cms_WV
Data source: Big Local News · About: big-local-datasette
283 rows where "filedate" is on date 2020-02-01
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4028 | 4028 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2016-10-17 | 203 | B | 0 | 1 | 353M11 | Based on review of the facility's notification of transfer/discharge form and staff interview, the facility failed to ensure the notice provided complete and correct information regarding the current professional person who reviews transfer/discharge appeals at the Inspector General's office Board of Review. and contained no telephone number. This had the potential to affect more than a limited number of residents. Facility census: 91. Findings include: a) On 10/13/16 at 4:30 p.m., review of the notification of transfer/discharge form provided by the facility found it included the name of the former professional person who reviewed transfer/discharge appeals at the Inspector General's Board of Review office and it's address. The name of the professional person who reviews transfer/discharge appeals in the Inspector General's Board of Review Office was incorrect. The current professional person assumed that position approximately one and one-half year's ago, and the facility's uniform notice was not revised to reflect this. The uniform transfer/discharge form did not contain the telephone number for the office of the Inspector General's Board of Review. During interview with the DON and the administrator on 10/13/16 at 4:30 p.m., they said they were unaware of those inaccuracies. | 2020-02-01 |
| 4029 | 4029 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2016-10-17 | 242 | D | 0 | 1 | 353M11 | Based on resident interview, medical record review, and staff interview, the facility failed to ensure one (1) of three (3) Stage 2 residents received services consistent with her plan of care, and which was significant to the resident. Resident #103 did not receive showers as frequently as desired. Facility census: 91. Resident identifier: #103. Findings include: a) Resident #103 During an interview on 10/11/16 at 11:54 a.m., Resident #103 voiced she would like a shower more often than received. Upon inquiry as to how often she would like a shower, the resident replied she had gone ten (10) days and seven (7) days, but since she had been at the facility she had to, tell them and tell them and tell them she wanted a shower. She said she wanted one more often than that. Resident #103 further added that she could shower herself, but required supervision. Licensed Practical Nurse (LPN) #24, interviewed on 10/13/16 at 4:30 p.m., said the facility maintained a shower book. Upon inquiry, the LPN reviewed the shower schedule and said Resident #103 was scheduled for a shower on Tuesday, Thursday, and Saturday every week. She stated a resident could request a shower anytime. The bathing detail report, dated 07/01/16 through 10/13/16, reviewed on 10/13/16 at 4:45 p.m., revealed no evidence Resident #103 received a shower for twenty-eight (28) of forty-four (44) opportunities. These dates were: - 07/12/16, - 07/14/16, - 07/16/16, - 07/21/16, - 07/23/16, - 07/26/16, - 07/30/16, - 08/02/16, - 08/06/16, - 08/11/16, - 08/13/16, - 08/16/16, - 08/20/16, - 08/27/16, - 09/03/16, - 09/06/16, - 09/08/16, - 09/10/16, - 09/15/16, - 09/17/16, - 09/20/16, - 09/22/16, - 09/24/16, - 09/27/16, - 10/01/16, - 10/08/16, - 10/11/16, or - 10/13/16. Nurse Aide (NA) #8, interviewed on 10/17/16 at 9:45 a.m., said Resident #103 rarely refused a shower and provided most of her own care. The NA voiced that Resident #103 required supervision of a staff member when in the shower. NA #8 stated the kiosk (electronic medical record used by nurse aides) all… | 2020-02-01 |
| 4030 | 4030 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2016-10-17 | 272 | D | 0 | 1 | 353M11 | Based on medical record, observation, resident interview, and staff interview, the facility failed to complete an accurate comprehensive assessment for one (1) of nineteen (19) Stage 2 sample residents. The admission minimum data set (MDS) inaccurately noted a resident as edentulous. Facility census: 91. Resident identifier: #44. Findings include: a) Resident #44 An observation on 10/11/16 at 1:59 p.m., revealed Resident #44 had a brown broken tooth in the upper left aspect of her mouth and had missing teeth in the lower region. Review of the 09/20/16 nursing admission assessment on 10/17/16 at 3:07 p.m. with Licensed Practical Nurse (LPN) #24 found the assessment noted Resident #44 had loose, broken, and likely carious teeth. The admission clinical health status assessment, dated 03/14/16, noted the resident had natural teeth, many missing, pulled. The admission minimum data set (MDS) with an assessment reference date (ARD) of 03/21/16, noted Resident #44 was edentulous and had no likely cavity, broken or carious teeth. The MDS Coordinator reviewed the MDS assessment and affirmed it was an inaccurate assessment. . | 2020-02-01 |
| 4031 | 4031 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2016-10-17 | 278 | D | 0 | 1 | 353M11 | Based on observation, medical record review, and staff interview, the facility failed to ensure accurate quarterly minimum data sets (MDS) for one (1) of nineteen (19) Stage 2 sample residents. The functional assessments related to activities of daily living (ADL) inaccurately noted Resident #51 as participating with ADL care. Facility census: 91. Findings include: a) Resident #51 Medical record review revealed the minimum data set (MDS), with an assessment reference date (ARD) of 09/13/16, identified Resident #51 had a decline in self-performance in the areas of bed mobility, dressing, and toilet use as compared to the previous MDS. The MDS noted Resident #51 required total assistance from staff for bed mobility, dressing, and toileting, and required extensive assistance for eating and personal hygiene. Physical Therapist (PT) #90, interviewed on 10/12/16 at 4:45 p.m., said the resident provided no assistance with his care and had not for a very long time. Upon inquiry as to whether the resident was able to participate in his care in (MONTH) (YEAR) or (MONTH) (YEAR), the PT voiced the resident was totally dependent and did not express emotions or pain. During observations on 10/11/16 at 10:51 a.m., and 12:19 p.m., the resident did not respond to verbal or physical stimuli when Nurse Aide (NA) #41 repositioned his legs and arms. The nurse aide said the resident did not interact and was totally dependent for care. She said the resident had been that way for a long time. NA #37, interviewed on 10/12/16 at 1:31 p.m., said Resident #51 was totally dependent upon staff for care and did not assist with dressing, toileting or bed mobility. Upon inquiry, the NA said the resident had not had any changes in the past several months, and was totally dependent upon staff for all activities of daily living. Licensed Practical Nurse (LPN) #24 interviewed on 10/13/16 at 4:36 p.m., also confirmed Resident #51 had no decline in ADLs over the last several months, and had been totally dependent upon staff during the MDS review in (M… | 2020-02-01 |
| 4032 | 4032 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2016-10-17 | 280 | D | 0 | 1 | 353M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to revise a care plan for a resident after the physician ordered alarms removed from her bed and wheelchair. This was a random observation of a resident whose focus sheet, derived from the resident ' s care plan, contained directives for a bed alarm and a wheelchair alarm. Resident identifier: #95. Facility census: 91. Findings include: a) Resident #95 A tour of the South front hall, on 10/05/16 at 3:00 p.m., found this resident self-propelling in her wheelchair in the corridor. She had no chair alarm in place. According to the focus sheet provided by the director of nursing (DON), this resident required a chair alarm when up in the chair, and a bed alarm at all times while in bed. Observation of the bed found no alarm present on her bed. Licensed Practical Nurse (LPN) #76 said the bed alarm was discontinued on 06/23/16. She was unsure about the chair alarm, and deferred to the assistant director of nursing (ADON). At that time, the DON provided a copy of the physician's orders [REDACTED]. There were no current orders for the use of bed alarms or chair alarms. Review of the care plan found a focus on falls related to impaired mobility and impaired cognition. Falls occurred on 02/06/16, 04/161/6, 04/17/16, 04/29/16, 04/30/16, 06/24/16, and 07/05/16. One of the interventions stated that staff verbally educated the resident on the importance of using a call bell when assistance was needed, and not turning alarms off. The DON acknowledged there were no current orders for alarms, and alarms should not have been mentioned in the current care plan. | 2020-02-01 |
| 4033 | 4033 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2016-10-17 | 371 | F | 0 | 1 | 353M11 | Based on observation, review of the 2013 Food and Drug Administration (FDA) Food Code, and staff interview, the facility failed to ensure staff preparing food trays were not wearing rings with stones. Staff identifiers: Dietary Service Specialist (DSS) #51, DSS #40, and Dietary Service Manager (DSM) #69. This had the potential to affect all residents. Facility census: 91. Findings Include: a) During an observation on 10/12/16 at 5:00 p.m., DSS #51, DSS #40, and DSM #69 were testing food temperatures for the evening meal and plating the food. All three (3) staff members had one ring with a diamond-like stone on their left ring fingers. DSM #69 stated she was unaware staff could not wear their wedding rings with stones in them. DSM #69, DSS #51, and DSS #40 immediately removed their rings. b) Review of the 2013 FDA food code found it included: Jewelry 2-303.11 Prohibition. Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. | 2020-02-01 |
| 4034 | 4034 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2016-10-17 | 441 | F | 0 | 1 | 353M11 | Based on observation, staff interview, medical record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to maintain an effective infection control program necessary to prevent the potential transmission of pathogens to the extent possible. Staff utilized improper hand hygiene, handled linens improperly, stored the ice scoop improperly, failed to utilize personal protective equipment, and failed to maintain safe practices when obtaining ice for a resident with contact precautions/isolation. This practice affected three (3) residents, but had the potential to affect all residents. Facility census: 91. Resident identifiers: Residents #51, #56, #57, and #90. Findings include: a) Resident #57 and #90 A random observation, on 10/12/16 at 2:56 p.m., revealed Resident #57 lying on a shower bed positioned adjacent to the wall outside of his room. A wet substance was on the floor beneath the shower bed and had created a large puddle that was streaming down the floor toward the end of the corridor. Licensed Practical Nurse (LPN) #15 exited the room and upon return, placed a towel on the floor over the liquid. The nurse placed her foot on the towel and wiped back and forth to clean the liquid, which was streaming down the hallway. With ungloved hands, the nurse bent down and continued wiping the fluid from the floor with the soiled towel. As LPN #15 finished wiping the spill, Resident #90 requested a drink. Without sanitizing her hands, the nurse entered the resident's room, obtained a green bottle, placed a straw in the drink and assisted the resident with consuming the beverage. Upon completion, the nurse washed her hands, turned off the faucet with a paper towel, and then wiped her hands again using the same paper towel utilized to turn off the faucet. Upon exit of the room, an inquiry as to what the nurse may have done differently, LPN #15 confirmed she should have washed her hands after cleaning up the liquid from the floor and before getti… | 2020-02-01 |
| 4035 | 4035 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2016-10-17 | 514 | D | 0 | 1 | 353M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain complete and accurately documented clinical records for one (1) of nineteen (19) Stage 2 residents. The facility did not maintain complete and/or accurately documented behavior flow sheets, which showed an accurate representation of the actual behaviors of the resident. Facility census: 91. Resident Identifier: #44. Findings include: a) Resident #44 Review of the behavior monitoring records dated May, June, July, August, September, and (MONTH) (YEAR) for this resident noted the following omissions in assessment: Day shift: 06/12/16 Evening shift: 07/02/16, 07/09/16, 09/01/16, 09/12/16, 09/15/16, 09/25/16, 09/26/16, 09/29/16 Night shift: 05/02/16, 05/23/16, 07/22/16, 08/08/16, 10/03/16 Progress notes, reviewed on 10/05/16 at 12:30 p.m., revealed notes that indicated Resident #44 exhibited behaviors that were not identified on the behavior flow sheets. Those notes were as follows: - 03/16/16 at 1:08 a.m. - A change of condition progress note (SBAR - Situation Background Assessment Recommendation) noted the nurse heard Resident #44 yelling and cursing and upon entering the room, observed the resident swatting at the nurse aide (NA). The NA informed the nurse the resident had become combative while she removed the resident ' s clothing and the resident had pulled the nurse aide's hair and hit the N[NAME] - 03/16/16 at 6:11 a.m. a behavior progress note indicated the resident became combative when NAs were changing her and the resident bit one NA (resulting in visible bit mark to the wrist) and clawed the other N[NAME] - 05/15/16 at 4:00 p.m. SBAR note indicated Resident #44 became combative when the nurse aides were transferring her from the bed to the wheelchair (w/c) and was not able to be redirected. - 06/27/16 at 3:30 p.m. SBAR note indicated Resident #44 was, .getting agitated, removing alarming seatbelt, yelling and cussing at staff. Interventions included r… | 2020-02-01 |
| 4036 | 4036 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2016-10-17 | 516 | B | 0 | 1 | 353M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure the privacy of residents' personal information. A random observation found personal information including names, birth dates, admitted s, and [DIAGNOSES REDACTED]. The former residents affected were Residents #123, #124, and #125. Facility census: 91. Findings include: a) During the initial tour of the facility on 10/04/16 at approximately 10:00 a.m., observation of a large bulletin board on the wall across from the North hall nurses' station found it contained Patient Overview Reports for three (3) former residents. The residents' names, dates of birth, and medical record numbers were darkened with a black marker, but still legible. No attempt was made to block their diagnoses, payers, admitted s, or discharge destinations. 1. Resident #123 - Her name, birth date, and medical record number were darkened with a black marker, but still legible. The report contained her admitted and discharge location. The payer source was Managed Care RU[NAME] [DIAGNOSES REDACTED]. The report showed her range of motion scores upon admission and discharge, and her bathing/showering scores upon admission and discharge. 2. Resident #124 - Her name, birth date, and medical record number were darkened with a black marker, but still legible. The report contained her admitted and discharge location. The payer source was Medicare Part [NAME] [DIAGNOSES REDACTED]. It noted her range of motion scores for gait and transfers upon admission and discharge, and her bathing/showering scores. 3. Resident #125 - His name, birth date, and medical record number were darkened with a black marker, but still legible. The report contained his admitted and discharge location. The payer source was the Veteran's Administration. [DIAGNOSES REDACTED]. His range of motion scores for gait and transfers were shown for admission and discharge. His bathing/showering and dressing scores were shown for admission and discharge… | 2020-02-01 |
| 4037 | 4037 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 157 | E | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to notify the resident's responsible party and/or physician of incidents of sexual abuse. This was evident for seven (7) of eight (8) residents reviewed for abuse. Resident identifiers: #51, #49, #24, #37, #1, #39, #26, #10, #62, #52, and #11. Facility census: 61. Findings include: a) Resident #51 Confidential Interviewees (CI) #3 and CI #4, in separate interviews, both said they had witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to whomever was the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. An incident report dated 12/08/16, described that Resident #51 was sitting in a recliner chair by the nurses' station, when male Resident #62 pulled up her shirt, and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. Review of the nurse progress report found no documentation on 12/08/16 about this incident between the two (2) residents. There was no evidence the facility informed the responsible party or the physician of these occurrences. b) Resident #49 During separate confidential interviews with CI #1, CI #2, CI #6, CI #10, and CI #11, all five (5) said they had witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Reside… | 2020-02-01 |
| 4038 | 4038 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 252 | E | 0 | 1 | WA6611 | Based on observation and staff interview, the facility failed to provide a homelike environment for residents by not having tablecloths and/or place mats on the dining tables. In addition, dinnerware and flatware were not removed from the individual serving trays during the breakfast meal. This practice had the potential to affect more than an isolated number of residents. Facility census: 61. Findings include: a) On 02/14/17 at 8:33 a.m., a second dining observation of the breakfast meal on the first floor of the nursing home unit revealed twenty-five (25) residents seated at various tables in the dining room/solarium/activity room. The plastic tables and wooden tables did not have tablecloths or place mats covering the surfaces of the tables. Staff served the residents' breakfast meals with the dinnerware, flatware, and other items left on the individual serving trays. At 8:40 a.m. on 02/14/17, after observing the breakfast meal service on the first floor dining room/solarium/activity room, the Assistant Director of Nursing (ADON)/Wound Nurse #112 agreed it was not a homelike environment for dining. She stated, They are being served cafeteria style and we only have fine dining for lunch with tablecloths and removing the plates from the trays. She further commented that she would ensure this dining practice would be corrected for all meals. . | 2020-02-01 |
| 4039 | 4039 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 272 | C | 0 | 1 | WA6611 | Based on Minimum Data Set (MDS) review, review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual), and staff interview, the facility failed to provide the dates of information used to complete the Care Area Assessments (CAA) for five (5) of five (5) residents reviewed during Stage 2. This affected all residents residing in the facility. Resident identifiers: #39, #26, #62, #11, and #10. Facility census: 61. Findings include: a) Resident #39 On 02/28/17 at 2:16 p.m., a review of the resident's annual MDS with an assessment reference date (ARD) of 06/16/16 revealed the CAA summary contained no dates of the CAA documentation. Areas that triggered and marked to be care planned contained interview/record, record, interview and activity record and see H&P (history and physical), but did not identify the dates of the referenced documents, interviews, or observations. b) Resident #26 A significant change MDS with an ARD of 11/25/16, contained no dates of the location of the CAA documentation. Areas that triggered and marked to be care planned contained interview/record, record, interview and activity record, but did not identify the dates of the referenced documents, interviews, or observations. c) Resident #62 A significant change MDS with an ARD of 11/25/16 contained no dates of the location of the CAA documentation. Areas that triggered and marked to be care planned contained interview/record, record, interview and activity record, but did not identify the dates of the referenced documents, interviews, or observations. d) Resident #11 The resident's admission MDS with an ARD of 09/08/16 contained no dates of the location of the CAA documentation. Areas that triggered and marked to be care planned contained, interview/record, record, interview, interview/observation/record, Activity participation record, Medication Administration Record [REDACTED]. e) Resident #10 The annual MDS with an ARD of 03/24/16, contained no dates of the location of the CAA documentation. Areas that wer… | 2020-02-01 |
| 4040 | 4040 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 279 | D | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop comprehensive and/or initial care plans based on the residents' current health condition/status that included measurable objectives and timetables to meet the resident's medical, nursing and psychosocial needs. Care plans lacked individualized goals and interventions for residents with, or at risk for pressure ulcers (Residents #74 and #75), and for a resident (#49) receiving antipsychotic medications. This practice was identified for three (3) of twenty-six (26) Stage 2 sample residents whose care plans were reviewed during the Quality Indicator Survey (QIS). Resident identifiers: #74, #75, and #49. Facility census: 61. Findings include: a) Resident #74 On 02/16/17 at 8:12 a.m., medical record review revealed this eighty-two (82) year old man was admitted to the facility after a thirteen (13) day stay in an acute care facility. The acute care hospital's discharge summary dated 12/18/16 listed [DIAGNOSES REDACTED]. The plan of care written in the discharge summary identified Resident #74's sacral decubitus ulcer. The plan stated, Protect skin from further breakdown and compromise. The interventions were, Frequent repositioning, keep patient active, and enforce aggressive wound care. The facility's admission physical assessment, written on 12/19/16 at 5:13 p.m. by Registered Nurse (RN) #153, stated, [AGE] year old male discharged from (Name) hospital and admitted to (Name) Nursing Care Facility II .with HX (history): Increased weakness. Pressure ulcers of sacral region .Incontinent to bowel and bladder .wears brief .Buttocks with old scar right proximal. Will continue to monitor. The Nurse Aide resident care record dated 12/19/16 at 9:57 p.m. noted Resident #74 required the assistance of one (1) with turning and repositioning, was a two (2) person transfer with a lift device, required assistance with all other activities of daily living (ADLS) including eating, and was … | 2020-02-01 |
