cms_WV
Data source: Big Local News · About: big-local-datasette
149 rows where "filedate" is on date 2019-07-01
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4740 | 4740 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 157 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to notify the responsible party, of an incapacitated resident, when the resident experienced a significant weight loss within thirty (30) days. This was true for one (1) of eleven (11) resident's reviewed during a complaint survey ending on 07/07/16. Resident identifier: #5. Facility census: 113. Findings include: a) Resident #5 Record review of the resident's weights at 7:30 a.m. on 07/07/16, found the following documented weights in the electronic medical record: --04/04/16 - 107 pounds --05/03/16 - 88.9 pounds --05/10/16 - 91.8 pounds --05/19/16 - 90.2 pounds --05/26/16 - 85 pounds --06/01/16 - 88.5 pounds --06/07/16 - 86.2 pounds --06/16/16 - 86.2 pounds --06/21/16 - 88.5 pounds --07/01/16 - 88.6 pounds The most recent nutritional assessment, completed on 04/27/16, by a registered dietician, revealed the following for Resident #5: --The resident's height was 63 inches and her weight was 107.0 pounds --The resident received a pureed diet with limitation of potassium rich foods. --A supplement previously initiated, but discontinued due to the resident's improved intake and weight gain. --The resident received a snack at 2:00 p.m. --The resident's previous weight loss and underweight body mass index was noted. --However, the resident's current weight at 107 pounds triggered as a significant gain. --The resident's body mass index noted as now within healthy limits, weight gain desirable --The resident noted as currently eating/drinking well with desirable weight gain. Review of the nursing notes found a, weight warning, note dated 05/06/16. The note indicated the resident had a continual and gradual weight loss despite the snacks and regular meals orders, and the assistance with eating. The noted indicated physician notification. Further record review found the physician had determined the resident lacked capacity to make medical decisions. The date the incapacity statement was… | 2019-07-01 |
| 4741 | 4741 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 280 | D | 1 | 0 | R67611 | > Based on record review and staff interview, the facility failed to revise the care plan for Resident #2 when the resident's therapeutic diet changed. This was true for one (1) of eleven (11) resident's whose care plans were reviewed during the complaint survey ending on 07/07/16. Resident identifier: #2. Facility census: 113. Findings include: a) Resident #2 Review of the resident medical record on 07/05/16 at 2:00 p.m. found a diet order, dated 05/25/16, for a dysphagia advanced diet with thin liquids. Review of the current care plan, updated on 06/13/16, revealed the problem as, Resident is at nutritional risk. The goals associated with this problem were: --Resident will have no signs or symptoms of dehydration and --Resident will maintain a stabilized weight with no significant changes. Interventions included: --Provide regular liberalized dysphagia puree diet with nectar thickened liquids as ordered with 8 ounces whole milk with meals. An interview with the dietary manager (DM), #67, at 4:15 p.m. on 07/05/16 verified the intervention on the care plan addressing nutritional status was incorrect. DM #67 stated the resident no longer received a liberalized dysphagia puree diet with nectar thickened liquids. He stated he diet was upgraded on 05/25/16, after an evaluation by the speech therapist. | 2019-07-01 |
| 4742 | 4742 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 309 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to consistently assess, monitor and attempt to manage or prevent Resident #7's pain. For Resident #1 the facility failed to follow the physician's orders [REDACTED]. This was true for two (2) of eleven (11) resident's medical records reviewed for quality of care during a complaint survey, ending on 07/07/16. Resident identifiers: #7 and #1. Facility census: 113. Findings include: a) Resident #7 Record review on 07/06/16 at 8:30 a.m. found a sixty-four (64) year old female resident admitted to the facility on [DATE]. The resident was discharged from a hospital, to the facility, for rehabilitation following total bilateral knees arthroplasty on 05/19/16. Other [DIAGNOSES REDACTED]. The facility's nursing notes, upon admission, indicated the resident was alert and oriented and able to voice her needs. Less than twenty-four (24) hours later, on 05/25/16, at 2:02 p.m., the resident was discharged to the hospital. Admitting medications included: [MEDICATION NAME]/[MEDICATION NAME] 5/325 to be administered every 4 hours, as needed, for pain. The hospital discharge summary noted the resident received her last dose of the pain medication at 3:00 p.m. on the day of discharge (05/24/16). Review of the nursing notes found the following documentation: --At 10:30 p.m. on 05/24/16, the resident was refusing to have CMP machine (continuous passive motion machine used for knee joint recovery) placed on at this time, currently waiting on pain medication from pharmacy. Pharmacy request for pain medication was faxed at 7:00 p.m. --A nursing note written at 6:59 a.m. on 05/25/16 revealed the resident resting in bed at this time. Upon putting resident on bed pan noted a small opened area to her right buttocks. Pain medication given as ordered due to the complaint of pain. Resident is complaining of some discomfort at this time but refuses pain medications said she feels different as of last dose giv… | 2019-07-01 |
| 4743 | 4743 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 325 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure two (2) of eleven (11) resident's records reviewed for the care area of nutritional status, maintained acceptable parameters of nutrition. For Resident #5, the facility failed to monitor the resident's significant weight loss (18 pounds in 30 days), and failed to ensure interventions implemented to address the resident's significant weight loss, remained in place. The facility failed to address Resident #9's (who is feed via a Percutaneous endoscopic gastrostomy (PEG) tube) 5 % weight loss and failed to monitor the resident's weight after admission for four (4) weeks to ensure further weight loss did not occur. Resident identifiers: #5 and #9. Facility census: 113. Findings include: a) Resident #5 Record review of the resident's weights at 7:30 a.m. on 07/07/16, found the following documented weights in the electronic medical record: --04/04/16-107 pounds --05/03/16 - 88.9 pounds --05/10/16 - 91.8 pounds --05/19/16 - 90.2 pounds --05/26/16 - 85 pounds --06/01/16 - 88.5 pounds --06/07/16 - 86.2 pounds --06/16/16 - 86.2 pounds --06/21/16 - 88.5 pounds --07/01/16 - 88.6 pounds The most recent nutritional assessment, completed on 04/27/16, by a registered dietician, revealed the following for Resident #5: --The resident's height was 63 inches and her weight was 107.0 pounds --The resident received a pureed diet with limitation of potassium rich foods. --A supplement previously initiated, but discontinued due to the resident's improved intake and weight gain. --The resident received a snack at 2:00 p.m. --The resident's previous weight loss and underweight body mass index was noted. --However, the resident's current weight at 107 pounds triggered as a significant gain. --The resident's body mass index noted as now within healthy limits, weight gain desirable --The resident noted as currently eating/drinking well with desirable weight gain. Review of the nursing notes found… | 2019-07-01 |
| 4744 | 4744 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 329 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility failed to ensure Resident #8's drug regimen was free from unnecessary medications. Resident #8 received excessive doses of an intravenous (IV) antibiotic. This was true for one (1) of 11 sampled residents. Resident Identifier: #8 Facility Census: 113. Findings include: a) Resident #8 A review of Resident #8's medical record at 1:30 p.m. on 07/06/16 found a physicians order dated 04/06/16 for [MEDICATION NAME] 3.375 milligrams IV every six (6) hours for 10 days. The resident was to receive a total of 40 doses of this medication. Review of the Medication Administration Record [REDACTED]. Resident #8 should have received her last dose of [MEDICATION NAME] on 4/16/16 at 6:00 p.m. however she received four doses on 04/17/16. She received a dose at 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m. on 04/17/16. She also received a dose at 12:00 a.m. on 04/18/16. These findings were reviewed with the Director of Nursing (DON) at 5:00 p.m. on 07/06/16 and with the Nursing Home Administrator (NHA) in the morning of 07/07/16. At 12:42 p.m. on 07/07/16 the NHA and DON both confirmed they had not additional information to provide in regards to these findings. | 2019-07-01 |
| 4745 | 4745 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 365 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to ensure the resident received the therapeutic diet ordered by the physician. This was true for one (1) of six (6) resident's whose meal service was observed during the complaint survey ending on 07/07/16. Resident identifier: #2. Facility census: 113. Findings include: a) Resident #2 Observation of the noon meal on 07/05/16 at 12:30 p.m. found Resident #2 eating the substitute meal, a(NAME)salad. The salad contained chunks of breaded chicken on a bed of lettuce. Review of the current physician's orders [REDACTED]. Interview with the speech therapist (PT) #98 at 2:10 p.m. on 07/05/16, revealed a dysphagia diet consists of serving soft vegetables, soft foods, with meats ground up. PT #98 stated a resident on this diet could have lettuce but should not have chunks of breaded chicken. At 3:21 p.m. on 07/05/16, the dietary manager (DM) #67 verified the resident's salad should have had ground chicken instead of the breaded chunks of chicken. DM #67 stated the resident was first served the regular meal which she did not want. The resident then requested the(NAME)salad which was the substitute meal. He said his staff probably did not know who the salad was for when requested by staff serving food in the dining room. | 2019-07-01 |
| 4746 | 4746 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 508 | D | 1 | 0 | R67611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility failed to obtain a chest x-ray ordered for Resident #9 by her attending physician. This was true for one (1) of eleven (11) sampled residents. Resident Identifier #9. Facility Census: 113. Findings Include: a) Resident #9 A review of Resident #9's medical record at 12:30 p.m. on 07/05/16 found a physician order [REDACTED]. Incentive spirometry 4 times daily. Repeat CXR (Chest X - Ray) after 4 (four) days. Further review of the record found the following nursing progress notes dated 12/19/16 (typed as written): . Now order to repeat chest x - ray post 4 days of PT left chest . Progress note date 12/21/15 noted, Resident resting in bed at this time. Resident was evaluated by respiratory therapy for incentive spirometry QID (four times a day) and chest PT daily. After initial treatment, resident had some coughing noted but no excretions emitted. Progress note dated 12/22/16 noted, Resident see (sic) by respiratory therapy today for chest pt and incentive spirometry. Resident has had some non productive coughing post incentive spirometry. Breath sounds are diminished in all fields. Respiratory therapy to continue for another two (2) days with follow up chest x-ray to be done on 12/26/15. Further review of the record found no evidence the x-ray ordered for 12/26/15 was ever obtained by the facility. The physician entered a progress note into Resident #9's record on 01/10/16 indicating there resident had completed Chest PT and needed a repeat chest x -ray. The repeat chest x-ray was again ordered on [DATE] and was obtained on 01/11/16. An interview with the Director of Nursing (DON) at 10:46 a.m. on 07/06/16 confirmed the x-ray which should have been obtained on 12/26/15 was not obtained as ordered by the physician. She stated, The next x-ray was not obtained until 01/11/16. She indicated, they must have missed getting it. | 2019-07-01 |
| 4747 | 4747 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2016-07-07 | 514 | D | 1 | 0 | R67611 | > Based on record review and staff interview the facility failed ensure complete documentation was in the medical record for meal consumption, snack intake and a neurological assessment. This was evident for four (4) of eleven (11) medical records reviewed. Resident Census was: 113. Findings include: a) Resident #1 On 07/07/16 at 2:25 p.m., a review of the medical record for this resident revealed the facility had not completed daily meal intake documentation. For the month of (MONTH) there were no intakes listed for breakfast on : 06/02, 06/14/16, 06/20/16, 06/26/16 and 06/28/16. There was no documentation of meal intakes at lunch on : 06/02/16, 06/08/16, 06/11/16, 06/14/16, 06/20/16, 06/26/16 and 06/28/16. Likewise, there was no intakes listed for dinner on : 06/07/16, 06/08/16, 06/09/16, 06/11/16, 06/12/16, 06/14/16, 06/16/16, and 06/26/16. Snack intakes were only shown to be given on 06/01/16, 06/02/16, 06/03/16, 06/15/16, 06/17/16, 06/18/16, 06/19/16, 06/22/16, 06/23/16, 06/24/16, 06/28/16 and 06/29/16. All the other days of the month were blank with no indication it was given and accepted or refused. b) Resident #3 Documentation of this medical record on 07/07/16 at 2:30 p.m. revealed no documentation for meal intake for the following occasions in (MONTH) (YEAR): --breakfast 06/11/16, 06/17/16, 06/18/16; --lunch: 06/11/16; and --dinner: 6/2/16, 6/6/16, 6/9/16, 6/12/16, 6/19/16, 6/24/16 and 6/26/16. c) Resident #4 A review of this resident's medical record on 07/07/16 at 2:40 p.m. indicated there was no documentation for meal intakes on the following occasions in (MONTH) (YEAR): --breakfast: 06/02/16, 06/11/16, 06/12/16, 06/14/16, 06/18/16, 06/19/16, 06/24/16, 06/25/16; --lunch: 06/02/16, 060/3/16, 06/11/16, 06/12/16, 06/14/16, 06/16/16, 06/18/16, 06/19/16, 06/24/16, 06/25/16; and --dinner: 06/02/16, 06/10/16, 06/12/16, 06/15/16, 06/17/16, 06/19/16, 06/20/16, and 06/25/16. All of these dates were verified with Employee #111 on 07/07/16 at 3:15 p.m. at which time she was given time to present any further evid… | 2019-07-01 |
| 4748 | 4748 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 157 | D | 0 | 1 | PDOU11 | Based on record review and staff interview, the facility failed to promptly notify the attending physician and responsible party when it was identified Resident #33 had experienced a severe weight loss in one (1) month. This was true for one (1) of three (3) residents reviewed for the Care Area of Nutrition during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #33. Facility census: 40. Findings include: a) Resident #33 A review of Resident #33's medical record at 1:51 p.m. on 02/11/16 found the following recorded weights: 02/03/15 115 pounds (lb.) 03/02/15 115.4 lb. 04/02/15 116.0 lb. 05/13/15 112.2 lb. 06/02/15 112.4 lb. 07/04/15 109.0 lb. 08/04/15 110.4 lb. 09/01/15 107.4 lb. 10/01/16 108.2 lb. 11/03/16 107.8 lb. 12/02/15 104.0 lb. 01/03/16 107.8 lb. 02/04/16 101.2 lb. Resident #33 had experienced a gradual weight loss over the last 12 months, culminating in a severe weight loss in one (1) month. The resident lost 6.1% of her body weight from 01/03/16 to 02/04/16, which was a severe weight loss. There was no indication in Resident #33's medical record to suggest her attending physician, responsible party, and/or Licensed Dietitian were ever notified of the resident's severe weight loss. The weight loss should have been identified on 02/04/16, when the weight of 101.2 lb. was entered into the resident's electronic medical record. During an interview with the Nursing Home Administrator/Licensed Dietitian (NHA/LD), at 5:47 p.m. on 02/11/16, when asked if nursing had notified her of the resident's weight loss, she stated that they had not. She was asked to review the resident's meal percentages from (MONTH) (YEAR) through present. Upon completion of her review, she was asked if she would agree that the resident had had a gradual decline in meal consumption since (MONTH) (YEAR). She stated, Unfortunately I would have to agree with that. When asked what her expectation was as far as being notified of weight changes, she stated that a significant or severe weight loss should be brought to her atte… | 2019-07-01 |
| 4749 | 4749 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 225 | F | 0 | 1 | PDOU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review and staff interview, the facility failed to ensure it did not employee individuals who had been found guilty of abuse, neglect, mistreatment of [REDACTED]. When the facility received the results of a Federal Bureau of Investigation (FBI) fingerprint criminal history record check, which revealed the individual may not meet qualifications for employment, the facility failed to ensure the individual was not prohibited from working in a nursing home. This was true for one (1) of ten (10) employees hired after 08/01/15. This practice had the potential to affect all residents at the facility. Employee identifier: #9. Facility census: 40. Findings include: a) Nurse Aide #9 Review of the personal record of Nurse Aide (NA) #9, at 11:00 a.m. on 02/12/16, found the NA was hired on 12/28/15. Further review of the personnel record found a letter, dated 01/25/16, which included, The Federal Bureau of Investigation (FBI) has completed a criminal history record check on the applicant listed below. Based upon the information furnished by your agency, the FBI background check results indicate that the applicant may not meet qualifications for licensing or employment . Pursuant to federal law, this information cannot be released directly to your agency. The applicant can request this information by completing the FBI Request for Rapsheet form At 11:15 a.m. on 02/12/16, Human Resources Director #58 was unable to provide evidence the facility had investigated the reasons NA #9 might not meet qualifications for employment. At 12:45 p.m. on 02/12/16, the administrator provided a copy of a West Virginia State Police rapsheet for NA #9. The rapsheet, dated 12/16/13, and the results of the rapsheet had been sent to another nursing home in the area, not this nursing home. When asked if the facility had a copy of this document prior to surveyor intervention, the administrator said, I am looking at this for the first time, same as you. At… | 2019-07-01 |
| 4750 | 4750 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 241 | D | 0 | 1 | PDOU11 | Based on observation and staff interview, it was determined resident dining was not provided in a manner and environment that maintained or enhanced each resident's dignity. Meal service was not coordinated to allow resident's dining together in the same dining room to be served at the same time. In addition, staff failed to speak respectfully by avoiding the use of labels for a resident. This was a random opportunity for discovery. Resident identifier: #2. Facility census: 40. Findings include: a) Observation of the evening meal on the third floor Observation of the evening meal began at 5:15 p.m. on 02/09/16 in the third floor dining room. There were three (3) residents seated at three (3) different tables in the dining room, Residents #42, #10, and #2. Residents #42 and #10 received their trays at 5:15 p.m. on 02/09/16. At 5:30 p.m., Activity Staff #38 entered the dining room. When asked why Resident #2 had not received his meal, Activity Staff #38 stated, He's a feeder, they will come in a minute. This comment was made where Resident #2 and the other residents in dining room could hear. At 5:40 p.m., Nurse Aide (NA) #25 served Resident #2 his evening meal and began assisting the resident to eat. At 5:42 p.m. on 02/09/16, Licensed Practical Nurse (LPN) #20, the nurse on the unit was asked why there was a delay in serving Resident #2. LPN #20 said, He doesn't usually eat in the dining room. At 6:32 p.m. on 02/11/16, the administrator was advised Resident #2 received his meal twenty-five (25) minutes after the other residents in the dining room were served. Also a staff member had referred to Resident #2 as a feeder, in the presence of all the residents in the dining room. The administrator made no comment. | 2019-07-01 |
| 4751 | 4751 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 272 | D | 0 | 1 | PDOU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to conduct an accurate comprehensive Minimum Data Set (MDS) assessment for one (1) of three (3) residents reviewed for the care area of accidents. The MDS assessment for Resident #44 was inaccurate in the area of behavior patterns. Resident identifier: #44. Facility census: 40. Findings include: a) Resident #44 A review of Resident #44's medical records on 02/11/16 at 1:30 p.m., revealed an admission date of [DATE]. The Admission MDS, with an assessment reference date (ARD) of 10/27/15, Item E1000A - Wandering - Impact, indicated Resident #44's wandering placed the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility). Review of the progress notes for assessment's look back period found no evidence of episodes of wandering, or attempts to wander, into dangerous areas. During an interview on 02/11/16 at 2:15 p.m., MDS Coordinator #29 said the resident's wandering did not place her at significant risk - the resident did not wander into other residents' rooms, just to the nurses' desk. The MDS Coordinator confirmed the MDS with an ARD of 10/27/15 was inaccurate. | 2019-07-01 |
| 4752 | 4752 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 278 | D | 0 | 1 | PDOU11 | Based on record review, review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, and staff interview, the individual assessing and certifying the accuracy of Section K of Resident #36's quarterly Minimum Data Set (MDS), failed to ensure the assessment was accurate in the area of weight loss. This was true for one (1) of three (3) residents reviewed for the care area of nutrition. Resident identifier: #36. Facility census: 40. Findings include: a) Resident #36 Review of the resident's medical record at 9:30 a.m. on 02/11/16, found a quarterly MDS with an assessment reference date (ARD) of 01/25/16. Section K, Item K0300 of the assessment identified the resident was on a physician prescribed weight loss regimen. Further review of the resident's medical record found no physician's orders indicating a prescribed weight loss program for Resident #36. At 10:39 a.m. on 02/11/16, the registered dietitian confirmed she incorrectly coded Section K of the quarterly MDS. She confirmed the resident was not on a physician prescribed weight loss regimen. The Resident Assessment Instrument (RAI) Version 3.0 Manual instructions for coding Item K0300 include, Code 1, yes on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% (five percent) or more in the past 30 days or 10 % or more in the last 180 days, and the weight loss was planned and pursuant to a physician's order The RAI manual defines a physician prescribed weight loss regimen as, A weight reduction plan ordered by the resident's physician with the care plan goal of weight reduction. (MONTH) employ a calorie restricted diet or other weight loss diets and exercise. Also includes planned diuresis. It is important that weight loss is intentional. | 2019-07-01 |
