were copies of documents handwritten by the clinical coordinator. They listed the day of the week, the time the bath was to be given. The resident's name was pre-filled on the bath sheet form. In the note section next to the resident's name, the resident's weight was recorded when they gave the bath, the date of the bath and the initials of the person who gave the bath. Resident #55's bath sheets for the month of (MONTH) (YEAR) revealed the resident only received a bath once weekly during the month. The resident had a bath recorded on the bath sheets on 05/… | 2019-01-01 |
| 5379 | 5379 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2015-05-22 | 279 | D | 0 | 1 | LSP711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews, the facility failed to develop a comprehensive care plan for one (1) of three (3) residents reviewed for range of motion. The physician's orders [REDACTED]. Resident identifier #48. Facility census: 88. Findings include: a) Resident #48 A review of Resident #48's medical record, on 05/19/15 at 3:46 p.m., found the resident's [DIAGNOSES REDACTED]. Resident #48's Minimum Data Set (MDS)assessment, dated 01/07/15, indicated the resident's cognition was moderately impaired with long and short term memory problems. The resident had functional range of motion impairment to the upper and lower extremities. Resident #48 required extensive to total assistance with activities of daily living. A review of Resident #48's active physician's orders [REDACTED]. A review of Resident #48's care plans, on 05/20/15 at 9:36 a.m., found there was no care plan to address the use of a hot pack. There was no evidence that hot packs were being implemented. During an interview on 05/20/15 at 3:51 p.m., Restorative Aid (RA) #91 stated the resident was currently on a restorative program for his hand contractures. She stated she did not apply hot packs to the resident's neck. During an interview on 05/20/15 at 3:51 p.m., Unit Coordinator #14 stated she was not sure if hot packs were currently being implemented. She indicated the hot packs had been used for the resident's neck pain. She stated sometimes the resident complained of neck pain and stiffness. She reviewed the resident's care plan and stated the use of a hot pack was not addressed on the care plan. During an interview on 05/21/15 at 10:39 a.m., Unit Coordinator (UC) #14 stated she spoke with Restorative Nurse #11 and they were restarting the hot packs. She indicated restorative staff felt like it would help when the resident had neck pain. UC #14 stated she was not sure why staff had stopped applying hot packs. During an interview on 05/21/15 at 8:35 a.m., Restorativ… | 2019-01-01 |
| 5380 | 5380 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2015-05-22 | 371 | F | 0 | 1 | LSP711 | Based on observations, interviews, and policy review, the facility failed to ensure sanitary food handling practices to prevent, to the extent possible, the outbreak of foodborne illness. Foods held on the steam table were not held at the minimum temperature which prevented the rapid and progressive growth of illness producing microorganisms (135 degrees Fahrenheit). In addition, personnel serving foods failed to monitor foods for proper temperatures and failed to maintain sanitary food handling practices during meal tray preparation. These practices had the potential to affect all residents who received nourishment from the facility's dietary department. Facility census: 88. Findings include: a) During tray line observation and interview, on 05/20/15 at 11:47 a.m., Dietary Aide (DA) #124 began checking the temperature of the foods on the steam table located in the dining room. There were 2 steam tables, a large main steam table and a side steam table with fewer food items. Observation revealed DA #124 did not check the temperature of a small pan of green beans on the large main steam table before she began meal service. She also did not check the temperatures of the food items on the side steam table. The side steam table items included mashed potatoes, hot milk, sweet potatoes, ground pork, and sliced roast beef. When informed of the failure to check the temperature of the green beans, she checked the temperature of the green beans, but still did not check the temperatures of the foods on the side steam table. The DA resumed meal service. DA #124 was then informed of the failure to check food temperature of the items on the side steam table. At 11:56 a.m., she checked the food temperature of the mashed potatoes and hot milk, but did not check the temperatures of the sweet potatoes, ground pork, and sliced roast beef. DA #124 then continued with meal service. Again DA #124 was informed she had not checked the temperatures of every food item on the side steam table. She then checked the ground pork and sliced roa… | 2019-01-01 |
| 5381 | 5381 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2015-05-22 | 441 | E | 0 | 1 | LSP711 | Based on observations and staff interviews, the facility failed to maintain an infection control program to prevent, to the extent possible, the onset and spread of infections. Residents' personal care items, in shared bathrooms on one (1) of three (3) units, were not labeled and/or properly stored. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: #48, #18, and #72. Facility Census: 88 Findings include: a) Resident #48 During an observation on 05/18/15 at 2:49 p.m., there were two (2) unlabeled, uncovered urine measuring cups and an unlabeled, uncovered urinal in Resident #48's shared bathroom. b) Resident #18 During an observation on 05/18/15 at 2:55 p.m., there was an unlabeled, uncovered bedpan with a brown smear on it, on the bathroom shelf of Resident #18's shared bathroom. There was also an unlabeled, uncovered urinal. c) Resident #72 During an observation on 05/18/15 at 3:56 p.m., there was an unlabeled, uncovered urine collection device (urine hat) in Resident #72's shared bathroom. d) Resident #48 (second observation) During another observation, on 05/22/15 at 7:51 a.m., there was an unlabeled urinal, partially covered with a white paper bag, on the shelf of Resident #48's shared bathroom. An observation and interview with Nurse Aide (NA) #73, on 05/22/15 at 7:56 a.m., revealed the unlabeled urinal in Resident #48's bathroom belonged to Resident #48. She stated it was used to empty the resident's urinary catheter bag. The white paper bag covering the urinal was torn, and had multiple holes in the bag. The NA stated the bag was supposed to cover the urinal. She said, It should have a name on it. NA #73 stated the urinal should have been labeled when it was brought to the resident's room, and should be covered and placed in the resident's bottom drawer by the resident's bedside. e) During an interview, on 05/22/15 at 9:00 a.m., the Director of Nursing stated it was not the facility's practice to label the residents' bedpans and urinals. She stated s… | 2019-01-01 |