| 4041 | 4041 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 280 | D | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise the care plan for one (1) of five (5) residents reviewed for unnecessary medications. Resident #34's care plan was not revised when her antipsychotic medication was discontinued. Resident identifier: #34. Facility census: 61. Findings include: a) Resident #34 Review of the medical record on 02/15/17 found diagnoses, which included [MEDICAL CONDITIONS], depression, and anxiety. Review of medications revealed she formerly received [MEDICATION NAME] (an antipsychotic) 50 milligrams (mg) in the morning and 75 mg at bedtime daily. Review of physician's orders [REDACTED]. During an interview with Registered Nurse #111 and the Director of Nursing (DON) on 02/15/17 at 2:30 p.m., they said she was getting very lethargic on the [MEDICATION NAME] and even wet herself in her sleep without knowing it. They said the physician discontinued the [MEDICATION NAME], and they had to work with the [MEDICATION NAME] in the interim to see how she did. The DON said the resident no longer received [MEDICATION NAME]. Review of the current care plan found one of her care plan interventions included [MEDICATION NAME] 75 mg daily and [MEDICATION NAME] 50 mg at bedtime. During a brief interview on 02/20/17 at 2:30 p.m., it was discussed with the DON that the [MEDICATION NAME] was discontinued on 12/26/16, but the care plan was not revised to indicate the medication was discontinued. The current care plan indicated the resident was receiving [MEDICATION NAME] 75 mg daily and [MEDICATION NAME] 50 mg at bedtime. She agreed the resident's care plan was not revised accordingly after the medication was discontinued. | 2020-02-01 |
| 4042 | 4042 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 282 | E | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to follow the comprehensive care plan for three (3) of five (5) residents reviewed for unnecessary medications. For Residents #34 and #49's the facility failed to implement their care plans directing to utilize nonpharmacological methods to treat behaviors prior to administering medications, and to assess the effectiveness of the as needed (PRN) antianxiety medication. The facility failed to implement Resident #10's care plan directing administration of insulins as ordered by the physician for the [DIAGNOSES REDACTED].#34, #49, and #10. Facility census: 61. Findings include: a) Resident #34 Review of the resident's medical record on 02/15/17 found [DIAGNOSES REDACTED]. The physician prescribed an antianxiety medication, [MEDICATION NAME] one (1) milligram (mg) every eight (8) hours as needed (PRN). The comprehensive care plan review revealed numerous nonpharmacological interventions such as offering a quiet environment, 1:1 (one person to one person), offer fluid/foods, toileting, conversing, activities, observe for pain, and calm approach, before administering the PRN [MEDICATION NAME]. The care plan also directed to monitor the effectiveness of the PRN medications. Review of the medical record found several instances this quarter where the care plan was not followed. - Review of the medical record found a nurse administered 1 mg of [MEDICATION NAME] on 12/07/16 at 8:00 p.m. The nurse progress notes provided no evidence of what, if any, nonpharmacological methods were attempted prior to administering the PRN medication. Also, the medical record was silent as to whether or not the medication was effective. - Review of the medical record found a nurse administered 1 mg of [MEDICATION NAME] on 12/11/16 at 9:00 p.m. for anxiety. Review of the medical record found no evidence of what if any nonpharmacological methods were attempted prior to giving the PRN medication. - Review… | 2020-02-01 |
| 4043 | 4043 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 319 | D | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, resident interview, and staff interview, the facility failed to ensure that a resident who displayed and/or was diagnosed with [REDACTED]. Resident #29 was admitted to the facility with a history of inpatient and outpatient treatment for [REDACTED]. The primary care physician #181 was notified of her aggressive behaviors and sexual comments on 10/18/16. Despite further notifications, no medication adjustments were made until 01/19/17. In addition, no psychological assessments or behavior management plan was provided when the resident's behaviors towards others increased in (MONTH) (YEAR). This was found for one (1) of one (1) residents reviewed for behaviors. The resident's behaviors had the potential to affect more than a limited number of the resident's fell ow residents. Resident identifier: Resident #29. Facility census: 61. Findings include: a) Resident #29 During an observation of the noon meal service on 02/13/17, Resident #29 was observed attempting to pinch a male nursing assistant's bottom as he escorted her to her table. Random observations on 02/22/17 and 02/23/17, found Resident #29 roaming freely throughout the unit and at times making inappropriate sexual comments to State Surveyors. Resident #29 repeatedly spoke about her desire for sexual relations as well as making comments about her lady parts. Licensed Practical Nurse (LPN) #119 was interviewed on 02/22/17 at 3:46 p.m. and reported Resident #29 was aggressive at times and had to be removed from activities because she makes loud inappropriate sexual comments about men and male visitors. Review of the medical record on 02/28/17 at 9:30 a.m., revealed Resident #29 was admitted to the facility in 2011. Her current [DIAGNOSES REDACTED]. She was independent with most of her activities of daily living and allowed to ambulate independently throughout the first floor of the facility. The nurses' behavior documentation from 09/01/16 thro… | 2020-02-01 |
| 4044 | 4044 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 329 | E | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the resident's medication regimen was free of unnecessary medications for two (2) of five (5) residents reviewed for unnecessary medications. Residents #34 and #49 received PRN (as needed) antianxiety medication without evidence of nonpharmacological methods attempted prior to the administration of the PRN medication. Nursing administered PRN antianxiety medications without evidence the behaviors warranted the PRN medication. Resident identifiers: #34 and #49. Facility census: 61. Findings include: a) Resident #34 Review of the resident's medical record on 02/15/17 found diagnoses, which included [MEDICAL CONDITION] disorder, [MEDICAL CONDITION], depression, and anxiety. The physician prescribed an antianxiety medication, [MEDICATION NAME] one (1) milligram (mg) every eight (8) hours as needed (PRN). - Review of the medical record found a nurse administered 1 mg of [MEDICATION NAME] on 12/07/16 at 8:00 p.m. There was no evidence in the nursing progress notes of what behaviors were present at that time, and what, if any, nonpharmacological methods were attempted prior to administering the PRN medication. The medical record was silent as to whether the medication was effective. There was no evidence to support the use of the PRN [MEDICATION NAME]. - Review of the medical record found a nurse administered 1 mg of [MEDICATION NAME] on 12/11/16 at 9:00 p.m. for anxiety and verbal abuse after nursing staff got her out from behind the nurses' station. There was no evidence of what behaviors were present at the time other than the staff did not want her behind the nurses' desk. There was no evidence of what, if any, nonpharmacological methods were attempted prior to giving the PRN medication. The nurse said only, Resident became verbally abusive with staff on redirection from behind the nurse's station. Then followed a staff aid to the kitchen asking for a cigarette. Th… | 2020-02-01 |
| 4045 | 4045 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 353 | F | 0 | 1 | WA6611 | Based upon family interview, staff interview, review of staffing documentation, review of payroll information, review of incident reports, and review of reports documenting the provision of incontinence care for dependent residents, the facility failed to deploy sufficient qualified nursing staff across all shifts to provide nursing and related services and to ensure resident safety. These findings had the potential to affect all residents residing in the facility. Resident identifiers: #21, #26, #52, and #49 Facility census: 61. Findings include: a) During the survey, complaints regarding staffing were voiced on both of the facility's two (2) units, the second floor unit (Nursing Care Facility Two (NCF2)) and Nursing Care Facility One (NCF1). The units are completely separate. NCF2 currently houses primarily residents who need assistance or are totally dependent on nursing staff for their activities of daily living (ADLs). NCF1 currently houses primarily residents who are more mobile, require less staff assistance with ADLs, but may have dementia, mental illnesses, and behaviors. Because of the unique needs presented on each unit, they were investigated for adequate staffing separately. b) NCF2 1. Two (2) family members voiced concern about inadequate staffing on NCF2 during the early stages of the survey. Interviewee #1 said there were often staffing concerns on day shift. The individual thought there were supposed to be two (2) nurses and three (3) Nurse Aides (NA) on day shift, but usually there were only two (2) NAs, and sometimes only one N[NAME] Interviewee #1 said there were many times when their family member had to wait a long time for needed care, and as a result was sometimes left to sit or lie in their own excrement. Interviewee #1 said the staff tried their best, but they just could not do it with only four (4) staff, let alone with three (3). Lots of the residents needed assistance, some needed the assistance of two (2) staff, and when things got busy, lots of residents waited long time for help. I… | 2020-02-01 |
| 4046 | 4046 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 356 | C | 0 | 1 | WA6611 | Based upon observation, staff interview, and review of staffing and payroll documentation, the facility failed to post complete and accurate staffing information. This had the potential to affect all residents and visitors. Facility census: 61. Findings include: a) On 02/13/17 at 11:10 a.m., during the initial tour of the facility, staffing sheets posted for review by residents and visitors were observed on the second floor unit, Nursing Care Facility Two (NCF2). The posting showed the facility name, the date, the shift, the census, and the total hours worked by Registered Nurses (RN), Licensed Practical Nurses (LPN), and Nurse Aides (NA), but did not show the total number of RNs, LPNs, and NAs working the shift. b) The 02/13/17 posting for the day shift showed there were two (2) nurses and one (1) nurse aide working on the unit. When asked if there was only one (1) NA working the day shift, RN #141 said the posting was not correct, that someone had come down from the third floor to cover and there were two (2). She pulled the posting sheet off the bulletin board and began to correct it. c) Complaints about inadequate staffing on both the second floor unit (NCF2) and the basement unit (NCF1) led to a detailed review of the staff posting, the schedules, and the payroll data for the period from 01/29/17 through 02/21/17. Numerous, almost daily discrepancies were noted between the posting sheets designed to keep residents and visitors informed about how many staff were working each unit and the actual hours reflected in the payroll information provided. d) When questioned about the discrepancies on 02/20/17 at 2:20 p.m., the facility's Administrator, #114, said, Almost none of the staff postings are accurate. | 2020-02-01 |
| 4047 | 4047 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 371 | E | 0 | 1 | WA6611 | Based on observation, staff interview, and facility policy review, the facility failed to prepare and store foods under safe and sanitary conditions. The outside oven doors were soiled, three (3) large storage bins containing sugar, flour, and thick-it sitting next to the oven were coated with grime, and the tile floor in the kitchen cooking area was dirty and stained. In addition, the residents' snack refrigerator contained unlabeled stored foods and a used hot/cold gel pack was stored among the frozen foods. These findings had the potential to affect all residents receiving foods from this central location. Facility census: 61. Findings include: a) Kitchen An initial tour of the kitchen on 02/13/17 at 11:29 a.m. with the Food Service Supervisor, revealed the following: -- the outside of the oven doors were soiled with dirt and running water marks. -- three (3) large storage bins on wheels containing sugar, flour, and thick-it sitting next to the oven/stove were soiled with dried grease and grime along the lower outer sides of the containers. -- the kitchen tile floor in the cooking area was stained and visibly dirty. A follow up observation of the kitchen on 02/22/17 at 8:30 a.m. with the Food Service Supervisor found same observations. The Food Service Supervisor was interviewed at this time and agreed the oven doors were soiled, the outside of the food storage bins located next to the oven/stove were coated with dried grease and grime, and the tile floor around the oven needed scrubbed. Kitchen cleaning schedules for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) 1st through the 14th, (YEAR) were reviewed with the Food Service Manager during an interview on 02/22/17 at 8:40 a.m. She acknowledged the cleaning schedules all said at the top of the form, Clean on a weekly basis (daily if needed) and please initial. The Food Service Manager agreed all of the cleaning schedules were incomplete, indicating the kitchen staff did not complete their assigned weekly cleaning duties. b) Snack refrigerator An observation of … | 2020-02-01 |
| 4048 | 4048 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 428 | D | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the physician responded to a pharmacy recommendation for the gradual dose reduction of an antipsychotic medication in a timely manner. This practice was found for one (1) of five (5) Stage 2 sample residents reviewed for unnecessary medications. Resident identifier: #10. Facility census: 61. Findings include: a) Resident #10 On 02/21/17 at 1:17 p.m., medical record review revealed this Resident #10, admitted on [DATE], had [DIAGNOSES REDACTED]. He was currently receiving Risperdal (an antipsychotic medication) 0.25 milligrams (mg) by mouth daily twice a day (BID) for schizoaffective disorder. The pharmacist's consultation report dated 02/03/16 noted the resident was receiving Risperdal 0.25 mg BID. The pharmacist recommended, Please consider a gradual dose reduction (GDR) while monitoring for re-emergence of target and/or withdrawal symptoms. The physician signed the report on 03/08/16 declining the recommendation of a GDR for the antipsychotic medication Risperdal (and provided the rationale for declining the recommendation). The Director of Nursing (DON) signed the report on 03/23/16. After reviewing the pharmacy consultation report on 02/27/17 at 12:40 p.m., the DON stated, I anticipate the GDRs being returned with physician decline or acceptance within two (2) weeks. Absolutely that is not a timely response as you can see it was over a month before he (Physician) filled out the form and longer for him (Physician) to return it to me, of course it is not timely. | 2020-02-01 |
| 4049 | 4049 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 431 | E | 0 | 1 | WA6611 | Based on review of controlled medication sheets, pharmacy reports, staff interview, and policy review, the facility failed to ensure controlled substance records were complete and contained information to show complete reconciliation by on-coming and off-going nurses. This was found for four (4) of four (4) narcotic books (two on nursing home unit 1 and two on nursing home unit 2) reviewed during medication storage. This practice has the potential to affect all residents. Facility census: 61. Findings include: a) Review of the four (4) shift change controlled substance inventory logs dated (MONTH) 27, (YEAR) through (MONTH) 15, (YEAR) on 02/16/17 at 8:45 a.m., found there were seventy-seven (77) blank signature spaces for reconciliation of the controlled medication counts at the change of shifts identified. The Director of Nursing (DON) reviewed the controlled substance logs during an interview on 02/16/17 at 9:28 a.m. She stated, There should not be any blanks for signatures on the narcotic sheets, and yes, there certainly are a lot. A review of the facility's Controlled Substance Policy and Procedure on 02/16/17 at 9:15 a.m. revealed on page 2, titled Procedure C. The change of shift audit will include 1) physical count and reconciliation by the oncoming nurse of the drugs and the Individual Resident's Narcotic Record and 2) inspection of the packaging to ensure integrity. The nurse going off duty shall witness the count and reconciliation. All counts will be documented on a change of shift signature record On 02/16/17 at 9:28 a.m., review of the monthly pharmacy reports for (MONTH) (YEAR) and (MONTH) (YEAR) found the controlled substance logs were not reconciled according to facility procedures and there were irregularities with accurate and complete reconciliation. During a follow-up interview on 02/16/17 at 11:37 a.m., the DON stated, Yes, pharmacy had told me about these irregularities and it also was reviewed in the QA (Quality Assurance) meetings. I had done education with the staff, but evidently, more e… | 2020-02-01 |
| 4050 | 4050 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 441 | E | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain an effective infection control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. Residents' briefs and toiletries were improperly stored on the bathroom floor. Dirty plungers were found behind the commodes, and bathrooms were not routinely checked and cleaned as needed. These findings had the potential to affect more than a limited number of residents residing in the facility. Resident identifier: #74. Facility census: 61. Findings include: a) Resident rooms 1. An observation of the restroom in room [ROOM NUMBER] on 02/13/17 at 2:53 p.m., revealed -- a package of briefs on the floor next to the commode -- bottles of shampoo, moisturizer, body wash, and lotion sitting on the floor between the toilet and shower. 2. The restroom in room [ROOM NUMBER], observed at 3:00 p.m. on 02/19/17, had: -- a plunger in an open plastic bag behind the toilet -- an open bag of briefs stored on the floor next to the garbage can. Registered Nurse #116 viewed the restrooms in rooms [ROOM NUMBERS] during an interview on 02/13/17 at 3:41 p.m. She reported storing briefs and toiletries on the restroom floor and leaving a plunger in the bathroom were infection control issues. Staff should be making rounds and checking the residents' rooms. 3. An observation of room [ROOM NUMBER] on 02/13/17 at 3:02 p.m. revealed: -- a soiled brief on the floor to the right of the toilet and a pair of pants on the floor on the left side of the toilet. A follow up observation of the restroom in room [ROOM NUMBER] on 02/14/17 at 9:48 a.m., revealed: -- a soiled brief and pair of sweat pants with visible stool on the floor by the commode. -- Remnants of stool were on the bathroom floor in front of the toilet where the resident's feet would rest when sitting on the commode. -- During a follow up observation of room [ROOM NUMBER] … | 2020-02-01 |
| 4051 | 4051 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 463 | D | 0 | 1 | WA6611 | Based on observation and staff interview, the facility failed to ensure all portions of the call light system were functioning. The call light system for two (2) resident bathrooms did not light up in the hallway above the doors to the rooms to alert staff of the residents' need for assistance. This was found for two (2) of thirty-five (35) resident bathrooms. Room numbers: #29 and #2. Facility census: 61. Findings include: a) Observations of the facility during Stage 1 of the Quality Indicator Survey revealed two (2) rooms did not have adequately functioning bathroom call light systems to allow residents to call for assistance. -- Room #29 On 02/14/17 at 3:00 p.m. during a bathroom observation, when the bathroom call light was pulled it sounded and lit up at the nurses' station, but did not light up above the resident's room to alert staff of the location. The Nursing Home Administrator (NHA) was present during this observation and verified the bathroom call light did not light up above the resident's door. The NHA commented maintenance would be notified to repair the light over the resident's door immediately. -- Room #2 At 4:39 p.m. on 02/14/17 observation found when the bathroom call light was activated, it sounded and lit up at the nurses' station, but did not light up above the resident's room to alert staff of the location. Registered Nurse #141 verified the bathroom call light did not light up above the resident's door. She said maintenance would be notified to repair the light over the resident's door. | 2020-02-01 |
| 4052 | 4052 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 468 | E | 0 | 1 | WA6611 | Based on observation and staff interview, the facility failed to maintain the corridors on the long hall and short hall on nursing home unit 1 with firmly secured handrails on each side of the corridors. Multiple handrails in the corridors utilized by residents in the main thoroughfares were discovered to be loose and/or pulled out of the wall when grabbed/pulled by hand or used as support to assist with locomotion. This had the potential to affect more than an isolated number of residents residing on nursing home Unit 1 who require assistance and/or were dependent with locomotion. Facility census: 61. Findings include: a) Short hall on nursing home Unit 1 The corridor handrail was loose and not secured to the wall on either side outside of: -- Room #2, -- Room #4, and -- Room #6. b) Long hall on nursing home Unit 1 The corridor handrail was loose and not secured to the wall on either side outside of: -- Room #32. -- Room #33, and -- Room #40, and actually came loose from the wall exposing a hole and the bolt used to anchor the handrail to the wall. -- The corridor handrail outside of the Pantry room door was missing an end piece exposing a sharp jagged edge on the remaining center handrail piece. -- The corridor handrail outside of the dining/solarium/activity room had a two (2) inch by two (2) inch hole with a depth of three and a half (3-1/2) inches on the wall on the underside of the handrail where an anchor bolt was removed and placed further up on the handrail. c) At the conclusion of the tour, accompanied by Nursing Home Administrator #114, Maintenance Supervisor #42, and Housekeeping Supervisor #91 on 02/15/17 between 2:40 p.m. to 3:05 p.m., all agreed the observed problems needed repaired and/or replaced. When asked whether they were aware of the issues, Maintenance Supervisor #42 stated, Yes, I tour here every day and see this every day, but no repairs have been done. | 2020-02-01 |