| 4753 | 4753 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 279 | D | 0 | 1 | PDOU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the development of a comprehensive care plan for one (1) of three (3) residents reviewed for the care area of nutrition. Resident #36's care plan did not include the facility's interventions to address the resident's weight loss. Resident identifier: #36. Facility census: 40. Findings include: a) Resident #36 Medical record review found the resident's weight on 11/04/15 was 115.4 pounds. On 12/09/15, the resident's weight was recorded as 113 pounds. On 01/04/16, the resident's weight was 108.4 pounds. Review of the physician's orders [REDACTED]. On 01/22/16, a physician's orders [REDACTED]. Review of the current care plan found no mention of any weight loss or the interventions added to address the resident's weight loss. Also the facility failed to document the percentage of the great shakes consumed by the resident to determine if this was an effective intervention for the resident's weight loss. An interview with the director of nursing at 3:01 p.m. on 02/11/16, confirmed the resident's care plan failed to address the resident's weight loss and the interventions implemented by the facility to address the weight loss. | 2019-07-01 |
| 4754 | 4754 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 282 | D | 0 | 1 | PDOU13 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide services by qualified persons in accordance with the care plan for one (1) of five (5) residents whose care plans were reviewed during the re-visit to the Quality Indicator Survey. The care plan for administering the resident's gastric tube feeding was not implemented. Resident identifier: #11. Facility census: 32. Findings include: a) Resident #11 Record review at 11:45 a.m. on 05/09/16, found the resident had a gastrostomy tube for a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Observation of the resident at 1:00 p.m. on 05/09/16 found he was in his room receiving his tube feeding. A bottle of [MEDICATION NAME] and a bag of water were infusing by way of the tube. Further observation of the feeding pump found the water was infusing at 40 ml per hour. At 1:10 p.m. on 05/09/16, Licensed Practical Nurse (LPN) #35, the resident's nurse, confirmed the resident was receiving water at 40 ml per hour instead of 30 ml as ordered by the physician. LPN #35 said she was not the nurse who set the feeding pump. She said, That was the midnight shift nurse, not me. Review of the current care plan found the problem: The resident requires tube feeding r/t (related to) dysphagia d/t (due to)[MEDICAL CONDITION]. The goal associated with the problem was: The resident will maintain adequate nutrition and hydration status aeb (as evidenced by) no s/s (signs and symptoms) of malnutrition or dehydration through review date. Interventions included: The resident is dependent with tube feeding and water flushes. See MD (doctor) orders for current feeding orders and flush. During an interview at 1:30 p.m. on 05/09/16, Registered Nurse (RN) #55, consultant, said LPN #35 was calling the doctor to let him know about the feeding. Medical record review at 3:00 p.m. on 05/09/16, found a nurse's note, dated 05/09/16 at 2:41 p.m., Spoke with (name of doctor) regarding flush rate b… | 2019-07-01 |
| 4755 | 4755 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 286 | D | 0 | 1 | PDOU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and clinical record review, the facility failed to maintain all resident assessments completed within the previous 15 months in the active clinical record. This was found for one (1) of thirty-one (31) sampled residents. Resident identifier: #44. Facility census: 40. Findings include: a) Resident #44 Review of the clinical record of Resident #44 revealed the resident was admitted to the facility on [DATE]. According to the list of assessments generated for the Quality Indicator Survey, the facility completed an admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/27/15 for this resident. However, review of the resident's paper and electronic clinical records found this assessment was not located in the resident's chart. In an interview on 02/12/16 at 1:30 p.m., Registered Nurse (RN) #74, Chief Nursing Officer (CNO), verified the MDS with the ARD of 10/27/15 was not in the electronic medical records and had been thinned from the paper medical records. She agreed Resident #44's active medical record did not contain the last 15 months of MDSs. | 2019-07-01 |
| 4756 | 4756 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 309 | G | 0 | 1 | PDOU12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to adequately assess and manage pain for Residents #30 and #11. This resulted in the residents experiencing pain which was avoidable, and therefore, was actual harm. Also, Resident #33 had physician's orders [REDACTED]. Staff failed to assess the residents' blood pressures and heart rate (pulse) prior to each administered dose. Resident identifiers: #30, #33, and #11. Facility census: 41. Findings include: a) Resident #30 Review of the clinical record for Resident #30, on 04/04/16 at 09:30 a.m., revealed she was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident #30 was severely cognitively impaired, unable to make herself understood, and was rarely able to understand others. Resident #30 was documented as requiring the extensive assistance of two (2) staff for bed mobility and transfers, and was incontinent of bowel functions and currently had a Foley catheter in place due to unstageable pressure ulcers on both buttocks. Observation on 04/05/16 at 11:00 a.m., found Resident #30 lying in bed. When asked about her abdomen, the resident held both hands over her abdomen and grimaced. The unit nurse was immediately notified of resident's indication of pain/discomfort. Even after the unit nurse was informed of the resident's grimacing and holding her hands over her abdomen, the resident was not assessed at that time. However, when this was brought to the attention of the director of nursing and physician, the nurse documented she had asked the resident about pain multiple times and the resident had denied pain. Review of the resident's current care plan found no interventions for pain evaluation/assessment and/or no treatments for pain management. Review of Resident #30's skilled charting notes found the following notes concerning pain (other notes were simply marked N/A - not applicable): -- 03/29/16 at 3:41 a.m.- Resident demonstrates non-verbal signs of pai… | 2019-07-01 |
| 4757 | 4757 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 323 | K | 0 | 1 | PDOU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on water temperature measurements, observations, medical record reviews, staff interviews, and review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), the facility failed to ensure the resident environment, over which it had control, was as free from accident hazards as possible. Water temperature measurements taken between 10:10 a.m. and 10:26 a.m. on 02/10/16 with the maintenance department using their thermometer found the following water temperatures in the resident hands sinks in resident rooms: Room 200 the water temperature was 140 degrees Fahrenheit (F) Room 204 the water temperature was 134.6 degrees F Room 300 the water temperature was 142.9 degrees F Room 303 the water temperature was 132.8 degrees F. This discovery was determined an immediate jeopardy (IJ) situation, with the potential to affect all residents who were able to independently wash their hands and who had cognitive impairments. At 12:10 p.m. on 02/10/16, the Nursing Home Administrator (NHA), the Chief Executive Officer (CEO), the Director of Nursing (DON) and the Assistant Chief Nursing Officer (ACNO) were notified of the IJ, and that it was due to the elevated water temperature. This immediate jeopardy began at 10:10 a.m. on 02/10/16 when Employee #63, a facility consultant working with the maintenance department, obtained the water temperature of 140 degrees Fahrenheit (F) in room 200. The facility provided a plan of correction at 1:47 p.m. on 02/10/16. The immediate jeopardy was abated at 2:50 p.m. on 02/10/16. No deficient practice remained after removal of the immediate jeopardy. Eleven (11) residents were identified as being at risk for serious harm as a result of the elevated water temperatures they all suffered from cognitive impairments and were identified by facility staff as able to independently wash their hands in resident hand sinks. The eleven (11) residents identifi… | 2019-07-01 |
| 4758 | 4758 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 325 | D | 0 | 1 | PDOU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #33 maintained acceptable parameters of nutrition as evidenced by an unidentified and unaddressed severe weight loss. This was true for one (1) of three (3) residents reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #33. Facility Census: 40. Findings include: a) Resident #33 A review of Resident #33's medical record at 1:51 p.m. on 02/11/16, found a physician's orders [REDACTED]. This order had a start date of 02/28/14. Further review of the record found a physician's orders [REDACTED]. This order was dated 11/24/15. A review of the pharmacy consultation reports found a consultation report dated 11/10/15, which was addressed by the attending physician on 11/20/15. This consultation report indicated Resident #33's [MEDICATION NAME] was reduced as a result of the pharmacist's recommendation for a Gradual Dose Reduction (GDR) of the medication. The physician accepted the recommendation and the order was implemented. Review of Resident #33's meal percentages, beginning in (MONTH) (YEAR) through present found the following: 1. For (MONTH) (YEAR), Resident #33 ate: -- 0 to 25% of her meals 2.3% of the time, -- 26 to 50 % of her meal 62.5% of the time, -- 51 to 75% of her meal 9.1% of the time, and -- 76 to 100 % of her meal 26.1% of the time. 2. For (MONTH) (YEAR), Resident #33 ate: -- 0 to 25% of her meal 5.1% of the time, -- 26 to 50 % of her meal 51.3% of the time, -- 51 to 75% of her meal 24.4% of the time, and -- 76 to 100 % of her meal 19.2% of the time. 3. For (MONTH) (YEAR), Resident #33 ate: -- 0 to 25% of her meal 12.3% of the time, -- 26 to 50% of her meal 47.9% of the time, -- 51 to 75% of her meal 23.3% of the time, and -- 76 to 100% of her meal 16.4% of the time. 4. For (MONTH) (YEAR), Resident #33 ate: -- 0 to 25% of her meal 22% of the time, -- 26 to 50% of her meal 64.8% of the time, -… | 2019-07-01 |
| 4759 | 4759 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 371 | F | 0 | 1 | PDOU11 | . Based on observation and staff interview, the facility failed to ensure foods were stored in a safe and sanitary manner. During an initial tour of the facility's kitchen, expired foods were found in the walk-in cooler. Additionally, the facility failed to consistently monitor the temperatures of the walk-in cooler and walk-in freezer on a daily basis. These practices had the potential to affect all residents currently residing at the facility. Facility census: 40 Findings include: a) Initial Tour of the Kitchen. An initial tour of the kitchen at 1:20 p.m. on 02/09/16 found the following outdated items in the walk in cooler and available for use: -- A container of spaghetti sauce with a prepared date of 04/05 and discard date of 04/08. It was learned this product was previously frozen. There was no date to indicate when it was thawed. -- A container of cole slaw with a preparation date of 02/05 and a discard date of 02/08. -- Four (4) gallons of two (2) percent milk which had the following best by dates imprinted on the jugs by the manufacture: Two with the best by date of 02/04/16, one (1) with a best by date of 02/08/16, and one (1) with a best by date of 01/27/16. The Licensed Dietitian/Nursing Home Administrator confirmed all items should have been discarded and not available for use. She stated that the milkman had just delivered the outdated milk and she was, Going to have a talk with him. She indicated the spaghetti sauce had been removed from the freezer to unthaw and they forgot to put a new date on it. When asked how long the spaghetti sauce was good for if kept frozen she replied, six (6) months. She then stated, I guess it has been longer than six (6) months already. Further observations of the kitchen found the temperature log for the walk-in cooler and freezer had not been consistently completed for the month of (MONTH) (YEAR). The only temperature for the walk-in cooler was obtained on 02/07/16. No other temperatures for the walk-in cooler had been obtained for the month of (MONTH) (YEAR). There w… | 2019-07-01 |
| 4760 | 4760 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 412 | D | 0 | 1 | PDOU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, physician interview, and staff interview, the facility failed to assist one (1) of three (3) residents reviewed for the care area of dental services during Stage 2 of the Quality Indicator Survey (QIS), to obtain outside needed dental services. Resident identifier: #11. Facility census: 40. Findings include: a) Resident #11 Observation of the resident's oral cavity during Stage 1 of the QIS at 12:51 p.m. on 02/10/16, found the resident had missing teeth. The resident also had what appeared to be a white hard buildup of an unknown substance resting on his lower gum. The depth of the substance caused the area between the lower lip and the chin to protrude outward. When asked what was in his mouth, the resident replied, My tongue. Record review at 10:00 a.m. on 02/11/16, found this [AGE] year-old male resident, admitted to the facility on [DATE], had current [DIAGNOSES REDACTED]. The resident had a feeding tube related to dysphagia (difficulty swallowing) due to a [MEDICAL CONDITION]. The resident's current care plan, dated 12/01/15, indicated the resident was totally dependent on staff for personal hygiene and oral care. At 11:30 a.m. on 02/11/16, observation of the resident's oral cavity with the director of nursing and Nurse Aide (NA) #42, found a white, hard substance, resting on and attached to the resident's lower gum. The substance was approximately 1 inch to 1 1/2 inch long and approximately 1/4 inch in thickness. The resident also had at least two (2) natural teeth in the upper gum, which appeared to have cavities. The resident denied any pain. The DON and the NA said the substance on the lower gum was the resident's natural teeth; however, both employees confirmed they had never seen anyone's natural teeth that were that large. On 02/11/16 at 2:14 p.m., after personally examining the resident's oral cavity, the resident's physician said, I think everyone just needs their mouth washed out occasionall… | 2019-07-01 |
| 4761 | 4761 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 441 | E | 0 | 1 | PDOU11 | Based on observations and staff interviews, the facility failed maintain an Infection Control Program to ensure a safe and sanitary environment to help prevent the development and transmission of disease and infection. Personal care supplies were stored in a manner that created a potential for contamination. This practice had the potential to affect residents residing on the 3rd floor. Facility census: 40. Findings include: a) Personal Care Items An observation of the employee bathroom on the 3rd floor on 02/10/16 at 10:30 a.m., found a three drawer plastic cart located beside the commode. The cart, which contained unused personal care supplies for residents, was between the commode and the wall with one side of the cart touching the wall and the other side touching the commode. Anyone using the commode would likely have contact with cart and possibly its contents. The drawers of the cart were not always completely closed, which could allow any activity which caused splashing or aerosolization from the commode to contaminate the supplies. The cart contained nail clippers, emery boards, hair brushes, bars of soap, wash basins, lotion, razors, deodorant, mouthwash, denture cups, mouthwash, and toothbrushes. During an interview with Registered Nurse (RN) #8, immediately following the observation, she stated the cart had been stored there to give the nurse aides access to the residents' personal care equipment without having to get a key from a nurse. She agreed this was not the appropriate area to store the residents' personal supplies. The cart was immediately removed from the employees' bathroom. | 2019-07-01 |
| 4762 | 4762 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 490 | F | 0 | 1 | PDOU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of employee personnel records and staff interview, the facility was not administered in an efficient, effective manner. Deficiencies related to Resident Behavior and Facility Practices and Administration were discovered during the current Quality Indicator Survey. The facility failed to ensure it did not employee individuals who had been found guilty of abuse, neglect, mistreatment of [REDACTED]. When the facility received the results of a Federal Bureau of Investigation (FBI) fingerprint criminal history record check, which revealed the individual might not meet qualifications for employment, the facility failed to ensure the individual was not prohibited from working in a nursing home. Additionally, the facility failed to comply with State law regarding new criminal background check requirements for applicants for employment as direct access personnel in long-term care facilities as required by State Code 16-49-9. This was true for ten (10) of ten (10) employees hired after 08/01/15. Employee identifiers: #9, #37, #33, #47, #3, #41, #14, #65, #24, and #44. Facility census: 40. Findings include: a) Nurse Aide #9 Review of the personal record of Nurse Aide (NA) #9, at 11:00 a.m. on 02/12/16, found the NA was hired on 12/28/15. Further review of the personal record found a letter, dated 01/25/16, which included, The Federal Bureau of Investigation (FBI) has completed a criminal history record check on the applicant listed below. Based upon the information furnished by your agency, the FBI background check results indicate that the applicant may not meet qualifications for licensing or employment . Pursuant to federal law, this information cannot be released directly to your agency. The applicant can request this information by completing the FBI Request for Rapsheet form At 11:15 a.m. on 02/12/16, Human Resources Director #58 was unable to provide evidence the facility had investigated the reasons NA #9 might not meet qualifica… | 2019-07-01 |
| 4763 | 4763 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 492 | F | 0 | 1 | PDOU11 | Based on review of employee personal files, correspondence with the State agency responsible for administering the State Code, and staff interview, the facility failed to comply with State law regarding new criminal background check requirements for applicants for employment as direct access personnel in long-term care facilities as required by State Code 16-49-9. This was true for ten (10) of ten (10) employees hired after 08/01/15. Employee identifiers: #9, #37, #33, #47, #3, #41, #14, #65, #24, and #44. Facility census: 40. Findings include: a) During review of employee personal files, as part of the extended survey requirements, at 7:00 p.m. on 02/11/16, Human Resource Director #58 verified the facility had not enrolled employees into West Virginia Cares Registry and Employment Screening (WV-CARES) as required by State Code 16-49-9. Human Resources Director #58 said she was not able to access the web-based agency. All ten (10) employees had a fingerprint federal background criminal check. 1. Nurse Aide (NA) #9 was employed on 12/28/15. 2. Licensed Practical Nurse (LPN) #37 was employed on 12/07/15. 3. Registered Nurse (RN) #33 was employed on 10/30/15. 4. Housekeeper #47 was employed on 09/01/15. 5. NA #3 was employed on 09/16/15. 6. LPN #41 was employed on 11/19/15. 7. LPN #14 was employed on 11/04/15. 8. RN #65 was employed on 12/14/15. 9. NA #24, was employed on 09/14/15. 10. NA #44 was employed on 12/28/15. West Virginia Code 16-49-9 established new criminal background check requirement for applicants for employment as direct access personnel in long-term care facilities. Effective 08/01/15, all nursing home facilities were required to . prescreen all direct access personnel applicants considered for hire for negative findings by way of an Internet search of registries and licensure databases through the WV Cares website. West Virginia Cares Registry and Employment Screening (CARES) is administered by the Department of Health and Human Resources and the WV State Police Criminal Investigation Bureau (CIB) … | 2019-07-01 |
| 4764 | 4764 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 497 | F | 0 | 1 | PDOU11 | Based on personnel file review and staff interview, the facility failed to complete a performance review at least every 12 months for four (4) of four (4) nurse aides whose personnel files were reviewed. Employee identifiers: #27, #48, #61, and #66. Facility census: 40. Findings include: a) Nurse Aides #27, #48, #61, and #66 An interview with Human Resources Manager #58, at 7:10 p.m. on 02/11/16, revealed four (4) nurse aides did not have performance evaluations that demonstrated competencies of nurse aide staff in consistently applying the interventions necessary to meet residents' needs. At 7:30 p.m. on 02/11/16, Chief Executive Officer (CEO) #72 provided a copy of an evaluation for nurse aides which the facility planned to use to evaluate the competency of nurse aide staff. CEO #72, stated the facility would start using the evaluation immediately. | 2019-07-01 |
| 4765 | 4765 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 514 | D | 0 | 1 | PDOU11 | Based on medical record review and staff interview, the facility failed to maintain clinical records for each resident in accordance with accepted professional standards and practices that were complete; accurately documented, readily accessible, and systematically organized for two (2) of three (3) residents reviewed for the care area of pressure ulcers during Stage 2 of Quality Indicator Survey (QIS), Residents #12 and #40 had wound assessments that were incomplete in the electronic medical records. Resident identifiers: #12 and #40. Facility census: 40. Findings include: a) Resident #12 Medical record review on 02/11/16 at 9:30 a.m., found Resident #12 had a pressure ulcer on the left hallux (big toe). This pressure ulcer developed on 12/08/15 and was a suspected deep tissue injury (SDTI). Observation on 02/11/15 at 11:00 a.m., with Registered Nurse (RN) #8, revealed Resident #12's pressure area on the left hallux had a necrotic area measuring six (6) centimeters (cm) in length and two (2) cm in width and depth unknown due to the necrotic wound bed. Further review of the medical records found weekly wound assessments for 01/14/16, 01/19/16, 01/26/16, 02/02/16 and 02/09/16. These assessments were found to be incomplete. The acquired date, stage of the wound, and appearance of the wound were left blank. b) Resident #40 Medical record review on 02/11/16 at 9:00 a.m., found Resident #40 had a pressure ulcer on the left heel. This pressure ulcer developed on 12/15/15 and was a suspected deep tissue injury (SDTI). Observation on 02/11/15 at 11:15 a.m., with RN #8, revealed Resident #40's pressure area on the left heel had a necrotic area measuring eight (8) centimeters (cm) in length and eight (8) cm in width and depth unknown due to the necrotic wound bed. Further review of the medical records found weekly wound assessments for 01/14/16, 01/19/16, 01/26/16, 02/02/16, and 02/09/16. These assessments were incomplete. The acquired date had conflicting dates of 12/15/15 and 12/17/15, the stage of the wound and appearan… | 2019-07-01 |