| 5382 | 5382 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2015-08-20 | 225 | D | 0 | 1 | ZLZ811 | Based on review of accident/incident reports and staff interview, the facility failed to ensure all allegations of mistreatment, neglect, injury of unknown origin, or abuse were reported immediately to the appropriate State agencies in accordance with this regulation. This was found for one (1) of fifty-three (53) accident/incident reports reviewed involving an injury of unknown origin. Resident identifier: #61. Facility census: 111. Findings include: a) Resident #61 A review of the accident/incident reports, on 08/20/15 at 9:00 a.m., revealed an incident report dated 06/18/15 identifying two (2) small bruises found on Resident #61's right breast. Record review noted the resident to be dependent on staff for transfers and required a mechanical lift. There was no evidence the facility documented this incident as an injury of unknown origin, nor was it thoroughly investigated or reported to the appropriate State agencies. b) After reviewing the the incident reports, on 08/20/15 at 2:30 p.m., the Director of Nursing (DON) agreed the incidents involving Resident #61, lacked a thorough investigation by the facility and absolutely should have been reported to the State agencies, according to the abuse prohibition policy for possible abuse and neglect. | 2019-01-01 |
| 5383 | 5383 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2015-08-20 | 253 | E | 0 | 1 | ZLZ811 | Based on observation, policy review, and staff interview, the facility failed to provide housekeeping and maintenance services necessary to ensure an orderly, sanitary, and comfortable environment by not performing routine and/or preventative maintenance services on oxygen concentrators. This was found for five (5) of five (5) residents reviewed during Stage 1 of the annual Quality Indicator Survey (QIS). Resident identifiers: #103, #111, #33, #52 and #42. Facility census: 111. Findings include: a) Observations during Stage 1 of the QIS, on 08/17/15 and 08/18/15, found the following: 1) Resident #103's Invacare oxygen concentrator labeled with a preventative maintenance sticker indicating the last service completed (MONTH) 2014 and due again in (MONTH) (YEAR). 2) Resident #111's Invacare oxygen concentrator's preventative maintenance sticker indicates the last service completed on 10/07/14 and was due again on 04/07/15. 3) Resident #33's Invacare oxygen concentrator's preventative maintenance sticker indicates services were last performed on 10/07/14 and were due on 04/07/15. 4) Residents #52 and #42's Perfecto2 oxygen concentrators were void of routine maintenance stickers. b) The facility policy titled: Oxygen: Concentrator with an effective date of 01/01/14, stated under section 13: Perform maintenance according to manufacturer's instructions and by approved preventative maintenance personnel. c) During a staff interview with Maintenance Supervisor #109, on 08/19/15 at 2:30 p.m., he reported the facility had just started conducting their own maintenance on the oxygen concentrators which consisted of changing the oxygen tubing and filters, and checking the oxygen flow. He was unaware of the maintenance stickers or any required routine maintenance due every six (6) months. In addition, he reported the Perfecto2 oxygen concentrators were new machines that had been recently put into service, and they did not have maintenance stickers in place. During a follow-up interview, at 2:45 p.m. on 08/19/15, Maintenance Sup… | 2019-01-01 |
| 5384 | 5384 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2015-08-20 | 371 | F | 0 | 1 | ZLZ811 | Based on observations and staff interview, the facility failed to follow proper sanitation and food-handling practices to prevent the potential for outbreak of foodborne illness. The facility failed to maintain appropriate temperatures of milk during food service in both the kitchen and the Coral dining room. They failed to ensure the cleanliness of a section of flooring and a trash can in the kitchen. In addition, the facility did not maintain the faucet of a handwashing sink and a faucet on a pot-filler to prevent leakage. This had the potential to affect all residents. Facility census: 111. Findings include: a) During the initial observation of the kitchen area at 11:45 a.m. on 08/17/15, the handwashing sink had a steady stream of water from the hot side of the faucet. There were splashes on the floor and the wall surrounding the sink. The faucet on the pot-filler was also leaking and dripping on equipment surfaces and the floor below it. At 12:10 p.m. on 08/19/15, during the follow-up visit to the kitchen, the faucet on the handwashing sink was again dripping. When brought to the attention of Maintenance Supervisor #109, he agreed it could only be turned off with extra force. He said he would fix it at once. b) During a follow-up visit in the kitchen at 11:40 a.m. on 08/19/15, for observation of preparation and service of the noon meal, the following infractions were observed: 1. A trash can located in the kitchen next to the double sink was dirty with dried food particles and liquid stains on both the inner and outer surfaces. 2. A strip of the floor located outside the walk-in refrigerator/freezer had bare/rough-surfaced concrete. The lower area of the wall meeting the concrete was dirty, stained, and missing areas of plaster. There were heavy accumulations of rust in both corners where concrete met the metal doors of walk-in refrigerator/freezer. Debris and rust could be seen in the pitted concrete. This area was shown to Food Service Director #110 and Maintenance Supervisor #109 at 12:10 p.m. on 08/19/15.… | 2019-01-01 |
Advanced export
JSON shape: default, array, newline-delimited
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 );