| 4053 | 4053 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 490 | F | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, resident interviews, family interviews, confidential interviews, staff interviews, record review, review of staffing and payroll information, policy review, review of facility documents, and record review, the facility was not being administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to notify residents' responsible party and or physician of incidents, failed to identify occurrences and protect residents from sexual abuse, failed to report occurrences of abuse and neglect to required State agencies, failed to ensure a safe environment, failed to ensure residents received appropriate care for pressure ulcers, and failed to provide sufficient staff across all units and shifts to meet the needs of residents. These finding had the potential to affect all residents living in the facility. Facility census: 61. Findings include: a) The facility failed to notify residents' responsible parties and/or physician of incidents of resident-to-resident sexual abuse, failed to identify incidents of sexual abuse and protect the subjects of the abuse, and failed to report incidents of abuse and neglect to required agencies. Medical record reviews, review of accident/incident reports, facility policy and procedure review, review of immediate and five (5) day reporting information, and staff interview, found the facility failed to identify three (3) male residents who were at risk for sexually abusing female residents, failed to develop interventions to prevent occurrences, and failed to monitor for changes that would trigger sexual behaviors. In addition, the facility failed to implement its written policies and procedures for the prohibition of sexual abuse, verbal abuse, and/or neglect. Female residents (#26, #39, #51, #49, #24, #37, and #1) were subjected to repeated no… | 2020-02-01 |
| 4054 | 4054 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 514 | E | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, confidential interviews, and policy review, the facility failed to maintain complete, accurately documented clinical records of each resident. Staff failed to accurately monitor and document Resident #75's, Resident #74's, and Resident #33's pressure ulcers, to include depth, any exudate (wound drainage) and a description of the pressure ulcer including surrounding tissue. Resident #74's medical record also contained an incorrect discharge date documented on the form used to document pressure ulcers. In addition, residents' medical records lacked documentation of incidents of sexual abuse. This practice had the potential to affect all residents residing in the facility. Resident identifiers: #75, #74, #33, #26, #39, #51, #49, #24, #37, and #1. Facility census: 61. Findings include: a) Resident #75 Review of the medical record on 02/15/17 at 9:07 a.m. found Resident #75, admitted on [DATE], had [DIAGNOSES REDACTED]. He was discharged from the facility to home on 01/18/17. The wound/pressure ulcer forms lacked documentation of any measurement of wound depth if present, exudate, description of the wound bed and surrounding tissue. -- On 12/27/17, the wound/pressure ulcer size was documented as 1 cm (centimeter) x (by) 1 cm -- On 01/02/17, the wound/pressure ulcer size was documented as 0.25 cm round -- On 01/9/17, the wound/pressure ulcer size was documented as not open -- On 01/16/17 the wound/pressure ulcer size was documented as not open The column titled Eschar/Necrotic was blank. The column titled site was documented on each of the previous dates as L (left) buttock. Also, a handwritten discharge date of [DATE] was documented on the form, when the resident was discharged from the facility on 01/18/17. After reviewing the wound/pressure ulcer forms for Resident #75 on 02/15/17 at 9:00 a.m., the Assistant Director of Nursing (ADON)/Wound Nurse #112 stated, No the form does not show an accurate measurem… | 2020-02-01 |
| 4055 | 4055 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 157 | E | 0 | 1 | X1PF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to notify Resident #139's attending physician when she experienced numerous episodes of [MEDICAL CONDITION] (low blood pressure) while receiving two (2) medications for hypertension (high blood pressure). This was true for one (1) of seventeen (17) sampled residents. Resident Identifier: #139. Facility Census: 100. Findings include: a) Resident #139 Review of Resident #139's medical record at 12:28 p.m. on [DATE], found she was admitted to the facility on [DATE] shortly after midnight. She was admitted from the hospital where she had the right upper lobe of her lung removed. She remained at the facility until she expired on [DATE]. Resident #139's admitting [DIAGNOSES REDACTED]. Resident #139's discharge medications from the hospital included the following medications used to treat hypertension: - [MEDICATION NAME] 25 milligrams (mg) every 12 hours, and - Amidarone 200 mg 2 tablets daily for seven (7) days then decrease to 200 mg daily thereafter. Review of the facility's admission orders [REDACTED]. Review of Resident #139's nursing admission assessment dated [DATE] at 12:45 a.m., found the resident's blood pressure on admission was ,[DATE] and she was orientated to person, place, and time. Further review of the record found that on [DATE] at 11:46 a.m., Resident #139's blood pressure was ,[DATE]. Further review of the record found a change in condition nursing note written at 9:40 p.m. on [DATE]. This change in condition note indicated Resident #139 had an unwitnessed fall in her room. At the time of her fall, the nurse obtained her vital signs. At 9:00 p.m., her blood pressure was recorded as ,[DATE]. The nurse also indicated the resident was confused. The resident's attending physician was notified of the fall, but there was no evidence to suggest that he was notified of Resident #139's [MEDICAL CONDITION]. ([MEDICAL CONDITION] can cause dizziness, which ca… | 2020-02-01 |
| 4056 | 4056 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 253 | E | 0 | 1 | X1PF11 | Based on observation and staff interview, the facility failed to provide services to ensure rooms were in good repair. Four (4) of twenty-nine (29) rooms observed during Stage 1 of the Quality Indicator Survey were found to have cosmetic imperfections such as missing cove base, peeling/missing wall paper, scratched areas, peeling paint, and scuffed doors and cabinet. Facility census: 100. Findings include: a) Stage 1 observations on 06/13/16 revealed the following cosmetic imperfections: 1. Unit 2 room 25 - cove base missing behind the door. 2. Unit 3 room 314 - the wall behind the sink had peeling and missing wallpaper, the board behind the bed was scratched, and the paint was peeling. 3. Unit 2 room 18 - the bathroom door had scratches and scuffs. 4. Unit 2 room 15 - had scuffs on the door and the cabinet that was beneath the sink. b) On 06/14/16 at 2:30 p.m., the maintenance director toured the identified rooms and confirmed the areas were in disrepair. | 2020-02-01 |
| 4057 | 4057 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 272 | E | 0 | 1 | X1PF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to conduct accurate comprehensive minimum data set (MDS) assessments for four (4) of thirty-two (32) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The comprehensive assessments for Resident #198 and #103 did not accurately identify the residents' pressure ulcers. Resident #104's assessment did not accurately reflect her life expectancy. Additionally, Resident #139's assessment did not accurately reflect her ability to ambulate in the corridor. Resident identifiers: #198, #103, #104, and #139. Facility census: 100. Findings include: a) Resident #198 Medical record review on 06/15/16 at 9:55 a.m., found Resident #198 was admitted to the facility on [DATE]. The admission nursing assessment/body audit, completed by Registered Nurse (RN) #49, identified the resident had a Stage 2 pressure ulcer on the sacrum. No measurements of the pressure ulcer were found. Review of Resident #198's admission MDS assessment with an assessment reference date (ARD) of 04/15/16, found the assessment indicated no pressure ulcers were present. Interview with the Director of Nursing (DON) on 06/15/16 at 10:30 a.m., confirmed the MDS with the ARD of 04/15/16 was inaccurate. Resident #198 was admitted to the facility with a Stage 2 pressure ulcer on the sacrum. b) Resident #103 Medical record review on 06/15/16 at 11:55 a.m., found Resident #103 was admitted to the facility on [DATE]. The admission nursing assessment/body audit completed by Registered Nurse (RN) #49, and the physician's history and physical, indicated the resident had a Stage 2 pressure ulcer on the sacrum and a surgical wound on the left thigh. No measurements were found. Review of Resident #103's admission MDS assessment with an assessment reference date (ARD) of 05/11/16, found Section labeled skin conditions coded as: one unstageable pressure ulcer on the sacrum. Interview with the director of nursing (DON) on … | 2020-02-01 |
| 4058 | 4058 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 279 | D | 0 | 1 | X1PF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observation, record review, and staff interview, the facility failed to develop care plans, based on the resident's comprehensive assessments, for two (2) of thirty-two (32) residents whose's care plans were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #122's activity care plan did not include interventions which were realistic and measurable. Resident #198's care plan did not address the resident's pressure ulcer. Resident identifiers: #122 and #198. Facility census: 100. Findings include: a) Resident #122 Record review at 8:00 a.m. on 06/16/16, found the resident's current care plan addressing activities was: - Care plan problem: Resident exhibits or is at risk for limited meaningful engagement related to cognitive impairments. - The goal associated with this problem: Resident will increase social engagement as evidenced by participation in one on one visits, small groups, and unstructured involvement with peers/family/staff. - Interventions included: Review monthly calendar with resident to identify interests and preferences. Review of the resident's most recent minimum data set (MDS), a significant change MDS, with an assessment reference date (ARD) of 03/31/16, noted the resident could not be interviewed because he was rarely/never understood. The MDS noted the resident was severely impaired in cognitive skills for daily decision-making. The Brief Interview for Mental Status (BIMS) could not be completed because the resident was rarely/never understood. Review of the most recent activity assessment, dated 04/01/16, noted an interview for daily and activity preferences could not be conducted with the resident. Observation of the resident in Stage I of the survey on 06/14/16 at 3:30 p.m., found the resident was non-verbal and unable to answer any questions. At 8:30 a.m. on 06/16/16, during an interview regarding the resident's current care plan Activity Director (AD) #65, agreed it would not be … | 2020-02-01 |
| 4059 | 4059 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 280 | D | 0 | 1 | X1PF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise the care plan for one (1) of four (4) residents reviewed for the care area of pressure ulcers. The care plan was not revised after the use of Hydraguard to the resident's right and left heels, and A&D ointment to her right and left legs was discontinued. Resident Identifier: #149. Facility Census: 100. Findings include: a) Resident #149 A review of Resident #149's care plan on 06/14/16 at 3:00 p.m., found an intervention, initiated on 03/15/16, to apply A&D ointment bilaterally to the resident's legs as ordered. There was also an intervention to cleanse the resident's left and right heels, pat dry, and apply Hydraguard as ordered. A review of the physician's orders [REDACTED]. Then simultaneously, there was a new order to apply A&D ointment to the right and left legs daily and PRN for itching. A review of the treatment administration record (TAR) found the A&D was discontinued on 04/05/16. The treatment to apply Hydraguard was discontinued on 03/29/16. Regional Resource Nurse (RRN) #133 on 06/14/16 at 4:00 p.m., stated there were physician orders [REDACTED]. The RRN stated the resident was admitted into the hospital, and the A&D ointment was not put back on the physician's orders [REDACTED]. The RRN confirmed the care plan was not revised to reflect the treatment updates. | 2020-02-01 |
| 4060 | 4060 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 282 | D | 0 | 1 | X1PF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, staff interview, and policy review, the facility failed to implement the care plan for two (2) of thirty-two (32) Stage 2 sampled residents. The facility did not implement Resident #139's care plan related to the treatment of [REDACTED].#153's care plan in regards to pain management. Resident identifiers: #139 and #153. Facility Census: 100. Findings include: a) Resident #139 1. [MEDICAL CONDITION] Review of Resident #139's medical record at 12:28 p.m. on [DATE], found she was admitted to the facility on [DATE] shortly after midnight. She was admitted from the hospital where she had the right upper lobe of her lung removed. She remained at the facility until she expired on [DATE]. Resident #139's admitting [DIAGNOSES REDACTED]. Resident #139's discharge medications from the hospital included the following medications used to treat hypertension: - [MEDICATION NAME] 25 milligrams (mg) every 12 hours, and - Amidarone 200 mg 2 tablets daily for seven (7) days then decrease to 200 mg daily thereafter. Review of the facility's admission orders [REDACTED]. A review of Resident #139's care plan found the following focus statement, (Residents Name) is at risk for complications related to a [DIAGNOSES REDACTED]. The goal associated with this focus statement was, Resident's blood pressure will remain within baseline parameters through next review. This goal had a target date of [DATE]. The goals associated with this problem statement included, Administer Meds (medications) as ordered and assess for effectiveness and side effects and report abnormalities to physician and obtain vital signs as ordered and report abnormalities to physicians. Review of Resident #139's nursing admission assessment dated [DATE] at 12:45 a.m. found the resident's blood pressure on admission was ,[DATE] and she was orientated to person, place and time. Further review of the record found that on [DATE] at 11:46 a.m., Resident #139's bl… | 2020-02-01 |
| 4061 | 4061 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 309 | G | 0 | 1 | X1PF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family interview, review of the facility's policies, and staff interview, the facility failed to ensure each resident was provided the necessary care and services to attain or maintain the highest practicable physical well-being. The facility did not ensure physician's orders [REDACTED]. Resident #198's [MEDICATION NAME] time/international ratio (PT/INR), a laboratory (lab) test, was not obtained as ordered resulting in actual harm. Resident #196's [MEDICATION NAME] test was not read seventy-two (72) hours after the administration. The facility failed to address Resident #139's [MEDICAL CONDITION] promptly, failed to assess her neurological status accurately, failed to complete neurological assessments after the resident experienced an unwitnessed fall, and failed to ensure the resident was transported to the right psychiatry office, therefore delaying the treatment of [REDACTED].#153 received adequate pain management by not assessing the effectiveness of an as needed pain medication. For [MEDICAL TREATMENT] Residents #149, #15, #111, #134, and #199, the facility failed to have blue clamps at the bedside as directed by the physician. Resident identifiers: #198, #196, #139, #153, #149, #15, #111, #134 and #199. Facility census: 100. Findings include: a) Resident #198 Review of the resident's medical record on [DATE] at 3:00 p.m., revealed a physician's orders [REDACTED]. Further record review found the PT/INR was obtained on [DATE] (Tuesday). On [DATE] the facility received the PT/INR results of 3.9, which was high. There was no evidence found in the resident's medical record indicating the physician was notified of the PT/INR results. The resident continued to receive [MEDICATION NAME] 5 milligrams (mg) on [DATE], [DATE], and [DATE], resulting in actual harm to the resident. Within 24 hours after discharge from the facility, the resident was admitted to the hospital for [MEDICATION NAME] toxicity. Interview wit… | 2020-02-01 |
| 4062 | 4062 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 314 | D | 0 | 1 | X1PF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #198, who had a pressure ulcer on admission, received the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. Resident identifier: #198. Facility census: 100. Findings include: a) Resident #198 Review of Resident #198's medical record on 06/15/16 at 9:55 a.m., found Resident #198 was admitted to the facility on [DATE]. The admission nursing assessment/body audit completed by Registered Nurse (RN) #49, indicated the resident had a Stage II pressure ulcer on the sacrum, but no measurements for the wound were found. The resident's admission orders [REDACTED]. No evidence of implementation of treatment and/or preventative measures was found in the resident's medical record (physician's orders [REDACTED].) The Skin Integrity Reports (SIR), reviewed on 06/15/16 at 11:05 a.m., found Licensed Practical Nurse (LPN) #88 completed the SIRs on 04/11/16. The nurse identified the area as moisture associated skin damage (MASD). Review of Resident #198's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 04/15/16, found it indicated no pressure ulcers were present. Interview with the Director of Nursing (DON) on 06/15/16 at 12:30 p.m., confirmed Resident #198 was admitted to the facility with a Stage II pressure ulcer on the sacrum. She further verified, after reviewing the resident's records, there were no orders for the care and treatment of [REDACTED]. She also confirmed the SIRs were inaccurate. | 2020-02-01 |
| 4063 | 4063 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 323 | D | 0 | 1 | X1PF11 | Based on record review and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible for Resident #153. Resident #153 had items placed on the fall mat which posed an accident hazard. Resident Identifier: #153. Facility Census: 100. Findings Include: a) Resident # 153 An observation of Resident #153 at 9:40 a.m. on 06/16/16, found the resident laying on her bed. Her bed was placed against the wall on the left side. On the right side of the bed was a fall mat which ran the length of the bed. The resident's over-bed table was placed on the mat and was running parallel to the bed. An additional observation and interview with the Nursing Home Administrator at 9:55 a.m. on 06/16/16, confirmed the over-bed table should not be on the fall mat. Another observation of Resident #153 at 3:11 p.m. on 06/16/16 found the resident was again in bed with the left side of her bed against the wall and a fall mat to the right side of the bed. On the fall mat was Resident #153's Rock-n-go wheelchair. The resident had her hand on the wheel of the chair and had her legs half way out of the bed. Clinical Reimbursement Coordinator (CRC) #8 was close by and was asked to come and assist the resident. She entered the room and assisted the resident back into the bed. The resident then again tried to climb out of bed at which time CRC #8 went and got other staff members to assist the resident into her wheelchair. When asked if Resident #153 was capable of getting her wheelchair and placing it on the mat, CRC stated, I doubt she could do that. She indicated the resident may have done it, but it was not very likely. | 2020-02-01 |
| 4064 | 4064 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 329 | E | 0 | 1 | X1PF11 | **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 during Stage 2 of the Quality Indicator Survey (QIS) was free from unnecessary medications. Resident #171 was receiving duplicate medications, (multiple medications of the same pharmacological class), without a clinical rationale. Resident identifier: #171. Facility census: 100. Findings include: a) Resident #171 Record review on 06/15/16 at 9:00 a.m., found the resident was admitted to the facility on [DATE]. The resident was currently receiving two (2) antidepressants: - [MEDICATION NAME] XR (extended release) 37.5 milligrams (mg) at bedtime for a [DIAGNOSES REDACTED]. - [MEDICATION NAME] 25 mg at bedtime for depression. On 04/18/16, the consultant pharmacist reviewed the resident's medications. The pharmacist documented the resident was receiving two antidepressants and ask the physician to please re-evaluate both antidepressants at the current dose. On 06/01/16, the pharmacist again evaluated the resident's drug regimen. The pharmacist reported to the physician, Pharmacy recommendations for (Resident #171) from (MONTH) have not been acted upon by the intended recipient of the recommendation in accordance with the State Operation Manual guidelines. Please follow up on the outstanding pharmacy recommendations to assure compliance. At 9:35 p.m. on 06/15/16, Registered Nurse (RN) #132, unit manager, confirmed the physician had not addressed the 04/18/16 pharmacist's report or the most recent 06/01/16 pharmacist's report. According to the guidance to surveyors for this regulation, duplicate therapy is generally not indicated, unless current clinical standards of practice and documented clinical rationale confirm the benefits of multiple medications from the same class or with similar therapeutic effects. An interview with the director of nursing (DON) on 06/16/16 at 10:30 a.m., found she was unable to provide any evidence the physic… | 2020-02-01 |
| 4065 | 4065 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 371 | E | 0 | 1 | X1PF11 | Based on observation, staff interviews, and the facility's guideline, the facility failed to maintain the Cafe nourishment refrigerator at proper temperature and failed to discard foods were expired and past their use by date. In addition, the resident room refrigerator temperatures were not being checked. This had the potential to affect more than a limited number of residents. Facility census: 100. Findings include: a) Cafe nourishment refrigerator Observation of the Cafe nourishment refrigerator on 06/13/16 at 11:35 a.m., found six (6) slices of American cheese with a use by date of 02/28/16, fresh ground horseradish eight (8) ounces with an open date of 04/19/16 and an expiration date on top of the lid of 01/12/15. In an interview with Cook #6 on 06/13/16 11:37 a.m., she confirmed the items should have been discarded. The cook said she checked the refrigerator once a week. Director of Dining Services #73 on 06/15/16 at 9:08 a.m., agreed the American cheese and the fresh ground horseradish should have been thrown away. She stated, The cook is to check this refrigerator daily and dispose of food that has expired or has passed their used by date. b) Resident refrigerators During a random observation on 06/15/16 at 3:25 p.m., it was discovered the Refrigerator Temperature Logs had missing daily temperatures. The Refrigerator Temperature Logs for resident refrigerators in 3A and 3B had missing temperatures on 06/02/16, and from 06/04/16 to 06/11/16. In room 12B, the missing temperatures were from 06/06/16 to 06/07/16, and 06/10/16 to 06/12/16, and for Room 16B there was a missing temperature for 06/06/16. During an observation with the Housekeeping Supervisor on 06/16/16 at 9:10 a.m., he verified the refrigerators in Rooms 3A, 3B, 12B, and 16B had missing temperatures on their Refrigerator Temperature Logs. At that time he provided a copy of the Refrigerator Temperature Logs with the missing daily temperatures. c) The facility's policy for Refrigeration/Freezer Temperature Standards, with a revision date of 12/01/… | 2020-02-01 |
| 4066 | 4066 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 428 | D | 0 | 1 | X1PF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the physician acted upon the consulting pharmacist's recommendations for a review of Resident #171's medications. The pharmacist identified the resident was receiving duplicate medications (multiple medications within the same pharmacological class) for treatment of [REDACTED]. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #171. Facility census: 100. Findings include: a) Resident #171 Record review on 06/15/16 at 9:00 a.m., found the resident was admitted to the facility on [DATE]. The resident was receiving two (2) antidepressants: - Effexor XR (extended release) 37.5 milligrams (mg) at bedtime for a [DIAGNOSES REDACTED]. - Zoloft 25 mg at bedtime for depression. On 04/18/16, the consultant pharmacist noted the resident was receiving two (2)antidepressants and ask the physician to please re-evaluate both antidepressants at the current use. On 06/01/16, the pharmacist again evaluated the resident's medications. The pharmacist reported, Pharmacy recommendations for (Resident #171) from (MONTH) have not been acted upon by the intended recipient of the recommendation in accordance with the State Operation Manual guidelines. Please follow up on the outstanding pharmacy recommendations to assure compliance. At 9:35 p.m. on 06/15/16, Registered Nurse (RN) #132, unit manager, confirmed the physician had not addressed the 04/18/16 pharmacist's report or the most recent 06/01/16 pharmacist's report. An interview with the director of nursing (DON) on 06/16/16 at 10:30 a.m., found she was unable to provide any evidence the physician had reviewed or acted upon the consulting pharmacist's recommendations of 04/18/16 and 06/15/16. The DON was unable to provide evidence the physician addressed the clinical rationale for the use of two (2) antidepressants. | 2020-02-01 |
| 4067 | 4067 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 465 | D | 0 | 1 | X1PF11 | Based on observation and staff interview, the facility failed to provide a safe and functional environment for one (1) of thirty-five (35) Census sample residents reviewed. The bed lock was not present/or functional on the bottom of the right side of the bed, allowing the bed to move freely. Resident Identifier: #165. Facility census: 100. Findings include: a) Resident #165 An observation of Resident #165's bed on 06/13/16 at 1:00 p.m., found the bed lock missing from the bottom right side of the resident's bed. The bed moved freely about. On 06/14/16 at 2:30 p.m., an observation of the bed lock revealed the brake remained missing from the bottom of the bed on the right side. The bed continued to moved about freely. During an observation and interview with the maintenance director on 06/15/16 at 10:15, he agreed the brake lock was missing on the right side of the bed. He said he would replace the brake that day. | 2020-02-01 |
| 4068 | 4068 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 502 | D | 0 | 1 | X1PF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain laboratory services as directed by the physician for one (1) of five (5) residents reviewed for unnecessary medications and one (1) resident's record reviewed during a random opportunity for discovery. Resident identifiers: #171 and #198. Facility census: 100. Findings include: a) Resident #171 Record review on 06/15/16 at 1:30 p.m., found a copy of a completed blood count (CBC) collected on 04/15/16, noting abnormal laboratory values. The resident's white blood cell count was high, the red blood cell count was low, the resident's hemoglobin was low, the platelet count was high, etc. The physician signed the report and documented the resident was currently receiving the antibiotic [MEDICATION NAME]. The physician did not document the date he reviewed the laboratory report. The physician did document, on the laboratory report, he wanted the CBC repeated in two (2) days. Further review of the resident's Medication Administration Record [REDACTED]. She received the medication from 04/14/16 through 04/23/16. At 2:00 p.m. on 06/15/16, Register Nurse (RN) #132, unit manager, called the laboratory and confirmed the second CBC was never obtained. At 10:12 a.m. on 06/16/16, these findings were discussed with the director of nursing, who confirmed staff were unable to locate a second CBC. b) Resident #198 Review of the resident's medical record on 06/15/16 at 3:00 p.m., revealed a physician's orders [REDACTED]. Further record review found the PT/INR was obtained on 04/12/16 (Tuesday). Interview with the director of nursing (DON), on 06/15/16 at 3:30 p.m., confirmed the PT/INR was not obtained on Monday (04/11/16) as the physician's orders [REDACTED]. | 2020-02-01 |
| 4069 | 4069 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 505 | D | 0 | 1 | X1PF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the physician was notified of laboratory results in a timely manner for one (1) random opportunity of discovery. The results of an ordered [MEDICATION NAME] time/international normalized ratio (PT/INR) tests were not promptly reported to the attending physician. Resident identifier: #198. Facility census: 100. Findings include: a) Resident #198 Review of the resident's medical record on 06/15/16 at 3:00 p.m., revealed a physician's orders [REDACTED]. Further medical record review on 06/15/16 at 3:30 p.m., found the physician was not notified of the PT/INR results. An interview on 06/15/16 at 3:40 p.m., with the director of nursing (DON), confirmed the ordered PT/INR was not called to the physician. The lab form remained unsigned. | 2020-02-01 |
| 4070 | 4070 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2016-06-16 | 514 | E | 0 | 1 | X1PF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to ensure nine (9) of thirty-four (34) resident records were complete, accurate, and accessible. Resident #139's medical record contained inaccurate neurological assessments. Resident #153's medical record contained incomplete Medication Administration Records (MAR) in regards to her as needed pain medication. Resident #149's medical record contained inaccurate information regarding the type of wound she had. The medical records of Residents #40 and #155 did not contain evidence of informed consents for the pneumonia vaccine. A staff member said the records were stored off site and it would take five (5) days to get the information. Resident #53's medical record contained results for a Complete Blood Count which was signed by the physician, but was not dated to indicate on what date the results were signed. Resident #196's medical record contained incomplete documentation related to the amount of nutritional supplement he drank. Documentation on Resident #103's wounds was inconsistent throughout the record. For Resident #198, the nurse completing his admission orders [REDACTED]. Additionally, his record contained no documentation regarding his transfer from the facility and did not consistently contain his meal consumption percentages. Resident Identifiers: #139, #153, #149, #40, #155, #171, #196, #103, and #198. Facility Census:100. Findings include: a) Resident #139 Review of Resident #139's medical record at 12:28 p.m. on [DATE]. found the resident was admitted to the facility on [DATE] and remained at the facility until [DATE] when she expired. The resident was admitted from the hospital following a surgery to remove the right upper lobe of her lung and placement of an [MEDICAL CONDITION] (the lower small intestine is brought out through the abdomen) following complications from the lung surgery. Review of the resident's record found two (2) nursing assessm… | 2020-02-01 |
| 4071 | 4071 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2015-09-30 | 159 | D | 0 | 1 | FG3Z11 | Based on review of the facility's financial records for the residents' personal funds accounts and staff interview, the facility failed to ensure the resident or responsible party as applicable, for (1) of four (4) residents whose financial records were reviewed, was informed when the resident's personal fund account was within $200.00 of the Social Security resource limit for West Virginia. Resident identifier: #28. Facility census: 87. Findings include: a) Resident #28 During a review of the personal funds accounts managed by the facility, at 9:00 a.m. on 09/30/15, the account of Resident #28 revealed she had a total balance on 09/28/15 of $2028.78. Resident #28 was a Medicaid recipient and the allowed Social Security Income (SSI) resource limit amount in West Virginia is $2000.00. Staff member #34, who was identified as the person responsible for managing the personal funds accounts, was interviewed at 10:15 a.m. on 09/30/15. When asked if the responsible party for Resident #28 was notified of the resident's account balance, she stated she did not know, but, it was her practice to notify the Social Worker assigned to the resident when a personal funds account balance reached $1,500.00. She presented a copy of the form letter used. During an interview at 10:30 a.m. on 09/30/15,Social Worker #44, who was assigned to Resident #28, acknowledged she had not informed the DHHR (Department of Health and Human Resources) representative, who was responsible for the resident, of the balance which was approaching the Medicaid asset limit and was now over that limit. She stated she was, Planning to talk to him about starting a burial account since she knew the resident did not have one, but had not done so yet. She said she was sure, when contacted, the resident's representative would agree. She acknowledged she had been made aware of the balance, but could not say when. During an interview with the Administrator at 11:30 a.m. on 09/30/15, she agreed it would have taken months for the balance of the personal funds account … | 2020-02-01 |
| 4072 | 4072 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2015-09-30 | 250 | D | 0 | 1 | FG3Z11 | Based on review of the facility's financial records for the residents' personal funds accounts and staff interview, the facility failed to provide medically-related social services for one (1) of four (4) residents whose personal funds accounts were reviewed in Stage 2 of the survey. A resident wh received Medicaid assistance was found to have a balance on 09/28/15, of $2028.78, which was above the Social Security Income (SSI) asset level of $2000.00 set forth by Medicaid in that state of West Virginia. Resident identifier: #28. Facility census: 87. Findings include: a) Resident #28 Review of the personal funds accounts managed by the facility, at 9:00 a.m. on 09/30/15, found the account of Resident #28 had a total balance on 09/28/15, of $2028.78. Resident #28 was a Medicaid recipient, and the allowed resource limit amount in West Virginia is $2000.00. In an interview at 10:15 a.m. on 09/30/15, Staff Member #34, who was identified as the bookkeeper responsible for managing the personal funds accounts, was asked if the responsible party for Resident #28 had been notified. She stated she did not know, but it was her practice to notify the Social Worker assigned to the resident when a resident's personal funds account balance reached $1,500.00. She presented a copy of the form letter used. During an interview at 10:30 a.m. on 09/30/15, Social Worker #44, who was assigned to Resident #28, acknowledged she had not informed the DHHR (Department of Health and Human Resources) representative and HCS (Health Care Surrogate) who was responsible for the resident of the balance which was approaching the SSI limit and was now over that limit. She stated she had not notified the responsible party because she had been on vacation. When asked, she said she usually notified the responsible party when the resident's account was fairly close to the maximum. She stated she was planning to talk to him about starting a burial account, since she knew the resident did not have one, but had not done so yet. She said she was sure, when c… | 2020-02-01 |
| 4073 | 4073 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2015-09-30 | 272 | D | 0 | 1 | FG3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure the accuracy of the initial comprehensive assessment for one (1) of twenty-four (24) Stage 2 sample residents. The resident's functional capacity related to contractures of the fingers of her dominant hand limiting her ability to eat independently was not accurate. Resident identifier: #59. Facility census: 87. Findings include: a) Resident #59 Review of the resident's medical record, on 09/29/15 at 12:30 p.m., revealed Resident #59 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/07/15, in Item S3100A was coded as 0, indicating no hand contractures. During an interview with Occupational Therapist (OT) #116, on 09/29/15 at 3:00 p.m., she confirmed the resident had contractures of her finger joints. The resident had been evaluated on admission for a decline in her upper extremity function, poor intake, joint pain and stiffness, and contracture management. The resident declined the recommendation for adaptive eating utensils. Observation of Resident #59's hands during activities on 09/29/15 at 3:15 p.m., noted them to be severely arthritic with enlarged stiff joints. She could not straighten her fingers. On 09/29/15 at 3:35 p.m., the MDS coordinator verified the admission MDS for Resident #59 was incorrectly coded for hand contractures. | 2020-02-01 |
| 4074 | 4074 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2015-09-30 | 279 | D | 0 | 1 | FG3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive and/or initial care plan based on a resident's current health condition/status that included measurable objectives and timetables to meet a resident's medical, nursing and psychosocial needs. Two (2) of twenty-four (24) Stage 2 sample residents whose care plans were reviewed during the Quality Indicator Survey (QIS) for the care areas of pressure ulcers and contractures were affected. Resident identifiers: #106 and #59. Facility census: 87. Findings include: a) Resident #106 On 09/23/15 at 12:30 p.m., a medical chart review revealed this [AGE] year-old female was admitted on [DATE]. Her initial admitting nursing assessment, dated 05/02/15 at 2:05 a.m., identified a reddened coccyx. On 05/17/15, a Stage II pressure ulcer measuring 2.5 centimeters (cm) by 2.0 cm by 0.1 cm with necrotic tissue was identified on the coccyx. The care plan revealed no individualized measurable goals or established interventions to meet the immediate needs of the resident at the time of admission for the identified reddened coccyx. The care plan lacked any interventions for the prevention of pressure ulcers for this resident who was identified at high risk for the development of pressure ulcers. During an interview with the Assistant Director of Nursing (ADON) on 09/30/15 at 9:10 a.m., she verified the care plan did not make any reference to Resident #106's reddened coccyx on admission, nor did it establish any goals or interventions to prevent further breakdown and development of pressure ulcers. b) Resident #59 Review of the resident's medical record, on 09/29/15 at 12:30 p.m., revealed Resident #59 was admitted to the facility on [DATE], under Hospice services for coronary [MEDICAL CONDITION] and [MEDICAL CONDITION] arthritis. The current care plan dated 08/11/15, failed to identify which services and when they were to be provided by the Hospice staff. In an interview on 09… | 2020-02-01 |
| 4075 | 4075 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2015-09-30 | 314 | G | 0 | 1 | FG3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, review of information from the National Pressure Ulcer Advisory Panel, The Resident Assessment Instrument Manual, and the Wound Ostomy and Continence Nurses Society, and staff interview, the facility failed to ensure that a resident admitted with impaired skin integrity and identified to be at risk for the development of pressure ulcers, received the necessary preventative treatment and/or services to prevent the development of a pressure ulcer. In addition, the nurse failed to maintain aseptic technique during wound care, creating a potential for cross contamination and infection when performing wound care. This practice was found for one (1) of three (3) Stage 2 sample residents reviewed for pressure ulcers during the Quality Indicator Survey (QIS). Resident #106. Facility census: 87. Findings include: a) Resident #106 Review of the resident's medical record on 09/23/15 at 12:30 p.m., revealed Resident #106 had a healing Stage III pressure ulcer to her coccyx and was being treated by the wound clinic every two (2) weeks. Her [DIAGNOSES REDACTED]. Her initial admitting nursing assessment, dated 05/02/15 at 2:05 a.m., identified a reddened coccyx. On 05/17/15 a Stage II pressure ulcer, measuring 2.5 centimeters (cm) by 2.0 cm by 0.1 cm with necrotic tissue was identified on the resident's coccyx. Resident #106 required visits to an out of State wound care clinic for treatment. Between the dates of 06/26/15 and 07/15/15, the coccyx wound had debridement performed by the wound clinic and the wound was upgraded to a Stage III. (Note: according to pressure ulcer staging definitions from the National Pressure Ulcer Advisory Council, the Resident Assessment Instrument Manual, and the Wound Ostomy and Continenct Nurses Society, once the wound developed necrotic tissue, it had progressed beyond a Stage II pressure ulcer. A pressure ulcer does not display necrotic tissue until at least Stage III. If … | 2020-02-01 |
| 4076 | 4076 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2015-09-30 | 431 | E | 0 | 1 | FG3Z11 | Based on observation, review of the Centers for Disease Control and Prevention (CDC) guidelines, and staff interviews, the facility, in coordination with the licensed pharmacist, failed to ensure secure storage of controlled medications. Benzodiazepines (Ativan) were stored in the medication refrigerator in a locked clear box, which was affixed to a removable wire shelf in the refrigerator. The facility also failed to ensure a multi-dose vial of tuberculin solution was properly labeled. This practice had the potential to affect more than a limited number of residents. Facility census: 87. Findings include: a) During an observation, on 09/28/15 at 1:45 p.m., one (1) of two (2) medication refrigerators contained 2 - 2 cc (cubic centimeter) vials of injectable Ativan stored in a locked clear box which was affixed to a removable wire shelf in the refrigerator. The refrigerator also contained a multi-dose vial of tuberculin (TB) solution was open and not dated to indicate when it was opened, or by when it needed to be discarded. In an interview, on 09/28/15 at 1:50 p.m., Director of Maintenance (DOM) #73 and Assistant Director of Nursing (ADON) #31 stated the medication refrigerator was purchased and put in use within the last year. DOM #73 stated he had installed the storage boxes to the shelf and confirmed the shelf was not permanently affixed to the refrigerator. The ADON #31 stated the facility should have dated the TB solution when they opened it. The ADON #31 disposed of the TB solution. Review of the CDC's recommendations for multi-dose vials includes: Medication vials should always be discarded whenever sterility is compromised or questionable. In addition, the United States Pharmacopeia (USP) General Chapter 797 (16 ) recommends the following for multi-dose vials of sterile pharmaceuticals: If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. | 2020-02-01 |
| 4077 | 4077 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2015-09-30 | 441 | F | 0 | 1 | FG3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility policy review, record review, and staff interview the facility failed to implement and/or maintain an Infection Prevention and Control Program. This was evidenced by the improper cleaning and storage of resident care equipment; failure to use the proper technique during wound care observation; and failure to provide evidence of adequate monthly infection control surveillance to prevent, to the extent possible, the onset and the spread of infection in the facility. These infractions directly involved the care of one (1) resident during observation and had the potential to affect the entire population. Resident identifier: #106. Facility census: 87. Findings include: a) The Infection Control Surveillance reports for (MONTH) and (MONTH) (YEAR) were received from RN #31 (Infection Preventionist) at 11:00 a.m. on 09/29/15. Review of the offered documentation failed to reveal an informative and complete picture of an ongoing collection, analysis, and interpretation of data to identify infections and infection risks used to try to reduce infection rates and to improve resident health status as required. The monthly surveillance report for (MONTH) and (MONTH) (YEAR) identified only the number of the type of infection and which wing of the facility the infection was located on. There was no identifying information of resident name, age, room number, or attending physician. The [DIAGNOSES REDACTED]. Additional information was requested several times during the morning of 09/30/15, and appropriate isolation requirements were presented, but additional evidence of surveillance was not received. During an interview with the Administrator and RN #31 at 11:50 a.m. on 09/30/15, the Administrator located an Infection Control Manual, which was in her office for review. It included a policy which was dated as reviewed/revised 08/24/10 and 12/11/13, entitled, Surveillance for Healthcare-Associated Infections. The facility policy req… | 2020-02-01 |
| 4078 | 4078 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 159 | D | 0 | 1 | KKFY11 | Based on staff interview, resident interview, policy review, and record review, the facility failed to notify the responsible party and/or resident when the resident's personal funds were within $200.00 of the supplemental security income (SSI) limit of $2,000.00. This was true for one (1) of one (1) resident reviewed for the care area of personal funds. Resident identifier: #137. Facility census: 105. Findings include: a) Resident #137 Review of the care area of personal funds, during Stage 2 of the Quality Indicator Survey (QIS), revealed Resident #137's personal funds account, managed by the facility, totaled $1,887.48 on 07/13/16 at 3:00 p.m. At 3:20 p.m. on 07/13/16, when asked how the facility notified residents/responsible parties when personal funds were within $200.00 of the $2,000.00 limit, Business Office Manager (BOM) #57 stated she notified Social Worker (SW) #108. BOM #57 verified she had no proof of notification of the resident/responsible party when the resident's personal funds were within $200.00 of the allowable amount for a single person receiving Medicaid benefits. She confirmed the allowable amount is was $2,000.00. BOM #57 verified awareness the resident could lose eligibility for Medicaid funding if personal funds exceeded $2,000.00. At 3:30 p.m. on 07/13/16, SW #108 said she had no proof, but believed she told the resident's responsible party about the account. SW #108 said the facility had taken the resident out for shopping trips to spend her money. At 2:00 p.m. on 07/14/16, review of the facility's policy entitled Resident Funds, revised on 04/15/16 found the policy included: -- In accordance with state regulations, all medical Assistance residents must be notified monthly when the resident's account reaches $200.00 of the state's asset level for Medicaid eligibility. -- Prior to notifying the resident/responsible party, review the account to ensure that all activity has been properly recorded (e.g., care cost withdrawals and deposits). -- Maintain a copy of the notification letter in … | 2020-02-01 |
| 4079 | 4079 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 164 | D | 0 | 1 | KKFY11 | Based on a random observation and staff interviews, the facility failed to provide privacy to Resident #39 when staff failed to close the privacy curtain and/or door to the resident's room when providing care. Resident identifier: #39. Facility census: 105. a) Resident #39 On 07/13/16 at 9:34 a.m., Nurse Aide (NA) #156 assisted Resident #39 with the resident's privacy curtain open. The resident's gown was inside her brief. NA #156 assisted the resident to pull up her brief and adjust her clothes. After this observation NA #156 said, Let's pull the curtain. On 07/14/16 at 11:58 a.m., when informed of what had happened with Resident #39's being exposed during personal care, Licensed Practical Nurse (LPN) #149 she had informed the director of nursing (DON). The director of nursing, when informed of the incident on 07/18/16 at 3:00 p.m., agreed the nurse aide should have pulled the privacy curtain before she began assisting the resident with pulling up her brief. | 2020-02-01 |
| 4080 | 4080 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 166 | D | 0 | 1 | KKFY11 | Based on family interview and staff interview, the facility failed to actively seek resolution to a complaint of missing personal items and keep the family apprised of the progress towards resolution. This was true for one (1) of one (1) resident who triggered the care area of personal property during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #74. Facility census: 105. Findings include: a) Resident #74 An interview with the resident's responsible party during Stage 1 of the Quality Indicator Survey revealed the responsible party reported some missing clothing to facility staff. The family member reported, during a visit in (MONTH) (YEAR), clothing was missing. A staff member in laundry told the family member to look in the lost and found. The family member reported she did and she found some of the missing items, but not all of them. She said the resident's name was marked in her clothing. When asked if the facility told her they would look for the missing items, she stated, No, they didn't do anything, I was the one who looked for the items. The family member stated she told the staff member working in laundry she had not found the resident's clothing. During an interview at 8:17 a.m. on 07/13/16 regarding the family member's concern Housekeeping Supervisor (HS) #169 said she remembered the following, About a couple of months ago (name of resident) told me a pair of blue pants were missing. The resident described the pants, and she found the pants in the lost and found. She returned the pants to the resident. She said, According to my evening shift girl, the daughter had also looked in lost and found and found some stuff but she (the daughter) didn't find everything when she looked. HS #169 said the staff member who talked to the daughter would be at work this evening and I could interview the staff member for more information. HS #169 identified Laundry Worker #164 as the staff member who talked with the daughter. HS #169 said the facility policy when family members reported missing cl… | 2020-02-01 |
| 4081 | 4081 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 226 | C | 0 | 1 | KKFY11 | Based on policy review and staff interview, the facility failed to ensure its abuse policy addressed the reporting of allegations of neglect. This practice had the potential to affect all residents. Facility census: 105. Findings include: a) On 07/14/16 at 4:30 p.m., review of the facility's abuse prohibition policy, revised on 10/15/15, the policy stated under Process 5., Upon receiving information concerning a report of suspected or alleged abuse, the Administrator or designee will: 6.1 Enter allegation into the Risk Management System (RMS) 6.2 Report as follows: . This section did not mention neglect. During an interview on 07/14/16, at 4:45 p.m., when questioned about the policy not addressing neglect under the section titled Process 5, Social Worker (SW) #157 said she would review the policy. On 07/18/16 at 2:11 p.m., SW #157 said the facility felt the statement under Process 1, The administrator or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property would address the reporting of neglect. SW #157 was told that even though the statement under Process 1. did address operationalizing policies, it did not address reporting neglect. In #5, the policy addressed reporting, but did not specify the facility would report allegations of neglect. At 3:00 p.m. on 07/18/16, SW #157 said a corporate employee would add the word neglect to the facility's abuse prohibition policy under #6 regarding allegations to be reported. | 2020-02-01 |
| 4082 | 4082 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 241 | D | 0 | 1 | KKFY11 | Based on observation and staff interview, the facility failed to ensure two (2) residents, observed during random dining observations, were provided dignity during dining. Staff members stood over the residents while assisting them to eat. In addition, a random observation found the facility failed to ensure privacy during personal care. Resident identifiers: #35, #150, and #39. Facility census: 105. Findings include: a) Resident #35 Observation of the noon meal on 07/11/16 at 12:52 p.m. revealed the resident was in his room, in bed, during the meal. Nurse Aide (NA) #98 stood over the resident while feeding him. At 1:05 p.m. on 07/11/16, when asked why she did not sit down while feeding the resident, NA #98 stated, His bed was up. When asked whether she asked the resident if she could put the bed down, she replied, No. A second observation of the meal service at 8:13 a.m. on 07/12/16, found NA#124 standing over the resident while feeding him his breakfast. At 8:44 a.m. on 07/12/16, NA #124 stated, Sometimes I sit down and sometimes I stand. At 8:44 a.m. on 07/12/16, Resident #35 said he did not mind if staff lowered his bed and sat down to feed him. He said, I just want them to stay as long as they can because I am lonesome and I like to talk to them. At 11:11 a.m. on 07/18/16, when informed of these observations, the Director of Nursing (DON) stated she was made aware of this issue and was being taken care of. b) Resident #150 Observation of the noontime meal on 07/11/16 beginning at 12:18 p.m., found Nurse Aide #162 was feeding Resident #150 while standing beside her. An interview with NA #162 at 12:30 p.m. on 07/11/16 confirmed that she fed Resident #162 while standing beside her. When asked if she should have been seated while feeding Resident #162 she stated, Well her bed is kind of high and there is no chair in the resident's room. A further observation found her bed was adjustable and pushing a button would lower or raise the bed. A folding chair sat beside the resident's nightstand. c) Resident #39 On 07/… | 2020-02-01 |
| 4083 | 4083 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 253 | E | 0 | 1 | KKFY11 | Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services to provide a safe, sanitary, orderly, and comfortable interior. Heavily soiled chairs, dirty and broken air conditioning units, and cosmetic imperfections to the walls and doors were identified in six (6) of thirty-three (33) rooms observed during Stage 1 of the Quality Indicator Survey (QIS). Facility Census: 105. Findings include: a) 100 Hall Observations of Room #115 at 3:31 p.m. on 07/11/16 and at 8:35 a.m. on 07/12/16, found two (2) chairs in the room that were heavily soiled with an unidentified substance. b) 200 Hall Observation of room 214 at 4:22 p.m. on 07/11/16 found the chair in the room heavily soiled with an unidentified substance and the air conditioning unit was dirty. Observation of room 217 at 4:25 p.m. on 07/11/16 found the chair in the room heavily soiled with an unidentified substance. c) 400 Hall Observation of room 407 at 1:42 p.m. on 07/11/16 found a large black scuffmark along the front wall beginning near the bathroom door. Observation of room 409 at 10:57 a.m. on 07/12/16 found the air conditioning unit contained dirt/debris and there was a hole in the bathroom door. Observation of room 410 at 1:14 p.m. on 07/11/16 found that the air conditioning unit had a broken slat. d) Tour with facility staff A tour with the Maintenance Director and Nursing Home Administrator beginning at 2:24 p.m. and ending at 2:43 p.m. on 07/14/16 confirmed these findings. | 2020-02-01 |
| 4084 | 4084 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 272 | D | 0 | 1 | KKFY11 | Based on record review and staff interview, the facility failed to conduct an accurate comprehensive minimum data set (MDS) assessment for Resident #107 in the area of behaviors. This was true for one (1) of one (1) resident reviewed for the care area of behavioral and emotional status during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #107. Facility Census: 105. Findings Include: a) Resident #107 A review of Resident #107's medical record at 10:28 a.m. on 07/18/16 found a Significant Change MDS with an assessment reference date (ARD) of 04/22/16. The assessment indicated Resident #107 demonstrated physical and verbal behavioral symptoms one (1) to three (3) days during the seven (7) day look back period. Further review of the resident's medical record found no evidence to support Resident #107's exhibited physical and verbal behaviors. An interview with Social Worker #108 (SW) at 10:28 a.m. on 07/18/16, confirmed the resident did not have behaviors documented in his medical record. She said she thought the look back period was 30 days instead of 7 days. She indicated she had talked to the MDS coordinator and they were going to do a correction for this MDS. | 2020-02-01 |
| 4085 | 4085 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 279 | D | 0 | 1 | KKFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan that addressed Resident #147's inability to initiate sleep. For Resident #109 the facility failed to develop a comprehensive care plan related to restrictions to her left arm due to her [MEDICAL TREATMENT] access. This was true for two (2) of twenty-three (23) resident care plans reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifiers: #147 and #109. Facility Census: 105 Findings Include: a) Resident #147 A review of Resident #147's medical record at 8:05 a.m. on 07/13/16 found a physician order [REDACTED]. Further review of the record found another physician's orders [REDACTED]. Further review of the record found a physician's orders [REDACTED].#147'[MEDICATION NAME] to 2.5 mg for two (2) weeks, and then discontinue. Additional review of the record found another physician's orders [REDACTED]. A review of Resident #147's care plan found it did not address the resident's inability to initiate sleep ([MEDICAL CONDITION]). An interview with the Director of Nursing (DON) at 9:52 a.m. on 07/13/16, confirmed the resident's care plan did not address the resident's inability to initiate sleep ([MEDICAL CONDITION]). b) Resident #109 Medical record review on 07/12/16 at 2:00 p.m. found a physician's orders [REDACTED]. The care plan dated 03/11/16, stated, Impaired renal function and is at risk for complications related to [MEDICAL TREATMENT], port with fistula. The goal established for this problem stated to maintain electrolyte balance and avoiding fluid overload. There was no goal established to prevent complications of the [MEDICAL TREATMENT] port with fistula as identified in the problem. The interventions for this care plan addressed complications that could occur with [MEDICAL TREATMENT]; however, there was no intervention for the restriction specified by the physician on 03/11/16 for No B/P is Left Arm. Further review … | 2020-02-01 |
| 4086 | 4086 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 282 | D | 0 | 1 | KKFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to implement the care plan interventions for a resident with a history of falls. Resident #109's call light and walker were not in reach as directed by the resident's care plan to prevent additional falls from unassisted ambulation. This affected one (1) of five (5) residents reviewed for the care area of falls during Stage 2 of the Quality Indicator Survey (QIS) survey. Resident identifier: #109. Facility Census: 105 Findings include: a) Resident #109 An observation of the resident's environment on 07/12/16 at 8:00 a.m., found the resident asleep in bed with her walker folded up behind the curtain out of her reach. Review of Resident # 109's care plan on 07/13/16 at 8:00 a.m., revealed this resident had a history of [REDACTED]. Interventions for this goal included non-slip socks when out of bed without shoes, one (1) person assist with transfers, place walker within reach, and remind the resident to use her call light when attempting to ambulate or transfer. Another observation of the resident on 07/13/16 at 8:20 a.m., found the resident sitting on the side of her bed eating breakfast. Her walker was again out of reach and folded up behind the curtain. Her call light was on the floor. Resident #109 wore a pair of regular socks (not non-skid), and her wheelchair was sitting in the hall. During an interview with Resident #109 on 07/13/16 at 8:35 a.m., she stated her call light was often out of reach on the floor. She stated when she had to go to the bathroom, she tried to get up by herself, and she fell because her legs gave out. Resident #109 stated there was no way to keep her call light cord in reach so it did not fall in the floor. On 07/13/16 at 8:40 a.m., the resident's call light was again on the floor out of the resident's reach. There was no clip on the call light or on the call light cord to secure it to the bed and prevent it from falling. Interview w… | 2020-02-01 |
| 4087 | 4087 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 309 | E | 0 | 1 | KKFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, resident interview, and staff interview, the facility failed to ensure physician ordered restrictions for no blood pressures to be taken in Resident #109's left arm six (6) of fifty-nine (59) times. The facility did not ensure Resident #109's condition was assessed prior to going to [MEDICAL TREATMENT] treatment and failed to ensure coordination of care with the [MEDICAL TREATMENT] center on eleven (11) of sixteen (16) days reviewed. Additionally, there was no evidence the facility assessed Resident #109 and identified that the resident experienced two (2) falls that were within one (1) hour of her returning from [MEDICAL TREATMENT]. This affected one (1) of one (1) resident reviewed for the care area of [MEDICAL TREATMENT] during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #109. Facility Census: 105. Findings include: a) Resident #109 1. Medical record for Resident #109 beginning on 07/12/16 at 2:00 p.m., revealed a physician's orders [REDACTED]. Review of the Vital Sign Summary sheet on 07/12/16 at 2:00 p.m., revealed Resident #109 had her blood pressure checked in her left arm at least six (6) times since 03/11/16. The vital sign summary record did not always specify in which arm her blood pressure was taken, but on 04/03/16, 05/06/16, 05/08/16, 05/22/16, 05/23/16, and 06/28/16 it was identified the left arm was used. 2. Further review of the medical record on 07/12/16 at 2:00 p.m. found the resident's scheduled days for [MEDICAL TREATMENT] were Monday, Wednesday, and Friday. Review of the communication record shared between the facility and the [MEDICAL TREATMENT] center found the facility was to complete the top half of the form, which included the resident's vital signs, weights prior to [MEDICAL TREATMENT], an examination of the access site, the time of the resident's last meal, medications given prior to [MEDICAL TREATMENT], resident's general condition, and a… | 2020-02-01 |
| 4088 | 4088 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 312 | E | 0 | 1 | KKFY11 | Based on record review, staff interview, and observations, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good personal hygiene and grooming. Resident #39 had patches of chin hair that needed removed and was not receiving showers. Resident #74 was not receiving showers. Resident identifiers: #39 and #74. Facility census: 105. Findings include: a) Resident #39 On 07/11/16 at 1:38 p.m., observations found Resident #39 long hairs on her chin. A care plan review on 07/13/16, at 10:30 a.m., revealed Resident #30 needed assistance with activities of daily living (ADL) due to dementia and generalized weakness. The care plan included the resident's ADL needs would be anticipated and met. The care plan did not indicate the resident refused care. During an interview with Nurse Aide (NA) #93, the NA agreed the resident had long chin hair and it should have been trimmed before it was noticed on 07/11/16 at 1:38 p.m. During an interview on 07/13/16, at 11:11 a.m., Licensed Practical Nurse (LPN) #149 said Resident #39 received two (2) showers a week and did not refuse to take them. A review of the activities of daily living record on 07/13/16 at 12:00 p.m. found Resident #39 had one (1) shower in (MONTH) (YEAR) and three (3) showers in (MONTH) (YEAR). NA #93 reviewed the ADL record for (MONTH) (YEAR) on 07/13/16 at 2:00 p.m. and agreed the resident did not receive showers twice a week. He also said she did not refuse showers. He informed an observation of the resident on 07/13/16 at 10:00 a.m. revealed she no longer had chin hair, he mentioned she had a shower on 07/12/16. On 07/18/16 at 2:30 p.m., the director of nursing (DON) provided the shower sheets for Resident #39. These sheets reflected the resident had showers on 04/17/16, 05/16/16, 05/23/16, 05/27/16, 06/01/16, 06/27/16, and 07/12/16. After reviewing the resident's ADL record and shower sheets, the DON agreed the documentation did not indicate the resident had two (2) s… | 2020-02-01 |
| 4089 | 4089 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 315 | D | 0 | 1 | KKFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, resident interview, and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for the care area of urinary catheter use had a valid medical justification to support the use of an indwelling Foley catheter. Resident identifier: #160. Facility census: 105. Findings include: a) Resident #160 During Stage 1 of the Quality Indicator Survey (QIS), at 3:36 p.m. on 07/11/16, the resident's nurse identified the resident had an indwelling Foley catheter. The nurse stated the catheter was for [MEDICAL CONDITION], but could not identify the reason for the resident's [MEDICAL CONDITION]. Medical record review on 07/12/2016 at 2:06 p.m. found the resident, admitted to the facility on [DATE], had admitting [DIAGNOSES REDACTED]. The resident had an indwelling Foley catheter when admitted to the facility. The admission nursing assessment noted the reason for the resident's catheter was Post surgery. The facility had not attempted to remove the resident's catheter since her admission. The guidance to surveyors for this regulation includes, A long term indwelling catheter (greater than 2 to 4 weeks) increases the chances of having a symptomatic UTI (urinary tract infection) & urosepsis (an infection in the blood secondary to a UTI). The incidence of bacteremia (bacteria in the blood) is 40 times greater in individuals with a long term indwelling catheter than in those without one . The resident has had three (3) urinary tract infections since admission, all of which required treatment with an antibiotic. Those were: 1. On 03/11/16, the resident began to receive the antibiotic [MEDICATION NAME] for seven (7) days for a UTI caused by [DIAGNOSES REDACTED] oxytoca. 2. On 04/22/16, the resident began to [MEDICATION NAME] a UTI. 3. On 05/22/16, the final urine culture report identified the organisms as Escherichia coli and [NAME]ella morganii for which the resident received Keflex When interviewe… | 2020-02-01 |
| 4090 | 4090 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 323 | D | 0 | 1 | KKFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review and staff interview, the facility failed to ensure Resident #109 received adequate supervision and assistive devices to prevent accidents. Resident # 109 could not reach her walker and her call light was in the floor and out of her reach.There was no clip or method to secure the call light so it could not fall in the floor. The facility also failed to ensure an assessment was completed and supervision was provided upon the residents return from dialysis after two (2) falls were experienced within one (1) hour of her returning from dialysis treatment. This was true for one (1) of five (5) residents reviewed for the care area of Accidents in Stage 2 of the QIS survey. Resident identifier: # 109. Facility Census: 105. Findings include: a) During an observation 07/12/16 at 9:00 a.m. Resident #109's environment was observed. The resident was observed sleeping in bed, her walker was observed folded up behind the curtain out of her reach. Review of Resident # 109's Medical Record on 07/13/16 at 8:00 a.m., revealed this resident had a history of [REDACTED]. Interventions established to meet this goal included Non-slip socks when out of bed without shoes, one person assist with transfers, place walker within reach, remind resident to use call light when attempting to ambulate or transfers. Dialysis Communication forms were observed to be incomplete and there was no evidence the resident was assessed upon her return from Dialysis treatments. Resident #109 was observed again on 07/13/16 at 8:20 a.m., sitting on the side of her bed eating breakfast. Her walker was again observed behind the curtain folded up and not within her reach. Her call light was observed laying in the floor. Resident #109 had on a pair of regular socks that were not non-skid and her empty wheelchair was sitting in the hall. During an interview with Resident #109 on 07/13/26 at 8:35 a.m., the resident stated her call light is o… | 2020-02-01 |
| 4091 | 4091 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 329 | D | 0 | 1 | KKFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #147's drug regimen was free from unnecessary medications. Resident #147 continued to receive a hypnotic medication for seven (7) days after it was discontinued. Subsequently, the same hypnotic medication was ordered for Resident #147 on an as needed (PRN) basis, and then switched to a scheduled medication although there was no significant use of the PRN medication prior to it being ordered as scheduled medication. After the discontinuation of the medication, it was restarted one week later with no evidence there was an indication for the medication for inability to initiate sleep. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifier: #147. Facility Census: 105. Findings Include: a) Resident #147 A review of Resident #147's medical record at 8:05 a.m. on 07/13/16 found a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. He received 5 doses out of 30 opportunities for him to receive the medication. Further review of the record found another physician's orders [REDACTED]. Review of the nursing progress notes found a change of condition note dated 01/09/16, of . Staff reports resident is up most of night reported to MD (medical doctor) per wife's request new orders noted to [MEDICATION NAME] qhs (every night) and d/c (discontinue) prn. Other than the note on 01/09/16, medical record review found no evidence of the resident's inability to initiate sleep. Further review of the record found a physician's orders [REDACTED].#147'[MEDICATION NAME] decreased to 2.5 mg for two (2) weeks and then discontinued. Resident #147 should have received his last dose [MEDICATION NAME] 05/04/16. However, review of the MAR for (MONTH) (YEAR) found Resident #147 continued to [MEDICATION NAME] until 05/11/16. Resident #147 received seven (7) doses [MEDICATION NAME] it should ha… | 2020-02-01 |
| 4092 | 4092 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 367 | D | 0 | 1 | KKFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, Resident #75 received food that was not within her dietary restrictions ordered by the physician. This was true for one (1) randomly observed resident of the twenty-two (22) residents in the main dining. Resident Identifier: #75. Facility Census: 105. a) Resident #75 Observations in the main dining area on 07/11/16 beginning at 12:40 p.m., observed Resident #75 was shaking her head. Nurse Aide (NA) #89 spoke to this resident and then requested a fruit cup from the kitchen. After receiving the fruit cup, the resident began to eat the fruit, then requested tator tots, (She was nonverbal, but could make her wants known by pointing) instead of the mashed potatoes on her plate). At 1:15 p.m. on 07/11/16, Dietary Cook #85 came out of the kitchen and told NA #122, and NA #89, that Resident #75 was on an Advanced Dysphagia diet and could not have tater tots. It was also verified she should not have the regular fruit cup she was eating. Resident #75's tray card identified the resident should receive an Advanced Dysphagia Diet, however, someone had written REGULAR on the resident's diet card with a pen. At 1:20 p.m. on 07/11/16, NA #122 said she wrote Regular on the tray card earlier because the resident wanted the regular meal and not the alternate. NA #89 stated she thought this REGULAR written on the tray card meant the resident was on a regular diet. Review of the physician's orders [REDACTED].#75's diet order was Regular/Liberalized Diet Dysphagia Advance texture, large portions with meals. The facility's menu spread sheet report provided on 07/19/16 at 11:00 a.m. by the Regional Dietary Manager for the lunch served on 07/11/16 found the resident should have received one-half (1/2) cup of apple sauce rather than a regular fruit cup. | 2020-02-01 |
| 4093 | 4093 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 441 | E | 0 | 1 | KKFY11 | Based on observation, policy review, review of the infection control monthly line listing, and staff interview, the facility's infection control program failed to maintain complete data for monitoring infections. The surveillance data did not include the symptoms exhibited by the residents for determining the type of infection present, the type of precautions indicated were not recorded, and did not identify when the infection was resolved. The facility also failed to keep a catheter bag and the tubing off the floor for Resident #136. These findings had the potential to affect more than an isolated number of residents. Facility Census: 105. Findings include: a) Infection Control Program A review of the facility's infection control monthly line listing for three (3) months, beginning on 07/12/16 at 2:00 p.m., found missing data as follows: -- April: 12 total infections - 2 infections did not list the symptoms, 6 did not list the type of precautions initiated, and 11 infections did not indicate whether the infections resolved. -- May: 14 total infections - 14 infections listed did not list the symptoms, and 14 did not list the date these infections were resolved. -- June: 5 total infections - symptoms, type of precautions, and dates of resolution were not identified for 5 of the infections. During an interview on 07/18/16 at 11:30 a.m., Registered Nurse (RN) Nurse Practice Educator #75 said she had done the facility's infection control monitoring for two (2) months. The RN stated the program utilized the surveillance definitions of infections in long term care facilities to determine whether the definition of an actual infection was met. RN #75 agreed she had not listed the residents' symptoms and had not always identified the precaution type and whether the infection resolved for (MONTH) and (MONTH) (YEAR). On 07/18/16 at 11:40 a.m., the Director of Nursing (DON) said they used nursing notes for the information regarding special types of precautions and dates infections resolved. The DON verified the infection con… | 2020-02-01 |
| 4094 | 4094 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 490 | E | 0 | 1 | KKFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During the facility's Quality Indicator Survey (QIS) conducted 10/12/15 through 10/20/15, the facility received deficiencies related to resident rights, quality of life, and quality of care. Those deficiencies were specifically related to provision of the care and services needed to enable residents to attain and/or maintain the highest practicable, physical, mental and psychosocial well being. These areas included prompt resolutions to grievances, dignity and respect during dining, [MEDICAL TREATMENT] care, activities of daily living (ADL) care to dependent residents, urinary catheter use, accident hazards, and unnecessary medications. An onsite revisit to the facility's QIS which ended 10/20/15 was conducted by the state agency on 01/11/16 through 01/15/16, at which time the facility was found in substantial compliance in the above mentioned areas. The facility is a special focus facility and therefore has a QIS survey every six (6) months. During the QIS survey conducted 07/11/16 through 07/15/16 it was found the facility again had deficient practices in the areas of resident rights, quality of life, and quality of care. The facility again failed to provide a prompt resolution to Resident #74's voiced grievance. Also for Resident #74 and Resident #39 the facility failed to ensure they received ADL care which they were dependent on staff to provide. For Resident #35 and #150 the facility failed to provide them with a dignified dining experience. For Resident #109 the facility failed to ensure corroboration of her [MEDICAL TREATMENT] care between the facility and the [MEDICAL TREATMENT] center and they failed to ensure her environment was as free from accident hazards as possible. For Resident #160 the facility failed to ensure that she had proper medical justification for the use of her indwelling Foley catheter. And for Resident #147 the facility failed to ensure his drug regimen was as free from unnecessary medications as possible. Facili… | 2020-02-01 |
| 4095 | 4095 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 514 | D | 0 | 1 | KKFY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure they maintained clinical records that were accurately documented. Two (2) of 23 sampled residents had inaccurate medical records. Resident #24's medical record did not reflect the percentage of intake for meals and Resident #172's record had an inaccurate admission nursing assessment. Resident identifiers: #172 and #24. Facility census: 105. Findings include: a) Resident #172 During an interview with Resident #172 on 07/12/16, at 9:55 a.m. she described her teeth as a mess. She said she had two (2) good teeth on the bottom and about four (4) on top. The admission minimum data set (MDS) with an assessment reference date (ARD) of 02/11/16 revealed the resident had obvious or likely cavity or broken natural teeth. Medical record review on 07/14/16, at 11:33 a.m. revealed a nursing admission assessment dated [DATE]. The dental section of the assessment listed the resident as having no dental issues. The resident's care plan review, on 07/14/16, at 12:00 p.m., revealed the resident was at risk for oral health or dental care problems as evidenced by carious teeth. During an interview with the director of nursing on 07/14/16, at 12:30 p.m. on 07/14/16, she confirmed the admission nursing assessment was inaccurate in the dental section. | 2020-02-01 |
| 4096 | 4096 | MOUND VIEW | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2016-01-08 | 252 | E | 0 | 1 | UKTS11 | Based on observation, resident interview, family interview, and staff interview the facility failed to provide a homelike dining environment which encouraged links with past experiences and contact with family members. Disallowing family members and/or visitors to be present in the dining room during mealtime fails to support the psychosocial needs of residents. This had the potential to effect more than an isolated number of residents. Facility census 95. Resident identifiers: Unique identifiers are used to protect the confidential nature of the interview, and she will be used regardless of the gender of the resident interviewed. Findings include: a) Initial tour of the facility and observation of the noon meal, at 12:15 p.m. on 01/04/16, revealed the main dining room was very full with all tables occupied. Interview with Dietary Manager (DM) #26, revealed the use of two (2) dining rooms, the main dining room and an auxiliary dining room located between the 500 and 600 halls on the other side of the building. She added that usually only the residents near the auxiliary dining room made use of it. Another room measuring approximately 24 feet by 20 feet and formerly used for dining located adjacent to the main dining room was no longer in use. Observation revealed no visitors in the dining room and when questioned, Registered Nurse (RN) #8 said the facility had made the decision not to allow family and/or visitors to accompany residents in the main dining room during meals, but would make arrangements if they asked to be with the resident during a meal. She said they had made the decision because of dignity concerns and explained they were told it was a dignity issue for visitors to witness residents eating who may have poor eating skills. She wasn't sure how long this policy had been in effect, but said it had been several months. She did admit, when asked, that space was also a reason. She stated the residents had been notified of this and a sign was posted. The main dining room and the sites of postings for the… | 2020-02-01 |
| 4097 | 4097 | MOUND VIEW | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2016-01-08 | 334 | C | 0 | 1 | UKTS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review the facility failed to educate each resident and/or their legal representative on the benefits and potential side effects of the influenza vaccine prior to administering the vaccine during the current (YEAR)-2016 flu season. This was found for five (5) of five (5) Stage 1 sampled residents reviewed during the annual Quality IndicatorSsurvey (QIS). Resident identifiers: #78, #71, #67, #76 and #6. Facility census: 95. Findings include: a) Review of medical records for Residents #78, #71, #67, #76, and #6, on 01/07/16 at 9:00 a.m., revealed all five (5) medical records lacked documentation indicating the resident and/or the resident's legal representative received education regarding the benefits and potential side effects of the influenza vaccine prior to administration during the current flu season. Residents #78, #67, #76, and #6 received the [MEDICATION NAME] flu vaccine on 10/23/15, and Resident #71 received the [MEDICATION NAME] flu vaccine on 10/28/15. Interview with the Medical Records Supervisor #21, on 01/07/16 at 9:30 a.m., confirmed the medical records did not contain consents and/or education regarding the benefits and potential side effects of the influenza vaccine during an interview. Interview with Registered Nurse (RN) #22, on 01/07/16 at 9:35 a.m., revealed she was unaware of the requirement to educate the resident and/or legal representative of the benefits and potential side effects of the current influenza vaccine prior to administering the annual flu shot. RN #22 acknowledged the facility did not hand out and/or educate the resident and/or legal representative prior to administering the annual influenza vaccine for the (YEAR)-2016 flu season. The facility vaccinations policy #4A, states under #4 of the section titled, Policy Interpretation and Implementation: Prior to the vaccinations, the resident or legal representative will be provided information and education re… | 2020-02-01 |
| 4098 | 4098 | MOUND VIEW | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2016-01-08 | 441 | D | 0 | 1 | UKTS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to maintain resident equipment (lap buddies) without breaks in the surface of the covers; hindering the proper sanitizing of the equipment to prevent the onset and spread of infection for two (2) random residents. Resident identifiers: #73 and #87. Facility census 95. Findings include: a) Resident #73 Observation of Resident #73 in her room (room [ROOM NUMBER]), at 9:30 a.m. on 0107/16, revelaed her sitting in her wheelchair with an over-lap pad (lap-buddy) torn in multiple places with the white stuffing protruding. b) Resident #87 Observation during the initial tour of the facility, at 12:30 p.m. on 01/04/16, revealed Resident #87 sitting up in a geri-chair in her room (room [ROOM NUMBER]) with an over-lap pad (lap-buddy) in place. The pad was worn through and torn in several places allowing the white padding to protrude from the washable covering. During an interview with the Director of Nursing and the Assistant Director of Nursing, at 11:00 a.m. on 01/07/16, they confirmed the poor condition of the worn and torn lap-buddy pad for Resident #73 and #87. They acknowledged the pad could not be thoroughly cleaned in this condition. | 2020-02-01 |
| 4099 | 4099 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 550 | D | 0 | 1 | HCZ012 | Based on observation and staff interview the facility failed to provide dignity to a resident. The facility failed to assist a resident for over an hour and a half when pants were visibly wet. This was a random opportunity for discovery. Resident identifier: #66. Facility census: 75 Findings included: a) Resident #66 An observation of Resident #66, fully viewable from hallway, on 05/28/19 at 12:00 PM, revealed Resident #66 stood at the foot of the bed with visible wet jeans. An additional observation of Resident #66, fully viewable from hallway, on 05/28/19 at 12:30 PM, revealed Resident #66 stood at the foot of the bed with visible wet jeans. An interview with Licensed Practical Nurse (LPN) #25, on 05/28/19 at 12:30 PM, revealed He doesn't usually do that and I will get it taken care of. An observation of Resident #66, fully viewable from hallway, on 05/28/19 at 1:30 PM, revealed Resident #66 continued to stand at the foot of the bed with visible wet jeans. An interview with LPN #25, 05/28/19 at 1:30 PM, revealed that They are getting ready to take him to the shower. | 2020-02-01 |
| 4100 | 4100 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 558 | D | 0 | 1 | HCZ011 | Based on observation, record review, and staff interview, the facility failed to provide services with reasonable accommodation for a resident. A Resident's call light was out of reach. This practice affected one (1) of twenty one (21) residents observed during the Long Term Care Survey Process (LTCSP). Resident identifier: #19. Facility census 80. Findings include: a) Resident #19 An observation of the Resident, on 03/25/19 at 1:55 PM, revealed the Resident was in bed. The Resident's call light was on the floor under the bed. The Resident could not see or reach the call light. An interview with the Licensed Practical Nurse (LPN) #15, on 03/25/19 at 2:00 PM, revealed the Resident's call light should be within reach at all times. The LPN placed the Resident's call light on the bed within reach of the Resident. A review of the Care Plan was conducted on 03/25/19 at 2:30 PM. The Care Plan, with a revision date of 02/05/19, had a focus of Resident is at risk for injury related to falls, cognitive, and history of multiple falls with the intervention Keep call bell within easy reach. Remind resident to use call light prior to transfers. | 2020-02-01 |
| 4101 | 4101 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 578 | D | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure all residents had formulated advanced directives, which included their wishes for cardiopulmonary resuscitation. This was evident for two (2) of twenty-one (21) residents. Resident identifiers: #28, #71. Facility census: 80. Findings include: a) Resident #28 Review of the medical record on [DATE] found this resident first came to the facility in (MONTH) 2019. The medical record contained an incomplete Physician order [REDACTED]. In the space provided for the physician/nurse practitioner/physician's assistant it contained an illegible signature which was dated [DATE]. In the space provided for the resident/guardian/medical power of attorney/surrogate there was no signature or date to attest to whether or not the resident's power of attorney (MPOA) agreed or disagreed with the POST directives. An interview was conducted with the licensed social worker (LSW) on [DATE] at 11:43 AM. She said she will take care of getting the POST signed by the resident's spouse (MPOA), as the resident's spouse is in the facility often to visit. A copy of the resident's POST form was provided by the administrator on [DATE] at 2:20 PM. On [DATE] at 3 PM the acting director of nursing (DON) provided a copy of the the resident's current recapitulation of physician's orders [REDACTED]. On [DATE], facility staff provided a copy of the current medication administration record (MAR). In the section allotted for Advance Directive at the top of each page of the MAR, it stated the resident was a full code status with full interventions, intravenous fluids as long as necessary, and feeding tube long-term. In parenthesis, it stated this was discontinued as of [DATE] at 14:52. An interview was conducted with the administrator and the acting DON on [DATE] at 12 PM. They provided no further information at this time related to the lack of representative's signature on the POST form, and the lack of d… | 2020-02-01 |
| 4102 | 4102 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 583 | E | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to protect the personal privacy of residents including personal and medical information. Documents, containing personal and medical information for multiple residents, were left unattended in an unsecured box in a clean linen room. Personal identifiers including residents' names, date of births, social security numbers, phone numbers, addresses, medications, diagnoses, and other health information were accessible. This was a random observation. This practice affected more than a limited number of residents. Facility census: 80. Findings include: a) Observation A random observation of the split hall between the [NAME]top Unit and Woodside Unit, on 03/26/19 at 11:30 AM, revealed the Clean Linen room was unlocked and accessible to anyone. Inside the door to the room was a large cardboard box that contained multiple medical and personal documents for residents. The documents included: -Resident face sheets -Physician orders -Assessments -Care Plans -Admission information The documents discovered in the box contained the following personal information: -Resident's names-Resident's addresses-Resident's phone numbers-Resident's Social Security Numbers-Resident's date of births-Resident's insurance information -Resident's next of kin information -Resident's physician information -Resident's diagnoses -Resident's medications b) Interviews An interview with the Support Director of Nursing (S-DON), on 03/26/19 at 11:35 AM, revealed the documents in the box should have never been left in the Clean Linen room. S-DON stated she would remove the box immediately. An interview with the Medical Records Director (MRD), on 03/26/19 at 11:38 AM, revealed the box of documents were overflow shred papers. The MRD stated they were in the Clean Linen room because she did not want them [DIAGNOSES REDACTED] up her office. | 2020-02-01 |
| 4103 | 4103 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 600 | K | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident council meeting, resident interviews, policy review, review of incident reports and staff interview the facility failed to ensure that each resident in the facility had the right to be free from sexual, physical, psychological and verbal abuse. The facility failed to prevent Resident # 44 from wandering about the facility, entering other residents' rooms, evoking resident to resident altercations and causing fear amongst the other residents. These findings were determined to pose an immediate jeopardy and the health and well-being and represents a pattern to affect more than a limited number of residents. The facility administrator was notified of the immediate jeopardy on [DATE] at 10:45 AM. The facility provided an immediate jeopardy abatement plan of correction on [DATE] at 2:20 PM. The abatement plan of correction included: --Resident #44 was placed on one on one supervision on [DATE] at 10:45 AM until an alterntive and equally effective intervention is identified. One [DATE], Resident #44 was sent to the Emergency Department of a local hospital at 1:00 PM for evaluation due to behaviors. --All interviewable residents were interviewed by the staff of the social services department on [DATE] to ensure there were no other residents affected by Resident #44's behavior. The administrator will interview all staff on [DATE] to determine whether they observed any abusive behaviors affecting non-interviewable residents by Resident #44. --On [DATE] Regional Vice President reeducated the Administrator and Social Services Director regarding abuse prohibition and neglect. This abuse prohibition and neglect training and resident rights training was provided to all staff on [DATE], including a posttest. Staff not availble on [DATE] were to be trained and tested prior to their next work shift. The immediacy of this deficient practice was abated on [DATE] at 4:50 PM. The post-abatement scope and severity was … | 2020-02-01 |
| 4104 | 4104 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 602 | D | 0 | 1 | HCZ011 | Based on resident interview, staff interview, and medical record review, the facility failed to ensure the resident's right to be free from misappropriation of property. This was evident for one (1) of twenty-one (21) sampled residents. Resident identifier: #71. Facility census: 80. Findings include: a) Resident #71 During an interview with the resident on 03/25/19 at 2:59 PM, he said his wallet was stolen soon after his admission to the facility in (MONTH) (YEAR). He said the wallet contained some cash and some personal identification (ID) cards such as his social security card, food stamp card, and an insurance paper. He said he kept the wallet in the top drawer of his bedside table which is beside his bed. He said the wallet would had to have been stolen, because someone would had to have opened the drawer to remove it. He said upon discovery of the missing wallet from his bedside table, that he went out to the nurses's station and reported the theft to the day shift staff who were at the station. When asked the outcome, he said no one did anything about it. He said he never heard anything back from anyone about replacing the cash or its contents. An interview was conducted with the acting director of nursing (DON) on 03/28/19 at 10:15 AM. After requesting an inventory list of personal possessions the resident had at the time he first came to the facility, the acting DON said she searched the medical record and could find no inventory list. An interview was conducted with the licensed social worker (LSW) on 03/28/19 at 11:30 AM. She said she recalled that at first housekeeping or someone said that he lost his wallet, but then later said he found it. She said this happened in (MONTH) (YEAR). She said she did not complete a grievance form. On 03/28/19 at noon an interview was conducted with the acting DON and the administrator 03/28/19 about the missing wallet and its contents. The latter said said she thought the LSW completed a grievance on it when it first occurred. Another interview was conducted with the LS… | 2020-02-01 |
| 4105 | 4105 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 609 | E | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of incident reports, staff interview and policy and procedures the facility failed to report alleged violations related to mistreatment and abuse. Facility failed to report abuse resulting in physical harm for a resident and failed to report immediately, no later than 2 hours, when involving abuse. This failed practice affected four (4) of 21 residents. Resident identifiers: #44, #42, #27 and #71. Facility census: 80. Findings included: a) Resident #44 A review of the Resident's nurses progress notes, on [DATE], revealed: - [DATE] at 11:45 PM Orders obtained from primary care physician include: cool pack on abrasion PRN (as needed) - [DATE] at 11:47 PM A Change in condition, eye contusion on [DATE] at night - [DATE] at 12:00 AM Nurse Practioner evaluated Resident for follow-up of left perioibtal ecchymosis (black eye) after being involved in a resident to resident altercation on [DATE]. Resident walks throughout the facility and enters rooms of other residents. Per staff reports Resident entered the room of another resident and refused to leave. At that point the other resident struck Resident #44. A Review of the facility's accidents and incidents reports, on [DATE] at 8:30 AM, revealed Resident #44 had the following multiple incidents that were not reported: - On [DATE] Resident obtained a pocket knife from his roommate and cut his wonderguard off his leg. - On [DATE] Resident had combative behavior with no injury - On [DATE] Resident had a resident to resident altercation with alleged abuse victim - On [DATE] Resident had a resident to resident altercation with alleged abuse victim resulting in a black eye - On [DATE] Resident had a resident to resident altercation without abuse resulting in a skin tear - On [DATE] Resident wandered into a female resident's room with only a t-shirt on and climbed in bed with her. Resident was escorted out of room. Female resident's roommate had to assist getting … | 2020-02-01 |
| 4106 | 4106 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 610 | D | 0 | 1 | HCZ011 | Based on resident interview, staff interview, and medical record review, the facility failed to thoroughly investigate an allegation of theft/misappropriation. This was evident for one (1) of twenty-one (21) sampled residents. Resident identifier: #71. Facility census: 80. Findings include: a) Resident #71 During an interview with the resident on 03/25/19 at 02:59 PM, he said his wallet, cash, and some identification cards were stolen from the top drawer of his bedside table in (MONTH) (YEAR) not long after he first came to the facility. He said he told day shift nursing staff that his wallet was stolen as soon as he found it was gone. He said he has not yet heard anything back from the facility and he does not know if they are still looking for it. An interview was conducted with the acting director of nursing (DON) on 03/28/19 at 10:15 AM. She said she was unable to find an inventory list of his possessions upon or after his admission to the facility. On 03/28/19 at 11:30 AM an interview was conducted with the licensed social worker (LSW). She said she recalls that someone, perhaps housekeeping, reported soon after his admission in (MONTH) (YEAR) that he had lost his wallet, but then someone later said he had found it. She said she did not talk with the resident about the wallet because she was under the impression that it had been found. She said she did not make out a grievance form in November. She said she is going back now to talk to him about the lost wallet and file a grievance report. She said no other staff members completed a grievance form on the alleged missing wallet, so therefore there was no follow-up. An Interview was conducted with the acting DON and the administrator on 03/28/19 at noon. The administrator said she recalls once hearing about his missing wallet a good while ago. She said she thought the LSW had previously completed a grievance on it. During an interview with the LSW on 03/28/19 at 12:30 PM, she said she just completed a grievance report with the resident. She said he told her th… | 2020-02-01 |
| 4107 | 4107 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 623 | D | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to give written notice to the resident's representative, and a copy of the notice to a representative of the Office of the State Long-Term Care ombudsman when a resident was transferred to an acute care facility This was evident for one (1) of three (3) residents reviewed for discharges. Resident identifier: #28. Facility census: 80. Findings include: a) Resident #28 Medical record review on 03/28/19 found this resident transferred to an acute care facility on 03/04/19, where the resident was subsequently admitted for inpatient services. Further review of the medical record found no evidence of a written notice of the transfer/discharge to the resident's legal representative and/or to the Office of the State Long-Term Care Ombudsman. At the time of the transfer there was also no evidence that the resident's representative received written notice of appeal rights including the name, address, and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the forms and submitting the appeal hearing request; the name, address and telephone number of the Office of the State Long-Term Care Ombudsman. An interview was completed with the licensed social worker (LSW) on 03/28/19 at 12:30 PM. She said she would look for a copy of bed hold and appeals information and written notice of transfer which may have been given to the resident and/or the resident's representative related to the transfer for hospitalization . At 3:15 PM on 04/01/19 an interview was conducted with the director of nursing (DON). She said there was no written transfer notice, or bed hold or appeals information conveyed to the resident's representative related to the (MONTH) hospitalization . She said they began inservice education on this topic on 03/29/19. An interview was conducted with the DON, the Corporate Clinica… | 2020-02-01 |
| 4108 | 4108 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 625 | D | 0 | 1 | HCZ011 | Based on medical record review and staff interview, the facility failed to provide written information to the resident's representative which specified the duration of the bed-hold when a resident was transferred for a hospitalization . This was evident for one (1) of three (3) residents reviewed for discharges. Resident identifier: #28. Facility census: 80. Findings include: a) Resident #28 Medical record review on 03/28/19 found this resident transferred to an acute care facility on 03/04/19, where the resident was subsequently admitted for inpatient services. Further review of the medical record found no evidence that written bed-hold information was provided to the resident's representative at the time of the hospitalization . An interview was conducted with the licensed social worker (LSW) on 03/28/19 at 12:30 PM. She said she would look for a copy of bed-hold and appeals information, and written notice of transfer, which may have been given to the resident and/or the resident's representative related to the transfer for hospitalization . At 3:15 PM on 04/01/19 an interview was conducted with the director of nursing (DON). She said there was no written transfer notice, or bed-hold, or appeals information conveyed to the resident's representative related to the (MONTH) hospitalization . She said they began inservice education on this topic on 03/29/19. An interview with the administrator was completed on 04/02/19 at noon. She provided no further information. | 2020-02-01 |
| 4109 | 4109 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 641 | D | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and medical record review, the facility failed to ensure the accuracy of the comprehensive assessments for two (2) of twenty-one (21) sampled residents. Resident identifiers: #37, #50. Facility census: 80. Findings include: a) Resident #37 Medical record review on 03/26/19 found this resident enrolled into a hospice program in (MONTH) (YEAR), and has remained a hospice patient since that time. Review of the minimum data set (MDS) with assessment reference date 02/04/19 found that she was incorrectly assessed as not receiving hospice services. An interview was conducted with the acting director of nursing and the administrator on 03/28/19 at noon about the inaccuracies of the 02/04/19 as it pertained to hospice services. No further information was provided prior to exit. b) Resident #50 A resident interview, on 03/25/19 at 2:07 PM, Resident #50 stated I receive [MEDICAL TREATMENT]. I go Tuesday, Thursday and Saturday. Resident #50 denied participation in hospice. A review of resident records, on 03/27/19 at 03:00 PM, revealed the care plan and physician orders for [MEDICAL TREATMENT]. The physician order stated, [MEDICAL TREATMENT] center phone number is: Fresenius [MEDICAL TREATMENT] [PHONE NUMBER] days: on Tuesday, Thursday, Saturday. Time for Pick up: 0530 for [MEDICAL TREATMENT] at 0640, (must be there by 0620) Transport to: Fresenius Nephrologists' name: Dr. Adeniyi. There was no physician order or care plan focus for hospice care. Further medical record review, on 03/27/19 at 3:17 PM, revealed a NO marked for [MEDICAL TREATMENT] on Resident #50's minimum data sheet (MDS.) The MDS revealed a NO to [MEDICAL TREATMENT] indicating Resident #50 does not receive [MEDICAL TREATMENT] in section O of the MDS. The MDS was marked Yes to Hospice indicating Resident #50 does participate in hospice care in section O of the MDS. A staff interview with the Support Director of Nursing (S-DON) #100, on 03/27/19 at 3:2… | 2020-02-01 |
| 4110 | 4110 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 655 | D | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview the facility failed to develop and implement a baseline care plan related to nutritional needs. This is true for one (1) of twenty-one (21) reviewed. Resident identifier: 229. Facility census: 80. Findings include: a) Resident #229 Resident #229's admission to the facility occurred on 03/22/19. While in the hospital the resident underwent [REDACTED]. Resident #229 primary hospital discharge diagnosis, includes a principle problem [MEDICAL CONDITION]. Other [DIAGNOSES REDACTED].>Tobacco use disorder [MEDICATION NAME] Depression Recent unintentional weight loss over several months Normocytic [MEDICAL CONDITION] Vitamin B 12 deficiency [MEDICAL CONDITIONS] Pelvic mass in female [DIAGNOSES REDACTED] The initial care plan with a date of 03/22/19 does not include dietary needs of Resident #229. The Kardex report includes, Encourage resident to consume all fluids of choice daily and during meals. On 04/01/19 at 12:19 PM this information was shared with the DON whom had no comment. | 2020-02-01 |
| 4111 | 4111 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 656 | E | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to develop and or implement a comprehensive person-centered care plan for residents. Care plans were either not developed or implemented for a resident's call light, pain, wandering, meal assistance, and psychoactive medications. This practice affected seven (7) of twenty one (21) residents observed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #19, #69, #44, #77, #28, #71, and #67. Facility census 80. Findings include: a) Resident #19 An observation of the Resident, on 03/25/19 at 1:55 PM, revealed the Resident was in bed. The Resident's call light was on the floor under the bed. The Resident could not see or reach the call light. An interview with the Licensed Practical Nurse (LPN) #15, on 03/25/19 at 2:00 PM, revealed the Resident's call light should be within reach at all times. The LPN placed the Resident's call light on the bed within reach of the Resident. A review of the Resident's Care Plan was conducted on 03/25/19 at 2:30 PM. The Care Plan with a revision date of 02/05/19 with a focus of Resident is at risk for injury related to falls, cognitive, and history of multiple falls with the intervention Keep call bell within easy reach. Remind resident to use call light prior to transfers. b) Resident #69 An interview with the Resident, on 04/02/19 at 9:30 AM, revealed the staff does not attempt any non-pharmacological interventions for pain. The Resident stated they just give me medication. The Resident stated the staff sometimes asks what his pain level is and rather the pain medication was effective. An interview with LPN #250, on 04/02/19 at 9:35 AM, revealed she does not attempt any non-pharmacological interventions before giving the resident his pain medications. The LPN stated she will ask the Resident what his pain is before giving pain medications but does not follow-up for the effectiveness of the medicati… | 2020-02-01 |
| 4112 | 4112 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 657 | E | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise care plans for four (4) of twenty-one (21) sampled residents. The needed revisions included capacity status, nutrition and feeding tube status, participation in the care planning meetings, bowel movements and constipation. Resident identifiers: Residents #42, #28, #27, #8. Facility census: 80. Findings include: a) Resident #42 Medical record review on 03/26/19 found that on 03/15/19 the physician determined this resident demonstrated incapacity to make medical decisions. The physician assessed the cause of the incapacity as dementia, and the nature of the incapacity as her inability to process information. This represented a change from the previous year when the physician assessed her as having capacity to make medical decisions. The acting director of nursing (DON) provided a copy of the current care plan on 03/27/19 at 3:00 PM. Page six (6) of the care plan contained a focus that she has capacity to make medical decisions. During an interview with the acting DON and the administrator on 03/28/19 at noon, they acknowledged their understanding that the care plan was not revised when her capacity status changed. An interview was conducted with the regular DON and with corporate Clinical Quality Specialist (CQS) employee #200 on 04/01/19 at 4:00 PM. It was discussed that the care plan was not revised to reflect the 03/15/19 change in capacity. The DON said she had not had time yet to look for any additional information. b) Resident #28 Review of the medical record on 03/26/19 found this resident has a continuous pump for tube feeding and receives no other dietary supplement from the kitchen. The current recapitulation of physician orders [REDACTED]. - Nothing by mouth (NPO) diet - may have up to four (4) ounces oral gratification of moist puree ice cream or honey consistency liquid if nurse deems him to be alert enough to participate. - Enteral feed order every s… | 2020-02-01 |
| 4113 | 4113 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 677 | D | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview the facility failed to provide nail care to a resident unable to carry out activities of daily living. Resident: #16. Facility census: 80. Findings include: a) Resident #16 A change in condition note with a date of 10/09/18 reveals the resident had a loose toenail. The specific toenail is not identified on the evaluation. Medical record reveal a podiatry assessment completed on 10/12/18. The results reveal Resident #16 has: difficulty walking, pain in feet/toes, and, to continue monitoring vascular status of the resident. A change in condition note with a date of 12/31/18 reveals a right great toe pressure ulcer. The physician/nurse practitioner ordered to cleanse the area and apply [MEDICATION NAME] ointment for three (3) days. Neither the (MONTH) of (YEAR) or (MONTH) of 2019 medication administration records has evidence the [MEDICATION NAME] ointment was applied to the right great toe. A change in condition note with a date of 03/17/19 reveals the resident to have a skin wound or ulcer on the right great toe with the base of the nail being brittle and cracking. On 03/17/19 the resident began taking Bactrim tablet 800-160 milligrams (mg), two (2) tablets twice a day for infection of the right great toe. After thirteen (13) doses of this medication the resident developed a rash. The medication was changed to, Keflex 500 mg every eight (8) hours, for five (5) days. Given for infection in the right great toe related to local infection of the skin and subcutaneous tissue. On 03/28/19 the medication administration was completed. A skin integrity report on 04/01/19 reveals the right great toe to be healed. On 04/02/19 at 8:45 AM observation, found the right great toe nail to be very long. The additional toe nails were also too long. Licensed nurse (LPN) #44 agreed the nail needed trimmed. On 04/02/19 8:50 AM the DON explained there is no referral for the podiatry to assess the resident, but … | 2020-02-01 |
| 4114 | 4114 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 684 | E | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to follow physician's orders for residents receiving respiratory care services, weight monitoring, and bowel protocols. There was also an order that was not specific for a medication. Theses practices affected six (6) of twenty-one (21) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #14, #47, #279, #77, #54, and #8. Facility census: 80. Findings include: a) Resident #14 An observation of the Resident, on 03/25/19 at 12:30 PM, revealed the Resident was in her wheelchair in her room. The Resident had an oxygen concentrator in the room and was receiving 2.5 liters of oxygen via nasal cannula. A review of the physician orders, on 03/25/19 at 12:40 PM, revealed the Resident was ordered Oxygen at 4 Liters per minute via nasal cannula continuously for shortness of breath. The order had a start date of 06/14/18. An interview with Licensed Practical Nurse (LPN) #15, on 03/25/19 at 12:45 PM, revealed the Resident should be receiving oxygen continuously at 4 liters and not 2.5 liters. b) Resident #47 An observation of the Resident, on 03/25/19 at 1:05 PM, revealed the Resident was in bed in her room. The Resident had an oxygen concentrator in the room and was receiving 4 liters of oxygen via nasal cannula. A review of the physician orders, on 03/25/19 at 1:15 PM, revealed the Resident was ordered Oxygen at 2 liters per minute via nasal cannula continuously. The order had a start date of 11/29/18. An interview with Licensed Practical Nurse (LPN) #15, on 03/25/19 at 1:20 PM, revealed the Resident should be receiving oxygen continuously at 2 liters and not 4 liters. The LPN stated sometimes the residents will change the oxygen levels themselves. c) Resident #279 An observation of the Resident, on 03/25/19 at 1:40 PM, revealed the Resident was in bed in her room. The Resident had an oxygen concentrator in the room and was receivi… | 2020-02-01 |
| 4115 | 4115 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 686 | D | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and medical record review, the facility failed to ensure physician ordered heel protectors were in place at all times on a resident with a newly acquired pressure ulcer on her ankle. Resident identifier: #37. Facility census: 80. Findings include: a) Resident #37 Observation on 03/26/19 at 02:30 PM, while accompanied by wound care nurse/licensed practical nurse (LPN) #76, found this resident had a small pressure wound on the right lateral ankle. LPN #76 said this pressure wound was discovered yesterday and assessed as a deep tissue injury. Observed at this time also were two (2) heel protectors lying at the foot of her bed on top of the covers. LPN #76 said the really thick padded boot was a Level two (2) device the resident wears on her right ankle. LPN #76 said the smaller, less thick one which lay alongside it on top of the covers was termed a regular heel protector. She said the latter was used on the left foot/heel which has no pressure wound. Upon inquiry as to why the resident was not wearing the heel protectors, LPN #76 said the nursing assistants probably removed them when they were in the room positioning the resident or providing toileting care in the bed. The resident was alert and oriented. She said she did not recall who removed the heel protectors, or when they were removed. LPN #76 applied the heel protectors to both feet. She said she will speak to the nursing assistants to remember to use the heel protectors when the resident is in the bed. At 2:35 PM on 03/26/19 LPN #76 said that she spoke with the resident's aide about the heel protectors the resident had orders for. Review of the medical record on 03/26/19 revealed a new physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the wound measurement flow sheet on 03/26/19 found the first measurement occurred on the day of discovery of the deep tissue injury on 03/25/19. The measurement on that date was 0.5 by 0.5 centi… | 2020-02-01 |
| 4116 | 4116 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 689 | E | 0 | 1 | HCZ011 | Based on observation, record review, and staff interview, the facility failed to provide an environment free from accident hazards over which it had control. The facility did not ensure a breathing treatment machine was secured in a resident's room, oxygen tanks were properly stored, and used razors were properly disposed of. These were all random observations. These practices had the potential to affect more than a limited number of residents. Resident identifier: #47. Facility census: 80. Findings include: a) Resident #47 A random observation of Resident #47, 03/25/19 2:30 PM, revealed the Resident was in bed with her eyes shut. There was a breathing treatment machine placed over the Resident's head on the over the bed light. The breathing treatment machine could have easily fallen onto the Resident while in bed. An interview with Licensed Practical Nurse (LPN) #15, on 03/25/19 at 2:35 PM, revealed the breathing treatment machine should have never been placed on the over the bed light above the Resident's bed. The LPN stated the breathing treatment machine could have easily fallen onto the Resident. The LPN removed the breathing treatment machine from the light and placed it on the Resident's bedside table. b) Oxygen Tanks A random observation of the split hall between the [NAME]top Unit and Woodside Unit, on 03/26/19 at 11:40 AM, revealed the Clean Linen Room was unlocked. Inside the Clean Linen Room was an unlocked door with the sign Caution: Oxidizing Cases Within. Inside the door was thirty-three (33) oxygen cylinders accessible to anyone. An interview with the Support Director of Nursing (S-DON), on 03/26/19 at 11:45 AM, revealed oxygen cylinders should be locked up away from access to the residents. c) Razors A random observation of the [NAME]top Unit, on 03/26/19 at 11:50 AM, revealed the Soiled Utility Room was unlocked. The room had a punch key lock but was not locked. The room container a topless bucket full of approximately 50 used razors. An interview with Nurse Aide (NA) #6, on 03/26/19 at 11:55 AM… | 2020-02-01 |
| 4117 | 4117 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 692 | D | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview the facility failed to develop and implement a baseline care plan related to nutritional needs. Resident identifier: 229. Facility census: 80. Findings included: a) Resident #229 Resident #229 admission occurred on 03/22/19. While in the hospital the resident underwent [REDACTED]. Resident #229 primary hospital discharge diagnosis, includes a principle problem [MEDICAL CONDITION]. Other [DIAGNOSES REDACTED].>Tobacco use disorder [MEDICATION NAME] Depression Recent unintentional weight loss over several months Normocytic [MEDICAL CONDITION] Vitamin B 12 deficiency [MEDICAL CONDITIONS] Pelvic mass in female [DIAGNOSES REDACTED] The initial care plan with a date of 03/22/19 does not have information related to dietary needs of Resident #229. The Kardex report includes, Encourage resident to consume all fluids of choice daily and during meals. Upon admission to the facility Resident #229 had a surgical wound, peripherally inserted central catheter (PICC) and a drain line placed in the abdomen. Medications upon admission to the facility includes [MEDICATION NAME] 750 milligrams (mg) in normal saline 7.5 milliliters (ml) infusion, every twelve (12) hours. [MEDICATION NAME] an antibiotic given for infection. Also, prescribed, Cefeprime two (2) grams/100 ml intravenous every eight (8) hours. Cefeprime is an antibiotic given for infection. Both the [MEDICATION NAME] and Cefeprime orders were completed on 03/30/19. A nursing note on 03/25/19 reveals the resident feels nauseous at times and appetite is poor. During initial tour of the facility on 03/25/19 at 3:32 PM the resident explained she is not eating well, and she does not like the food brought to her. States the day before this interview she requested soup but it was not delivered to her. The resident received [MEDICATION NAME] four (4) mg on, 03/26/19 and on 03/28/19 for nausea and vomiting. On 03/27/19 the resident rec… | 2020-02-01 |
| 4118 | 4118 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 695 | D | 0 | 1 | HCZ011 | Based on observation, medical record review, and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. Oxygen therapy was not being administered as ordered by the physician. These practices affected three (3) of six (6) residents reviewed for respiratory care during the Long Term Care Survey Process (LTCSP). Resident identifiers: #14, #47, and #279. Facility census: 80. Findings include: a) Resident #14 An observation of the Resident, on 03/25/19 at 12:30 PM, revealed the Resident was in her wheelchair in her room. The Resident had an oxygen concentrator in the room and was receiving 2.5 liters of oxygen via nasal cannula. A review of the physician orders, on 03/25/19 at 12:40 PM, revealed the Resident was ordered Oxygen at 4 Liters per minute via nasal cannula continuously for shortness of breath. The order had a start date of 06/14/18. An interview with Licensed Practical Nurse (LPN) #15, on 03/25/19 at 12:45 PM, revealed the Resident should be receiving oxygen continuously at 4 liters and not 2.5 liters. b) Resident #47 An observation of the Resident, on 03/25/19 at 1:05 PM, revealed the Resident was in bed in her room. The Resident had an oxygen concentrator in the room and was receiving 4 liters of oxygen via nasal cannula. A review of the physician orders, on 03/25/19 at 1:15 PM, revealed the Resident was ordered Oxygen at 2 liters per minute via nasal cannula continuously. The order had a start date of 11/29/18. An interview with Licensed Practical Nurse (LPN) #15, on 03/25/19 at 1:20 PM, revealed the Resident should be receiving oxygen continuously at 2 liters and not 4 liters. The LPN stated sometimes the residents will change the oxygen levels themselves. c) Resident #279 An observation of the Resident, on 03/25/19 at 1:40 PM, revealed the Resident was in bed in her room. The Resident had an oxygen concentrator in the room and was receiving 2.5 liters of oxygen via nasal cannula. A review of the physician orders, on 03/25/19 at 1:45… | 2020-02-01 |
| 4119 | 4119 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 697 | D | 0 | 1 | HCZ011 | Based on resident interview, staff interview, and medical record review, the facility failed to ensure pain management was provided to a Resident consistent with professional standards of practice and the person centered care plan. Non-pharmacological interventions were not provided and the effectiveness of pharmacological interventions were not assessed for Resident #69. This practice affected one (1) of two (2) residents reviewed for pain management during the Long Term Care Survey Process (LTCSP). Facility census: 80. Findings include: a) Resident #69 An interview with the Resident, on 04/02/19 at 9:30 AM, revealed the staff does not attempt any non-pharmacological interventions for pain. The Resident stated they just give me medication. The Resident stated the staff sometimes asks what his pain level is and rather the pain medication was effective. An interview with LPN #250, on 04/02/19 at 9:35 AM, revealed she does not attempt any non-pharmacological interventions before giving the resident his pain medications. The LPN stated she will ask the Resident what his pain is before giving pain medications but does not follow-up for the effectiveness of the medication. A review of the Resident's Care Plan was conducted on 04/02/19 at 10:15 AM. The Care Plan, with a review date of 03/21/19, had a focus of Resident exhibits or is at risk for alterations in comfort with the goal of pain relief with non-pharmacological interventions for mild pain and pharmacological interventions for unrelieved moderate to severe pain. The Care Plan included the interventions, Evaluate pain characteristics, quality of pain, severity of pain, location of pain, and precipitating and relieving factors of the pain and medicate the Resident as ordered and monitor for effectiveness. Further review of the Resident's medical record, on 04/02/19 at 10:30 AM, revealed no documentation the Resident was receiving non-pharmacological interventions or assessment of the effectiveness of pharmacological interventions. An interview with the Director o… | 2020-02-01 |
| 4120 | 4120 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 730 | F | 0 | 1 | HCZ011 | Based on review of the facility personnel files, staff interview and policy and procedure review, the facility failed to ensure annual performance evaluations were completed for five of five nursing assistants reviewed. Staff Identifiers: NA #14, NA#1, NA#34, NA#43 and NA#5. Findings included: a.) A review of the personnel file information for NA# 14, showed a hire date of 05/20/13. A review of the facility documentation showed no evidence of a performance evaluation being completed annually during (YEAR). b.) A review of the personnel file information for NA# 1, showed a hire date of 10/04/04. A review of the facility documentation showed no evidence of a performance evaluation being completed annually during (YEAR). c.) A review of the personnel file information for NA#34, showed a hire date of 03/31/03. A review of the facility documentation showed no evidence of a performance evaluation being completed annually during (YEAR). d.) A review of the personnel file information for NA#43 , showed a hire date of 08/02/88. A review of the facility documentation showed no evidence of a performance evaluation being completed annually during (YEAR). e.) A review of the personnel file information for NA# 5, showed a hire date of 11/16/99. A review of the facility documentation showed no evidence of a performance evaluation being completed annually during (YEAR). f.) On 03/27/19, at 09:14 AM an interview the Administrator revealed annual performance appraisals for NA#14, NA#1, NA#34, NA#43 and NA#5 have not been done on an annual basis and there are no performance evaluations to review for any of these. | 2020-02-01 |
| 4121 | 4121 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 761 | E | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of policy and procedures, the facility failed to ensure medications are properly stored, are properly labeled with an expiration date when opened and/or not used past the expiration date. Facility census: 80 Findings included: a.) [NAME]top Medication cart On 03/26/19, at 10:54 AM, an observation of [NAME]top medication cart noted a [MEDICATION NAME]for R#8, with a handwritten date of 02/22/19 on the medication. An interview, on 03/26/19, at 10:57 AM, with LPN#90, verified the [MEDICATION NAME] was being administered to R#8 but should have been discarded because it exceeded the 28 day discard policy. On 03/26/19, at 10:54 AM, an observation of the [NAME]top medication cart noted a [MEDICATION NAME] opened but no date of when the medication was opened and put into use. An interview, on 03/26/19 at 10:59 PM, with LPN#90, verified the [MEDICATION NAME] should have been dated when opened and put into use. A review of the policy and procedure: LTC Facility's Pharmacy Services and Procedures Manual, 5.3 Storage and Expiration Dating of Medication, Biologicals , Syringes and Needles, Revision 10/31/16, noted : Once any medication or biological package is opened, the facility should follow manufacturers /suppliers guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date when opened. b.) [NAME]top Medication room An observation of the [NAME]top medication room, on 03/26/19, at 11:14 AM, revealed a package of a controlled medication, [MEDICATION NAME], in the refrigerator but not locked in an affixed box. An interview with LPN#8, on 03/26/19, at 11:15 AM, stated the [MEDICATION NAME] should be locked in the lock box and verified it was not in the locked affixed compartment of the refrigerator. A review of the policy and procedure Controlled Drugs: Management of , revisi… | 2020-02-01 |
| 4122 | 4122 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 812 | E | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and a review of Food Handler Permits, the facility failed to store food in accordance with professional standards for food service safety, ensure cleanliness of food storage areas, and to ensure all dietary staff had current Food Handler Permits. The facility contained several areas with undated, expired, and opened resident food items, several employees did not possess current Food Handler Permits, and there was a dirty refrigerator and food bin in the kitchen. These practices had the potential to affect more than a limited number of residents. Facility census: 80. Findings include: a) Woodside Dining Room An observation of the Woodside Back Dining Room, on [DATE] at 11:30 AM, revealed the room was not secured and had cabinets with no locks. The cabinets contained the following undated food items: -Two (2) packs of opened and unlabeled graham crackers. -One (1) opened and undated Fudge Round. The Fudge Round was hard. -One (1) container of Franks Red Hot Sauce with an expiration date of (MONTH) (YEAR). -One (1) container of Mrs. Butterworth's Maple Syrup with an expiration date of (MONTH) (YEAR). -One (1) box of vanilla instant pudding with an expiration of (MONTH) (YEAR). -Two (2) opened container of self rising flour with an expiration date of (MONTH) (YEAR). -One (1) box of Clover Valley Popcorn with an expiration date of (MONTH) (YEAR). -One (1) large opened and undated bag of graham crackers. -One (1) opened and undated bag of onions. -One (1) opened and undated bag of potatoes. The potatoes had grown large sprouts. An interview with the Activity Director (AD), on [DATE] at 11:35 AM, revealed the Woodside Back Dining Room was accessible to any resident at any time. The AD stated some activities are held in the room. The AD stated all the food items in the cabinets were old and needed thrown away. The AD stated she would remove the food items immediately. b) Conclusion of a the brief kitchen tour on… | 2020-02-01 |
| 4123 | 4123 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 835 | F | 0 | 1 | HCZ011 | Based on record review, staff interview, and policy review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident residing in the facility. The facility failed to implement policies and procedures to ensure each resident in the facility had the right to be free from physical, psychological and verbal abuse, and failed to report alleged violations related to mistreatment and abuse. The facility failed to provide care for residents with physical, mental and psychosocial needs relating to dementia care. The facility failed to implement personnel policies to ensure all nurse aides had received a performance evaluation on an annual basis. The facility failed to implement policies for clinical care in order for each resident to maintain acceptable parameters of nutritional status. The facility failed to ensure a safe, functional and comfortable environment for residents, staff and the public. The facility failed, through the quality assessment and assurance committee, to develop and implement appropriate plans of action to correct identified quality deficient practices. These deficient practices had the potential to affect all residents. Facility census: 80 Findings included: Cross-reference the following deficient practices for findings for F835. a.) F600 b.) F609 c.) F730 d.) F744 e.) F867 f.) F692 g.) F921 | 2020-02-01 |
| 4124 | 4124 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 842 | D | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure an accurately documented and readily accessible medical record for two (2) of twenty-one (21) sampled residents. Resident identifiers: #28, #71. Facility census: 80. Findings include: a) Resident #28 Medical record review on 04/01/19 found behavior monitoring flow sheets for targeted behaviors for (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019. The backs of those forms contained areas in which to record the names and strength of the psychoactive medication the resident received, and the corresponding [DIAGNOSES REDACTED]. An interview was conducted with the director of nursing (DON) on 04/02/19 at 10:00 AM. She said that typically night shift staff complete the names/dosages of the psychoactive medications and the corresponding diagnoses. She said someone must have forgotten to record that bit of information on the behavior monitoring flow sheets for the months of February, March, and (MONTH) 2019. An interview was completed with the administrator on 04/02/19 at noon. She provided no further information at this time. b) Resident #71 Review of the medical record on 04/01/19 found the behavior monitoring flow sheets were absent from the hard copy of the medical record for the months of (MONTH) (YEAR) and (MONTH) 2019. Behavior monitoring sheets for (MONTH) 2019 and (MONTH) 2019 were found on the hard copy of the medical record, and were copied. The spaces provided in which to list the targeted behaviors symptoms were blank. On 04/02/19 at 9:55 AM the director of nursing (DON) provided copies of the missing (MONTH) (YEAR) and (MONTH) 2019 behavior monitoring flow sheets that she had designated other staff to copy. Also provided at this time were copies of the behavior monitoring flow sheets for (MONTH) 2019 and (MONTH) 2019. Those two (2) copies contained three (3) hand-written, targeted behavior symptoms to monitor. An interview was conducted with the DON on 04/02/1… | 2020-02-01 |
| 4125 | 4125 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 867 | F | 0 | 1 | HCZ011 | Based on record review, observation, resident interview, family interview, staff interview , policy review, incident reports review and resident council meeting, the facility's quality assessment and assurance (QA&A)committee failed to identify and act upon quality deficiencies during the daily operation of the facility in which it had, or should have had knowledge. The facility failed to: --Keep residents with dementia safe and failed to protect residents from wandering residents for, Resident, #44, #42, #27, #13, and #14. --Report alleged violations for, Resident #44, #42, #27, and #71. --Maintain nutrition needs for Resident #229. --Ensure annual performance reviews were completed. --Maintain a safe, functional and clean environment. Findings included: Cross-reference for the following deficient practices for the findings of F867. a) F600 b) F609 c) F730 d) F744 e) F692 f) F867 g) F921 | 2020-02-01 |
| 4126 | 4126 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 880 | E | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy and procedure review, the facility failed to ensure topical pain medication patches were disposed of in a sanitary manner and failed to ensure that linens were washed and stored properly. This practice had the potential to affect more than a limited number of residents. Resident census: 80 a ) Medication administration An observation during medication administration on 3/26/19 at 10:54 AM, noted LPN#90 removing a [MEDICATION NAME] Pain patch from R# 57. LPN #90 stated she needed another nurse to witness the disposal of the medication and placed the [MEDICATION NAME] Pain patch that was removed from R#57 in the top of the medication cart where other medications were being stored. On 3/27/19 @09:24 AM, an interview with the Administrator, verified placing the [MEDICATION NAME] in the medication cart after removing it from a resident's body was not an acceptable infection control practice. b.) Linen care and storage Observation of the laundry facility, on 3/27/19 @ 01:10 PM, the door ensuring a separation of the clean area from the soiled area, was standing open. An interview, on 03/27/19 at 1:15 PM, with the Laundry Supervisor, revealed the door arm was broken and was removed . It was also observed when the door was closed, air was moving from dirty to the clean side where linens were being dried and folded. It was verified at this time, with the laundry Supervisor , the door could not be sealed to prevent the air flow from the soiled utility into the clean area, causing a cross contamination of clean linens. A review of the policy and procedure, revision date of 03/01/18, showed, under section 2.4, ventilation should not flow from soiled processing areas to clean laundry areas | 2020-02-01 |
| 4127 | 4127 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 883 | D | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interview, policy and procedure review, and review of Centers for Disease Control (CDC) recommendations, the facility failed to ensure each resident received pneumococcal vaccine in accordance with accepted guidelines. The facility failed to assess the immunization status on admission and/or offer and administer the pneumococcal vaccine in accordance with guidelines for two of six residents reviewed. Resident identifiers: R#74, and R#28. Census: 80 Findings included: a.) Resident #74 (R#74) Record review for R#74 noted the resident had received [MEDICATION NAME] 23 vaccine (PPSV23) on 11/16/17 and did not receive the Prevnar 13 vaccination (PCV13) until 03/23/19. On 04/01/19 at 09:15 AM , an interview with LPN #76 verified R#74 should have received the vaccine sooner and was an error in timing and not in accordance with facility policy. b.) Policy and Procedure A review of Centers for Disease Control Guidelines and review of the facility's policy and procedure IC601: Pneumococcal Vaccine, revision date of 11/28/17, noted that PCV13 is to be administered one year after the date of receiving PPSV23. Additionally, if an adult received the PCV13 first, the PPSV23 would be administered one year from when the PCV13 vaccination was received. b) Resident #28 Review of the medical record on 03/28/19 found this resident first came to the facility in early (MONTH) 2019. The minimum data set (MDS), with assessment reference date (ARD) 01/25/19, assessed that the influenza and pneumococcal status was unknown and was not offered at the facility. Review of the medical record found that he received a Prevnar 13 vaccination in (YEAR) by history, and he had a [MEDICATION NAME] skin test soon after admission to the facility in (MONTH) 2019. There was no evidence that the influenza or the pneumococcal 23 vaccines were offered to him until 03/21/19. He received the pneumococcal 23 vaccination at the facility on 03/21/1… | 2020-02-01 |
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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 );