| 4766 | 4766 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 520 | F | 0 | 1 | PDOU12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, review of facility policies, and staff interview, the facility's quality assessment and assurance committee (QAA) failed to identify and correct quality deficiencies which they were aware of. The QAA failed to develop and implement plans of action to correct quality deficiencies, including monitoring the effect of implemented changes and making needed revisions to the action plan for deficiencies identified during the Quality Indicator Survey (QIS), ending on 02/12/16. Repeat citations were found for F225, F325, and F371. The facility's plan of correction identified 03/29/16 as the date when the previously cited deficient practices would be corrected. It was determined the facility remained noncompliant and all of the issues were not corrected as indicated in it's plan of correction. The practice had the potential to affect all residents at the facility. Facility census: 41. Findings include: Based on record review, observation, policy review, and staff interview, the facility was not administered in a manner that enabled it to use it's resources effectively and efficiently to enable each resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The systems to ensure optimum quality of care and/or quality of life were not established and/or implemented. Issues cited at the prior survey, completed on 02/12/16, were not corrected. Repeat citations were found for F225, F325, and F371. The facility's plan of correction identified 03/29/16 as the date when the previously cited deficient practices would be corrected. It was determined the facility remained noncompliant and all of the issues were not corrected as indicated in its plan of correction. The practice had the potential to affect all residents at the facility. Facility census: 41. Findings include: a) Background checks Review of employee personal files, correspondence with the State agency responsible for admi… | 2019-07-01 |
| 4767 | 4767 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 522 | C | 0 | 1 | PDOU11 | Based on staff interview and interview with the Office of Health Facility Licensure and Certification (OHFLAC), the facility failed to provide written notice to the State agency responsible for licensing the facility, when there was a change in the director of nursing. This had the potential to affect all residents at the facility. Facility census: 40. Findings include: a) Notification of a change of the Director of Nursing (DON) During investigation of the facility's extended survey on 02/12/16 at 9:30 a.m., review of the active employee roster found Registered Nurse (RN) #65 was listed as the current DON. The roster reflected RN #65 was hired on 12/14/15. At 10:00 a.m. on 02/12/16, the administrator confirmed she did not notify the State agency (OHFLAC) responsible for licensing the facility, when the new DON was hired. At 10:10 a.m. on 02/12/16, RN #65 said she assumed the DON position sometime in (MONTH) (YEAR), but she did not know the exact date of her appointment. At 12:32 p.m. on 02/12/16, the state agency (OHFLAC) confirmed the facility did not provide written notice of a change in the DON. | 2019-07-01 |
| 4768 | 4768 | ST. JOSEPH'S HOSPITAL | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2016-03-31 | 272 | D | 0 | 1 | 6SHE11 | **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 (RAI Manual), and staff interview, the facility failed to ensure an accurate and complete comprehensive Minimum Data Set (MDS) assessment for four (4) of eleven (11) residents whose MDSs were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #4's MDS was inaccurately coded in the area of behavior. The MDSs for Residents #12 and #7 were incorrectly coded in the area of oral/dental status. The MDS for Resident #9 was incorrectly coded in the area of medications. Resident identifiers: #4, #12, #9, and #7. Facility census: 16. Findings include: a) Resident #4 Record review at 10:00 a.m. on 03/30/16, found a significant change MDS with an assessment reference date (ARD) of 12/22/15. The resident was coded as wandering 1 to 3 days during the assessment reference period. At 10:36 a.m. on 03/30/16, the Director of Nursing, Registered Nurse (RN) #3, said the resident's MDS should not have been coded for wandering because, If she (the resident) goes somewhere she has a purpose and she needs the assistance of one staff member for locomotion on and off the unit. At 10:40 a.m. on 03/30/16, RN #20, who completed the MDS, was asked for verification of the resident's wandering behavior used to complete the 12/22/15 MDS. At 11:06 a.m. on 03/30/16, RN #20 said she realized she coded the wandering section of the MDS incorrectly. She said, I have no verification, I thought that because the resident will get up unassisted that would be wandering because she is oblivious to safety needs. The RAI manual defines wandering as the act of moving (walking or locomotion in a wheelchair) from place to place with or without a specified course or known direction. RNs #3 and #20 verified Resident #4 did not wander in the facility. b) Resident #12 Observation of the resident during Stage 1 of the QIS, at 1:20 p.m. on 03/28/16, found the resident had… | 2019-07-01 |
| 4769 | 4769 | ST. JOSEPH'S HOSPITAL | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2016-03-31 | 278 | D | 0 | 1 | 6SHE11 | Based on record review and staff interview, the individual assessing and certifying the accuracy of the number of pressure ulcers in Section M for Resident #17, and rejection of care in Section E of Resident #1's and Resident #23's Minimum Data Set (MDS) assessments, failed to ensure the assessments were accurate. Resident identifiers: #17, #1, and #23. Facility census: 16. Findings include: a) Resident #17 Review of Resident #17's medical record on 03/31/16 at 9:55 a.m., found a quarterly MDS assessment with an assessment reference date of 11/14/15. Review of the MDS found Section M entitled skin conditions, indicated the resident had four (4) pressure ulcers during the seven (7) day look back period. Review of Resident #17's weekly pressure ulcer evaluation dated 11/13/15, completed by Registered Nurse (RN) #20, indicated the resident had the following wounds: -- Stage 2 pressure ulcer to right hip measuring 4.5 centimeter (cm) in length and 3.5 cm in width and less than 0.25 cm in depth. -- Stage 3 pressure ulcer to left heel measuring 1 cm in length and 1.5 cm in width and less than 0.25 cm in depth. -- Stage 2 pressure ulcer to coccyx measuring 3 cm in length and 2.2 cm in width and less than 0.25 cm in depth. -- Stage 4 pressure ulcer to left buttock measuring 2.5 cm in length and 1.5 cm in width and 0.5 cm in depth. -- Stage 2 pressure ulcer to right buttocks measuring 5 cm in length and 4.5 cm in width and less than 0.25 cm in depth. An interview with RN #20, at 12:30 p.m. on 03/31/16, confirmed the MDS with the ARD of 11/14/15 did not accurately reflect Resident #17's pressure ulcer status. She confirmed the resident had five (5) pressure ulcers at the time of the assessment, not four (4), as indicated on the assessment. b) Resident # 1 A review of Resident #1's medical record, at 2:08 p.m. on 03/29/16, found a 14-day MDS with an ARD of 02/03/16. Review of the MDS found Item E 0800, entitled Rejection of Care - Presence & Frequency, indicated Resident #1 rejected care on a daily basis during the seven (7… | 2019-07-01 |
| 4770 | 4770 | ST. JOSEPH'S HOSPITAL | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2016-03-31 | 309 | D | 0 | 1 | 6SHE11 | **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 for Resident #17 to meet her highest practicable physical mental and psychosocial well-being. Resident #17's sliding scale insulin was not administered according to the physician established parameters. Resident Identifier: #17. Facility Census: 16. Findings include: a) Resident #17 A review of Resident #17's medical record at 8:13 a.m. on 03/29/16, found a physician's orders [REDACTED]. If blood sugar is 151 to 200, give 3 units. If blood sugar is 201 to 250, give 6 units. 251 to 300, give 9 units. If blood sugar is 301 to 350, give 12 units. If blood sugar is 351 to 400, give 15 units. If blood sugar is 401 to 450, give 18 units. This medication was ordered on [DATE] and was an active order at the time of this review. Review of Resident #17's Medication Administration Record [REDACTED]. Based on the physician's orders [REDACTED]. Also, on 02/23/16, Resident #17 received six (6) units of insulin for a blood sugar reading of 251. Based on the physician's orders [REDACTED]. An interview with Registered Nurse (RN) #3 and RN #20 at 2:33 p.m. on 03/29/16, confirmed on 03/22/16 and 02/23/16, Resident #17 did not receive her insulin dosage according to the physician's orders [REDACTED]. | 2019-07-01 |
| 4771 | 4771 | ST. JOSEPH'S HOSPITAL | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2016-03-31 | 325 | D | 0 | 1 | 6SHE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #28 maintained acceptable parameters of nutrition as evidenced by an unidentified and unaddressed severe weight loss. This was true for one (1) of three (3) residents reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #28. Facility Census: 16. Findings include: a) Resident #28 A review of Resident #28's medical record at 9:50 a.m. on 03/29/16, found this resident was admitted to the facility on [DATE] after surgical repair of fractured right femur. Other [DIAGNOSES REDACTED]. Review of electronic weight record found the following weights recorded: -- 11/18/15 - 111 pounds (lbs.) -- 11/25/15 - 104 lbs. -- 12/02/15 - 101 lbs. Resident #28 lost 6.31% of her body weight from 11/18/15 to 11/25/15, which was a severe weight loss. From 11/18/15 to 12/02/15, Resident #28 had lost 9% of her body weight. Review of Resident #28's physician orders [REDACTED]. -- On admission (11/13/15) - 1800 calorie American Diabetes Association (ADA) diet as directed by the physician. -- On 11/16/15 - an order for [REDACTED]. -- On 11/19/15 - an order for [REDACTED]. -- On discharge date (12/02/15) an order written [REDACTED]. No further orders were were found in the resident's medical record concerning diet and snacks. Review of Resident #28's meal percentages, beginning 11/13/15 (admission) through 12/03/15 (discharge) found the following: -- Consumed 76 - 100 percent (%) was consumed 63% of the time. -- Consumed 51-75 % was consumed 15% of the time. -- Consumed 26-50 % was consumed 3 % of the time. -- Consumed 0% (refused) 18% of the time. Review of diabetic friendly snacks, started on 11/17/15 through 12/3/15 found: -- The 10:00 a.m. snacks were consumed 50% of the time at 76-100%, and refused the other 50% of the time. -- The 2:00 p.m. snack was consumed 21% of the time and refused the other 69% of the time. Review of t… | 2019-07-01 |
| 4772 | 4772 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2016-01-14 | 166 | D | 0 | 1 | D0ID11 | Based on family interview, staff interview, policy review, and review of facility records, the facility failed to ensure prompt efforts were made to a grievance concerning lost clothing. The facility failed to promptly initiate an investigation into the lost item when first notified. This was found for one (1) of three (3) investigations into residents' lost personal possessions. Resident identifier: #96. Facility census: 159. Findings include: a) Resident #96 During an interview with a family member of non-interviewable sample Resident #96, on 01/11/16 at 5:00 p.m., the family member stated that a recent Christmas gift of a new pair of pajamas belonging to the resident was missing. While the family usually did the resident's laundry, she was concerned the new pajamas had gone into the facility laundry and not been returned. She stated she had reported the missing pajamas to the nurse aide (NA) caring for her family member, NA #7, and believed that a search for the pink flowered fleece pajamas with the resident's name on the pajamas was underway. On 01/13/16, the Unit Manager of the resident's unit, Unit Manager #19, was interviewed regarding the missing pajamas and the status of the investigation that the family member believed was underway. The Unit Manager was unfamiliar with the situation and reported that she had no knowledge of the missing pajamas. She added the usual procedure would be for the staff member who learned of the missing item to complete a lost property form or verbally report the missing item to either the charge nurse or directly to the Unit Manager. When the Unit Manager learned of the missing item, she would complete a Grievance/Concern form. In this case, because she had not learned of the missing item, no investigation was underway. After learning of the missing clothing, the Unit Manager promptly initiated an investigation by telephoning the family member and learning the details of the missing pajamas. The Unit Manager went to the facility laundry and described the missing item to the l… | 2019-07-01 |
| 4773 | 4773 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2016-01-14 | 241 | E | 0 | 1 | D0ID11 | Based on random observations, staff interviews, overheard resident comments, and record review, it was determined that resident dining was not provided in a manner and environment that maintained or enhanced each resident's dignity. Meal service was not coordinated to allow residents dining together at the same table to be served at the same time. Additionally, disposable plates, bowls, cups, and flatware were routinely used. This had the potential to affect more than a limited number of residents. Facility census: 159. Findings include: a) Third floor meal observations 1. Observations of dining service on the 3rd floor, on 01/11/16 at 11:40 a.m., revealed 2 carts were delivered to the unit. Four (4) staff began passing the food trays to the residents. Two (2) of four (4) residents at one (1) table were served their meals and began eating their food independently. The other two (2) alert residents were served juice, but were not served their meals until 26 minutes after the first two (2) residents were served. At 11:43 a.m. on 01/11/16, three (3) residents were seated at one (1) of the half circle tables in the dining room. One (1) resident was being fed by a staff member and the other two (2) residents had their trays in front of them, covered with a lid, but they were not eating or being assisted with their meals. At 12:05 p.m., Nurse Aide (NA) #30 began assisting the other two (2) residents. The two (2) residents had waited for 20 minutes for assistance with their meals while the other resident seated with them had been fed by the staff. Observation of another table in the dining room revealed four (4) residents seated and waiting for their meal. One (1) of the four (4) was served at 11:40 a.m., and she began feeding herself. The other two (2) residents seated at this table did not receive their meals until 11:55 a.m., and they were both able to feed themselves once they were served. During this meal observation, residents were observed to be drinking from disposable cups. In an interview on 01/11/16 at 1:00 p… | 2019-07-01 |
| 4774 | 4774 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2016-01-14 | 242 | D | 0 | 1 | D0ID11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and resident interview, the facility failed to ensure residents had the right to make choices about aspects of their lives in the facility that are significant to the resident. Two (2) residents (#9 and #166) were not given a choice regarding their shower schedules and one (1) resident (#9) was not afforded the choice to have coffee between meals, or tomato soup as a meal substitute, when desired. Two (2) of three (3) residents reviewed for Choices in Stage 2 were affected. Resident identifiers: #9 and #166. Facility census: 159. Findings include: a) Resident #9 During an interview with cognitively intact Resident #9, on 01/11/16 at 11:29 a.m., she revealed she received a shower 2 times a week. She stated the staff chose the days and times she received her showers. A second interview with Resident #9 on 01/12/16 at 1:35 p.m., revealed the staff have never asked her about what her preference would be regarding when she would like to receive her showers. She stated she received her shower two (2) times a week and the facility informed her of when she would be showered. She stated when the staff come to get her for her shower, that is when she gets her shower. b) Resident #166 An interview with Resident #166 on 01/11/16 at 2:19 p.m., revealed he was never asked by the staff when he would like to have his showers. He said the staff just told him when his showers were going to be. c) Interview with Nurse Aide #30, on 01/11/16 at 2:30 p.m., revealed she was not sure how the residents were initially identified or scheduled for their shower days, but they were added to the shower list. She did the showers as they were assigned to her. She stated most residents received a shower two (2) times a week. Interview with 3rd floor Unit Manager #90, on 01/13/16 at 1:02 p.m., revealed when a resident was admitted to a designated room in the facility, they were assigned to a certain shower day. She gave an example of, if… | 2019-07-01 |
| 4775 | 4775 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2016-01-14 | 253 | D | 0 | 1 | D0ID11 | Based on observation and staff interview, it was determined that resident care equipment was not consistently maintained in a sanitary manner for four (4) of twenty-one (21) sample rooms. Bedpans and urinals were not properly stored, covered, and/or changed timely, and a tube feeding pole and wheelchair were not clean. Rooms: 315, 321, 319, and 320. Facility census: 159. Findings include: a) Room 315 During a tour of the facility on 01/11/16, an unbagged urinal dated 07/28/15 was observed in the bathroom of room 315. The urinal was hanging over the grab bar beside the toilet. The name of the current female resident of the room was written on the urinal. b) Room 321 Also on 01/11/16, two (2) unbagged urinals were observed in the bathroom for Room 321. They were labeled with resident names and were dated 11/28/15. c) Room 319 Also on 01/11/16, two (2) bed pans and one (1) urinal, all unbagged, were observed in the bathroom of Room 319. The four (4) residents who used this bathroom, shared it with rooms 318 and 319. All of the residents were female and did not use a catheter. d) Room 320 A tube feeding pole in Room 320 was observed to have formula spills on its base on 01/11/16 at 10:55 a.m. The resident's wheelchair was also noted to have an accumulation of dust and grime on the lower surfaces. e) The issues regarding the resident care equipment observed on 01/11/16, were observed to remain in their described locations and condition on 01/12/16 and 01/13/16. f) On 01/13/16 at 3:00 p.m., during an interview 3rd Floor Unit Manager #90, regarding the resident care equipment, Rooms 315, 321, 319, and 320 were observed for the previously identified issues. Unit Manager #90 stated bedpans and urinals should be replaced weekly, and should have been bagged. The rooms observed were on the river side of the building. She stated that the river side of the building should have had their equipment replaced on Mondays. Additionally, she pointed to a cleaning schedule for the staff that was broken down by room number and day. Roo… | 2019-07-01 |
| 4776 | 4776 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2016-01-14 | 279 | D | 0 | 1 | D0ID11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident receiving [MEDICAL TREATMENT] service had an individualized, comprehensive care plan developed to address his [MEDICAL TREATMENT] care needs. This affected one (1) of thirty-one (31) Stage 2 sampled residents. The facility identified 3 of 159 current residents as receiving [MEDICAL TREATMENT] services. Resident identifier: #213. Facility census: 159. Findings include: a) Resident #213 Review of Resident #213's medical record revealed the resident was admitted to the facility on [DATE] from an acute hospital with a [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 12/25/15 indicated the resident was receiving [MEDICAL TREATMENT] services. Review of the resident's admission physician's orders [REDACTED]. The orders further stated Resident #213 was to receive medications after [MEDICAL TREATMENT] and have meals and snack provided during [MEDICAL TREATMENT]. The orders stated the resident had a Permacath to the left chest wall for [MEDICAL TREATMENT]. Access would be maintained by the [MEDICAL TREATMENT] center. The 12/22/15 admission orders [REDACTED]. Further review of the medical record found no evidence of an individualized, comprehensive care plan developed to address the resident's [MEDICAL TREATMENT] care needs. Review of nursing progress notes from the time of the resident's admission on 12/22/15 through 01/14/15, verified the resident received [MEDICAL TREATMENT] services as ordered. On 01/14/16 at 9:14 a.m., MDS Nurse #126 verified there was no individualized comprehensive care plan developed to address Resident #213's [MEDICAL TREATMENT] care needs. | 2019-07-01 |
| 4777 | 4777 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2016-01-14 | 280 | E | 0 | 1 | D0ID11 | Based on record review, resident interview, and staff interview, the facility failed to ensure residents were afforded the right to participate in care planning, and the facility failed to encourage residents to participate in care planning, including encouraging attendance at care planning conferences, if they so desired. This involved three (3) of three (3) residents reviewed in Stage 2 for participation in care. Resident identifiers: #5, #9, and #57. The Stage 2 sample was 31. Facility census: 159. Findings include: a) Residents #5, #9, and #57 During interviews with Resident #5 on 01/11/16 at 11:01 a.m., Resident #9 on 01/11/16 at 11:32 a.m., and Resident #57 on 01/11/16 at 11:19 a.m., the residents revealed the staff did not include them in decisions regarding their care plans, and they had never been invited to a meeting to discuss their ongoing care. During an interview with Minimum Data Set (MDS) Staff #124, at 3:00 p.m. on 01/12/16, he said he made a list of residents whose care plan meetings were due and gave the list to Receptionist #137. He stated it was her responsibility to send out all of the invitations. He stated he was unsure if Receptionist #137, sent out the invitations to both the residents and the families. An interview with Receptionist #137 revealed she only sent the invitations to the residents' families. She said she was unaware of how, or if, the residents were invited to their quarterly care plan meetings. MDS Staff #124 said it might be the Social Services staff who sent out the care plan meeting invitations to the residents. An interview with the Social Service Staff #125 on 01/12/16 at 3:30 p.m., revealed she did not send out any invitations to the residents to attend their care plan meetings. She stated she thought the receptionist was sending out the care plan meeting invitations to the residents by internal mail. She stated she had just had a conversation with the MDS Staff #124, and they had identified that the process was not being followed and the residents were not currently … | 2019-07-01 |
| 4778 | 4778 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2016-01-14 | 282 | D | 0 | 1 | D0ID11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to implement the care plan interventions for a Gradual Dose Reduction for Resident #87. This affected one (1) of five (5) residents sampled for the Care Area of Medication Review. Resident identifier: #87. Facility census: 159. Findings include: a) Resident #87 Resident #87 had [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had Non-Alzheimer's Dementia and there were no behaviors identified on the quarterly assessment. The most recent care plan, reviewed on 01/14/16 at 8:41 a.m., indicated the resident was at risk for complications related to [MEDICAL CONDITION] medication. Staff were to complete behavior monitoring flow sheets, gradual dose reduction as ordered, and to monitor for continued need of medication. Review of the medical record on 01/14/16 at 8:47 a.m., found the physician's orders [REDACTED]. On 12/02/15, the consultant pharmacist completed a review of Resident #87's medications. The pharmacist's consultation report included the, Resident recently tolerated a reduction of [MEDICATION NAME] from 1 mg twice a day to 0.75 mg at noon and 1 mg at night on 4/24/15. Recommendation: Please consider a further reduction of antipsychotic therapy, [MEDICATION NAME] to 0.75 mg twice a day, with the end goal of discontinuation while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. The document was signed by the nurse practitioner and included, I decline the recommendations above and do not wish to implement any changes due to the reasons below. Resident hospice and end of life. Has continued [MEDICAL CONDITION]. Failed GDR (gradual dose reduction) in past. Would likely worsen quality of life. Review of the medical record, including nurses' notes and behavioral monitoring sheets, did not find any indication the resident had any episodes of behaviors. On 01/14/16 at 9:19 a.m., the nurses' note… | 2019-07-01 |
| 4779 | 4779 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2016-01-14 | 329 | D | 0 | 1 | D0ID11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of policies and procedures on Gradual Dose Reduction and Behavioral Monitoring, the facility failed to attempt a gradual dose reduction for Resident #87 and failed to offer nonpharmacologic interventions prior to administering an antianxiety medication to Resident #100. No behaviors were documented for either resident. This affected two (2) of five (5) residents sampled for the Care Area of Medication Review. Resident identifiers: #85 and #100. Facility census: 159. Findings include: a) Resident #85 Review of this resident's medical record on 01/14/16 at 8:41 a.m., found the resident had [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment, dated 11/25/15, indicated the resident had Non-Alzheimer's Dementia and there were no behaviors identified on the quarterly assessment. The most recent care plan indicated the resident was at risk for complications related to [MEDICAL CONDITION] medication; staff would complete behavior monitoring flow sheets, gradual dose reduction as ordered, and monitor for continued need of medication. Continued medical record review on 01/14/16 at 8:47 a.m., found the physician's orders [REDACTED]. On 12/02/15, the consultant pharmacist completed a Consultation Report. The report included, Resident recently tolerated a reduction of [MEDICATION NAME] from 1 mg twice a day to 0.75 mg at noon and 1 mg at night on 4/24/15. Recommendation: Please consider a further reduction of antipsychotic therapy, [MEDICATION NAME] to 0.75 mg twice a day, with the end goal of discontinuation while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. The document was signed by the nurse practitioner the response, I decline the recommendations above and do not wish to implement any changes due to the reasons below. Resident hospice and end of life. has continued [MEDICAL CONDITION]. Failed GDR (gradual dose reduction) in past. Would likely wor… | 2019-07-01 |
| 4780 | 4780 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2016-01-14 | 364 | E | 0 | 1 | D0ID11 | Based on observations and staff interviews, the facility failed to serve residents on the Homestead unit food at proper temperatures to enhance palatability. This affected thirteen (13) residents who were served family style in the Homestead dining room. Facility census: 159. Findings include: a) On 01/11/16 at 12:15 p.m., the food cart was delivered to the Homestead unit where 13 residents ate with family style dining. The food was delivered in a green cart; the hot food was on top and cold food on the bottom. Nurse Aide (NA) #31, took out the food and begun to check the temperature of the foods before service to the residents. The grilled cheese was recorded as 110 degrees Fahrenheit (F) and the chicken tenders at 90 degrees F. When interviewed about the food temperatures, the NA was not aware of what the proper food temperatures were supposed to be. She had a paper with temperatures on it that listed different types of foods. She stated the activity person and another NA usually did the food service, but they were not there today. She stated there was a book, but she did not know where it was. NA #2, who was helping NA #31, stated she did not know what the proper temperatures were supposed to be either. Residents were served the grilled cheese and tomato soup and began eating their food. At 1:00 p.m., NA #31 was observed putting the Ambrosia fruit dessert into bowls and served six (6) residents. NA #31 was asked if she had checked the fruit dessert's temperature. She responded that she had not because she did not know she was supposed to. NA #31 took the temperature of the fruit dessert and it was 55 degrees. She stated she did not know what the temperature of cold food was supposed to be. The Homestead Unit Manager was observing and stated she did not know what the temperature of the cold food should be either. Residents were observed eating the dessert. Chef Manager #70, was notified. He came to the unit and stated that no temperature had been taken of the dessert before it left the kitchen. The dessert had … | 2019-07-01 |
| 4781 | 4781 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2016-01-14 | 371 | E | 0 | 1 | D0ID11 | Based on observations and interviews, the facility failed to serve residents meals in a sanitary manner on the Homestead unit during the observed lunch and dinner meals. Staff failed to change gloves and/or wash their hands after having contact with environmental objects and other residents, before handling foods. Staff also created the potential for cross contamination between residents. Facility census: 159. Findings include: a) On 01/11/16 at 12:15 p.m., during observations of food delivery to the Homestead unit for the noon meal service, Nurse Aide (NA) #31 put the foods onto platters and in large bowls. The NA stated the residents served themselves during their home style dining. NA #31 wore gloves, but touched the kitchen cabinets, pulled open drawers, and placed her hand on a resident's shoulder while passing the food while wearing the gloves and without changing them or washing her hands. NA #31 asked the residents if they wanted mashed potatoes. The residents were eating grilled cheese and sweet potatoes and, placing the partially eaten food back onto their plates. When the residents were served the mashed potatoes, NA #31 tapped the spoon of mashed potatoes onto each of the residents' plates to remove the potatoes from the serving utensil. The silverware the residents used to eat with had been in contact with the resident plates. When the utensil used for the mashed potato came into contact with each plate, it potentially caused cross contamination of each additional resident's plate. NA #31 gave 11 of of the 13 residents sitting in the dining room mashed potatoes from the serving bowl that had been tapped onto the residents' plates. One resident was observed to be eating her mashed potatoes with her fork and then stabbed the sweet potatoes with her fork to get some onto her plate from the community bowl at the table. She did not use the serving spoon. b) On 01/13/16 at 6:07 p.m., observations in the Homestead unit's far dining room noted the first cart was delivered at 6:07 p.m Ten (10) residents were … | 2019-07-01 |
| 4782 | 4782 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2016-01-14 | 372 | B | 0 | 1 | D0ID11 | Based on observations of the dumpsters, it was determined the hinged dumpster was not consistently closed, thereby allowing trash to blow out of the container and collect in the area behind the facility along the railroad tracks and the river wall. This had the potential to affect all residents. Facility census: 159. Findings include: a) Observations of the dumpster on 01/11/16 at 8:15 a.m. and 2:00 p.m., on 11/12/16 at 11:30 a.m., on 11/13/16 at 3:30 p.m., and on 01/14/16 at 2:00 p.m., found the hinged lid on the dumpster left open on each of the four (4) days of the survey. Adjacent to the hinge-lidded dumpster was a trash compactor. The door to the compactor was consistently observed to be closed. Observations on 01/11/16 at 8:15 a.m., noted the contents of the dumpster were bagged; however, there was trash blowing around the area. The trash included numerous cigarette butts, napkins, drink lids, bread wrappers, a green bell pepper, empty soda cans and bottles, a large blue plastic bag, straws, pepper packet wrappers, candy wrappers, a portion of a broken fluorescent light bulb, and Pride butter packets. During observation and interview with Dietary Manager #70 on 01/11/16 at 8:15 a.m., he stated kitchen staff utilized the compacter, and housekeeping utilized the dumpster. The back area of the facility butted up against a railroad track and the river wall. The facility grounds ended at the top of the raised area between the curb and the railroad tracks. The majority of the trash was on the railroad tracks and near the wall, not the facility's property. During an interview with Maintenance Director #16, on 01/13/16 at 3:00 p.m., he stated that since the railroad track was not their property, they did not pick up trash on that property. He believed that the majority of the trash observed fell out of the trash truck during their daily pick up at the facility. He stated that the trash service was responsible for getting out of their truck and picking up what they spilled. | 2019-07-01 |
| 4783 | 4783 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2016-01-14 | 467 | E | 0 | 1 | D0ID11 | Based on observations and staff interviews, it was determined that for two (2) of the four (4) shower rooms in the facility, the ventilation system was inadequate. The second and third floor shower rooms had standing water in the rooms and evidence that the shower floor tile and the grout, and the adjoining corridor floor tiles, were water damaged by regular exposure to water. The lack of functioning ventilation made a very humid and uncomfortable environment in which to receive a shower. Additionally, the humid environment provided a favorable environment for gnats. This had the potential to affect more than a limited number of residents. Facility census: 159. Findings include: a) During observations of the shower rooms on 01/12/16, between 4:00 and 4:30 p.m., with Maintenance Director #16, the fans designed to pull air from the shower rooms were observed to be nonfunctional. The rooms were humid and had standing water on the floors. When holding a tissue up to the ceiling vent, there was no obvious air movement from the vent. The following day, on 01/13/16 at 3:00 p.m., the Maintenance Director reported he had investigated the motors to the two (2) shower room fans on the roof of the facility. Both were burned out and providing none of the desired air circulation. He ordered two (2) new motors earlier in the day; they would arrive in 2-3 days and he planned to install them as soon as they arrived. On 01/14/16, the shower rooms were observed at 8:00 a.m. before any showers had been given for the day. There was standing water on the floors of both the 2nd and 3rd floor shower rooms that remained from showers given the previous day. On 01/14/16 at 4:00 p.m., the Maintenance Director reported the motors had arrived, and he had installed them. | 2019-07-01 |
| 4784 | 4784 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2016-01-14 | 469 | E | 0 | 1 | D0ID11 | Based on observations, review of pest control invoices, resident interview, and staff interview, it was determined the facility had a gnat problem on two (2) of the four (4) units of the facility. Gnats were observed on the second and third floors of the facility throughout the survey. Resident #68 voiced that the gnats were bothersome. This had the potential to affect more than a limited number of residents. Resident identifier: #68. Facility census: 159 Findings include: a) During an interview, with Resident #68 at 10:30 a.m. on 01/11/16, she stated she did not find the facility to be clean and comfortable because there were so many gnats flying around. She stated that, in fact, there were so many gnats in the television room across the hall from her room, that when she tried to eat her evening meal there on 01/10/16, she had to leave the room and her meal behind because the gnats were so bothersome. During the interview there were gnats observed flying around in room #206, where the interview was conducted. Gnats were observed on 01/11/16 in room 202 at 3:45 p.m. and in room 210 at 4:00 p.m. An occasional gnat was observed around the second floor unit throughout the days on 01/11/16, 01/12/16, and 01/13/16. On 01/12/16 gnats were observed in both the second and third floor shower rooms between 4:00 p.m. and 4:30 p.m. during a look at the shower rooms with Maintenance Director #16. There was a strip of fly paper hanging from the ceiling over the toilet in the second floor shower room. There were numerous gnats stuck to the fly paper. He stated he had not hung the fly strip and did not know where it had come from. Evidence/documentation of the facility's pest control program was requested and provided on 01/13/16 at 3:00 p.m. Three (3) invoices from (Name) Pest Control were provided. They were dated 10/28/15, 11/25/15, and 12/23/15. During each visit, the gnat problem was addressed, as well as other concerns. During a follow-up interview with the Maintenance Director on 01/14/16, he stated he did not believe tha… | 2019-07-01 |
| 4785 | 4785 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2016-01-14 | 514 | D | 0 | 1 | D0ID11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately document the administration of an antianxiety medication ([MEDICATION NAME]) for one (Resident #100) of five residents reviewed for unnecessary medications. Resident identifier: #100. Facility census: 159. Findings include: a) Resident #100 This resident, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Review of the medical record on 01/13/16 at 11:18 a.m., found the current physician's orders [REDACTED]. Review of the Medication Administration Records (MAR) for (MONTH) (YEAR) and (MONTH) (YEAR) found the resident received the medication nine (9) times. However, the nurses had documented on the Schedule II drug sheet on fifteen (15) occasions that the [MEDICATION NAME] was removed. According to the MAR, the resident received the [MEDICATION NAME] 0.25 mg on: 12/24/15, 12/28/15, 01/01/16, 01/02/16, 01/06/16, 01/08/16, 01/09/16, 01/11/16, and 01/12/16 Review of the resident's Schedule II drug sheet for the [MEDICATION NAME] 0.25 mg indicated the nurses signed the medication out as being removed on: 12/24/15, 12/26/15, 12/28/15, 12/29/15, 12/30/15, 12/31/15, 01/01/16, 01/02/16, 01/06/16, 01/08/16, 01/09/16, 01/10/16, 01/11/16, 01/12/16, and 01/13/16. On 01/14/16 at 1:27 p.m., during an interview, Director of Nursing (DON) #119 verified the documentation of the [MEDICATION NAME] 0.25 mg on the Medication Administration Record [REDACTED]. Facility nursing staff failed to accurately document the antianxiety medication [MEDICATION NAME] in the resident's medical record. | 2019-07-01 |
| 4786 | 4786 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 223 | D | 0 | 1 | V5RK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, staff interview, Centers for Disease Control and Prevention interview, State Epidemiology interview, and policy review the facility did not ensure one (1) of nine (9) residents, reviewed for abuse allegations in Stage 2 of the quality indicator survey (QIS), was free of abuse. Resident #14 was involuntarily secluded due to a history of a multi-drug resistant organism. Resident identifier: #14. Facility census: 81. Findings include: a) Resident #14 During a Stage 1 interview, on 01/11/16 at 12:55 p.m., Resident #14 related he only participated in activities in his room. The resident related he was told he had an infection and could not go outside of his room for activities. A physician's orders [REDACTED]. Review of the care plan, on 01/12/16, at 4:00 p.m. revealed a focus, initiated on 06/19/14 related to isolation precautions due to Resident #14 had a history of [REDACTED]. Interventions indicated gloves would be worn upon entry of the room, and other PPE (personal protective equipment) would only be required if substantial contact with resident expected. The Carbapenem Resistant [MEDICATION NAME] (CRE) policy, reviewed on 01/12/16 at 2:59 p.m., revealed the purpose was to prevent transmission ., and to ensure compliance with federal and state regulations .according to centers for disease control (CDC) guidelines. The policy also indicated isolation would be discontinued after completion of antibiotic therapy, then in thirty (30) days if three (3) consecutive cultures obtained from the source of infection were negative, unless otherwise advised the isolation would remain discontinued. An interview with the infection control preventionist, Licensed Practical Nurse (LPN #106), on 01/13/16 at 10:02 a.m., revealed she utilized the CRE toolkit and the CDC had been contacted when Resident #14 was admitted to the facility. The nurse related one infectious disease specialist indicated the resident … | 2019-07-01 |
| 4787 | 4787 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 225 | F | 0 | 1 | V5RK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, medical record review, policy review, reive of personnel records, and the Affordable Care Act, the facility failed to ensuer they screened one (1) of ten (10) employees by not ensuring they completed crominal background checks. Additionally, they failed to throughly investigate and report allegations of abuse/neglect for three 93) of nine (9) residents reviewed for abuse and neglect. These practices had the potential to affect all residents in the facility. Resident identifiers: Resident #48, #77, and #106. Facility census: 81. Findings include: a) Resident #48 During a Stage 1 interview, on 01/19/16 at 11:53 a.m., Resident #48 related that he felt like staff did not want to come to his room at times. He related he believed he had been vervbally abused. The resident related the incidents occurred more than once over the past couple of months. Resident #48 also related he felt like some of the staff got rough with him, because they had to provide care for him. Additionall, the resident related he had been left in urine and poop and not enough staff was available. He related the licensed practice nurses or registered nurses would answer the call bell, but would not provide care, and he had to wait for thirty 930) minutes. He further added, It gets old. The resident related he told the supervisor. Upon inquiry, Resident #48 related he told Social Worker (SW #76). The minimum datea set (MDS) with an assessment reference date (ARD) of 10/20/15, reviewed on 01/14/5 at 8:08 a.m., revealed a brief interview for mental status (BIMS) score of 14, indicating Resident #48 was cognitively intact. The highest attainable score was 15. Further review revealed he was totally dependent upon staff for bed mobility, transfer, toileting, personal hygiene and bathing. Concern/complaint/grievance forms, and reportable allegations, reviewed on 01/13/15, revealed no evidence the facaility had filed/reported an allegation … | 2019-07-01 |
| 4788 | 4788 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 226 | F | 0 | 1 | V5RK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, medical record review, policy review and review of the Affordable Care Act (ACA) guidelines, the facility failed to operationalize abuse/neglect policies and procedures for screening, training, identification, prevention, and investigating allegations of abuse and neglect for three (3) of nine (9) residents reviewed. The facility failed to thoroughly investigate allegations of neglect for Resident #77. The facility failed to identify an allegation of neglect and protect a resident after an allegation of neglect was made by Resident #48. The facility failed to ensure Resident #14 was free from abuse. Resident #14 was involuntarily secluded from other residents and activities. The facility failed to report an allegation of neglect to State agencies for Resident #106. In addition, they failed to operationalize screening policies and procedures to ensure completion of a fingerprint based criminal background check for one (1) of ten (10) employee personnel files reviewed. These practices had the potential to affect all residents in the facility. Resident identifiers: Resident #14, #48, #77, and #106. Facility census: 81. Findings include: a) Resident #48 During a Stage 1 interview, on 01/19/16 at 11:53 a.m., Resident #48 related he felt like staff did not want to come to his room at times. He related he believed he had been verbally abused. The resident said the incidents occurred more than once over the past couple of months. Resident #48 also related he felt like some of the staff got rough with him, because they had to provide care for him. Additionally, the resident related he had been left in urine and poop and not enough staff was available. He related the licensed practical nurses or registered nurses would answer the call bell, but would not provide care, and he had to wait for thirty (30) minutes. He further added, It gets old. The resident related he told the supervisor. Upon inquiry, Residen… | 2019-07-01 |
| 4789 | 4789 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 246 | D | 0 | 1 | V5RK11 | Based on observation, resident interviews, and staff interview, the facility failed to provide reasonable accommodations for one (1) of thirty-five (35) Stage 1 sample residents. Resident #48 was unable to access the pull cord for the over-bed lights. Resident identifier: #48. Facility census: 81. Findings include: a) Resident #48 During Stage 1 room observations for Resident #48, on 01/11/16 at 1:58 p.m., the resident reported he was unable to reach the pull cord for his over-bed light. The pull cord enabled him to turn on his light. Observations at this time revealed the pull cord for the over-bed light was too short for the resident to reach. The observation of the light cord being too short for Resident #48 was discussed with the Director of Maintenance on 01/21/16 at 10:05 a.m. He stated the resident needed to be able to turn his light on. | 2019-07-01 |
| 4790 | 4790 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 253 | E | 0 | 1 | V5RK11 | Based on observations and staff interview, the facility failed to provide maintenance and housekeeping services necessary to maintain a comfortable and sanitary interior for eight (8) of twenty nine (29) rooms observed during Stage 1 of the Quality Indicator Survey (QIS). Rooms 104, 305 and 306 had sink tops with rough edges and a white film around the sinks. Rooms 102 and 203 had furniture with damage. Room 204 needed a longer pull cord for the over- bed light and Rooms 300 and 100 had an unpainted bathroom door and cove base pulled away from the wall. This had the potential to affect more than an isolated number of residents. Room identifiers: #100, #102, #104, #203, #204, #300, #305 and #306. Facility census: 81. Findings include: a) Sink tops --Room #104 was observed, on 01/11/16 at 12:47 p.m., to have white film on the sink top. --Room #305 was observed, on 01/12/16 at 9:55 a.m., to have rough edges on the front of the sink base and a white film around the sink. --Room #306 was observed, on 01/12/16 at 8:30 a.m., to have rough edges on the front of the sink base and a white film around the sink. b) Furniture --Room #102 was observed, on 01/11/16 at 1:09 p.m., to have a night stand with missing veneer. --Room #203 was observed, on 01/11/16 at 12:13 p.m. Room #203 had a four (4) drawer chest with missing veneer and drawers that were not closing properly. c) Light pull cord --Room #204 was observed, on 01/11/16 1:58 p.m., to have a short over-bed light pull cord. d) Door and cove base --Room #300 was observed, on 01/12/16 at 9:01 a.m., to have a bathroom door with unpainted areas. --Room #100 was observed, on 01/11/16 at 12:47 p.m. Room #100 had cove base pulling away from the wall. During an interview with the Maintenance Director on 01/21/16 at 9:45 a.m., agreed the sink tops, furniture, light pull cord, bathroom door and cove base all needed repaired. | 2019-07-01 |
| 4791 | 4791 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 278 | D | 0 | 1 | V5RK11 | **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 accurately reflected the [DIAGNOSES REDACTED].#3 and #47. Section I - Active [DIAGNOSES REDACTED]. Resident identifiers: #3 and #47. Facility census: 81. Findings include: a) Resident #3 A review of the medical record, for Resident #3 on 01/13/16 at 7:50 a.m., revealed the quarterly MDS assessment with the assessment reference date (ARD) of 10/15/15 did not accurately reflect a [DIAGNOSES REDACTED]. During further review, it was noted in the physician's orders [REDACTED].#3 had an order for [REDACTED]. An interview on 01/13/15 at 8:22 a.m., with Registered Nurse (RN) #86, the RN verified Section I - Active [DIAGNOSES REDACTED].#3. b) Resident #47 The MDS assessment review for Resident #47 on 01/19/16 at 11:00 a.m. revealed an MDS with the assessment reference date of 12/26/15. The 14 day PPS MDS Minimum Data Set Assessmt (MDS) with the assessment reference date (ARD) of 12/26/15 indicated the assessment did not include the [DIAGNOSES REDACTED]. Review of the MDS significant change with ARD of 12/15/15 did indicate the resident had a [DIAGNOSES REDACTED]. This [DIAGNOSES REDACTED]. Discussion with the MDS Coordinator on 01/19 /16 at 10:15 a.m. revealed the [DIAGNOSES REDACTED]. Current physician's orders [REDACTED]. | 2019-07-01 |
| 4792 | 4792 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 279 | E | 0 | 1 | V5RK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff interview it was determined the facility had not included goals for advanced directive specifics or end of life care on resident care plans. This would ensure staff members would provide treatment in accordance with resident wishes. This included seven (7) of seven (7) residents in the Stage 2 sample which were reviewed for advanced directives. Resident identifiers: #17, #95, #42, #100, #3, #98, and #29. Facility census: 81. Findings include: a) Resident #17 Review of the medical record, 01/19/16 at 10:00 a.m., for this resident revealed there were orders for comfort measures only. The current care plan did not address the resident's advanced directives. The Physician order [REDACTED]. The resident's advance directives and specific wishes for end of life were not identified in the care plan. An interview with Registered Nurse (RN) #86 on 01/20/16 at 9:30 a.m revealed that they had not been placing he advanced directive issues as part of the care plan. b) Resident #95 A review of the medical record, on 01/20/16 at 10:30 a.m., revealed the resident had orders for Do Not Resuscitation. The care plan did not include any specifics regarding the advanced directives. The POST form dated 08/24/15 had Do Not Resuscitation indicated. Other directives were IV fluids long term if needed and feeding tube long term. These were not in the current care plan to ensure the staff would implement the resident's wishes. Discussion with nursing staff as listed above. in example a. c) Resident #42 Review of Resident #42's medical record, on 01/20/16 at 10:30 a.m., showed the resident had a POST form, which indicated the following directives should be implemented per his wishes: The POST form revealed that he wanted full measures taken, IV for long term and no tube feeding. However, the care plan stated comfort measures were to be implemented. These directives were not in the current care plan. RN #86 was interviewed on 01/2… | 2019-07-01 |
| 4793 | 4793 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 309 | D | 0 | 1 | V5RK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and medical record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental or psychosocial well-being for one (1) of five (5) residents reviewed for unnecessary medications. The facility failed to adequately assess and monitor a resident who experienced an exacerbation of [MEDICAL CONDITIONS]. Resident identifier: 96. Facility census: 81. Findings include: a) Resident #96 During a Stage 1 interview, on 01/11/16 at 1:10 p.m., Resident #96 expressed he utilized an inhaler for shortness of breath. The resident related, I had to give my inhaler up. When you need it, you just smother. Here you have to ask for it .I don't (do not) like it at all. Sometimes I go up there and there is no one at the desk at all, and I smother and am uncomfortable, and it makes me mad. I am not mental. Upon inquiry, the resident related he had not discussed it with the physician, but I talk to the nurse all the time. They can't (cannot) do anything unless he tells them. Don't (Does not) make sense to me. Sometimes I go out there and there is two (2) of them, and they are busy doing other things and had to wait. The resident related he always had one on me, wherever I went, I had it, but they took it away from me here. The resident related he had been in the facility about two (2) months. Another interview with Resident #96, on 01/13/16 at 8:31 a.m., revealed his status as I'm (I am) fair. I'd (I would) say I am fair. The resident further added, I just can't (cannot) seem to connect here. The resident related he would go to the hospital, and sometimes had to wait a long time, but would sit and converse with other men. The resident said he was able to talk about his feelings and they would give him nerve pills. The resident related he was unsure of what the facility administered him, but indicated he used inhalers and took a blood thinner medication… | 2019-07-01 |
| 4794 | 4794 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 161 | E | 0 | 1 | KC5S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's surety bond, interview with staff at the Office of Health Facility Licensure and Certification (OHFLAC), and staff interview, the facility failed to maintain an approved surety bond, or otherwise assure the security of all personal funds of residents deposited with the facility. This had the potential to affect the sixty-eight (68) residents for whom the facility managed a personal funds account. Facility census: 87. Findings include: a) During the survey in (MONTH) (YEAR), the facility provided a copy of its surety bond for resident trust funds. The policy term was from [DATE] to [DATE]. b) The facility did not have an approval letter from the Office of Health Facility Licensure and Certification (OHFLAC), and a copy of the surety bond as approved by the Attorney General's office. Each facility is required by State law to send their original bond to the Office of Health Facility Licensure and Certification, the holder of the bonds. OHFLAC, in turn, sends the original bonds to the Attorney General's office for review and approval each year. The Attorney General's office will stamp the bond once approved and return the original bond to OHFLAC. c) Upon request for the status of the bond on [DATE] at 3:41 p.m., confirmation was received from OHFLAC that the bond submitted by the facility expired on [DATE]. d) In an interview with the administrator, on [DATE] at 3:45 p.m., she said the bond was submitted today to OHFLAC via Fedex, but it would not arrive at OHFLAC, nor would it be approved by the Attorney General's office, prior to survey exit. | 2019-07-01 |
| 4795 | 4795 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 164 | E | 0 | 1 | KC5S11 | Based on observation, staff interview, and resident interview, the facility failed to ensure the right to personal privacy for four (4) of four (4) residents reviewed for the care area of privacy. The facility provided no means to prevent wandering confused residents from entering their rooms. This practice affected four (4) residents, but had the potential to affect more than an isolated number of additional residents. Resident identifiers: #23, #120, #128, and #53. Facility census: 87. Findings include: a) Resident #23 Observation on 10/26/15 at 2:30 p.m., revealed a female resident walked into Resident #23's room and climbed into his bed. He immediately screamed at her and she got up and walked out of the room. At 2:45 p.m., observation revealed a second resident, Resident #73, entered the room and attempted to sit on the resident's bed. After Resident #73 was assisted out of the room, Resident #23 said the residents who lived on the Solana unit, previously a locked Alzheimer's unit, repeatedly entered his room. Upon inquiry, Resident #23 said the facility had not offered him any means to deter the roaming confused residents from entering his room. b) Resident #120 During a Stage 1 resident interview, on 10/26/15 at 2:30 p.m., two (2) female residents entered Resident #120's room between 2:30 p.m. and 2:45 p.m. The first resident climbed into the roommate's bed and exited after Resident #120 and the roommate yelled at her. The second non-communicating resident was assisted from the room by the surveyor. Resident #120 reported this was a continuous occurrence. He said the residents who resided on the Solana unit, previously a locked Alzheimer's unit, entered his room from either the bathroom door or the hallway door. He stated they often climbed into their beds, carried items out of the room, and sometimes attempted to take food off of their meal trays while they were eating in their room. Resident #120 reported he and his roommate requested a slide lock to at least keep the bathroom door closed, but the reques… | 2019-07-01 |
| 4796 | 4796 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 223 | E | 0 | 1 | KC5S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, accident/incident report review, facility policy and procedure review, and staff interview, the facility failed to ensure each resident had the right to be free from physical abuse. Two (2) residents alleged physical abuse by the same resident (Resident #83). The facility did not thoroughly investigate or address the allegations to ensure the prevention of additional abuse to these residents and/or other residents. Residents #9 and #28 were affected; however, this practice had the potential to affect more than an isolated number of other residents. Facility census: 87. Findings include: a) Resident #9 On 11/04/15 at 8:40 a.m., a medical record review was conducted for Resident #9. This resident was admitted on [DATE]. [DIAGNOSES REDACTED]. A continuing review of the medical record revealed this resident had capacity to make health care decisions. In addition, according to the significant change minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/06/15, Resident #9 had a score of 11 on the Brief Interview for Mental Status (BIMS), indicating the resident was only moderately cognitively impaired. A review of incident/accident reports, on 11/04/15 at 9:00 a.m., revealed on 07/18/15 at 4:40 p.m., Resident #9 was heard yelling while sitting in her wheelchair in the hallway. The report indicated Licensed Practical Nurse (LPN) #102 observed Resident #83 had his hands on the back of Resident #9's neck and was pushing her head forward. The incident/accident report event section indicated this was a resident-to-resident altercation with alleged abuse. The report noted the victim was Resident #9. The event section on Resident #83's incident report also indicated this was a resident-to-resident altercation, with alleged abuse. b) Resident #28 On 11/04/15 at 8:26 a.m., a medical record review was conducted for Resident #28. This resident was originally admitted on [DATE]. [DIAGNOSES REDACTED]. … | 2019-07-01 |
| 4797 | 4797 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 224 | D | 0 | 1 | KC5S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of accident/incident reports, facility policy and procedure review, and staff interview, the facility failed to implement its Abuse Prohibition written policies and procedures to ensure each resident had the right to be free from abuse. Resident #83 allegedly physically abused Residents #9 and #28. The facility had no evidence their abuse policies and procedures to investigate the abuse and to protect residents from abuse were implemented for either resident's alleged abuse. Resident identifiers: #9, #28, and #83. Facility census: 87. Findings include: a) Resident #9 On 11/04/15 at 8:40 a.m., a medical record review was conducted for Resident #9. This resident was admitted on [DATE]. [DIAGNOSES REDACTED]. A continuing review of the medical record revealed this resident had capacity to make health care decisions. In addition, according to the significant change minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/06/15, Resident #9 had a score of 11 on the Brief Interview for Mental Status (BIMS), indicating the resident was only moderately cognitively impaired. A review of incident/accident reports, on 11/04/15 at 9:00 a.m., revealed on 07/18/15 at 4:40 p.m., Resident #9 was heard yelling while sitting in her wheelchair in the hallway. The report indicated Licensed Practical Nurse (LPN) #102 observed Resident #83 had his hands on the back of Resident #9's neck and was pushing her head forward. The incident/accident report event section indicated this was a resident-to-resident altercation with alleged abuse. The report noted the victim was Resident #9. The event section on Resident #83's incident report also indicated this was a resident-to-resident altercation, with alleged abuse. b) Resident #28 On 11/04/15 at 8:26 a.m., a medical record review was conducted for Resident #28. This resident was originally admitted on [DATE]. [DIAGNOSES REDACTED]. Resident #28's score on the B… | 2019-07-01 |
| 4798 | 4798 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 226 | E | 0 | 1 | KC5S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, accident/incident report review, facility policy and procedure review, and staff interview, the facility failed to operationalize its policies and procedures for protection of residents, identification of abuse, and investigation of allegations of abuse for two (2) residents who alleged physical abuse by the same resident (Resident #83).There was no evidence policies and procedures were operationalized to ensure the prevention of additional abuse to these residents and/or other residents. Residents #9 and #28 were affected; however, this practice had the potential to affect more than an isolated number of other residents. Facility census: 87. Findings include: a) Resident #9 On 11/04/15 at 8:40 a.m., a medical record review was conducted for Resident #9. This resident was admitted on [DATE]. [DIAGNOSES REDACTED]. A continuing review of the medical record revealed this resident had capacity to make health care decisions. In addition, according to the significant change minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/06/15, Resident #9 had a score of 11 on the Brief Interview for Mental Status (BIMS), indicating the resident was only moderately cognitively impaired. A review of incident/accident reports, on 11/04/15 at 9:00 a.m., revealed on 07/18/15 at 4:40 p.m., Resident #9 was heard yelling while sitting in her wheelchair in the hallway. The report indicated Licensed Practical Nurse (LPN) #102 observed Resident #83 had his hands on the back of Resident #9's neck and was pushing her head forward. The incident/accident report event section indicated this was a resident-to-resident altercation with alleged abuse. The report noted the victim was Resident #9. The event section on Resident #83's incident report also indicated this was a resident-to-resident altercation, with alleged abuse. b) Resident #28 On 11/04/15 at 8:26 a.m., a medical record review was conducted for Resident #… | 2019-07-01 |
| 4799 | 4799 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 241 | E | 0 | 1 | KC5S11 | Based on observation, staff interview, and resident interview, the facility failed to maintain an environment which promoted respect for private space for (4) of four (4) residents reviewed for dignity and respect. The facility provided no means to prevent wandering confused residents from entering these residents' private spaces. This practice affected four (4) residents, but had the potential to affect more than an isolated number of additional residents. Resident identifiers: #23, #120, #128, and #53. Facility census: 87. Findings include: a) Resident #23 Observation on 10/26/15 at 2:30 p.m., revealed a female resident walked into Resident #23's room and climbed into his bed. He immediately screamed at her and she got up and walked out of the room. At 2:45 p.m., observation revealed a second resident, Resident #73, entered the room and attempted to sit on the resident's bed. After Resident #73 was assisted out of the room, Resident #23 said the residents who lived on the Solana unit, previously a locked Alzheimer's unit, repeatedly entered his room. Upon inquiry, Resident #23 said the facility had not offered him any means to deter the roaming confused residents from entering his room. b) Resident #120 During a Stage 1 resident interview, on 10/26/15 at 2:30 p.m., two (2) female residents entered Resident #120's room between 2:30 p.m. and 2:45 p.m. The first resident climbed into the roommate's bed and exited after Resident #120 and the roommate yelled at her. The second non-communicating resident was assisted from the room by the surveyor. Resident #120 reported this was a continuous occurrence. He said the residents who resided on the Solana unit, previously a locked Alzheimer's unit, entered his room from either the bathroom door or the hallway door. He stated they often climbed into their beds, carried items out of the room, and sometimes attempted to take food off of their meal trays while they were eating in their room. Resident #120 reported he and his roommate requested a slide lock to at least keep th… | 2019-07-01 |
| 4800 | 4800 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 248 | D | 0 | 1 | KC5S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and staff interview, the facility failed to provide an ongoing activities program to meet the interests and needs for three (3) of six (6) Stage 2 residents reviewed for the provision of activities. When the facility discontinued their Alzheimer's unit, all structured daily activities geared to meet the needs of those residents were also discontinued. The available scheduled group activities did not meet the identified individual needs of these residents with dementia, short attention spans, and/or behaviors. Resident identifiers: #73, #99, and #50. Facility census: 87. Findings include: a) Residents #73, #99, and #50 resided on the Solana unit, which was previously a secured Alzheimer's unit. The facility discontinued the Alzehimer's unit, and on 04/20/15, the doors of the secured unit were unlocked. These residents no longer had a confined area to wander, and no longer were provided on-going structured activities based on their assessed needs. 1. Resident #73 Review of the medical record, on 10/28/15 at 2:20 p.m., revealed Resident #73 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was identified at risk for limited meaningful engagement related to her cognitive loss, confusion, and short attention span. The resident was unable to make her needs known, and was at risk for falls. Her behaviors included pacing to the point of exhaustion. The resident's recreational assessment, dated 05/19/15, noted the resident was rarely/never understood. Her favorite activities included music, food, and social events. The accommodations listed related to her cognitive loss included small groups, decreased environmental clutter, verbal prompts, physical prompts (hand over hand), simple noncomplex directions, and sensory focused activities. The summary stated she was confused, had a short attention span, and often wandered. The assessment noted: She needs adapted activities to her cognition, with fo… | 2019-07-01 |
| 4801 | 4801 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 253 | E | 0 | 1 | KC5S11 | Based on observation and staff interview, the facility failed to provide effective housekeeping and maintenance services in ten (10) of thirty-five (35) resident rooms. Concerns included window drapes hanging off drapery hooks; rusted, dusty, and/or spider webs in air conditioner/heater unit vents; improperly applied caulking around a sink; stained and/or discolored tile and caulking around toilet bases; marred, chipped, and/or soiled over-the-bed tables; scratched and marred doors; and soiled, stained, and/or discolored door thresholds, walls, floors, and ceilings. In addition heaters in hallways had a large accumulation of rust and discoloration on their vents. Room numbers: #104, #114, #118, #139, #152, #156, #157, #160, #164 and #166. Findings include: a) On 10/28/15 from 11:45 a.m. until 12:20 p.m., accompanied by Housekeeping Supervisor #103 and the Maintenance Supervisor #27, a tour of the facility was conducted. At the conclusion of the tour, both agreed the environmental issues observed during the tour required cleaning, repairs and/or replacement: 1. Room #104: The tile around the base of the toilet in the bathroom was stained and discolored. 2. Room #114: Both of the over-the- bed tables in the room had chipped and missing finish around the edges. 3. Room #118: The interior bathroom door frame was scratched and marred one half (1/2) of the way up from the floor. 4. Room #139: The sink located in the resident room had a one and one-half inch (1 1/2) chipped area in the front of the porcelain and very thick caulking (improper application) around the sink counter connecting it to the wall. \ 5. Room #152: The tile around the base of the toilet in the bathroom was stained and discolored. 6. Room #156: The window valance was hanging down and off the drapery hooks on the left side of the window. The room air-conditioner/heater unit had a thick coating of dust and spider webs in the vents. The wall under the sink in the residents' room was stained and discolored with large brown areas. The floor threshold to … | 2019-07-01 |
| 4802 | 4802 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 272 | D | 0 | 1 | KC5S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to conduct an accurate comprehensive Minimum Data Set (MDS) assessment for two (2) of thirty-five (35) Stage 2 sample residents reviewed during the Quality Indicator Survey (QIS). The assessments related to Resident #137's falls and Resident #83's behaviors were not accurate. Resident identifiers: #137 and #83. Facility census: 87. Findings include: a) Resident #137 On 10/28/15 at 3:00 p.m., medical record review revealed Resident #137 was admitted to the facility on [DATE]. Nursing progress notes and incident/accident reports indicated the resident had a fall with injury on 10/09/15. The admission MDS, with an assessment reference date (ARD) of 10/15/15, indicated the resident had no falls since admission. Section J1800, related to falls since admission/entry or reentry or Prior Assessment was assessed as No. After reviewing the MDS on 10/28/15 at 3:40 p.m., the Director of Nursing (DON) agreed and verified the MDS not accurate. She stated, It should have been coded as Yes since the resident had a fall on 10/09/15. During an interview with MDS Nurse #49, on 10/28/15 at 4:00 p.m., she stated, I went by the change in condition form and it only stated laceration and it did not state she had a fall. I should have checked further because the MDS is incorrect. b) Resident #83 On 11/03/15 at 10:05 a.m., a review of incident/accident reports revealed Resident #83 was involved in twelve (12) resident-to-resident altercations from 04/30/15 to 08/29/15. His documented behaviors included wandering, slapping and punching residents, entering multiple resident rooms (which was upsetting to the residents), and going into female residents' rooms and pulling mattresses off the beds. A review of the resident's annual MDS, with an ARD of 07/17/15, on 11/03/15 at 10:30 a.m., revealed the section for behaviors, E0200, indicated behaviors were not exhibited. The behaviors for assessment at E0200 inclu… | 2019-07-01 |
| 4803 | 4803 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 278 | D | 0 | 1 | KC5S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete accurate quarterly assessments for two (2) of thirty-five (35) Stage 2 sampled residents. The quarterly minimum data sets (MDS) assessment for Resident #45 was inaccurate related to falls. Resident #73's quarterly MDS was inaccurate related to wandering. Resident identifiers: #45 and #73. Facility census: 87. Findings include: a) Resident #45 The resident's medical record and incident and accident reports, for the most recent three (3) months, were reviewed on 10/29/15 at 9:00 a.m. The resident's quarterly assessment, with an assessment reference date (ARD) of 10/01/15, contained a falls assessment under section J of the minimum date set (MDS). This assessment did not match the incident reports and nurse progress notes related to falls. On 10/29/15 at 2:50 p.m., interviews were conducted with MDS registered nurse (RN) #49, and RN/MDS trainee #94. After their review of the medical record, they agreed the quarterly assessment with the ARD of 10/01/15 contained incorrect assessments in the area of falls. RN #94 said she coded section J1900 incorrectly on the 10/01/15 quarterly assessment. Part A incorrectly assessed the number of falls the resident sustained [REDACTED]. The resident actually sustained two (2) or more falls since the last assessment. In part C of section J1900, Employee #94 said she incorrectly assessed the resident with two (2) or more falls with major injury since the last assessment. The resident actually had no falls with major injury since the last assessment. Employee #94 said she would promptly complete a MDS modification to correct the inaccuracy of the assessments in the area of falls. b) Resident #73 Review of the medical record, on 10/28/15 at 2:20 p.m. revealed Resident #73 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The social service assessment, dated 08/17/15, stated under section D titled Mental Health / Behav… | 2019-07-01 |
| 4804 | 4804 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 279 | E | 0 | 1 | KC5S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop care plans with measurable goals and interventions for five (5) of thirty-five (35) Stage 2 residents whose care plans were reviewed. These residents' care plans for activities did not contain specific interventions related to identified activity needs and preferences. Resident identifiers: #45, #99, #50, #73, and #83. Facility census: 87. Findings include: a) Resident #45 Review of the medical record, on 11/03/15 at noon, revealed this [AGE] year old resident came to the facility in 2010. [DIAGNOSES REDACTED]., until the Alzheimer's unit closed on 04/20/15. His care plan indicated he was at risk for limited meaningful engagement related to cognitive loss, confusion, wandering, and a very short attention span. It specified the need for activities adapted to his cognition, with short duration sensory focused activities. Interventions included using props and materials that were tactile to provide sensory stimulation; however, the recommended props and materials were not named and identifiable. Also, the types of short duration sensory focused activities he enjoyed were not identified. Another intervention included using sensory interventions related to his previous life roles and interests; however, the care plan did not identify his previous life roles. It also not identify any of his interests other than coffee, quiet, and being warm. During an interview with the activity director (AD), on 11/03/15 at 10:30 a.m., she agreed this resident's care plan interventions lacked specificity. When asked how all staff members who worked with the resident would know, from the care plan, how to engage the resident in activities of choice, she answered by saying , there was always room for improvements in care planning. At this time, the AD also discussed activities in which the resident participated which were not a part of his care plan. She said sometimes the resident sa… | 2019-07-01 |
| 4805 | 4805 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 282 | D | 0 | 1 | KC5S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the care plans were implemented for two (2) of thirty-five Stage 2 residents whose care plans were reviewed. Resident #129's respiratory assessment was not completed as required in the care plan. In addition, the care plan for Resident #74 was not implemented related to pain management. Resident identifiers: #129 and #74. Facility census: 87. Findings include: a) Resident #129 On [DATE] at 1:47 p.m., a review of the resident's discharge medical record revealed Resident #129 was admitted on [DATE]. [DIAGNOSES REDACTED]. A review of the care plan, on [DATE] at 3:30 p.m., revealed an intervention, dated [DATE], Check breath sounds and respiratory function for rate, rhythm, depth, rhonchi, wheezes q (every) shift and with a change in condition, notify physician of changes from baseline. A concurrent review of the nursing assessments and notes revealed from [DATE] until [DATE], only eight (8) assessments noted breath sounds. On [DATE] at 3:45 p.m., the director of nursing (DON) was asked to assist in finding evidence the care plan intervention to check breath sounds and respiratory function each shift was implemented. The DON confirmed, on [DATE] at 4:24 p.m., there was no evidence the care plan intervention to assess breath sounds and respiratory function each shift was implemented for Resident #128. b) Resident #74 Review of the medical record began on [DATE] at 9:00 a.m. This [AGE] year old resident came to the facility on [DATE] and expired on [DATE]. [DIAGNOSES REDACTED]. The resident refused continuation of [MEDICAL TREATMENT] services. A care plan focus identified the resident's expressed desire for palliative/comfort care measures only. There was a care plan for pain. Interventions were to medicate for pain and monitor for effectiveness. Other care plan interventions were to evaluate pain characteristics: quality, severity, location, and utilize the pain scale. Revie… | 2019-07-01 |
| 4806 | 4806 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 309 | G | 0 | 1 | KC5S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide care and services to ensure two (2) of thirty-five (35) Stage 2 sample residents attained or maintained the highest practicable well-being. The facility failed to assess Resident #83 related to his ability to reside in a setting which was not secure (locked) and structured as when he resided in the facility's previous Alzheimer's unit. In addition, the facility failed to recognize and address the resident's adjustment difficulties to his new environment. These failures resulted in mental/psychological harm to the resident. For Resident #74, the facility failed to assess the efficacy of as needed (PRN) pain medications after its administration. Resident identifiers: #83 and #74. Facility census: 87. Findings include: a) Resident #83 This resident was admitted to the facility's Alzheimer's unit on [DATE]. His [DIAGNOSES REDACTED]. On [DATE], the facility mailed a letter to resident's family members informing them of the closure of the Alzheimer's unit, effective [DATE]. The letter stated: After careful considerations and evaluations of the patients we care for at Salem Center, it has been determined that current Alzheimer unit would better meet the needs of our patients and residents if it was converted to standard skilled nursing skilled nursing unit. Therefore on (MONTH) 20, (YEAR), we will convert this unit to skilled nursing. This will not represent a significant change for our residents who are currently cared for on this unit. (Name of company) physicians and clinical nursing leadership have evaluated the residents and believe that a skilled nursing unit is appropriate to meet our residents needs. On [DATE], the doors to the locked Alzheimer's unit were unlocked, and the facility no longer provided the services of an Alzheimer's unit. At 10:00 a.m. on [DATE], review of the medical records for Resident #83 revealed his [DIAGNOSES REDACTED]. The record was silent for… | 2019-07-01 |
| 4807 | 4807 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 332 | D | 0 | 1 | KC5S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of the facility's list of medications to not crush, the facility failed to ensure a medication error rate of less than five percent (5%). Extended release tablets were crushed and an ordered medication was omitted. Medication errors were identified for two (2) of six (6) residents observed during medication pass. Three (3) medication errors, out of forty-eight (48) opportunities for error, resulted in a medication error rate of 6.25%. Resident identifiers: #10 and #98. Facility census: 87. Findings include: a) Resident #10 On 10/27/15 at 8:14 a.m., observation of medication administration revealed registered nurse (RN) #61 crushed a [MEDICATION NAME] 600 milligram (mg) tablet, and crushed a Klor Kon 20 MeQ (milliquivalent) Extended Release tablet. The former is a medication used to treat respiratory congestion, and the latter is a potassium supplement. She then mixed those medications in applesauce, and administered them to Resident #10. Review of the facility's Do Not Crush list, on 10/27/15 at 10:00 a.m., found that both of these medications are extended release tablets, and neither are supposed to be crushed. Review of the Medication Administration Record [REDACTED]. Review of the medication cart found that neither the box of [MEDICATION NAME], nor the box of Klor Kon, in which these medications were stored, contained warning labels from the pharmacy to alert staff not to crush these medications. The director of nursing (DON), on 10/27/15 at noon, said that since Klor Kon was available in a liquid form, she would order it from the pharmacy. She was not aware [MEDICATION NAME] should not be crushed. During an interview with the facility's consultant pharmacist, by telephone on 10/29/15 at 3:10 p.m., she agreed that neither [MEDICATION NAME] nor Klor Kon extended release tablets should be crushed. She said there was a Do Not Crush list on the front of each MAR indicated… | 2019-07-01 |
| 4808 | 4808 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 371 | E | 0 | 1 | KC5S11 | Based on observation and staff interview, the facility failed to ensure safe storage of food to ensure the prevention of foodborne illnesses to the extent possible. Foods in the refrigerators on the units were not labeled, dated, and/or discarded when expired. This practice had the potential to affect more than an isolated number of residents. Facility census: 87. Findings include: a) Observation of the snack refrigerator in the family room on the Solana hall, on 10/28/15 at 8:15 a.m., revealed a package of frozen waffles labeled use by 05/03/15, ten (10) unlabeled and undated bowls of vanilla pudding, and an unlabeled plate of five (5) peanut butter sandwiches. b) The snack refrigerator on Hilltop was viewed on 10/28/15 at 8:20 a.m. It contained five (5) unlabeled and undated bowls of pudding and a partially eaten chicken dinner dated 09/28/15. c) Both refrigerators were examined by the food service supervisor, Employee #57, during an interview on 10/28/15 at 8:30 a.m. He removed the food items and confirmed the waffles were outdated, the pudding bowls and sandwiches lacked a label that included an expiration date, and the chicken dinner was expired. | 2019-07-01 |
| 4809 | 4809 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 425 | D | 0 | 1 | KC5S11 | Based on observation, staff interview, review of manufacturer's guidelines, review of guidance provided by the facility's pharmacy, and review of the Centers for Disease Control and Prevention guidelines, the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. A multi-dose vial of insulin was open for greater than the number of days specified by the manufacturer, creating a potential to negatively impact the safety and/or potency of the medication. This affected one (1) of eight (8) residents, residing on the Hilltop back hall, who received insulin injections. Resident identifier: #30. Facility census: 87. Findings include: a) Resident #30 Observation of the Hilltop back hall medication cart, on 04/27/15 at 4:00 p.m., found an opened, partially used multi-dose vial of Lantus insulin, prescribed for Resident #30. The date inscribed on the vial, 09/14/15, indicated the date this vial was initially opened. Registered nurse (RN) #65 was present and said the vial should have been disposed of twenty-eight (28) days after the initial opened date, and it was not. She immediately disposed of the vial. During an interview with the director of nursing (DON), on 04/28/15 at 10:45 a.m., she agreed the vial of insulin should have been discarded at twenty-eight days after opening. She provided a copy of the facility's pharmacy recommendations for medications and biologics to ensure that medications and biologicals Have not been retained longer than recommended by manufacturer or supplier guidelines. Review of manufacturer's guidelines found directives to dispose of opened vials of Lantus insulin after twenty-eight (28) days, even if the vial still contained insulin. According to the Center for Disease Control and Prevention (CDC) guidelines, once a multi-dose vial has been opened or accessed (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 the opened vial. Th… | 2019-07-01 |
| 4810 | 4810 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 431 | E | 0 | 1 | KC5S11 | Based on observation, review of medication room refrigerator temperature logs, review of narcotic shift count log, policy review, and staff interview, the facility failed, in collaboration with the consulting pharmacist, to maintain safe and secure use and storage of medications. The facility failed to consistently monitor temperatures of either of the two (2) medication storage refrigerators. In addition, the facility did not consistently verify reconciliation of their locked narcotics on the Solana unit. These practices had the potential to affect more than an isolated number of residents. Facility census: 87. Findings include: a) Medication Room Refrigerators Observation of the Hilltop medication storage room, on 10/27/15 at 4:00 p.m., found three (3) days in the past month had no recorded temperatures of the medication room refrigerator. Registered Nurse (RN) #65 said the facility strived to ensure the temperature of the medication room refrigerator was checked once daily on the night shift. Review of the (MONTH) temperature log found three (3) days in (MONTH) which had no temperature recorded as follows: 10/02/15, 10/03/15, and 10/07/15. RN #65 verified the same. Observation of the Solana unit medication storage room, on 10/27/15 at 5:00 p.m., found the absence of any recorded temperatures for their medication room refrigerator. During an interview with Licensed Practice Nurse #54 at this time, she said this unit received the current medication room refrigerator about two (2) weeks ago, and they must not have begun recording the temperatures. She said nursing staff was supposed to record the temperature of the medication room refrigerator once daily on the night shift. Three (3) bottles of unopened insulin were stored in this refrigerator. An interview was completed with the director of nursing (DON), on 10/28/15 at 10:45 a.m. She said two (2) or three (3) weeks ago they obtained a new medication room refrigerator for the Hilltop unit. After the new refrigerator arrived, they gave Hilltop's old refrigerator … | 2019-07-01 |
| 4811 | 4811 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 441 | F | 0 | 1 | KC5S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to maintain an effective infection control program to prevent and control, to the extent possible, the onset and spread of infection within the facility. Staff practiced improper, unsanitary cleaning of a urinal and bedpan which belonged to a resident who had a multi-drug resistant organism in his urine. in addition, bedpans, urinals, a urine collector, and a toilet seat riser were soiled and/or stored improperly in resident bathrooms. While this directly affected residents who resided in rooms 148, 151, 128, 104, 114, 118, 139, and/or the residents who shared the same bathrooms, staff's failure to practice infection control related to bedpans, urinals, urine collection devices, and toilet seat risers had the potential to affect all residents in the facility, . Facility census: 87. Findings include: a) room [ROOM NUMBER] A random observation made during the initial tour of the facility on 10/26/15 at 3:29 p.m., revealed a gray-colored plastic bedpan sitting on the back of the grab bar in the corner of the bathroom. The bedpan was unbagged, and was not labeled with the name of the resident to whom it belonged. This bathroom was shared by the two (2) residents who resided in room [ROOM NUMBER] and the adjoining room which housed one (1) resident. The following morning, on 10/27/15 at 8:58 a.m., a gray colored bedpan still sat on the back portion of the grab bar in the corner of the bathroom. It still was unbagged, and was not labeled with the name of the resident to whom it belonged. Registered Nurse (RN) #69 was shown the bedpan at that time. She said all bedpans were supposed to be bagged, stored in the resident's bedside stand, and labeled with the resident's name. She said she would dispose of this bedpan. b) room [ROOM NUMBER] During an observation on 10/26/15 at 3:44 p.m., a round, plastic, tubular toilet seat riser looked quite dirty. The back of the seat … | 2019-07-01 |
| 4812 | 4812 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 456 | F | 0 | 1 | KC5S11 | Based on observation and staff interview, the facility failed to maintain essential food service equipment in safe operating condition. The facility's ice machine was coated with a chalky off-white crust on both the inside and the outside. This practice had the potential to affect all residents residing in the facility. Resident census: 87. Findings include: a) Observations of the ice machine, on 10/28/15 at 11:00 a.m., found a significant build up of a chalky off-white coating on the front and sides of the ice machine, inside the ice scoop holder, and on the inner top and inner door surfaces around the rubber gasket. b) An interview, on 10/28/15 at 11:40 a.m., with Maintenance Supervisor #27, in the company of Housekeeping District Manager #104 Housekeeping Supervisor (HKS) #103, confirmed the ice machine had a lime/calcium build up on the inside and outside, and needed cleaned. HKS #103 stated housekeeping employees wiped down the ice machine every other day. Upon further discussion, he agreed the ice machine was not clean. c) On 10/28/15 at 1:35 p.m Food Service Manager #57 stated the ice machine alerted the facility when maintenance needed done; but it did not specifically alert staff when the machine needed delimed. He said he was unable to determine if the machine was delimed during its last maintenance on 09/30/15. He agreed the machine needed cleaned on the inside as well as the outside. d) The ice machine was found clean on the inside and outside during a follow up observation on 10/29/15 at 8:40 a.m. | 2019-07-01 |
| 4813 | 4813 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 490 | G | 0 | 1 | KC5S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, and staff interview, the facility was not administered in a manner to effectively provide care and services to ensure the highest practicable well-being for eight (8) of thirty-five (35) sample residents. The facility closed their Alzheimer's Unit, unlocked the secure unit, and discontinued the services previously provided the residents who resided on that unit. This resulted in a discontinuation of a structured environment and a discontinuation of the services specifically designed for residents with Alzheimer's dementia. -- Resident #83 was not properly assessed for this transition. In addition, the facility failed to recognize and address the resident's adjustment difficulties to his new environment. This resulted in psychological harm to the resident. -- The facility failed to develop care plans and/or activities to meet the activity needs and preferences for Residents #73, #99, and #50 who once had structured activities on the Alzheimer's unit. -- The facility failed to ensure the right to personal privacy, dignity, and respect for Residents #23, #120, #128, and #53 when residents who previously resided on the Alzheimer's unit began wandering into their rooms. Residents #83, #73, #99, #50, #23, #120, #128, and #53 were found specifically affected; however, the practice had the potential to affect more than an isolated number of other residents. Facility census: 87 Findings include: a) Resident #83 This resident was admitted to the facility's Alzheimer's unit on 06/14/13. His [DIAGNOSES REDACTED]. On 04/20/15 the Alzheimer's unit was closed, the door to the Alzheimer's unit were unlocked, and the facility no longer provided the services of an Alzheimer's unit. Prior to the closure, the facility sent a letter to the affected families. It included, in part, This will not represent a significant change for our residents who are currently cared for on this unit. (Name of company) physic… | 2019-07-01 |
| 4814 | 4814 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 514 | D | 0 | 1 | KC5S11 | Based on record review and staff interview, the facility failed to maintain accurate, complete clinical records for two (2) of thirty-five (35) residents reviewed during Stage 2 of the quality indicator survey (QIS). The hard copy medical records contained multiple pages of undated records. Resident identifiers: #30 and #129. Facility census: 87. Findings include: a) Resident #30 Review of medical records, on 10/28/15 at 8:23 a.m., revealed undated hard copies of medical records which included four (4) pages of activities of daily living (ADL) documentation, two (2) pages of behavioral monitoring, two (2) pages of medication side effects monitoring, and two (2) pages of pain monitoring. At 2:54 p.m. on 10/28/15. Medical Records Employee #50 agreed the hard copies should have been dated at the time the forms were used for documentation. b) Resident #129 A review of the medical record for discharged Resident #129 was completed on 10/28/15 at 2:56 p.m. This review revealed the activities of daily living (ADL) form did not identify when this form was completed. It contained no month or year. In an interview with the director of medical records, on 10/28/15 at 2:44 p.m., she confirmed the ADL form did not contain any information related to the month or year in which the form was completed. She agreed the ADL form should have been properly dated when the form was completed. | 2019-07-01 |
| 4815 | 4815 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2015-11-04 | 520 | G | 0 | 1 | KC5S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, and staff interview, the facility's quality assessment and assurance (QA&A) committee failed to develop and implement plans of action, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained, to correct quality deficiencies of which it was aware, or should have been aware, in the daily operation of the facility. After unlocking the Alzheimer's unit and discontinuing services specific to the needs of residents with Alzheimer's dementia who resided on the unit, the QA&A committee failed to identify and act upon those residents' behaviors toward others, failed to ensure interventions to reduce negative behaviors, and failed to ensure appropriate activities for the residents formally residing on the Alzheimer's unit. The QA&A committee failed to identify that optimum care and services, to ensure the highest practicable well-being of each resident, was not addressed before and after the facility closed their Alzheimer's Unit. -- Resident #83 was not properly assessed for this transition. In addition, the resident's adjustment difficulties to his new environment were not identified and addressed. This resulted in psychological harm to the resident. -- There was a failure to develop care plans and/or activities to meet the activity needs and preferences for Residents #73, #99, and #50 who once had structured activities on the Alzheimer's unit. -- There was a failure to ensure the right to personal privacy, dignity, and respect for Residents #23, #120, #128, and #53 when residents who previously resided on the Alzheimer's unit began wandering into their rooms. Eight (8) thirty-five (35) sample residents (#83, #73, #99, #50, #23, #120, #128, and #53) were specifically affected; however, the practice had the potential to affect more than an isolated number of other residents. Facility census: 87 Findings include: a) … | 2019-07-01 |
| 4816 | 4816 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2016-02-19 | 272 | D | 0 | 1 | UI4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to complete accurate comprehensive assessments for two (2) of eleven (11) Stage 2 residents. The comprehensive minimum data set (MDS) assessment for Resident #15 did not reflect the [DIAGNOSES REDACTED]. Resident #20's assessment did not indentify the use of a Foley catheter. Resident identifiers: #15 and #20. Facility census: 35. Findings include: a) Resident #15 A review of the resident's medical record on 02/18/16 at 2:21 p.m., revealed the annual MDS with an assessment reference date ARD of 02/01/16, Section I - Active Diagnoses, did not include [MEDICAL CONDITION], A-Fib, [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. She was also taking [MEDICATION NAME] 200 mg once daily for A-Fib and [MEDICATION NAME] 40 mg twice daily for GERD. During an interview on 02/18/16 at 2:50 p.m., the MDS Coordinator reported she did not complete Section I of the comprehensive MDS assessment accurately to include the [DIAGNOSES REDACTED]. b) Resident #20 On 02/17/16 at 3:30 p.m., review of Resident #20's physician's orders [REDACTED].#16 French Foley catheter. The Foley catheter was to be changed monthly and whenever needed. A review of the resident's annual MDS with an ARD of 12/06/15, on 02/17/16 at 3:41 p.m., found Item H0100 - Appliances, did not identify the resident had an indwelling catheter. In an interview on 02/17/16 at 4:26 p.m., DON #33 stated the resident did have an indwelling Foley catheter. She agreed the annual MDS was coded inaccurately and said, I will do a correction. | 2019-07-01 |
| 4817 | 4817 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2016-02-19 | 278 | E | 0 | 1 | UI4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the individual(s) assessing and certifying the accuracy of sections of the minimum data set (MDS) assessments for four (4) of eleven (11) residents. The assessments for Residents #21 and #7 did not accurately reflect active diagnoses. Resident #48's assessment did not accurately reflect the resident's continence status, and Resident #37's assessment did not accurately reflect the resident's pressure ulcers. Resident identifiers: #21, #48, #37, and #7. Facility census: 35. Findings include: a) Resident #21 The resident's quarterly MDS assessment, with an assessment reference date (ARD) of 01/14/16, did not identify the [DIAGNOSES REDACTED]. The resident had orders for [MEDICATION NAME] 10 milligrams (mg) once a day and [MEDICATION NAME] 0.25 mg once in the morning and 0.5 mg at bedtime. The resident's [DIAGNOSES REDACTED]. The MDS, with an ARD of 01/14/16, did not identify depression or anxiety in Section I - Active Diagnoses. This was discussed with Director of Nursing #33, and the Administrator on 02/18/16 at 2:50 p.m. Director of Nursing #33 and the Administrator verified these conditions were not identified on the quarterly MDS, but should have been. b) Resident #48 A review of Resident #48's physician's orders [REDACTED]. The quarterly MDS, with an ARD of 12/09/15, reviewed on 02/19/16 at 9:52 a.m., found Item H0100 identified the resident had an indwelling catheter; however, Item H0300 - Urinary Continence, did not reflect that the resident had an indwelling catheter. In an interview on 02/19/16 at 10:12 a.m., the DON reviewed the resident's quarterly MDS with an ARD of 12/09/15 upon request. After reviewing the assessment, the DON stated, The assessment is inaccurate. The resident should have been coded under urinary incontinence as having an indwelling catheter. c) Resident #37 On 02/19/16 at 10:43 a.m., review of Resident #37's quarterly MDS with an ARD of 02/02/16, found Item M0210 assessed… | 2019-07-01 |
| 4818 | 4818 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2016-02-19 | 280 | D | 0 | 1 | UI4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and staff interviews, the facility failed to revise a care plan for two (2) of three (3) residents reviewed for pressure ulcers. Resident #20's care plan did not reflect the treatment of [REDACTED]. Resident #1's pressure ulcer had healed and the care plan reflected the care the resident required treatment for [REDACTED].#20 and #1. Facility census: 35. Findings include: a) Resident #20 On 02/18/16 at 1:50 p.m., Licensed Practical Nurse (LPN) #23 provided treatment to Resident #20's Stage II (2) pressure ulcer on his right buttocks. The resident had a physician's orders [REDACTED]. A review of the resident's care plan on 02/18/16 3:16 p.m., found the problem: Resident is at risk for pressure ulcer R/t (related to) to immobility and bowel incontinence. Rarely will agree to get out of bed. Likes to lay on his left side to look out the door. He will not turn. A review of the care plan interventions found no interventions to treat the pressure ulcer on the resident's right buttocks. In an interview with the Director of Nursing on 02/18/16 at 4:50 p.m., she reviewed Resident #20's care plan and confirmed the care plan should have been revised to reflect the intervention for the pressure ulcer on his right buttocks. b) Resident #1 On 02/18/16 at 10:00 a.m., review of Resident #1's care plan, with a start date of 01/01/16, found a care plan for actual skin breakdown, with a potential for additional breakdown related to limited mobility and debility. There was an intervention for [MEDICATION NAME] (a foam dressing) to the area on her right lower leg as ordered. The interventions also directed the staff report any increase in size, redness, draining or odor to the physician, and for staff to assess and record the condition and size of the wound weekly. An observation of Resident #1's wound treatment by Licensed Practical Nurse (LPN) #23 on 02/18/16 at 10: 40 a.m., revealed the LPN only provided wound treat… | 2019-07-01 |
| 4819 | 4819 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2016-02-19 | 282 | D | 0 | 1 | UI4U11 | Based on observation, medical record review, and staff interview, the facility failed to implement the intervention in the care plan for one (1) of three (3) residents reviewed for pressure ulcers. The care plan had an intervention to measure and record size and condition of the wound weekly. Resident identifier: #1. Facility census: 35. Findings include: a) Resident #1 A review of Resident #1's care plan found a problem statement regarding a pressure ulcer with actual skin breakdown, related to limited mobility and debility, with the potential for additional skin breakdown. The start date of this care plan was 01/01/16. The plan included an intervention to measure and record the size and condition of the left hip wound weekly. A review of the weekly wound measurements found the staff did not complete a weekly wound measurement to the left hip/buttocks for the weeks of 01/10/16 to 01/16/16, 01/24/16 to 01/30/16, 01/31/16 to 02/06/16, and 02/07/16 to 02/13/16. Observation on 02/18/16 at 10:45 a.m., the found the resident received treatment to a Stage III (3) pressure ulcer on her left hip/buttocks. In an interview on 02/18/16 at 2:00 p.m., the director of nursing (DON) agreed staff were not measuring the wound weekly as outlined in the resident's care plan. | 2019-07-01 |
| 4820 | 4820 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2016-02-19 | 425 | D | 0 | 1 | UI4U11 | Based on observation, staff interview, and review of the facility's policy, the facility failed to dispose of outdated medication stored in the medication room refrigerator. Twelve (12) packets of Floranex granules were found in the facility's medication refrigerator that were past their expiration date. This had the potential to affect a limited number of residents. Facility census: 35. Findings include: a) Facility's Medication Refrigerator Medication storage inspection on 02/17/16 at 2:00 p.m., found twelve (12) packets of Floranex granules (used to restore and maintain normal bacterial balance) in the medication refrigerator with the expiration date of 01/16 (January (YEAR)). Licensed Practical Nurse (LPN) #23, who was present during the review, confirmed the Floranex should have been removed from the refrigerator. Pharmacist Assistant #50, also present during the inspection when the expired Floranex granules were found in the medication refrigerator, stated, I print off a sheet that tells me all of the medication that will expire the week before they expire. I then replace the medication the following week with new ones, but our printer was not working. Therefore I was unable to print off a list of medication that was going to expire. The facility's policy, reviewed on 02/19/16 at 3:50 p.m., included, . medications shall be checked for expiration dates and all expired medication shall be removed from stock/storage. | 2019-07-01 |
| 4821 | 4821 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2016-02-19 | 441 | D | 0 | 1 | UI4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and a review of the facility's policy/procedure, the facility's Infection Control Program failed to ensure staff employed appropriate infection control practices to help prevent the development and transmission of disease and infection. A nurse failed to wash her hands and change gloves after administering medications through a gastrostomy tube and prior to applying a topical medication to a resident's right knee. This affected one (1) of four (4) residents observed during medication pass observation. Resident Identifier: #1. Facility census: 35. Findings include: a) Resident #1 During observations of medication administration on 02/17/16 at 9:12 a.m., Licensed Practical Nurse (LPN) #32 administered Resident #1's medication through a gastrostomy tube. After administrating the medications through the resident's gastrostomy, without washing her hands or changing her gloves, the LPN applied a topical ointment ([MEDICATION NAME] gel 1%) to the resident's intact right knee. On 02/17/16 at 9:15 a.m., LPN #32, when asked about handwashing and changing gloves between administering the medications and applying the ointment to the resident's knee, she stated, I should have removed my gloves, washed my hands and re-applied a new pair of gloves to apply the topical medication to the resident's right knee. During an interview, with the DON, about the observation on 02/17/16 at 9:26 a.m., the DON stated the nurse should have removed her gloves and washed her hands, and then applied another pair of gloves prior to administering the topical medication. On 02/18/16 at 8:30 a.m., review of the facility's policy/procedure regarding applying topical ointment found it included, . the nurse will perform hand hygiene. If the skin is not broken, apply sterile gloves. Otherwise, apply clean gloves. | 2019-07-01 |
| 4822 | 4822 | EASTBROOK CENTER | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2015-11-05 | 156 | E | 0 | 1 | ZW2211 | 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 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: 129. Findings include: a) On 11/02/15 at 11:25 a.m., an observation of the facility revealed there was no written information posted to inform a resident about how to apply for and use Medicare benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. In an interview on 11/03/15 at 3:15 p.m., the Assistant Nursing Home Administrator agreed the facility had not prominently posted the information regarding how residents could apply for and use Medicare benefits. | 2019-07-01 |
| 4823 | 4823 | EASTBROOK CENTER | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2015-11-05 | 253 | D | 0 | 1 | ZW2211 | Based on observation and staff interview, the facility failed to ensure it provided effective housekeeping and maintenance services for one (1) of thirty-five (35) resident rooms observed during Stage 1 of the Quality Indicator Survey (QIS). The resident bathroom in Room #131 had a raised toilet frame which was in poor repair. Room identifier: #131. Facility census: 129. Findings include: a) Room #131 On 11/03/15 at 9:05 a.m., an observation revealed the bathroom in Room #131 had a raised toilet frame. The frame had paint missing, exposing a one (1) inch by five (5) inch section of rusted metal. A tour on 11/06/15 at 1:35 p.m. with the Maintenance Supervisor, verified the raised toilet seat frame was in poor repair and needed replaced. | 2019-07-01 |
| 4824 | 4824 | EASTBROOK CENTER | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2015-11-05 | 318 | D | 0 | 1 | ZW2211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure one (1) of three (3) sample residents with limited range of motion (ROM) received care to maintain the resident's highest level of function, and/or prevent an avoidable decline of range of motion. Resident #10 had an ankle contracture and did not receive services to prevent worsening of the contracture. Resident identifier: #10. Facility census: 129. Findings include: a) Resident #10 An interview, on 11/03/15 at 7:51 a.m., with Licensed Practical Nurse (LPN) #143, revealed Resident #10 had a contracture of the ankle and foot joint. Upon inquiry, on 11/03/15 at 1:40 p.m., LPN #143 reviewed the medical record and related the resident did not receive range of motion (ROM) services or have a splint device in place. During an observation on 11/03/15 at 8:15 a.m., Resident #10 was lying in bed. His right leg was bent, with his foot flat on the bed. His left leg was bent at the knee. No obvious contracture was evident. On 11/04/15 at 4:00 p.m., Nurse Aide (NA) #111 revealed the resident did not receive range of motion services, unless provided by restorative nursing or therapy. She also confirmed the resident did not wear a splint device. The significant change minimum data set (MDS), with an assessment reference date (ARD) of 09/19/15, reviewed on 11/04/15 at 5:38 p.m., revealed a [DIAGNOSES REDACTED]. Review of the resident's care plan, at 5:50 p.m. on 11/04/15, found restorative services related to the contracture were noted as resolved. The services were discontinued on 10/05/15. A physician's orders [REDACTED]. In an interview on 11/05/15 at 9:10 a.m., Restorative Nurse Aide (RNA) #160 said Resident #10 did not want to participate with ROM. She related the resident would only allow staff to work with him for about five (5) minutes. Physical Therapy Assistant (PTA) #9, interviewed on 11/05/15 at 9:47 a.m., reviewed therapy notes, and related the resid… | 2019-07-01 |
| 4825 | 4825 | EASTBROOK CENTER | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2015-11-05 | 371 | E | 0 | 1 | ZW2211 | Based on observation, staff interview, and review of the facility's dietary rules, the facility failed to ensure food items in one (1) of two (2) nutritional pantries were stored under sanitary conditions. Drinks in the second floor nutritional pantry refrigerator were not dated when they were opened. In addition, observations revealed dirty dishes were found in areas of the second floor nutritional pantry on more than one occasion. This had the potential to affect more than a limited number of residents. Facility census: 129. Findings include: a) Nutritional Pantry on the second floor @ The initial tour of the facility, with Licensed Practical Nurse #115, on 11/02/15 at 10:45 a.m., revealed the following sanitation issues in the nutritional pantry on the second floor: 1. Two (2) gray bowls with oatmeal left in them were on top of the counter. 2. In the refrigerator, the following items were found lacking a date as to when they were first opened: - One (1) liter of Dr. Pepper that was opened. The bottle was half (1/2) full. - Two (2) percent (%) dairy pure milk in a one (1) pint container was opened and was three-fourths (3/4) full. The dairy pure milk was not dated as to when it was opened. - An opened 46.7-ounce container of Nectar thickened lemon flavored water. A fourth (1/4) of the frozen Nectar thickened flavored water remained in the container. The nectar thickened lemon flavored water was not dated as to when it was opened. - a 2.2 liter bottle of clear water was open with a fourth (1/4) of the water left, was sitting on the top of a cabinet that contained oxygen cylinders. 3. LPN #115 threw away the bottle of Dr. Pepper. She confirmed the facility should label and date all food placed in the refrigerator. LPN #115 stated, The two (2) bowls that had some remains of oatmeal in them belonged to a resident who resided in the facility. The bowls of oatmeal were from breakfast, and the bowls should have been taken to the kitchen. An observation on 11/02/15 at 12:45 p.m., with Director of Nursing #49, found the… | 2019-07-01 |
| 4826 | 4826 | EASTBROOK CENTER | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2015-11-05 | 431 | E | 0 | 1 | ZW2211 | Based on observation, staff interview, and review of the facility's pharmacy policy, the facility failed to ensure safe storage of medications in one (1) of two (2) medication storage room refrigerators. The facility had not consistently monitored the refrigerator temperatures in the second (2nd) floor medication storage room refrigerator to ensure medications were stored under proper temperature controls. This had the potential to affect more than a limited number of residents. Facility census: 129. Findings include: a) Second floor medication storage room refrigerator temperature Observation of the second (2nd) floor medication storage room refrigerator temperature logs on 11/04/15 at 2:38 p.m., with Licensed Practical Nurse (LPN) #142, revealed a clip on the front of the refrigerator with refrigerator temperature logs for (MONTH) and (MONTH) (YEAR). The only dates the temperatures were recorded on the log were, 09/14/15, 09/15/15, 09/16/15, and 09/17/15. There were no temperatures recorded on the log for (MONTH) (YEAR) as of 11/04/15 at 2:38 p.m. The LPN acknowledged the temperatures were not recorded. LPN #142 stated, I do not know the reason why the temperatures were not being checked and recorded. LPN #142 said, I will go and ask another nurse. LPN #142 asked LPN #120, on 11/04/15 2:40 p.m., where the refrigerator temperature logs were. LPN #120 stated after reviewing the medication storage room refrigerator temperature log, The temperatures were not being checked and record consistently for the month of (MONTH) and (MONTH) (YEAR). She did not know if the temperatures were checked and recorded for October. LPN #120 stated, The night shift nurse has the responsibility for checking and recording the temperatures. In an interview on 11/04/2015 at 4:20 p.m., Director of Nursing (DON) #49 was asked whether temperatures were recorded for October. She provided the refrigerator temperature log for (MONTH) (YEAR). The only refrigerator temperatures recorded on the log were for 10/09/15, 10/17/15, 10/20/15, and 10/31… | 2019-07-01 |
| 4827 | 4827 | ST. MARY'S HOSPITAL | 515113 | 2900 FIRST STREET | HUNTINGTON | WV | 25702 | 2016-02-04 | 279 | D | 0 | 1 | BYUN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure a comprehensive care plan was developed based on comprehensive assessments for three (3) of three (3) residents reviewed for the care area of urinary tract infection [MEDICAL CONDITION] during Stage 2 of the Quality Indicator Survey (QIS). Resident #128, #60, and #18 developed a UTI after admission, requiring antibiotic treatment. The resident's care plans failed to reflect the identification of the UTIs and the facility's plan for treatment. Additionally, Resident #18's care plan did not address the resident's ,[MEDICAL CONDITION]. difficle that was present on admission. Resident identifiers: #128, #60, and #18. Facility census: 16. Findings include: a) Resident #128 Medical record review for Resident #128, at 8:27 a.m. on 02/03/16, revealed an 11/03/15 admitted to the hospital-based skilled nursing unit for therapy after an aortic valve replacement and a coronary artery bypass. Further record review revealed an 01/21/16 discharge date , as the resident went home. On 11/04/15, the physician ordered blood cultures and a urinalysis with culture and sensitivity (UA/C&S) due to an increase in the resident's white blood cell count. The facility notified the physician of the laboratory results of the UA/C&S on 11/06/15. The resident's physician ordered the antibiotic,[MEDICATION NAME] milligrams (mg), two times a day (BID), for 7 days for a urinary tract infection. Review of the resident's 14-day MDS, with an assessment reference date (ARD) of 11/17/15, found the resident was coded as having a UTI in Section I - Active Diagnoses, Item I2300. Review of the care plan for Resident #128 with MDS Coordinator/Registered Nurse #2, at 8:31 a.m. on 02/03/16, confirmed the care plan did not reflect the resident's UTI and the facility's treatment. b) Resident #60 Medical record review for Resident #60 on 02/03/16 at 1:00 p.m., revealed an 08/17/15 admitted to the hospital-based skill… | 2019-07-01 |
| 4828 | 4828 | ST. MARY'S HOSPITAL | 515113 | 2900 FIRST STREET | HUNTINGTON | WV | 25702 | 2016-02-04 | 309 | E | 0 | 1 | BYUN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each resident received care and services to assist residents in attaining and/or maintaining their highest practicable level of well-being. Residents #160 and #164 had physician's orders [REDACTED]. Staff failed to assess the residents' blood pressures prior to each administered dose. Resident identifiers: #160 and #164. Facility census: 16. Findings include: a) Resident #160 On 02/03/16 at 10:30 a.m., a review of Resident #160's medical record revealed an admission date of [DATE]. Admission physician's orders [REDACTED].>-- Carvedilol 12.5 milligrams (mg) by mouth (PO) two times a day for the treatment of [REDACTED]. Hold if heart rate (HR) less than 60. (Some medications for high blood pressure also cause the heart rate to slow.) A review of the Medication Administration Record [REDACTED]. The resident's blood pressures were not consistently obtained prior to the administration of the medication. No blood pressures could be located prior to the administration of Carvedilol on: -- 01/22/16 -10:00 a.m. -- 01/23/16 -10:00 p.m. -- 01/24/16 -10:00 a.m. and 10:00 p.m. -- 01/25/16 -10:00 p.m. -- 01/26/16 -10:00 p.m. -- 01/27/16 -10:00 a.m. and 10:00 p.m. -- 01/30/16 -10:00 p.m. -- 01/31/16 -10:00 a.m. and 10:00 p.m. -- 02/01/16 -10:00 a.m. and 10:00 p.m. -- 02/02/16 -10:00 a.m. An interview, on 02/04/16 at 10:08 a.m., revealed Clinical Manager (CM) #1, confirmed the resident received Carvedilol twice daily. The CM further confirmed Resident #160's blood pressures should have been obtained prior to the administration of the medication. She further stated she would expect the staff to obtain the blood pressure within one hour of administering the medication b) Resident #164 On 02/03/16 at 2:30 p.m., a review of Resident #164's medical record revealed an admission date of [DATE]. Admission physician's orders [REDACTED].>-- Carvedilol 25 milligrams (mg) by mouth (PO) two times a… | 2019-07-01 |
| 4829 | 4829 | ST. MARY'S HOSPITAL | 515113 | 2900 FIRST STREET | HUNTINGTON | WV | 25702 | 2016-02-04 | 371 | E | 0 | 1 | BYUN11 | Based on observation and staff interview, the facility failed to ensure food was stored under sanitary conditions which created the potential for foodborne illnesses. The facility failed to ensure an internal thermometer was present in a refrigerator to ensure items were kept at proper temperature. This had the potential to affect all residents who received food items from the kitchen. Facility census: 16. Findings include: a) Initial tour of the kitchen The initial tour of the facility's kitchen with the dietary manager, at 8:45 a.m. on 02/02/16, found the tray-line triple door refrigerator had no internal thermometer; therefore, there was no means to ensure food was stored and maintained at a temperature of 41 degrees Fahrenheit or below. The dietary manager stated the refrigerator did have a thermometer because temperatures were recorded daily, so someone must have misplaced it. | 2019-07-01 |
| 4830 | 4830 | ST. MARY'S HOSPITAL | 515113 | 2900 FIRST STREET | HUNTINGTON | WV | 25702 | 2016-02-04 | 428 | D | 0 | 1 | BYUN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the physician failed to act upon recommendations by the licensed pharmacist for irregularities and concerns identified during the evaluation of the medication regimen for one (1) of five (5) residents reviewed for unnecessary medications. The physician failed to provide clinical indications for Resident #160's Lasix. Resident identifier: #160. Facility census: 16. Findings include: a) Resident #160 On 02/03/16 at 11:40 a.m., review of the physician's orders [REDACTED]. Medical record review for Resident #160, on 02/03/16 at 12:10 p.m., revealed a pharmacy consultation report dated 01/22/16. The report indicated the resident needed an indication (diagnosis) for the Lasix. At 3:00 p.m. on 02/02/16, the Pharmacy Consultation Report and the Physician's Progress Notes for Resident #160 were reviewed with Registered Nurse (RN) #1, the Clinical Manager (CM). She verified the physician had not provided an indication (diagnosis) as required. | 2019-07-01 |
| 4831 | 4831 | HILLCREST HEALTH CARE CENTER | 515117 | 462 KENMORE DRIVE | DANVILLE | WV | 25053 | 2016-01-29 | 242 | D | 0 | 1 | N8J711 | Based on family interview, resident interview, and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of choices during Stage 2 of the Quality Indicator Survey (QIS), received personal care consistent with his preferences regarding an aspect of his life that was significant to him. Resident #79 did not receive showers consistent with his past routine. Resident identifier: #79. Facility census: 84. Findings include: a) Resident #79 An interview with the resident and his friend at 12:47 p.m. on 01/26/16, found the resident did not receive the same number of baths or showers in a week based on his past routine and preferences. The resident's friend said people often thought the resident was a preacher because he always wore dress pants and a dress shirt during his normal daily routine. She (the friend) said the resident's appearance was extremely important to him. The resident said he normally bathed daily when at home. The resident's friend said the facility only offered showers two (2) times a week. Review of the resident's activities of daily living (ADL) records for January, (YEAR) found the resident's shower days were Wednesdays and Saturdays. The resident received showers on 01/02/16, 01/06/16, 01/09/16, 01/13/16, 01/16/16, 01/20/16, 01/23/16, and 01/27/16. Review of the medical record found a 12/29/15 note from the activity director, . He takes great pride in his appearance . He has a friend that usually visits him often. His friend usually encourages him to engage in activities and attends church with him when visiting During an interview at 2:10 p.m. on 01/28/16, the director of nursing (DON), when asked how the facility determined a resident's shower schedule, said all residents received two (2) showers a week and more if they indicated a preference for more showers. She said the interview determining the resident's shower preferences would not be recorded in the resident's medical record. The DON said the facility had a computer based program, similar to … | 2019-07-01 |
| 4832 | 4832 | HILLCREST HEALTH CARE CENTER | 515117 | 462 KENMORE DRIVE | DANVILLE | WV | 25053 | 2016-01-29 | 253 | E | 0 | 1 | N8J711 | Based on observations and staff interview, the facility failed to provide maintenance and housekeeping services necessary to maintain a comfortable and sanitary interior for twelve (12) of thirty-three (33) rooms observed during Stage 1 of the Quality Indicator Survey. Cove molding was missing, walls had gouges and holes, doors were scraped and scratched, a resident bathroom had a continuous urine odor, wallpaper was torn, and privacy curtains were not hooked in the track in the ceiling. In addition to the resident rooms, the kitchen and the dining room walls had disintegrated where the wall met the floor; tiles in the East wing hallway were cracked; the cove molding in the East wing hallway was damaged, and the wallpaper in the dining room was splattered with dried debris. Resident rooms: 134, 137, 139, 149, 150, 152, 155, 158, 102, 106, 116, and 119. This had the potential to affect more than an isolated number of residents. Facility census: 84. Findings include: a) Kitchen Observation at 9:30 a.m. on 01/26/16, found the cove molding was missing along the bottom of the wall behind the ice machine. The wall had disintegrated approximately 4 inches up from the floor. A large buildup of debris was present behind the missing wall on the floor where the tile ended and the bottom of the wall was missing. The same was found at the entrance to the kitchen, when entering from the main dining room. b) East Wing The floor tile was chipped and cracked leaving the floor in poor repair at both sets of fire doors on the East wing, The cove molding in the hallway leading to the nurses' station was dirty, scraped and scratched. c) East Wing Resident Rooms 1. Room 134 Observation at 9:47 a.m. on 01/27/16 found the cove molding was missing around the sink. Pieces of plaster were missing from the walls. The walls of the room were nicked and scratched. Several hooks in the privacy curtain were not hooked in the track mounted to the ceiling allowing the privacy curtain to droop from the ceiling. 2. Rooms 137 and 139 At 9:13 a.m. on … | 2019-07-01 |
| 4833 | 4833 | HILLCREST HEALTH CARE CENTER | 515117 | 462 KENMORE DRIVE | DANVILLE | WV | 25053 | 2016-01-29 | 279 | D | 0 | 1 | N8J711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview the facility failed to develop a comprehensive care plan to reflect Resident #5's long history of medication seeking. This was true for one (1) of one (1) resident reviewed for the care area of Pain Recognition and Management during Stage 2 of the Quality Indicator Survey. Resident Identifier: #5. Facility Census: 84. Findings Include: a) Resident #5 During a Stage 1 interview with Resident #5, she indicated she needed her pain medication increased to every four (4) hours because every six (6) hours did not control her pain. A review of Resident #5's medical record at 12:00 p.m. on 01/27/16, found a nursing progress note dated 07/22/15, . Resident on [MEDICATION NAME] q (every) four (4) hours but her insurance will only pay for 120 tablets monthly. Reported this to (name of resident's attending physician) . new order change [MEDICATION NAME] to q 6 hours routinely. An interview with Licensed Practical Nurse (LPN) #10 at 12:51 p.m. on 01/27/16, confirmed Resident #5 often complained that her pain was unmanaged and requested increases in pain medication. LPN #10 indicated during this interview that Resident #5 was a medication seeker and described this as one of her behaviors. An interview with the Director of Nursing (DON) at 2:21 p.m. on 01/27/16, confirmed the note written on 07/22/15 did not contain the whole story. She indicated Resident #5 was a medication seeker. She stated, No matter how much medication she gets she always wants more. She indicated she would have to search her record, but there was documentation going back several years that demonstrated this behavior. She indicated said the nurse likely called the physician and likely told her that Resident #5 still complained of pain, but that she was sleeping all day and all night. She stated the nurse likely relayed to the physician that Resident #5 had no physical signs of pain and that is why the medication was decrea… | 2019-07-01 |
| 4834 | 4834 | HILLCREST HEALTH CARE CENTER | 515117 | 462 KENMORE DRIVE | DANVILLE | WV | 25053 | 2016-01-29 | 329 | D | 0 | 1 | N8J711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of five (5) residents reviewed for the care area of unnecessary medications was free from unnecessary medications. Resident #79 received Ambien, a hypnotic medication, for one year without any attempt of a gradual dose reduction (GDR) to determine if symptoms/conditions could be managed by a lower dose, or if the dose of medication could be discontinued. Resident identifier: #79. Facility census: 84. Findings include: a) Resident #79 Record review on 01/28/16 at 11:00 a.m. found the resident was admitted to the facility on [DATE]. The resident's admitting [DIAGNOSES REDACTED]. The resident was admitted with the hypnotic medication, Ambien, 10 milligrams (mg), at bedtime for [MEDICAL CONDITION]. On 04/29/15, the pharmacist reviewed the resident's medications and advised the [MEDICATION NAME] due for a hypnotic drug evaluation. The physician responded to the recommendation with: Medical, environmental and psychosocial stressors have been eliminated as possible causes, and an order change may be harmful to the patient. The benefit vs (verses) risk has been considered, and the currently (typed as written) therapy will be evaluated every 30 days hereafter. On 10/09/15, the pharmacist again reviewed the resident's medications and advised the physician:[MEDICATION NAME] due for a hypnotic drug evaluation The physician's response to the recommendation was: Medical, environmental and psychosocial stressors have been eliminated as possible causes, and an order change may be harmful to the patient. The benefit vs risk has been considered, and the currently (typed as written) therapy will be evaluated every 30 days hereafter. Previous attempts at order change and or reduction have been unsuccessful. Continue the current order. At 3:30 p.m. on 01/28/16, the director of nursing (DON) confirmed the physician had never attempted to reduce [MEDICATION NAME] the resident's admiss… | 2019-07-01 |
| 4835 | 4835 | HILLCREST HEALTH CARE CENTER | 515117 | 462 KENMORE DRIVE | DANVILLE | WV | 25053 | 2016-01-29 | 514 | D | 0 | 1 | N8J711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medical record was complete and accurate for Resident #5. The medical record indicated Resident #5's pain medication was decreased because her insurance would not cover the full number of pills required each month. However, staff interviews and record reviews confirmed the medication was decreased for other reasons, not because of insurance nonpayment. This was true for one (1) of one (1) residents reviewed for the care area of Pain Recognition and Management during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #5. Facility Census: 84. Findings Include: a) Resident #5 A review of Resident #5's medical record at 12:00 p.m. on 01/27/16, found a nursing progress note dated 07/22/15, . Resident on [MEDICATION NAME] q (every) four (4) hours but her insurance will only pay for 120 tablets monthly. Reported this to (name of resident's attending physician) . new order change [MEDICATION NAME] to q 6 hours routinely. An interview with the Director of Nursing (DON) at 2:21 p.m. on 01/27/16 confirmed the note written on 07/22/15 did not contain the whole story. She stated that it was was very poor documentation. She indicated the facility would never not give a resident pain medication if she needed it just because her insurance would not pay for it. She stated, We buy medicine all the time if the insurance will not pay for it. She was then asked why Resident #5's pain medication was truly decreased on 07/22/15. She indicated Resident #5 was a medication seeker. She stated, No matter how much medication she gets, she always wants more. She said she would have to search her record, but there was documentation going back several years that demonstrated this behavior. She indicated the nurse called the physician and likely told her that Resident #5 still complained of pain, but that she was sleeping all day and all night. She stated the nurse likely relayed … | 2019-07-01 |
| 4836 | 4836 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2016-07-01 | 312 | D | 1 | 0 | NW2R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, family interview, staff interviews, the facility failed to provide showers and hair washing for one (1) of four (4) residents reviewed for assistance with activity of daily living. Resident identifier: #5. Facility census 58. @ Findings include: a) Resident #5 @ An observation on 06/27/16 at 4:40 p.m., revealed Resident #5's daughter in the doorway of her father's room telling nursing assistant (NA) #14; her father's hair is greasy, and she wanted him to have his hair washed. In an interview with the daughter following the observation, she revealed her father had not received a shower or had his hair washed since 06/21/16. @ In an observation of Resident #5's hair with Licensed Practical Nurse (LPN) #3 on 06/27/16, the LPN stated, His hair looks sweaty, and he needs to have his hair washed. @ A review of the shower schedule on 06/28/16 at 2:00 p.m., found Resident #5 is to receive his shower on Wednesday and Thursday. The activity of daily living bathing form which indicates what type of bath the resident received revealed on 06/22/16 (Wednesday), revealed the resident did not receive a shower. On 06/25/16 (Saturday), the resident received a partial bath, nothing was written to state the reason the resident received a partial bath instead of a shower. The record did not reveal the resident had his hair washed. A review of the resident's record found no evidence the resident had received a shower/ nor had his hair washed since being admitted to the facility on [DATE], until after surveyor intervention on 06/27/16. The resident received a shower, and had his hair was washed on 06/28/16. @ During a review and interview with LPN #4 on 06/28/16 at 2:10 p.m., the LPN stated that she had reviewed Resident #5's record and confirmed there was no evidence he had received a shower or had his hair washed. The LPN did confirm the resident did receive his shower, and had his hair washed today (06/28/16). | 2019-07-01 |
| 4837 | 4837 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2016-07-01 | 465 | D | 1 | 0 | NW2R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, staff interviews, and repair requisitions the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents' toileting needs for one (1) bathroom out of five (5) bathrooms. Resident bathroom affected B-2 and B-4 . Facility census 58. @ Findings include: @ a) Bathroom between B-2 and B-4. @ Observation of the bathroom between B-2 and B-4 on 06/27/16 at 4:35 p.m., found a sign on both bathroom doors indicating they were out of order, and to not use them. @ Observation of the bathrooms on 06/28/15 at 8:30 a.m., found the bathrooms continued to have an out of order sign on the doors. @ Observation of the commode on 06/28/16 at 9:50 a.m., revealed there was brown substance in the commode. @ In an interview on 06/28/16 at 1:00 p.m. with Maintenance Assistant (MA) #8, revealed he came in today, and due to the flooding in the area he has not been here. He said he was just told by the Housekeeper #9. @ On 06/29/16 at 8:30 a.m., a plumbing company was present within the building and during his observation of the commode that is between room B-2 and B-4's bathroom, the mechanic stated, You need to remove the toilet, check and see what is causing you not to be able to flush the toilet and replace with an commode that will flush just about anything down the toilet. @ In an interview with the Administrator and Resident #7 who reside in room B-2 on 06/29/16 at 8:40 a.m., the Administrator asked the resident, How long has the toilet not been working. The resident stated, The toilet has not been working for two (2) weeks. The resident confirmed that he had been using the staffs' bathroom. The resident said the housekeeper will flush the toilet, and then the toilet will work one time, and the housekeeping staff has been using a plunger every day. @ On 06/29/16 at 10:00 a.m., MA #8 confirmed the staff are using the plunger daily for some time to unstop the commode, but he could not remember how long … | 2019-07-01 |
| 4838 | 4838 | MEADOWVIEW MANOR | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2016-07-20 | 224 | D | 1 | 0 | KIXL11 | > Based on observation, staff interview, family interview, policy review, and review of reportable allegations, the facility failed to ensure a resident was free of neglect for one (1) of six (6) sample residents. The facility failed to provide activity of daily living (ADL) care in a timely manner for a dependent resident. Resident identifiers: Resident #53. Facility census: 59. Findings include: a) Resident #53 A random observations on 07/12/16 at 10:55 a.m., revealed Resident #53 sitting in her chair, with the support pillow behind her neck and the cushion in place beneath her heals. During another observation at 1:20 p.m., the resident was observed seated in her chair, in the same position. Subsequent observations revealed the resident seated in her wheelchair. At 4:34 p.m. Nurse Aide (NA) #99 and #102 provided incontinence care for Resident #53. NA #102 reported the resident had been up all day and she hoped Resident #53 was not a mess. The resident's daughter was present during care and related she wanted to observe also. The NA's utilized the lift and transferred Resident #53 to bed. When NA #102 exposed the resident, observation revealed the brief was saturated with urine. Staff turned the resident to her left side for care, exposing a blanchable purple discoloration over the buttocks area. Licensed Practical Nurse (LPN) #51 was notified staff had voiced Resident #53 had been out of bed since 10:30 a.m. without incontinence care. When the LPN observed the brief she exclaimed, Oh, wow! and related she would follow-up. During a conversation with the administrator, on 07/13/16 at 11:30 a.m., she related she had been informed of the incident, and that the director of nursing (DON) had spoken with the dayshift nurse aide who indicated Resident #53 had been transferred to bed at 12:30 p.m., changed and transferred back to her chair. Upon inquiry, at 4:00 p.m., as to whether the incident had been reported to the appropriate State agencies, the administrator related it had not, because Resident #53 had been chang… | 2019-07-01 |
| 4839 | 4839 | MEADOWVIEW MANOR | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2016-07-20 | 253 | D | 1 | 0 | KIXL12 | > Based on observation and staff interview, the facility failed to clean and store a resident's care equipment in a sanitary manner. Facility staff stored a bedpan in a resident's bathroom after use, without first cleaning and/or disinfecting the bedpan. This was evident one (1) of five (5) residents observed for perineal care and toileting. Resident identifier: #3. Facility census: 53. Findings include: a) Resident #3 During an observation on 10/03/16 at 9:30 a.m. a nurse aide (NA) #53 removed a bedpan from beneath Resident #3. The bedpan contained extremely strong smelling urine. NA #53 emptied the contents into the commode, then placed the bedpan on the toilet seat in the resident's bathroom. She removed her gloves and washed her hands. She obtained a clean, white, terry cloth bath towel and wet it at the sink. After donning a new pair of gloves, she wiped the inside of the bed pan with the white towel. She then placed the towel into a dark-colored plastic bag. After inserting the bedpan into another dark-colored plastic bag, she placed the bagged bedpan in a white cabinet which was mounted on the bathroom wall. She removed her gloves, closed the cabinet door with the back of her arm, and washed her hands again. She gathered all the bags of soiled linen and garbage and carried them to the soiled utility room. On 10/03/16 at 1:55 p.m. an interview was conducted with NA #13, while in the presence of licensed practical nurse Employee #89. Upon inquiry, NA #13 said that after a resident uses a bedpan, staff is supposed to empty the contents of the bedpan into the commode, then place the bedpan inside a plastic bag. Staff then transports the bedpan to the soiled utility room. In the soiled utility room, they use disinfectant wipes with bleach to clean the bedpan, or use the hopper if there is any fecal material on it. NA #13 said she will check Resident #3's bedpan, and take care of the situation if needed. She added that sometimes employees may decide to store the bagged bedpan in the bathroom cabinet if they are … | 2019-07-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );