cms_WV
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153 rows where "filedate" is on date 2020-04-01
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3854 | 3854 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 156 | D | 0 | 1 | DBHB11 | Based on staff interview and record review, the facility failed to ensure Resident #43 received notice of the decision to terminate Medicare covered services two (2) days prior to the proposed end of Medicare services. This was true for one (1) of three (3) residents reviewed for the mandatory care area of liability notices and beneficiary appeal. Resident identifier: #43. Facility census: 62. Findings include: a) Resident #43 At 1:25 p.m. on 01/18/17, Business Office Manager (BOM) #4, provided a copy of the notice of Medicare non-coverage form, Centers for Medicare and Medicaid Services (CMS) form # , issued to Resident #43. The form noted the resident's Medicare services would end on 11/29/16. The first day of non-skilled services would begin on 11/30/16. The resident's responsible party signed the form on 11/29/16. BOM #43 said she was only the keeper of the form, she did not provide the form to the resident's responsible party. She identified the social worker as the employee responsible for issuing the form. At 1:43 p.m. on 01/18/17, Social Worker #84 was unable to provide documentation the responsible party was notified of the determination to end services two (2) days before the proposed cut of services. The responsible party could have been contacted by telephone if unavailable to sign the form; however, no documentation was available to substantiate contact was made with the responsible party within the required time frame. Providing the notice two (2) days prior the end of services allows the resident/responsible party time to contact the Quality Improvement Organization (QIO) if they wish to appeal the decision. Resident #43 remained in the facility with benefit days remaining when the notice of Medicare non-covered services form was given. | 2020-04-01 |
| 3855 | 3855 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 160 | D | 0 | 1 | DBHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to release the balance of two (2) deceased residents ' personal funds to the individual or probate jurisdiction administering the individual's estate as provided by State law. Resident identifiers: #96 and #32. Facility census: 62. Findings include: a) At 10:59 a.m. on [DATE], review of the care area of person funds review with the Accounts Payable (AP) Employee #9 found the following: 1. Resident #32 Resident #96 expired on [DATE]. At the time of death, the resident had $963.45 remaining in her personal funds account. On [DATE], a check for this amount was issued to a funeral home. 2. Resident #96 Resident #96 expired on [DATE]. The balance remaining in the personal funds account at the time of death was $158.10. On [DATE], a check was issued to a funeral home for this amount. b) Upon the death of a resident, the balance of the personal funds can only be released to the individual or probate jurisdiction administering the resident's estate. AP #9 confirmed the funeral home was not the probate jurisdiction administering the estates of Residents #32 and #96. c) At 8:40 a.m. on [DATE], these findings were discussed with the administrator, director of nursing, and Vice President of Operations #112. The administrator said the check issued to the funeral home for Resident #32 was still in the outgoing. She retrieved the check from the mail after surveyor intervention. | 2020-04-01 |
| 3856 | 3856 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 241 | D | 0 | 1 | DBHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random observation and staff interview, the facility failed to ensure Resident #43 had a dignified dining experience during the noon time meal on 01/16/17. Resident #43 was not served lunch as the same time as her roommate. Resident identifier: #43. Facility Census: 62. Findings include: a) Observation of the noon time meal on 01/16/17 beginning at 11:30 a.m. found two (2) residents in room [ROOM NUMBER] . The staff served Resident #38 (Bed A) her noon time meal at 11:45 p.m. on 01/16/17. Nursing staff brought a meal for Resident #43 (Bed B) at 12:07 p.m. on 01/16/17. This was twenty-two (22) minutes after her roommate was served her food. Nursing had to bring Resident #43's meal from the dining room cart. An interview with the Director of Nursing (DON) at 12:10 p.m. on 01/16/17 confirmed Resident #43 was not served at the same time as her roommate. She further verified both roommates should have received their trays at the same time. | 2020-04-01 |
| 3857 | 3857 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 242 | D | 0 | 1 | DBHB11 | Based on resident interview, family interview, record review, and staff interview, the facility failed to ensure two (2) of three (3) resident's reviewed for the care area of choices during Stage 2 of the Quality Indicator Survey (QIS) received personal care consistent with their past interests. The residents' choice for bathing practices, an aspect of their lives that was significant to them, was not consistent with their past preferences. Resident identifiers: #69 and #35. Facility census: 62. Findings include: a) Resident #69 At 11:47 a.m. on 01/16/17, when asked, Do you choose how many times a week you take a bath or shower? the resident responded No, and said he would shower every day if at home. The resident said when he was admitted to the facility in (MONTH) (YEAR), he was told by staff what his shower days would be. He did not feel he had a choice because, That is the schedule here. At 12:40 p.m. on 01/17/17, when asked how the facility determined a resident's shower schedule, corporate Registered Nurse (RN) #108 identified Licensed Practical Nurse (LPN) #93 as the one who would have spoken to Resident #69 regarding his shower scheduled. At 12:45 p.m. on 01/17/17, LPN #93 said the resident's room number and bed determined shower schedules. She said she told the residents when they would receive their showers and if she received no feedback, she assumed this schedule was okay with the resident. On 01/17/17 at 12:55 p.m., the surveyor and the director of nursing (DON) spoke with the resident regarding the shower schedule. Resident #69 said he would like a shower daily and the evening would be fine with him. The DON told the resident his request would be honored. Review of the care plan found the resident had capacity to make decisions regarding his care. b) Resident #35 The resident's medical power of attorney (MPOA), interviewed during Stage 1 of the QIS at 12:53 p.m. on 01/16/17, said the resident did not receive the same number of showers based on past preference. The MPOA said showers were given three … | 2020-04-01 |
| 3858 | 3858 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 253 | E | 0 | 1 | DBHB11 | Based on observation and staff interview, the facility failed to ensure the overhead vents in the shower room and in room #14 were free from dust. This had the potential to affect more than an isolated number of residents currently residing in the facility. Facility Census: 62. Findings Include: a) Observations on 01/18/17 at 10:40 p.m. found the overhead vent in the facility's shower room to be covered with a thick layer of dust. The dust was thick it was hard to determine how many slats were in the vent because the dust gathered on each individual slat was so thick that the dust was meeting and the separation of the slats was not visible. This was also true for the overhead vent in the resident bathroom of room #14. A tour with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) between 8:52 a.m. and 8:59 a.m. on 01/19/17 confirmed the vents in the shower room and in room #14 needed cleaned. | 2020-04-01 |
| 3859 | 3859 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 272 | D | 0 | 1 | DBHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Resident Assessment Instrument (RAI) version 3.0 manual, and staff interview, the facility failed to ensure three (3) significant change in status (SCSA) Minimum Data Set (MDS) assessments for Resident #20 accurately reflected medications Resident #20 received during the seven (7) day lookback periods. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #20. Facility Census: 62. Findings include: a) Resident #20 1. A review of Resident #20's medical record at 9:47 a.m. on 01/18/17 found the SCSA MDS with an assessment reference date (ARD) of 05/20/16, identified the resident received an anticoagulant medication seven (7) of the seven (7) days during the lookback period. Review of Resident #20's Medication Administration Record [REDACTED]. 2. Review of the SCSA MDS with an ARD of 06/30/16, found it identified the resident did not receive an antianxiety medication during the 7-day lookback period. The assessment also identified the resident received an anticoagulant during this period. Review of Resident #20's MAR for the look back period of 06/24/16 through 06/30/16 found Resident #20 received [MEDICATION NAME] (an antianxiety medication) seven (7) of the seven (7) days during the look back period and did not receive any anticoagulant medications during the lookback period. 3. The SCSA MDS with an ARD of 12/31/16 indicated the resident received an anticoagulant medication seven (7) of the seven (7) days during the lookback period. Review of Resident #20's MAR for the look back period of through 12/25/16 through 12/31/16 found Resident #20 did not receive any anticoagulant medications during the look back period. b) A review of the RAI manual at 11:30 a.m. on 01/18/17 found the following coding instructions, Antianxiety: Record the number of day an anxiolytic medication was received by… | 2020-04-01 |
| 3860 | 3860 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 278 | D | 0 | 1 | DBHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Resident Assessment Instrument (RAI) version 3.0 manual, and staff interview, the individual completing the medication section of Resident #20's quarterly Minimum Data Set (MDS) failed to accurately reflect what types of medications Resident #20 received during the seven (7) day look back period. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #20. Facility Census: 62. Findings include: a) Resident #20 A review of Resident #20's medical record at 9:47 a.m. on 01/18/17, found the Quarterly MDS with an ARD of 09/30/16 identified the resident received an anticoagulant medication seven (7) of the seven (7) days during the look back period. The assessment also identified the resident did not receive a diuretic during the seven (7) day look back. Review of Resident #20's Medication Administration Record [REDACTED]. A review of the RAI manual at 11:30 a.m. on 01/18/17 found the following coding instructions pertaining to item N0410 G, Diuretic: Record the number of day a diuretic medication was received by the resident at any time during the 7-day look back period (or since admission/entry if less than 7 days). Further review of the RAI manual found the following coding instructions for item N0410E, Anticoagulant (e.g. [MEDICATION NAME], or low molecular weight [MEDICATION NAME]): Record the number of days an anticoagulant medication was received by the resident at any time during the 7 day look back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medication such as aspirin/extended release, [MEDICATION NAME], or [MEDICATION NAME] here. An interview with Registered Nurse (RN) MDS Coordinator #81 at 11:42 a.m. on 01/18/17 confirmed the quarterly MDS with an ARD of 09/30/16 was inaccurate in the area of medications. She indicated that she counted… | 2020-04-01 |
| 3861 | 3861 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 279 | D | 0 | 1 | DBHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a care plan based on a resident's comprehensive assessment. This practice affected one (1) of six (6) residents whose care plans were reviewed for the care area of unnecessary medications. The care plan for Resident #89 did not address pain. Resident #89. Facility census: 62. Findings include a) Resident #89 A review of the medical record for Resident #89 on 01/18/17 revealed the comprehensive Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/21/16 identified the resident had a [DIAGNOSES REDACTED]. Review of the resident's comprehensive care plan found it did not address pain. An interview on 01/19/17 at 9:15 a.m. with the director of nursing (DON) verified the comprehensive care plan did not address pain for Resident #89. | 2020-04-01 |
| 3862 | 3862 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 280 | D | 0 | 1 | DBHB11 | Based on family interview, observation of the resident, record review, and staff interview, the facility failed to keep the resident/responsible party informed regarding decisions for care and treatment. This was true for one (1) of one (1) resident reviewed for the care area of participation in care planning. Resident identifier: #35. Facility census: 62. Findings include: a) Resident #35 On 01/16/17 at 12:53 p.m., during Stage 1 of the Quality Indicator Survey (QIS), the responsible party of Resident #35 said she did not feel staff included her in decisions regarding medicine, therapy, and other treatments. The resident's medical power of attorney (MPOA) provided the following example: She said she asked for a different wheelchair that would allow some support for her mother's neck. She said her mother had broken her neck during a fall at the facility and since that time, her mother's ability to hold her head upright had been decreasing. She said she asked for a reclining wheelchair like the ones she had seen other residents using at the facility. She said she was told none was available. According to the MPOA, no one had followed up with her regarding a wheelchair for her mother. She said her mother no longer used her current wheelchair for locomotion and she felt her mother would be more comfortable if she could have a wheelchair that reclined instead of her current wheelchair that required her mother to sit upright. Observation of the resident during the interview with the MPOA, noted her sitting upright in a Broda chair with her chin resting on her chest During an interview at 9:31 a.m. on 01/19/17, Certified Occupational Therapy Assistant (COTA) #100 said a screen for positioning was completed in (MONTH) (YEAR). On 12/05/16, Occupational Therapist (OT) #107 had a handwritten note on the screen indicating the family wanted to hold off on the screening. COTA #100 provided a copy of a second screen dated 12/29/16 that noted, Refer patient to OT for further evaluation secondary to patient family request patien… | 2020-04-01 |
| 3863 | 3863 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 281 | E | 0 | 1 | DBHB11 | Based on record review, policy review, and staff interview, the facility failed to provide services according to accepted standards of clinical practice in regards to medication administration for 39 of 62 residents currently residing in the facility. Two (2) Licensed Practical Nurses (LPN) administering evening and bedtime medications did not sign their names on the Medication Administration Record [REDACTED]. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: #67, #78, #29, #75, #55, #1, #14, #23, #74, #36,#38, #50, #77, #52, #65, #57, #17, #3, #2, #35, #8, #56, #28, #22, #70, #95, #79, #7, #97, #89, #24, #58, #47, #72, #21, #20, #46, #61, and #15. Facility Census: 62. Findings include: On 01/18/17 at 9:30 p.m., the facility was entered to observe evening shift's medication pass. LPN #94 and LPN #95 said all of their medications had been given and there were not any medication passes to be observed at that time. LPN #94 was requested to provide medication administration records (MAR) for residents randomly chosen for review. Upon asking for the MAR for Resident #54, LPN #94 stated she had not yet passed the medications to Resident #54. LPN #94 was told when she did give Resident #54's medications, the surveyor would use that opportunity to observe the medication pass for Resident #54. At 10:04 p.m., while preparing to do the medication pass for Resident #54, LPN #94 said she had not yet signed off on any of the medications she had administered that evening. LPN #94 stated she had started giving medications at 7:00 p.m. and had yet to sign off on any of the medications given. When LPN #94 was asked, When should you sign off on medications? she stated, When I give them. I should sign off and document that they are given as soon as I give them. On 01/18/17 at 10:10 p.m., LPN #95 was asked her if she had signed off on the medications she had given that evening. LPN #95 stated she had not signed the EMAR (electronic medication administration records) at the tim… | 2020-04-01 |
| 3864 | 3864 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 282 | E | 0 | 1 | DBHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure care plan interventions were implement for four (4) of eighteen (18) resident's whose care plans were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #69's insulin was not administered according to physician's orders [REDACTED]. Resident #35's care plan was not implemented for weight loss. Resident #61's interventions for fall prevention were not implemented according to the care plan. The facility did not implement the intervention to provide supplements to Resident #10 as outlined in the care plan. Resident identifiers: #69, #35, #61, and #10. Facility census: 62. Findings include: a) Resident #69 Review of the resident's current care plan found the problem: Hyper/[DIAGNOSES REDACTED] (high/low blood sugar) related to insulin dependent diabetic status. The revision date for this problem was 12/04/16. The goal associated with this problem was: Resident will be free from any signs or symptoms of hypo/[MEDICAL CONDITION] as evidenced by absence of frequent urination, increased thirst, fruity breath, stupor, sweating, tremor, confusion, etc. daily through next review period. Interventions included: Administer insulin per physician's orders [REDACTED].>Record review found the resident was admitted to the facility on [DATE]. Review of the current physician's orders [REDACTED]. The parameters specified to contact the physician if the resident's blood sugar (BS) was less than 60 or greater than 400. Review of the Medication Administration Record [REDACTED]. [MEDICATION NAME] flex pen solution Pen-injector 100 unit/ml (milliliter). Inject 10 units subcutaneously after meals for diabetes mellitus. [MEDICATION NAME] Solution 100 unit/ml (insulin [MEDICATION NAME]) Inject 35 unit subcutaneously at bedtime for diabetes mellitus. In (MONTH) (YEAR), the resident was to receive; [MEDICATION NAME] flex pen solution Pen-injector 100 unit/ML (millil… | 2020-04-01 |
| 3865 | 3865 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 309 | E | 0 | 1 | DBHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and resident interview, the facility failed to implement Resident #78's physician's orders for finger stick blood sugars and sliding scale insulin coverage for twenty-five (25) days after admission. For Resident #78, the facility also failed to obtain an ordered basic metabolic panel (BMP), failed to ensure the resident kept an appointment with a consulting physician ([MEDICATION NAME]), and failed to administer/hold an antihypertensive ([MEDICATION NAME]) according to the physician ordered parameters. For Resident #9, the facility failed to ensure arrangements were provided for two appointments with consulting physicians (psychiatrist and urologist), failed to administer [MEDICATION NAME] (steroid) as directed for the treatment of [REDACTED]. For Resident #10, the facility failed to administer Nepro (supplement) as directed by the physician orders. The physician ordered the supplement to be given three (3) times a day, but the facility only administered it twice daily. For Resident #27, the facility failed to establish a care plan based on the resident's assessed needs for transfers. For Resident #69, the facility failed to follow the physician's parameters for insulin and the nursing staff held the resident's insulin without physician input. This was true for five (5) of eighteen (18) sampled stage 2 residents reviewed during Quality Indicator Survey (QIS). Resident identifiers: #78, #9, #10, #27, #69. Facility Census: 62 Findings include: a) Resident #78 Review of Resident #78 medical records on 01/18/17 at 10:00 a.m. found this seventy-seven (77) year old female was admitted to the facility on [DATE] from an acute care hospital. Her [DIAGNOSES REDACTED]. Discharge instructions from the acute care facility and approved by the attending physician at the facility included: 1. Finger sticks before meals and night (four times daily) for thirty (30) days and administer sliding scale insulin using … | 2020-04-01 |
| 3866 | 3866 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 322 | E | 0 | 1 | DBHB11 | Based on record review and staff interview, the facility failed to ensure complications from Resident #61's feeding tube were minimized by providing the correct type, rate, and volume of the feeding as ordered by the resident's attending physician. Resident #61 was not given the correct bolus feedings from 12/11/16 through 01/10/17. This was true for one (1) of one (1) resident reviewed for the care area of tube feeding during Stage 2 of the quality indicator survey (QIS). Resident #61. Facility Census: 62. Findings Include: a) Resident #61 A review of Resident #61's medical record found the following nutrition/weight progress note written by the facility's registered dietitian (RD): -- RD note dated 12/09/16 (typed as written): RD TF (tube feeding) note. Diet; Reg. (regular) pureed. PO (by mouth) intake past week 51 - 75% X (symbol for times) 3 (three) meals and 76-100% X 3 days. Adequate po intake. TF: Glucerna 1.2 1 (one) can 2 (two) X day w/ (with) 120 cc (cubic centimeter) flush bid (twice a day) = (symbol for equals) 570 kcal (kilocalorie), 28.4 gm (grams) prot. (protein), 384 cc free fluid, 624 cc w/ flushes. Wt. (weight) history: 12/9 (2016) 149# (pounds), 11/2 (2016) 156.8#, 6/3 (2016) 155.8# - wt. loss trend x 1, 3, and 6 months. Rec. (Recommend) TF - Glucerna 1.5 bolus 1 can 2 X a day w/ 120 cc flush bid to provide 712 kcal, 39 gm prot., 360 cc free fluid, 600 cc w/ current flushes. Weekly wts. (weights) x 4. Will fup (follow up) prn (as needed). Further review of the medical record found on 12/11/16 Resident #61 began receiving Glucerna 1.5 one (1) can two (2) times daily as recommended by the RD. However, upon further review of the Medication Administration Record [REDACTED]. According, to the MAR, Resident #61 received one (1) can of Glucerna 1.2 and one (1) can of Glucerna 1.5 twice daily at 9:00 a.m. and 9:00 p.m. beginning on 12/11/16 through 01/07/17, when he should have only received one (1) can of Glucerna 1.5 two (2) times daily at 9:00 a.m. and 9:00 p.m. Further review of the record found th… | 2020-04-01 |
| 3867 | 3867 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 323 | E | 0 | 1 | DBHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to ensure the environment over which it had control was as free from accident hazards as possible. Staff did not consistently implement planned interventions across all shifts to help prevent Resident #61 from falling. This was true for one (1) of three (3) residents reviewed for the care area of accidents during Stage 2 of the Quality Indicator Survey (QIS). Additionally, the Oak Hall had multiple pieces of equipment sitting in the hall making the hall congested and creating trip hazards and blocking residents' access to the handrails. In addition, the handrails on the Oak Hall were not free of splinters. These randomly discovered issues were found throughout the course of the QIS and had the potential to affect more than an isolated number of residents. Resident Identifier: #61. Facility Census: 62. Findings Include: a) Resident #61 A review of Resident #61's medical record at 2:17 p.m. on 01/17/17 found he had the following falls within the last 30 days: -- 12/23/16 at 4:00 a.m. - Resident #61 was found sitting on the floor beside his bed and reported he was trying to go to the bathroom. -- 01/13/17 at 2:30 a.m. - Resident was laying on floor beside his bed. He stated that he was trying to go to the bathroom. -- 01/14/17 at 5:30 a.m. - Resident was found lying on the floor. The resident's pants were down and there was feces on the floor. The resident was unable to state what he was trying to do when he fell . -- 01/16/17 at 6:45 a.m. - The resident was found sitting on the floor with his back against the bed. The resident was again unable to tell the staff what happened. A review of Resident #61's care plan found a focus statement (typed as written): Potential for falls related to HX (history of) falls with fracture which is complicated by Alzheimer's Disease, muscle weakness and other multiple medical problems. Resident is able to ambulate (walk) independently a… | 2020-04-01 |
| 3868 | 3868 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 325 | D | 0 | 1 | DBHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure a resident received a therapeutic diet for weight loss. In addition, monitoring and evaluation of the effectiveness of the interventions added for weight loss did not occur due to inaccurate documentation of the amount consumed by the resident. This was true for one (1) of three (3) residents reviewed for the care area of nutrition. Resident identifier: #35. Facility census: 62. Findings include: a) Resident #35 During Stage 2 of the Quality Indicator Survey (QIS), the resident was selected for review due to a weight loss. Record review found the resident's weight was 120.9# (pounds) on 11/02/16. On 11/23/16, the resident was discharged to the hospital. She returned to the facility on [DATE] at which time her recorded weight was 113.4# on 11/25/16. The facility acknowledged the resident's weight loss on 11/29/16. The physician was contacted and did not add any interventions as the resident was already receiving house shakes. Review of the physician's orders [REDACTED]. The resident's weight was 110.5# on 01/02/17, 111.4# on 01/06/17, and 111# on 01/10/17. On 01/9/17, the dietary manager recorded the following note: This is a dietary note on (name of resident) for her quarterly review of 1/2/17. (Name of resident) has had a 10.4# weight loss during the review of this quarter which is 8.6%. Her current weight is 110.5 and she is eating 51-75% of all meals. She eats in the Atrium room and is receiving a house shake BID (two times a day). On 12/01/16, the registered dietitian saw the resident. The dietitian noted the weight loss and documented the resident had a weight gain in the past week and weight could fluctuate due to the use of a diuretic. The resident's weight was 117# on 12/01/16. House shakes were to continue. On 01/11/17, the dietitian saw the resident and ordered 1 fortified food item per tray, 8 ounces of whole milk, and ice cream with lunch and d… | 2020-04-01 |
| 3869 | 3869 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 353 | E | 0 | 1 | DBHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, policy review, and observation, the facility failed to ensure qualified nursing staff provided day to day care to meet the resident's needs and in an environment which promoted each resident's physical, mental, and psychosocial well-being, to enhance their quality of life. The facility failed to implement Resident #78's diabetes management (finger sticks and sliding scale insulin) for twenty-five (25) days after the resident's admission, failed to obtain an ordered basic metabolic panel (BMP), failed to ensure the resident kept an appointment scheduled with a consulting physician ([MEDICATION NAME]), and failed to administer/hold an antihypertensive ([MEDICATION NAME]) according to the physician ordered parameters. For Resident #9, the facility failed to ensure arrangements were provided for two (2) appointments with consulting physicians, failed to administer [MEDICATION NAME] (steroid) as directed for the treatment if exacerbation of [MEDICAL CONDITIONS], and failed to notify the physician when the resident's blood sugars were outside of the physician ordered parameters. For Resident #10, the facility failed to administer Nepro (supplement) as directed by the physician orders. For Resident #27, the facility failed to ensure the assessed lift, transfer and positioning assessment correlated with the resident's care plan to ensure staff knew how to safely transfer the resident. For Resident #69, the facility failed to follow the physician ordered parameters for insulin and the nursing staff held the resident's insulin without orders. For Residents #67, #78, #29, #75, #55, #1, #14, #23, #74, #36,#38, #50, #77, #52, #65, #57, #17, #3, #2, #35, #8, #56, #28, #22, #70, #95, #79, #7, #97, #89, #24, #58, #47, #72, #21, #20, #46, #61, and #15, nurses failed to document medications immediately after administration. These practices had the potential to affect more than a limited number of res… | 2020-04-01 |
| 3870 | 3870 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 371 | E | 0 | 1 | DBHB11 | Based on observation and staff interview, the facility failed to store and prepare food under sanitary conditions. During the tour of the kitchen, food was discovered in the refrigerator opened and not dated, and the convection oven was found dirty. This had the potential to affect all residents who received food from this central location. Facility census: 62 Findings include a) Kitchen tour During the kitchen tour on 01/16/17 at 11:05 a.m., a 12 ounce bag of cranberries was found opened and not dated in the reach in refrigerator and the inside glass of the door of the top convection oven had a heavy accumulation of a grease-like substance. In an interview on 01/16/17 at 11:08 a.m., the dietary manager (DM) verified the 12 ounce bag of cranberries was not dated after opening and he also agreed the top convection oven needed cleaned. | 2020-04-01 |
| 3871 | 3871 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 425 | D | 0 | 1 | DBHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide pharmaceutical services to meet the needs of Resident #54. Melatonin was not available to be given to the residetn as order by the physician. This was true of one (1) of thirty-four (34) opportunities for medication administration. Resident identifier: #54. Facility census: 62. Findings include: a) Resident #54 The pharmacy failed to ensure Resident #54's prescribed Melatonin 5 milligram (mg) was available for the resident. At 10:50 p.m. on 01/18/17, LPN #94 stated the pharmacy had been contacted by day shift requesting Resident #54's prescribed Melatonin 5 mg by mouth at bedtime, but the pharmacy had yet to send it. LPN #94, accompanied by the surveyor, checked the emergency supply of medication to see if melatonin was available in the emergency stock of medication. In the facility's emergency stock of medication, Melatonin 3 mg tablets was the only dosage of Melatonin found. LPN was unable to administer the 5 mg of Melatonin on 01/18/17 as prescribed. Review of physician's orders [REDACTED]. | 2020-04-01 |
| 3872 | 3872 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 441 | D | 0 | 1 | DBHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to implement practices designed to prevent infection and/or cross-contamination for one (1) of two (2) residents reviewed in Stage 2 of the Quality Indicator Survey (QIS) for residents administered medication via a Gastrostomy Tube ([DEVICE]). This had the potential to affect any resident receiving feedings and/or medications via a [DEVICE]. Resident identifier: #20. Facility Census: 62 Findings include: a) Resident #20 On 01/16/17 at 3:14 p.m., during observation of medication pass, RN #91 administered medication via Resident #20's [DEVICE]. The syringe used to funnel the medication and water flushes popped off the end of the [DEVICE] while the nurse administered the medications. The syringe dropped onto the resident's exposed stomach, outside of resident's brief, and outside of the [DEVICE] dressing, which were unclean surfaces. The RN picked up the syringe and placed it back on the end of the [DEVICE] and continued administering the water flushes and other medication. An interview with the RN, after she completed Resident #20's medication pass, revealed the RN agreed she should have cleaned the syringe or obtained a new syringe before continuing to give the medication through the [DEVICE]. | 2020-04-01 |
| 3873 | 3873 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 514 | E | 0 | 1 | DBHB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure complete and accurate documentation for thirty-nine (39) of forty (40) resident's receiving evening and bedtime medications, and one (1) resident monitored for the percentage of nutritional supplements consumed. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #67, #78, #29, #75, #55, #1, #14, #23, #74, #36, #38, #50, #77, #52, #65, #57, #17, #3, #2, #35, #8, #56, #28, #22, #70, #95, #79, #7, #97, #89, #24, #58, #47, #72, #21, #20, #46, #61, #15, and #35. Facility Census: 62 Findings include: a) On 01/18/17 at 10:25 p.m., an interview with the recently acting interim director of nurses, Registered Nurse (RN #109), revealed facility policy and standard of practice dictate nurses sign the EMAR at the time medications were given. The RN verified that by not documenting in the EMAR at the time the medications were given, would cause the record to be inaccurate for the time the residents received their medication. RN #109 stated disciplinary actions would be taken for both LPN#94 and LPN#95. A list of all residents that had evening and bedtime medication given by LPN #94 and LPN #95, and whose MARs had not been signed by LPN #94 and LPN #95 at the time the medications were given to the residents, was requested. The requested list of resident's names provided on 01/18/17 at 11:03 p.m., revealed LPN #94 gave medications to twenty-nine (29) residents without documenting medications had been given in the EMAR (electronic medication administration record) at the time they were given. LPN #95 gave medications to ten (10) residents without documenting medications had been given in the EMAR at the time they were given. b) Resident #35 During Stage 2 of the Quality Indicator Survey (QIS), the resident was selected for review due to a weight loss. Review of the physician's orders [REDACTED]. Observation of the resident at 2:20 p.m.… | 2020-04-01 |
| 3874 | 3874 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 520 | C | 0 | 1 | DBHB11 | Based on record review and staff interview, the facility failed to ensure the medical director or his designee attended quarterly Quality Assurance and Assessment (QA&A) meetings. This practice was discovered during review of the mandatory facility task of QA&[NAME] Facility census: 62. Findings include: a) The QA&A quarterly attendance sign-in sheets were reviewed with the administrator at 9:16 a.m. on 01/19/17. Review of the attendance sign-in sheets from 01/01/16 to 01/19/17 found the medical director only signed two (2) attendance sheets - 04/28/16 and 10/27/16. The administrator was unable to verify the medical director or his designee attended quarterly QA&A meetings as required by the regulations. | 2020-04-01 |
| 3875 | 3875 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2016-11-18 | 155 | D | 0 | 1 | TJMH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to ensure Resident #52 was afforded the right to have her advance directives incorporated into her treatment regimen, failed to communicate this choice to the Interdisciplinary Team (IDT), and failed to ensure that when the resident experienced a severe weight loss, her treatment reflected this choice. Resident identifier: #52. Facility Census: 52. Findings include: a) Resident #52 Review of Resident #52's medical records on 11/17/16 at 10:00 a.m. found the resident was admitted to the facility on [DATE]. A West Virginia Physician order [REDACTED]. A review of Resident #52's medical record at 9:11 a.m. on 11/17/16, found the following recorded weights (All weight loss/gain Percentages calculated using the following formula % of body weight loss = (usual weight - actual weight)/(usual weight) x 100.): -- Date of admission 01/20/16 - 172.4 pounds (lb) -- 01/31/16 - 169 lbs. -- 02/02/16 - 169 lbs. -- 02/09/16 - 167 lbs. -- 02/15/16 - 168 lbs. -- 02/23/16 - 174 lbs. -- 03/01/16 - 175 lbs. -- 04/01/16 - 176 lbs. -- 05/03/16 - 170 lbs. -- 06/06/16 - 168 lbs. -- 07/05/16 - 165 lbs. -- 07/07/16 - 165 lbs. -- 07/11/16 - 165 lbs. -- 08/02/16 - 161 lbs. -- 09/08/16 - 152 lbs. -- 10/03/16 - 149 lbs. -- 11/01/16 - 148 lbs. From 08/02/16 through 09/08/16, Resident #52 lost 9 lb or 5.6% (percent) in 30 days - a severe weight loss in 30 days. From 06/06/16 through 09/08/16, Resident #52 lost 16 lb or 9.5% in 90 days - a severe weight loss 90 days. From 03/01/16 through 09/08/16 Resident #52 experienced a 23 lb or 13.1% in 180 days - a severe weight loss in 180 days. Guidance to Surveyors related to suggested parameters for evaluating significance and unplanned and undesired weight loss, found in Appendix PP of the CMS (Centers for Medicare and Medicaid Services) State Operations Manual contained the following: Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5… | 2020-04-01 |
| 3876 | 3876 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2016-11-18 | 242 | D | 0 | 1 | TJMH11 | Based on resident interview, record review, and staff interview, the facility failed to respect the right of one (1) of three (3) residents reviewed for the care area of choices, to exercise autonomy regarding what the resident considered to be an important aspect of life. Resident identifier: 21. Facility census: 52. Findings include: a) Resident #21 At 7:25 p.m. on 11/14/16, when asked, Do you choose when to get up in the morning? The resident replied, They wake me up early. The resident said she would prefer to sleep until 7:00 a.m. on most mornings. Review of the resident's last minimum data set (MDS), an annual, with an assessment reference date (ARD) of 08/25/16, found the resident scored a 15 on her Brief Interview for Mental Status (BIMS). (A score of 15 is the highest score obtainable and indicates the resident is cognitively intact.) In addition, the resident's 08/25/16 MDS also noted the resident felt it was very important to choose her own bedtime. The MDS did not include the question, how important is it to you to choose when to get up in the mornings. The resident's nurse aide (NA), NA #133, stated during an interview at 9:45 a.m. on 11/17/16 that nursing communicates the resident's care needs on a flow sheet in the computer or on the resident's care plan. She was unaware of any written communication regarding the resident's wishes for being awaken in the mornings. She did say the resident's son visited the resident early in the mornings. When asked if the son would wake the resident, she said she thought he did not awaken her if she was sleeping. Review of the general flow sheet noted it included the resident's ambulation, restorative nursing, turn and reposition every 2 hours, and encourage fluids. Review of the most recent care plan found no specific direction regarding the resident's preferred waking time. Review of the reportable allegations of abuse, neglect, and misappropriation of personal property to the proper state authorities found a reported allegation regarding Resident #21. The report… | 2020-04-01 |
| 3877 | 3877 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2016-11-18 | 280 | D | 0 | 1 | TJMH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to revise three (3) of seventeen (17) care plans reviewed during Stage 2 of the Quality Indicator Survey (QIS) when the residents experienced a change in condition. The facility did not revise Resident #27's care plan when the resident experienced a decline in urinary continence. Resident #46's care plan was not revised after a significant weight loss. Resident identifiers: #27 and #46. Facility census: 52. Findings include: a) Resident #27 The QIS triggered a review for urinary incontinence for Resident #27 when the admission minimum data set (MDS), with an assessment reference date (ARD) of 06/20/16, identified the resident as occasionally incontinent (less than 7 episodes of incontinence), compared to the quarterly MDS, with an ARD of 09/07/16, when the resident was coded as frequently incontinent. During an interview at 1:04 p.m. on 11/17/16, the director of nursing (DON) said there should be a bladder assessment upon admission and a second assessment when the resident had a decline. The DON said the resident did not have the capacity to participate in a re-training program. Review of the resident's medical record with the DON found no bladder assessments and no documentation present to verify the resident's decline had been addressed in any way. There was no information in the medical record to support the decline had been assessed. Review of the current care plan found a problem statement of, Requires ADL (activities of daily living) assistance r/t (related to) generalized weakness, cognitive deficit, decreased mobility, and history of falls. The goal associated with the problem: ADL needs will be met daily with resident participating within her abilities. Approaches included: Encourage every 2 hours and prn (as needed) toileting to maintain continence. This approach was dated 06/27/16. This was the only care plan referencing the resident's bladder incontine… | 2020-04-01 |
| 3878 | 3878 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2016-11-18 | 282 | D | 0 | 1 | TJMH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement Resident #43's care plan intervention of, [MEDICATION NAME] per orders. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator survey. Resident Identifier: #43. Facility Census: 52. Findings include: a) Resident #43 A review of Resident #43's medical record beginning at 7:30 a.m. on 11/16/16 found a care plan problem statement of: Potential alteration in nutritional and hydration status r/t (related to) dementia with behavioral disturbances, depression, anxiety, confusion, dx (diagnosis) diabetes. Significant weight loss noted this review, hx (history of) significant weight gain previously. On diuretic with potential for dehydration. This problem statement had a start date of 07/07/16 with most recent revision date of 09/21/16. The goal associated with this problem statement was: Resident will consume 50% or more of meals, consume supplements and have adequate intake of fluids to meet nutrition and hydration needs and have weight stabilization through next quarter. This goal had a target date of 12/21/16. The interventions associate with this goal included: [MEDICATION NAME] per orders. Further review of the medical record found an order with a start date of 07/20/16 for [MEDICATION NAME] 20 units once daily at 8:00 p.m. Review of Resident #43's Medication Administration Record [REDACTED]. (The order did not specify any conditions for which this medication could be held, therefore, physician notification was indicated.): -- In (MONTH) (YEAR), Resident #43's [MEDICATION NAME] was held on 08/06/16, 08/07/16, 08/09/16, 08/10/16, and 08/19/16. The reason this medication was held on these dates was not documented in the medical record and was unknown. -- In (MONTH) (YEAR), Resident #43's [MEDICATION NAME] was held on 09/02/16, 09/06/16, 09/07/16, 09/08/16, and 09/30/16. The reason this … | 2020-04-01 |
| 3879 | 3879 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2016-11-18 | 309 | K | 0 | 1 | TJMH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide diabetic management as ordered by the physician to provide consistent treatment to a resident who had a [DIAGNOSES REDACTED]. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). The facility's failure to follow the physician's orders [REDACTED].#43's Diabetes placed her at an immediate risk for serious harm and/ or death, which resulted in the determination of an immediate jeopardy. The facility's Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified of the immediate jeopardy at 2:57 p.m. on 11/16/16. The NHA submitted a Plan of Correction (P[NAME]) to abate the immediacy at 5:15 p.m. on 11/16/16. After the P[NAME] was reviewed and accepted by the State agency at 5:30 p.m. on 11/16/16, the survey team confirmed implementation of the corrective actions and the immediacy was abated at 6:25 p.m. on 11/16/16. Resident Identifier: #43. Facility Census: 52. Findings: a) Resident #43 A review of Resident #43's medical record beginning at 7:30 a.m. on 11/16/16 found the following physician's orders [REDACTED]. -- Order with start date of 05/10/16 - If blood sugar is over 200 Consistently Call MD (Medical Doctor). -- Order with a start date of 09/19/16 - If patient does not eat do not give coverage. -- Order with start date of 11/22/15 - [MEDICATION NAME] per sliding scale: BS (Blood Sugar) 200-249 give 4 units BS 250 - 299 give 8 units BS 300 - 349 give 12 units BS 350 - 399 give 16 units BS is greater than 399 give 20 units Special instructions: Accu Check before meals and at bedtime with sliding scale coverage (If resident does not eat do not give insulin coverage). -- Order dated 10/13/16 to discontinue the 2:00 a.m. accu check with sliding scale coverage (SSC). -- Order with a start date 07/20/16 - [MEDICATION NAME] 20 units once daily once a day a… | 2020-04-01 |
| 3880 | 3880 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2016-11-18 | 315 | D | 0 | 1 | TJMH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed The facility failed to assess one (1) of three (3) resident's reviewed for the care area of urinary incontinence, when the resident experienced a decline in urinary incontinence to determine if services could be provided to achieve or maintain as much normal urinary function as possible. Resident identifier: #27. Facility census: 52. Findings include: a) Resident #27 The Quality Indicator Survey (QIS) triggered a review for urinary incontinence for Resident #27. This area triggered because the admission, minimum data set (MDS), with an assessment reference date (ARD) of 06/20/16, identified the resident as occasionally incontinent (less than 7 episodes of incontinence), compared to the 90 day MDS, a quarterly, with an ARD of 09/07/16, when the resident was assessed as frequently incontinent. The director of nursing (DON) was interviewed at 1:04 p.m. on 11/17/16. She said there should be a bladder assessment upon admission and a second assessment when the resident had a decline. The DON said the resident did not have the capacity to participate in a re-training program. Review of the medical record with the DON found no bladder assessments and no documentation present to verify the resident's decline had been addressed in any way. There was no information in the medical record to support the decline was assessed. Review of the current care plan found the problem: Requires ADL (activities of daily living) assistance r/t (related to) generalized weakness, cognitive deficit, decreased mobility, and history of falls. The goal associated with the problem: ADL needs will be met daily with resident participating within her abilities. Approaches include: Encourage every 2 hours and prn (as needed) toileting to maintain continence. This approach was dated 06/27/16. This was the only care plan referencing the resident's bladder incontinence. Review of the facility's policy for Bowel and Bla… | 2020-04-01 |
| 3881 | 3881 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2016-11-18 | 325 | G | 0 | 1 | TJMH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure two (2) of three (3) residents reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey (QIS) maintained acceptable parameters of nutritional status. Resident #52 experienced a severe weight loss and the facility failed to monitor the resident's weight on a weekly basis, failed to notify the physician of the severe weight losses, and failed to communicate and address the resident's wishes to have a feeding tube as directed in her advance directives. This practice resulted in actual harm for Resident #52. Additionally, the facility failed to provide Resident #46 with the recommended nutritional supplement. Resident identifiers: #52 and #46. Facility census: 52. Findings include: a) Resident #52 A review of Resident #52's medical record at 9:11 a.m. on 11/17/16, found the following recorded weights (All weight loss/gain Percentages calculated using the following formula % of body weight loss = (usual weight - actual weight) / (usual weight) x 100.): Date of admission 01/20/16 - 172.4 pounds (lb) 01/31/16 - 169 lb 02/02/16 - 169 lb 02/09/16 - 167 lb 02/15/16 - 168 lb 02/23/16 - 174 lb 03/01/16 - 175 lb 04/01/16 - 176 lb 05/03/16 - 170 lb 06/06/16 - 168 lb 07/05/16 - 165 lb 07/07/16 - 165 lb 07/11/16 - 165 lb 08/02/16 - 161 lb 09/08/16 - 152 lb 10/03/16 - 149 lb 11/01/16 - 148 lb From 08/02/16 through 09/08/16, Resident #52 lost 9 lbs or 5.6 percent (%) in 30 days (severe weight loss). From 06/06/16 through 09/08/16, Resident #52 lost 16 lb or 9.5% in 90 days (severe weight loss). From 03/01/16 through 09/08/16, Resident #52 experienced a 23 lb or 13.1% in 180 days (severe weight loss). From 03/01/16 until 09/08/16, Resident #52 lost 9 lb or 5.6% in 30 days, 16 lb or 9.5% in 90 days, and 23 lb or 13.1% in 180 days. This represents a significant weight loss. Resident #52's meal percentage intakes were reviewed and found to be poor and in… | 2020-04-01 |
| 3882 | 3882 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2016-11-18 | 332 | D | 0 | 1 | TJMH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and policy review, the facility failed to administer medications appropriately for Resident #61. One (1) of three (3) nurses, Licensed Practical Nurse (LPN) #41, made three (3) errors of twenty-nine (29) opportunities for error, resulting in a medication error rate of 10.34 percent (%). The findings included: 1. Observations on 11/16/16 at 7:45 a.m. revealed LPN #41 administered [MEDICATION NAME] 17 grams to Resident #61. The physician's order [REDACTED]. This resulted in medication error #1. Interview with LPN #41 on 11/16/16 at 9:36 a.m., confirmed the nurse gave twice the amount of [MEDICATION NAME] as ordered by the physician. 2. Observation on 11/16/16 at 7:45 a.m., revealed LPN #41 administered [MEDICATION NAME] 40 milligrams (mg) to Resident #61. The nurse administered the [MEDICATION NAME] after Resident #61 had completed her breakfast meal. The physician's orders [REDACTED]. This resulted in medication error #2. Interview with LPN #41 on 11/16/16 at 9:36 a.m., confirmed the nurse should have administered the [MEDICATION NAME] prior to the breakfast meal. 3. Observation on 11/16/16 at 9:35 a.m. revealed LPN #41 cut a [MEDICATION NAME] 25 mg tablet. This tablet was not scored. When the [MEDICATION NAME] tablet was cut, it broke into multiple pieces. The physician's orders [REDACTED]. This resulted in error #3. Review of the facility's policy, Administration of oral medication on 11/16/16 at 9:40 a.m., found under procedure: --Verify the order --Uncoated tablets may be scored for easy division. For correct dosage, break only tablets that are scored. Interview with Pharmacist #155 on 11/16/16 at 10:53 a.m., found the licensed nurses are only to cut tablets in which are scored. She agreed the unscored [MEDICATION NAME] should not have been cut. She confirmed the administration of the [MEDICATION NAME] was inconsistent and dosage would be inaccurate. Interview with LPN #41 on 11/16/16 at 11:00 a.m., confir… | 2020-04-01 |
| 3883 | 3883 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2016-11-18 | 514 | D | 0 | 1 | TJMH11 | Based on record review and staff interview the facility failed to maintain an accurate and complete medical record for Resident #46. This was true for one (1) of three (3) residents reviewed for the care area of Activities of Daily Living during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #46. Facility Census: 52. Findings include: a) Resident #46 A review of Resident #46's medical record in the morning of 11/17/16 found the following physician orders (typed as written): -- Ensure that right shoulder immobilizer is snug on pt (patient) prior to any transfers. -- Sling to right arm at all times. Observations of Resident #46 at 12:45 p.m. on 11/17/16 found restorative nursing assisting the resident to ambulate. At the time of the observation, Resident #46 was not wearing an arm sling or a shoulder immobilizer on her right arm. Restorative Nurse Aide (RNA) #91 and RNA #2 assisted the resident in standing up from a seated position in her wheelchair and assisted her in walking down the hallway. An interview with the Director of Nursing (DON) on 11/17/16 at 1:42 p.m. confirmed the resident had not been wearing the shoulder immobilizer or arm sling. She stated the resident ' s husband had given them back and told them she did not need them anymore. She could not recall exactly when that happened, but thought it was around the same time he took her for a follow up with her orthopedic doctor. A final Interview with the DON at approximately 10:30 a.m. on 11/18/16, confirmed there was no physician's order ever written to discontinue the resident's arm sling and shoulder immobilizer and there should have been. She indicated from what she could tell the husband had taken her to the orthopedic appointment and they never followed up with writing the order to discontinue the sling and immobilizer. | 2020-04-01 |
| 3884 | 3884 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 225 | E | 0 | 1 | 5Q6I11 | Based on a random opportunity for discovery, staff interview, policy review, review of the abuse/neglect reporting requirements for West Virginia nursing homes and nursing facilities, and review of an employee disciplinary action form, the facility failed to thoroughly investigate and report allegations of neglect/abuse to the appropriate State agencies immediately in accordance with State law. This had the potential to affect more than an isolated number of residents. Resident identifiers: #91 and #77. Facility census: 75. Findings include: a) Employee disciplinary action form 1. On 08/16/16 at 4:00 p.m., an unrequested employee education and counseling form was found lying beside a surveyor's computer in the conference room where surveyors were working. No personnel files were in the room as there were times when no members of the survey team were present. How the document came to be in the conference room could not be determined. The employee education and counseling form included: - The name of Nurse Aide (NA) #74 - Date of the employee education and counseling form: 06/02/16 - The form required documentation for Area of Improvement: Define Situation. Poor Resident care-Resident's are being left up in wheelchairs without being checked on. Resident's are not being put to bed in a timely manner. (Name of Resident #91) reported that you were very hateful and rough putting her feet in the bed this evening. Also, she stated that last week you took her call light from her. (Name of Resident #77) does not want you to do her showers after your attitude last week. This is unacceptable work performance. Told oncoming CNA (certified nurse aide) that Resident didn't want her shirt off when in fact resident was never checked on. - The resolution for action taken: CNA needs to be aware that we are here to take care of the needs of the resident. This is the 2nd employee counseling/education form from this nurse. Next is written warning, followed by suspension and then termination if this problem isn't corrected. CNA needs t… | 2020-04-01 |
| 3885 | 3885 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 226 | D | 0 | 1 | 5Q6I11 | Based on a random opportunity for discovery, staff interview, policy review, review of the abuse/neglect reporting requirements for West Virginia nursing homes and nursing facilities, and review of an employee disciplinary action form, the facility failed to implement its policy for investigation and reporting of allegations of abuse and neglect. This had the potential to affect more than an isolated number of residents. Resident identifiers: #91 and #77. Facility census: 75. Findings include: a) Employee disciplinary action form 1. On 08/16/16 at 4:00 p.m., an unrequested employee education and counseling form was found lying beside a surveyor's computer in the conference room where surveyors worked when not out on the nursing units. No personnel files were in the room as there were times when no members of the survey team were present. How the document came to be in the conference room could not be determined. The employee education and counseling form included: - The name of Nurse Aide (NA) #74 - Date of the employee education and counseling form: 06/02/16 - The form required documentation for Area of Improvement: Define Situation. Poor Resident care-Resident's are being left up in wheelchairs without being checked on. Resident's are not being put to bed in a timely manner. (Name of Resident #91) reported that you were very hateful and rough putting her feet in the bed this evening. Also, she stated that last week you took her call light from her. (Name of Resident #77) does not want you to do her showers after your attitude last week. This is unacceptable work performance. Told oncoming CNA (certified nurse aide) that Resident didn't want her shirt off when in fact resident was never checked on. - The resolution for action taken: CNA needs to be aware that we are here to take care of the needs of the resident. This is the 2nd employee counseling/education form from this nurse. Next is written warning, followed by suspension and then termination if this problem isn't corrected. CNA needs to have better time ma… | 2020-04-01 |
| 3886 | 3886 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 241 | D | 0 | 1 | 5Q6I11 | Based on observations, resident interview, and staff interview, the facility failed to provide dignity for one (1) of three (3) residents for the care area of dignity. The facility failed to assist Resident #31 with removal of long hair on her chin, around her upper lip and the corners of her mouth. Resident identifier: #31. Facility census: 75. Findings include: Resident #31 Observations during Stage I of the Quality Indicator Survey on 08/16/16 at 9:55 a. m. revealed Resident #31 had long hair on her chin and around her upper lip and corners of her mouth. In an interview with the Resident #31 on 08/16/16 at 1:57 p.m., she stated, I am 62, and I cannot remove the hair off my chin or around my lips. They do not remove the hair. I will have to wait until I get out of here in order to have someone to remove the hair. In an interview and observation with Nurse Aide (NA) #117 on 08/16/16 at 2:06 p.m., she confirmed the resident did have long hair on her upper lip, around the corners of her lips, and on her chin. The NA confirmed that she took care of this resident and she had never removed the hair on the resident's face. On 08/16/16 at 2:15 p.m., review of Resident #31's admission minimum data set (MDS) assessment with the assessment reference date (ARD) of 06/09/16 found Resident #31 scored a 15 on her Brief Interview for Mental Status (BIMS - a test to help determine a resident's cognitive abilities), indicating the resident was cognitively intact. The MDS also identified the resident required the extensive assistance of staff to maintain her personal hygiene, which includes shaving. In an interview on 08/16/2016 2:33 p.m., Licensed Practical Nurse (LPN) #36 stated, Yes ma'am, she has hair on her chin, upper lip and corners of her mouth and I do not know if anyone has ever asked her if she would like to have them removed. She said she did not have to go and look at her she knew the resident had hair on her chin and around her lips. The LPN stated, The resident is blind and she cannot see the hair on her chin, and … | 2020-04-01 |
| 3887 | 3887 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 279 | D | 0 | 1 | 5Q6I11 | Based on record review and staff interview the facility failed to develop a comprehensive care plan that contained measurable objectives (goals) regarding his inappropriate sexual behaviors. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #24. Facility Census: 75. Findings Include: a) Resident #24 A review of his medical record on 08/17/16 02 at 12:30 p.m., found the resident's care plan included a focus statement (typed as written) of, Sexual inappropriateness, making comments about staffs body parts. Mades (sic) comments when they bend over or provide any type of continence care. Often says he cannot clean his private area when certain staff are working and demands that they provide the care although he can do so himself. This focus statement was added to his care plan on 09/01/15. The goal associated with this focus statement was (typed as written), Patient will have no complications from (SPECIFY) through next review date. This goal, initiated on 09/01/15, was reviewed/revised on 08/12/16, 07/28/16, 05/04/16, 02/12/16, 02/03/16, and 11/11/15. On none of these dates was there a measurable goal defined. In an interview at 3:24 p.m. on 08/17/16, the Director of Nursing (DON) confirmed the goal was never developed. She agreed they needed to specify what the targeted behaviors were instead of leaving the word specify on the care plan. | 2020-04-01 |
| 3888 | 3888 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 280 | D | 0 | 1 | 5Q6I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revised the care plans for two (2) of twenty-one (21) residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey. The facility failed to revise Resident #31's care plan to address her refusal of her showers. In addition, the care plan for Resident #46 was not revised to address how often the resident's Foley catheter should be changed and by whom. Resident Identifiers: #31 and #46. Facility census: 75. Findings include: a) Resident #31 In an interview with Nurse Aide (NA) #117 on 08/16/16 at 1:57 p.m., she reviewed Resident #31's information on the kiosk (a computer system that displays information about a resident's care needs to direct care staff, where they document the care provided) and replied that Resident #31 had refused her shower that day. The NA confirmed the resident was to receive her showers on Tuesday and Friday. The NA said the resident often refused her showers. On 08/16/16 at 1:45 p.m., review of Resident #31's care plan found a plan initiated on 06/16/16 regarding the resident resisting care at times related to anxiety, adjustment to the nursing home, and that she could become verbally abusive toward staff. The care plan focus did not identify the resident refused showers, nor were individualized interventions established for what staff should do when the resident refused her showers. The care plan initiated on 06/14/16 related to the resident's activity of daily living self-care deficit due to [MEDICAL CONDITIONS], anxiety, and a history of falls did not address the resident's refusal of showers either. In an interview with the unit charge nurse, Licensed Practical Nurse (LPN) #36 at 2:27 p.m. on 08/16/16, when asked whether Resident #31 refused her showers, the LPN said the resident did not want her shower today. The LPN said the shower team asked for a NA on the floor to shower the resident in her room as the resident preferre… | 2020-04-01 |
| 3889 | 3889 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 282 | E | 0 | 1 | 5Q6I11 | Based on record review and staff interview, the facility failed to ensure implementation of his care plan in regards to his risk for dehydration. This was true for one (1) of three (3) residents reviewed for the care area of hydration during Stage 2 of the Quality Indicator Survey. Resident Identifier: #24. Facility Census: 75. Findings include: a) Resident #24 A review of Resident #24's medical record at 8:25 a.m. on 08/18/16 found a care plan focus initiated 12/04/15 of, (typed as written) (Resident #24's Name) has potential dehydration or potential fluid deficit r/t (related to) Diuretic use. The goal associated with this care plan was, (typed as written) Patient will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor through review period. This goal, last reviewed on 08/12/16, had no changes made to it since first initiated on 04/01/15. The interventions related to this focus statement and goal included, (typed as written) Monitor and notify physician of acute symptoms leading to or indicative of dehydration, including persistent symptoms of diarrhea; nausea/vomiting unresolved past 48 hours; persistent output exceeding intake past 48 hours; abnormal labs (laboratory). Further review of his medical record found the resident's intakes and outputs were recorded on a daily basis. Review of the intake and output records found the following: --On 05/11/16 - his output was 75 cubic centimeters (cc) greater than his intake. --On 05/12/16 - his output was 1750 cc greater than his intake. --On 05/13/16 - his output was 930 cc greater than his intake. --On 05/25/16 - his output was 1390 cc greater than his intake. --On 05/26/16 - his output was 170 cc greater than his intake. --On 05/27/16 - his output was 1140 cc greater than his intake. --On 05/28/16 - his output was 1470 cc greater than his intake. --On 06/17/16 - his output was 1940 cc greater than his intake. --On 06/18/16 - his output was 1180 cc greater than his intake. --On 06/19/16 - his output was 250 cc greater than his … | 2020-04-01 |
| 3890 | 3890 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 312 | D | 0 | 1 | 5Q6I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, and staff interview, the facility failed to ensure residents who were unable to carry out activities of daily living, received care and services for grooming. This was true for two (2) of three (3) residents reviewed for the care area of activities of daily living (ADL). Resident identifiers: #52 and #31. Facility census: 75. Findings include: a) Resident #52 Observation of the resident at 12:02 p.m. on 08/15/16 found she had multiple, noticeable, dark, long hairs on her chin. Review of the resident's most recent minimum data set (MDS), a quarterly, with an assessment reference date (ARD) of 08/01/16, found the resident required the extensive assistance of one staff member for personal hygiene. Personal hygiene is defined on the MDS as combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers). During an interview on 4:12 p.m. on 08/16/16, the resident's Nurse Aide (NA), NA #33, said the resident did not want anything done about the hairs on her chin. At 4:19 p.m. on 08/16/16, the resident was interviewed in her room with Licensed Practical Nurse (LPN) #55 present. The resident said she wanted the hairs gone - I don't want to look like a man. LPN #55 said he would get a razor and have NA #33 take care of the issue immediately. b) Resident #31 Observation on 08/16/16 at 9:55 a. m., during Stage I of the Quality Indicator Survey, revealed Resident #31 had long hair on her chin and around her upper lip and corners of her mouth. In an interview with Resident #31 on 08/16/16 at 1:57 p.m., she stated, I am 62, and I cannot remove the hair off my chin or around my lips. They do not remove the hair. I will have to wait until I get out of here in order to have someone to remove the hair. In an interview and observation with NA #117 on 08/16/16 at 2:06 p.m., NA #117 confirmed the resident did have long hair on her upper lip, around her lips … | 2020-04-01 |
| 3891 | 3891 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 412 | D | 0 | 1 | 5Q6I11 | Based on resident interview, staff interview, and medical record review, the facility failed to ensure one (1) of three (3) resident's reviewed for the care area of dental services, received a follow up dental appointment. Resident identifier: #52. Facility census: 75. Findings include: a) Resident #52 Observation of the resident's oral cavity at 12:05 p.m. on 08/15/16, found the resident had several missing teeth and teeth that appeared to be broken off at the gum line. Review of the last annual minimum data set (MDS) assessment, with an assessment reference date (ARD) of 02/08/16 noted the resident assessed as having obvious or likely cavities or broken natural teeth. On 07/02/15, the resident had a dental consult. The consult noted the resident needed surgical extraction of teeth #03, #05, #18, #20, and #29 (teeth are numbered 1 through 32 beginning with the left upper molar). The resident had poor oral hygiene and generalized gingivitis. Further review of the medical record found no evidence the resident had received a follow up dental appointment to have the teeth extracted. On 08/17/16 at 8:13 a.m., Registered Nurse (RN) #95 was asked if the facility had scheduled a follow up appointment for the resident? At 9:17 a.m. on 08/17/16, RN #95 provided nursing notes dated 07/06/15 and 07/07/15 indicating the facility had tried to contact the resident's responsible party, the Department of Health and Human Services (DHHR). RN #95 said, I guess we dropped the ball, when they (the DHHR) never signed and returned the consent papers. RN #95 was unable to provide any evidence the facility pursued the removal of the resident's teeth after contacting the DHHR on 07/07/15. | 2020-04-01 |
| 3892 | 3892 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 514 | E | 0 | 1 | 5Q6I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, physician interview, and staff interview, the facility failed to ensure the medical records of four (4) of twenty-one (21) residents whose medical records were reviewed during Stage 2 of the Quality Indicator Survey were complete and accurate. Resident #1's medical record did not contain the results of an esophagogastroduodenoscopy (EGD). Resident #27's physician orders did not contain the milligrams (mg) of a medication ordered by the physician. Resident #82's medical record contained a physician's order that belonged to a different resident. Resident #52's medical record did not support an attempted Gradual Dose Reduction (GDR) failed. Resident Identifiers: #1, #27, #82, and #52. Facility Census: 75. Findings Include: a) Resident #1 A review of Resident #1's medical record at 1:18 p.m. on 08/16/16 found a nursing progress note dated 04/04/16 that was an appointment/return note. This note indicated that Resident #1 had returned from her scheduled EGD and the results of the EGD were sent back with the resident and reviewed at that time. Further review of the record revealed the results of the EGD were not contained in the medical record. On 08/17/16 at 11:05 a.m., Medical Records Assistant #16 provided a copy of the EGD results. When asked where these results were located, she indicated she had to call and get a new copy faxed to the on that day because the results received on 04/04/16 could not be located at the facility. b) Resident #27 Observation during the medication administration pass on 08/17/16 at 8:14 a.m., revealed Unit Charge Nurse - Licensed Practical Nurse (UCN-LPN) #108 administered Resident #27's Senna 8.6 milligram (mg) two (2) tablets via gastrostomy tube (a tube used to provide nutrition, fluids, and medications who cannot safely swallow.). A review of Resident #27's (MONTH) (YEAR) physician's order on 08/18/16 at 8:45 a.m., revealed the resident received Senna 2 tablets via [DEVICE] 2 times a day fo… | 2020-04-01 |
| 3893 | 3893 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 154 | D | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure Resident #170 was given information in advance sufficient enough for her to make a knowledgeable health care decision in regards to a fluid restriction which her attending physician at the hospital (who was also her attending physician at the facility) had recommended upon her discharge from the hospital on [DATE]. This was true for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT]. Resident Identifier: #170. Facility Census: 178 Findings include: a) Resident #170 A review of Resident #170's medical record at 9:00 a.m. on 09/23/16, found a discharge summary completed by Resident #170's attending physician while she was at the hospital. The discharge summary completed on 08/22/16 included her attending physician recommended a fluid restriction due to her status as a [MEDICAL TREATMENT] patient and her [DIAGNOSES REDACTED]. The same physician was also her attending physician at the facility. During an interview with the corporation's Chief Medical Officer Medical Doctor (CMO-MD) #271 at 10:20 a.m. on 09/23/16, when asked why Resident #170, a [MEDICAL TREATMENT] patient, was not ordered a fluid restriction upon her return from the hospital on [DATE], he replied not every one on [MEDICAL TREATMENT] needed a fluid restriction. He indicated that people in the community very seldom ever restrict their fluid. He proceeded to state the risk and benefits related to not watching her fluid intake was explained to the resident, but she was alert and orientated and able to make her own decisions. Therefore, she had the right refuse the fluid restriction which is why she was not currently ordered a fluid restriction. CFO-MD #271 was then asked if the conversation explaining the risk and benefits related to her refusal of a physician recommended fluid restriction was documented in her medical record. He informed the surveyor that this … | 2020-04-01 |
| 3894 | 3894 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 155 | D | 0 | 1 | 0MB311 | Based on record review and staff interview, the facility failed to establish and maintain policies about a resident's right to refuse treatment. This had the potential to affect all residents currently residing at the facility. Facility Census: 178. Findings Include: a) Policy In the early afternoon of 09/23/16, the Assistant Nursing Home Administrator (ANHA) was asked to provide the facility's policy and/or procedures which were followed when a resident wished to exercise their right to refuse treatment. At 2:44 p.m. on 09/23/16, the ANHA and Nursing Home Administrator (NHA) both confirmed the facility did not have a policy in regards to the residents' right to refuse treatment. They provided the facility's advance directive policy. This policy did include the following statement, Prior to or upon admission of a resident to the facility, the Social Service Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate and advance directive. The remaining eight (8) statements contained in the policy were solely directed to written advanced directives such as medical power of attorney or a living will, and not the right to accept or refuse medical treatment. At approximately 3:00 p.m. on 09/23/16, the Admissions Coordinator #77 was asked to provide what written information was given to residents upon admission to the facility in regards to advance directives and their right to accept and/or refuse medical treatment other than an advance directive. She referred to the facility's Admission Information Packet pages 14 - 26. The information contained on these pages specifically related to the creation of and the authority of written advance directives such as a Medical Power of Attorney or Living Will. It did not include any information pertaining to the residents' right to accept or refuse medical treatment other than the creation of a written adv… | 2020-04-01 |
| 3895 | 3895 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 157 | D | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to notify Resident #170's attending physician when she experienced unrelieved pain and she refused six (6) out of eight (8) [MEDICAL TREATMENT] treatments in the month of (MONTH) (YEAR) due to pain from her [DEVICE]. This was true for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT]. Resident Identifier: #170. Facility Census: 178. Findings include: a) Resident #170 A review of Resident #170's medical record at 10:00 a.m. on 09/21/16 found the resident was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Further review of the record on 09/21/16 at 3:00 p.m., found an admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 08/29/16, identified the resident scored 15 of a possible 15 for the Brief Interview for Mental Status (BIMS) - indicating the resident was cognitively intact. Review of Resident #170's medical records found on multiple occasions Resident #170 refused [MEDICAL TREATMENT] treatments from 09/06/16 through 09/22/16. An interview with Resident #170 at 9:35 a.m. on 09/22/16, revealed she was not going to [MEDICAL TREATMENT] because of pain caused from the [DEVICE] which was placed on 09/05/16. The record contained no information to indicate Resident #170's attending physician and/or nurse practitioner were notified of her refusals of [MEDICAL TREATMENT] and/or pain. The [MEDICAL TREATMENT] center, on two (2) occasions, 08/25/16 and 09/08/16, sent recommendations to discontinue Resident #170's [MEDICATION NAME]. The facility did not address this. She continued to receive the medication and the physician had not been notified of the recommendations as of 09/22/16. In an interview on 09/22/16 at approximately 10:05 a.m., the Director of Nursing (DON) was informed of Resident #170's multiple documented occasions when the resident refused [MEDICAL TREATMENT] treatme… | 2020-04-01 |
| 3896 | 3896 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 163 | D | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure Resident #170 was afforded the right to choose her personal physician upon admission to the facility. This was true for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT]. Resident Identifier: #170. Facility Census: 178. Findings Include: a) Resident #170 A review of Resident #170's medical record at 4:00 p.m. on 09/23/16, found she had two (2) recent admissions to the facility. She was admitted on [DATE], discharged to the hospital 08/12/16 and was readmitted on [DATE]. Review of the admission orders [REDACTED]#272). Resident #170's record contained a history and physical completed by DO #272 which on 08/23/16. This History and Physical contained the following statement, Patient admitted to my services but requests to be changed to (Name of attending Medical Doctor (MD) #273 as he is her regular provider. Review of the nursing progress notes found a note dated 08/27/16 at 9:42 a.m. stating, (Name of MD #273) arrived at facility identifying patient as a long time patient of his, he requested patient be switched from (Name of DO #272) to his care in facility. Also contained in Resident #170's medical record was a form titled, Consent for Treatment and Release of Information. This form indicated that Resident #170 had designated MD #273 as her attending physician, however his name was marked out and replaced with DO #272's name. This form was signed by the resident on 08/12/16. The name of the physician was changed by the nurse completing the form and it was unknown if it was done prior to or after the resident signed the form. An interview with Resident #170 at 4:15 p.m. on 09/23/16, confirmed she was not given a choice of physician upon admission to the facility. She stated, I had one Doctor when I first got here because I did not know (Name of MD #273) came here. When I found out he came here I told them I wanted to be … | 2020-04-01 |
| 3897 | 3897 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 241 | D | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain or enhance each resident's dignity as evidenced by staff using labels in reference to the resident's feeding ability. This affected one (1) randomly observed resident. Resident identifier: #388. Facility census: 178. Findings include: a) Resident #388 On 09/19/16 at 11:51 a.m., Resident #388 sat in a chair between his bed and the doorway. He wore a hospital gown, and a blanket covered his shoulders and upper arms. Numerous covered food items sat on an over-bed table in front of him. Nurse Aide (NA) #195 stood at the roommate's bed and opened the tray for the roommate. Another staff person entered the room to see if the resident's needed help. NA #195 relayed to the other staff person that Resident #388 was a feeder. This statement could be heard in the hallway outside the resident's room. Medical record review on 09/21/16 at 2:00 p.m. found this resident recently came to the facility. The admission minimum data set (MDS) assessment, with an assessment reference date (ARD) 09/14/16, assessed Resident #388 with severely impaired cognitive skills. Section G of the MDS assessed need for extensive staff assistance with bed mobility and transfer, dressing, eating, toilet use, personal hygiene, and total dependence for bathing. [DIAGNOSES REDACTED]. Section K of the MDS assessed feeding difficulties which included the loss of liquids or solids from his mouth when eating or drinking; holding food in his mouth or cheeks, or residual food in his mouth after meals; and coughing or choking during meals or when swallowing medications. Subsequently, he required a mechanically altered diet. During an interview with the director of nursing (DON) on 09/21/16 at 3:30 p.m., she said that referring to a resident as a feeder was not an acceptable practice at this facility. She spoke her belief that staff knew better than to do that, because this is a dignity issue. | 2020-04-01 |
| 3898 | 3898 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 250 | D | 0 | 1 | 0MB311 | Based on resident interview and staff interview, the facility failed to assist Resident #235 in maintaining or improving her ability to manage her everyday psychosocial needs. Social services failed to discuss with resident concerns arising from a visitor visiting after recommended visiting hours. This was true for one (1) of four (4) residents reviewed for choices. Resident identifier: #235. Facility Census: 178 Findings include: a) Resident #235 During a Stage 1 interview on 09/19/16 at 3:20 p.m., Resident #235 revealed a friend came to visit her late one night. The resident stated they (her friend and Resident #235) had both worked as night shift nurses for years, and at night was the only time her friend could visit. The resident said they went to the dining room and even outside during the visits, so as not to disturb any of the other residents. Resident #235 stated her friend was badly scolded on two (2) different occasions for visiting late in the night and was made to feel like a child. The night shift supervisor made her leave the first time, and her friend called the administrator to make sure it was alright to visit at night, if they did it quietly and did not disturb other residents. Her friend was told by the administrator that she could visit, but did need to be respectful of other residents. The friend came back around 1:00 a.m. to visit the next night after clarifying with the Administrator it was all right to visit. According to the resident, the night shift supervisor stopped the visit again. The resident stated, The supervisor brought a second nurse with her. The second nurse stood behind the supervisor with her arms folded across her chest while the supervisor yelled at my friend. The supervisor told my friend, you are a nurse and should know better. We have patients here that need their sleep. Resident #235 stated her friend was upset and embarrassed and demanded an incident report be filled out. When asked if an incident report had been filled out, the resident said, Yes, I think so. I don't… | 2020-04-01 |
| 3899 | 3899 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 253 | E | 0 | 1 | 0MB311 | Based on observation, random observation and staff interviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The cosmetic imperfections included peeling wallpaper, damaged chair railing, missing caulking around sinks and commodes, damaged sink tops, a light casement and cable box had pulled away from wall, missing paint, broken and stained floor tiles, and odors. Room identifiers: A1, A3, C1, C3, C5, C12, D4, D5, D7, D8, D9, E5, F11, G2, and G13. Facility census: 178. Findings include: a) Cosmetic imperfections --Room A1 - observed on 09/19/16 at 2:48 p.m., had wallpaper peeling away from the wall above resident's bed. --Room A3 - observed on 09/19/16 at 2:37 p.m. - the chair had scuffed arms. --Room C1 - observed on 09/20/16 at 9:54 a.m. - had torn wallpaper behind resident's bed. --Room C3 - observed on 09/20/16 at 9:23 a.m. - had splintered chair railing behind the resident's bed, a sink top with damaged Formica, and a cracked board above the cove base. --Room C5 - observed on 09/20/16 at 8:41 a.m. - had splintered chair railing behind the bed and the board above the cove base was splintered. --Room C12 - observed on 09/20/16 at 10:18 a.m. - had chair railing and wallpaper separated from the wall, walls had missing paint, and the entrance door had peeled paint. --Room D4 - observed on 09/20/16 at 12:44 p.m. - had broken floor tile under the sink, the light housing over the bed had pulled away from the wall and the walls had areas of paint, that did not match. --Room D5 - observed on 09/20/16 at 8:44 a.m. - had a dirty heating/cooling unit and stains around the base of the commode. --Room D7 - observed on 09/20/16 at 8:49 a.m. - had a sink with missing caulking and the front of the sink top had been poorly repaired. --Room D8 - observed on 09/20/16 at 9:07 a.m. - had a sink with missing caulking. --Room D9 - observed on 09/20/16 at 9:52 a.m. - had a closet door with scuff marks. --Room E5 - observed on 09/20/16 at 9:42 a… | 2020-04-01 |
| 3900 | 3900 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 279 | D | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop individualized and measurable goals for a resident with behaviors, who was treated with psychoactive medications. This was evident for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #225. Facility census: 178. Findings include: a) Resident #225 Medical record review on 09/21/16 at 1:30 p.m., found this [AGE] year-old resident had [DIAGNOSES REDACTED]. disorder, depression, mood disorder, [MEDICAL CONDITION], and [MEDICAL CONDITION] other than [MEDICAL CONDITION]. Daily medications included [MEDICATION NAME] (an antianxiety medication) one (1) milligram (mg) three (3) times daily; [MEDICATION NAME] (antipsychotic medication) twenty-five (25) mg daily at bedtime; and [MEDICATION NAME] (an antidepressant medication) fifteen (15) mg daily at bedtime. The most recent quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) off 07/22/16, assessed he received antipsychotic, antianxiety, and antidepressants daily. The Brief Interview for Mental Status (BIMS) assessed his score as three (3), which indicated severely impaired cognition for decision-making. Review of the care plan found a problem/focus that the resident received antipsychotic medication due to a [DIAGNOSES REDACTED]. It noted the resident exhibited mood changes for no apparent reason, and could become upset and aggressive. Also he resisted and/or refused activities of daily living care at times, hit staff, cursed and yelled. The care planned goal for this problem simply stated Resident will receive lowest dose possible with no side effects noted through next review period. The care plan contained another focus/problem area that he received antianxiety medication related to behaviors of agitation as evidenced by hitting staff, cursing and yelling, due to the [DIAGNOSES REDACTED]. Further review of the care plan found a focus/problem that… | 2020-04-01 |
| 3901 | 3901 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 280 | D | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #179's care plan was revised when her order for a fluid restriction was discontinued. This was true for one (1) of four (4) residents reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #179. Facility Census: 178. Findings Include: a) Resident #179 A review of Resident #179's medical record at 2:43 p.m. on 09/20/16, found a physician's orders [REDACTED]. A review of Resident #179's current care plan at 3:00 p.m. on 09/20/16, found a focus statement related to the resident's risk for altered nutritional and hydration status. The interventions related to this focus statement included, Provide a 1000 ml per day fluid restriction per md (medical doctor). An interview with the Director of Nursing (DON) at 2:12 p.m. on 09/21/16 confirmed the resident's care plan needed revised because she was no longer on a fluid restriction. | 2020-04-01 |
| 3902 | 3902 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 309 | H | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, and resident interview the facility failed to assess Resident #170's pain by location, quality, intensity, pattern, frequency, timing, and duration. There was no evidence the facility attempted to develop interdisciplinary nonpharmacological strategies to manage the resident ' s pain. The resident suffered actual harm by the facility's failure to ensure the most effective pain management possible for the resident. Review of Resident #170's medical records, staff interviews and resident interviews found on multiple occasions from [DATE] through [DATE] the resident had refused [MEDICAL TREATMENT] treatments. An interview with Resident #170 revealed she was not going to [MEDICAL TREATMENT] because of pain caused from the [DEVICE], which was placed on [DATE]. The record contained no information to indicate Resident #170's attending physician and/or the nurse practitioner were notified of her refusals of [MEDICAL TREATMENT] and/or pain. On [DATE] and [DATE], the [MEDICAL TREATMENT] center sent recommendations to discontinue Resident #170's [MEDICATION NAME]; however, she continued to receive this medication and the physician had not been notified of the recommendations as of [DATE]. Additionally, for Resident #170, the facility failed to correlate care between the facility and the [MEDICAL TREATMENT] center and failed to administer the Renavela as directed by the nephrologist. For Resident #225, the facility failed to provide effective pain management by failing to assess his level of pain prior to the administration of an as needed (PRN) pain medication. The facility failed to reassess the resident to determine the effectiveness of the pain medication. These issues were found for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT] and for one (1) of five (5) reviewed for the care area of unnecessary medications. Resident identifier: #170 and #225. Facility census:… | 2020-04-01 |
| 3903 | 3903 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 441 | E | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and infection control surveillance record review, the facility failed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. The infection control surveillance records did not contain needed information. One (1) randomly observed resident's Continuous Passive Motion (CPM) machine was stored directly on an unclean surface, and one randomly observed staff member did not use proper hand hygiene. These practices had the potential to affect more than an isolated number of residents. Resident identifiers: #389, #1001, and #1002. Employee identifier: #128. Facility census: 178. Findings include: a) Infection Control Program On 09/21/16 at 8:14 a.m., an interview with Infection Control Nurse (ICN) #140 who was responsible for the Station 2 side of the facility, revealed there had been a change in the infection control log form the facility used. When asked how and where she tracked the antibiotics used, ICN #140 appeared surprised, paused and said, I guess we don't have to anymore, it's not on the form. The Infection Control Nurse went on to say, We use to track antibiotic names, now just whether the resident is on IV (Intravenous) antibiotic or by mouth. Review of Station 1's infection control book on 09/21/16 at 8:48 a.m., revealed incomplete tracking on the (MONTH) (YEAR) Infection Control Log. On line #10 (Resident #1001) in the column where the organism should have been listed an antibiotic ([MEDICATION NAME]) was listed with no reference to the organism. On line #11 (Resident #1002) the column where the organism should have been listed an antibiotic ([MEDICATION NAME] and Vanc) was listed with no reference to the organism. An interview with Corporate Registered Nurse (RN) #170, on 09/22/16 at 9:21 a.m., verified it was important to know the antibiotics used and the organisms when reviewing the entire infection contr… | 2020-04-01 |
| 3904 | 3904 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 505 | D | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to promptly notify Resident #179's attending physician of the results of a basic metabolic panel (BMP) which was ordered on [DATE]. This was true for one (1) of four (4) residents reviewed for the care area of nutrition during the Quality Indicator Survey (QIS). Resident Identifier: #179. Census: 178. Findings include: a) Resident #179 A review of Resident #179's medical record at 2:43 p.m. on 09/20/16 found a physician's orders [REDACTED]. Upon further review of the record, the results of the BMP could not be located, nor was there any evidence the attending physician was ever notified of the results of the BMP. At 9:49 a.m. on 09/21/16, the results of the BMP and any information related to the notification of the attending physician were requested from the Assistant Director of Nursing (ADON) Registered Nurse (RN) #140. She stated that she would have to go to medical records and look for the information because she did not see it in the chart. An additional interview with ADON #140 at 11:02 p.m. on 09/21/16, revealed the lab result was not in the record and there was no information available to indicate the attending physician was ever notified of the lab results. She indicated the process was that the Nurse Practitioner or the Attending Physician would sign the lab and there would not be any notes or orders if they did not order any changes. She said that since she could not find the lab results she could not prove the attending physician was ever notified. These findings were reviewed with the Director of Nursing at 2:12 p.m. on 09/21/16 and as of the time of exit on 09/23/16, no additional information was provided. | 2020-04-01 |
| 3905 | 3905 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 507 | D | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain all laboratory (lab) testing results in the resident's clinical record for one (1) of four (4) residents reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey (QIS) and one (1) of three (3) residents reviewed for the care area of hospitalization during Stage 2 of the QIS. Resident #179's record did not contain the results of a Basic Metabolic Panel (BMP) which was ordered to be done on 09/12/16. Resident #151's medical record did not contain the results of a Comprehensive Metabolic Panel (CMP) and a magnesium level obtained on 09/13/16. Resident Identifiers: #151 and #179. Facility Census: 178. Findings Include: a) Resident #151 A review of Resident #151's medical record at 11:16 a.m. on 09/21/16 found a physician's orders [REDACTED]. Upon further review of the medical record, the results of the CMP and magnesium level could not be located. There was however, a nursing progress note dated 09/13/16 which indicated the lab results were reviewed by the Nurse Practitioner with new orders noted. Upon further review of the physician's orders [REDACTED]. During an interview with Assistant Director of Nursing (ADON) Registered Nurse (RN) #140 at 3:09 p.m. on 09/21/16, the results of the CMP and magnesium level were requested. She indicated that she would have to look for them. At 4:26 p.m. on 09/21/16, the Director of Nursing (DON) confirmed they could not locate the requested lab results and had to have a copy faxed to the facility after the surveyor requested them. b) Resident #179 A review of Resident #179's medical record at 2:43 p.m. on 09/20/16 found a physician's orders [REDACTED]. Upon further review of the resident's record, the results of the BMP could not be located. At 9:49 a.m. on 09/21/16 the results of the BMP were requested from the Assistant Director of Nursing ADON - RN #140. She stated that she would have to go to medical re… | 2020-04-01 |
| 3906 | 3906 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2016-07-27 | 279 | E | 0 | 1 | H9WH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to use the results of the assessment to develop, review, and/or revise the residents' comprehensive care plans. Six (6) of twenty-one (21) sampled residents' care plans lacked individualized, measurable, objectives and time tables. The care plans failed to address the long-term use of psychoactive medications and/or anticoagulants. Resident identifiers: #85, #39, #74, #42, #92, #21. Facility census: 85. Findings include: a) Resident #85 Review of the medical record, on 07/26/16 at 10:30 a.m., found the significant change minimum data set (MDS), with assessment reference date (ARD) of 02/10/16, assessed that she received antidepressant medications seven (7) days per week. The most recent quarterly assessment, with ARD 05/04/16, said the same. Review of the medical record found the resident with the following Diagnoses: [REDACTED]. She received various dosages of [MEDICATION NAME] since 01/27/15. Currently, she receives [MEDICATION NAME] thirty (30) milligrams (mg) daily. On 06/15/16 she began an antipsychotic medication ([MEDICATION NAME]), one (1) mg. daily. On 06/22/16 the physician changed the dosage of [MEDICATION NAME] to 0.5 mg. twice daily. Review of the care plan found the only mention of psychoactive medication use fell under the focus area of risk for falls. The care plan stated receives antidepressants. The care plan was silent for the use of the antipsychotic medication ([MEDICATION NAME]), or the potential side effects of the psychoactive medications. The care plan was silent for the goals the facility hoped to achieve related to the use of the antidepressant and antipsychotic medications. An interview was conducted with the MDS/Registered Nurse (MDS/RN) #124 on 07/26/16 at 11:15 a.m. She acknowledged that the resident had been on antidepressant medications for a long time. She said the antipsychotic medication ([MEDICATION NAME]) was fairly new, and would sho… | 2020-04-01 |
| 3907 | 3907 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2016-07-27 | 309 | D | 0 | 1 | H9WH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and pharmacist interview the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical mental and psychosocial well-being, in accordance with physician orders [REDACTED]. This is true for two (2) of twenty-one (21) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Residents: #42, and #74. Facility census: 85. Findings include: a) Resident #42 1. Review of medical records, on 07/25/16 at 2:45 p.m., revealed a [DIAGNOSES REDACTED]. A physician order [REDACTED]. During interview, on 07/26/16 at 2:45 p.m., the facility pharmacist stated it is no longer standard practice to obtain the pulse before giving [MEDICATION NAME], if the resident has shown a stable pulse above sixty for at least two months. On 07/26/16 at 10:59 a.m., the director of nursing (DON) presented evidence the physician added to the [MEDICATION NAME] order on 05/13/16 to check the pulse and hold [MEDICATION NAME] if the resident had a pulse of less than sixty (60) beats per minute. Review of the Medication Administration Record [REDACTED]. 2. Continued review of the medical records revealed a [DIAGNOSES REDACTED]. Review of the MAR indicated [REDACTED]. The dates include: --06/08/16 with a blood glucose value of 77 --06/10/16 with a blood glucose value of 74 --06/14/16 with a blood glucose value of 74 --06/16/16 with a blood glucose value of seventy-six 76 --06/17/16 with a blood glucose value of seventy-five 75 During the interview on 07/26/16 the DON agreed the facility staff should have followed physician orders. b) Resident #74 Review of the medical records on 07/25/16 at 11:51 a.m., revealed a physician order [REDACTED]. The documentation concerning blood pressures revealed of one-hundred and thirteen (113) opportunities to follow the physician order [REDACTED]. The residents blood pressure was obtain on sixty-two days of the 113 days. On 07/25/16 at 1:29 p.… | 2020-04-01 |
| 3908 | 3908 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2016-07-27 | 333 | D | 0 | 1 | H9WH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, family interview, and review of published medication use information the facility failed to ensure one (1) of six (6) residents in the sample was free of a significant medication error. Resident #21 received an incorrect dosage of an anticoagulant medication for an extended period of time resulting in break-through bleeding. Resident identifier: #21. Facility census: 85. Findings include: a) Resident #21 A review of the clinical record for Resident #21, on 07/20/16 at 9:30 a.m., revealed she was non-communicative, total care for all activities of daily living, and had a feeding tube. She is out of bed daily for short period only and is on a turning schedule. Her [DIAGNOSES REDACTED]. During a family interview with her daughter at 11:00 a.m. on 07/19/16, she said the resident had been on anticoagulants for years because of a stroke and a pacemaker, but they were discontinued prior to her eye surgery in (MONTH) (YEAR). She said, a month ago she discovered the medication was not reordered after the surgery and had the nurse contact the physician. The medication was reordered at that time. She further said, a few days ago a nurse told her the wrong dose was administered, made her blood very thin, and could account for some of the bleeding around her feeding tube. The daughter said the medication dose was corrected and she was doing fine. A review of the clinical record revealed the facility was aware of the incident as reported on 07/15/16, by LPN #137 and RN #114. An incident report was filed and the investigation was active at the time of the survey. Review of the clinical record revealed the resident received a subcutaneous injection of [MEDICATION NAME] 30 milligrams (mg) daily until it was discontinued on 10/07/15, at the request of the physician in preparation for a surgical procedure. The medication was not reordered until 06/17/16 when the family discovered it was not being given. The handwritten o… | 2020-04-01 |
| 3909 | 3909 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2016-07-27 | 371 | E | 0 | 1 | H9WH11 | Based on observation, staff interview, and the review of the Food Code the facility failed to properly date and label food items to prevent the potential outbreak of foodborne illness. A nourishment pantry on the 500 unit had in-house prepared plastic covered plates of cottage cheese and onions without proper dates/labels. This practice had the potential to affect all residents residing on the 500 unit. Facility census: 85. Findings include: a) An observation tour of the storage of foods in the snack/nourishment refrigerator located on the 500 unit at 1:00 p.m. on 07/18/16 (Monday), revealed the following: --two (2) small plates with individual servings of cottage cheese, covered with plastic wrap with a colored sticker indicating it had been placed there the preceding Tuesday (7 days prior); --one (1) small plate of sliced onions, covered with plastic wrap with a colored sticker indicating it had been placed there the preceding Friday (4 days prior); and --one (1) container with an individual serving of applesauce covered with plastic wrap and a colored sticker indicating it had been there since Thursday (5 days prior). Nurse Aide (NA) #74 was present during the observation and explained that each of the different colored dots, located in a container on the counter adjacent to the refrigerator, indicated a day of the week and was applied to a container of food by the aides when placed in the refrigerator. When she was asked how long the food should be retained in the refrigerator, she immediately removed all the items in question and said she would dispose of them. She stated they had been there too long. b) During an interview with the Director of Nurses (DON) at 11:30 a.m. on 07/26/16, she stated the facility operated under guidance of the Food and Drug Administration (FDA) Food Code and presented a copy of a page from the Food Code containing Section 3-501.17 (A) which indicated refrigerated foods could be held for a maximum of 7 days. She insisted that the colored dot on the foods removed were within that bo… | 2020-04-01 |
| 3910 | 3910 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2016-07-27 | 428 | D | 0 | 1 | H9WH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the pharmacist identified and/or reported drug irregularities to the physician and/or the Director of Nursing for one (1) of six (6) residents. Resident's #21 anticoagulant medication was filled and permitted by the facility's pharmacy in an excessive high dosage (10 x the previous dose). The pharmaceutical label stated a route of administration that was warned against by the manufacturer. Resident identifier: #21. Facility census: 85. Findings include: a) Resident #21 A review of the clinical record for Resident #21, on 07/20/16 at 9:30 a.m., revealed she was non-communicative, total care for all activities of daily living, and had a feeding tube. She is out of bed daily for short period only and is on a turning schedule. Her [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident received a subcutaneous injection of Lovenox 30 milligrams (mg) daily until it was discontinued on 10/07/15, at the request of the physician in preparation for a surgical procedure. The medication was not reordered until 06/17/16 when the family discovered it was not being given. The handwritten order by the Nurse Practitioner, dated 06/17/16, for a subcutaneous injection of Lovenox 30 mg daily was correctly entered onto the MAR (medication administration record) and administered to the resident from 06/18/16 through 06/24/16. Record review revealed a Pharmacy Requisition Report with an order on 06/24/16 recorded as: --Lovenox Solution 300 MG/3ML - Route: Intramuscularly with directions: Inject 1 vial intramuscularly one time a day related to OTHER LONG TERM (CURRENT) DRUG THERAPY. The order was created by: Registered Nurse (RN) #56. There was also an order [REDACTED]. This order was created by: Licensed Practical Nurse (LPN) #120. A review of the Order Summary Reports and the physician's orders [REDACTED]. The order was transcribed via computer to the MAR indicated [REDACTED… | 2020-04-01 |
| 3911 | 3911 | PENDLETON MANOR | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2016-07-27 | 514 | E | 0 | 1 | H9WH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the accuracy of the clinical records for four (4) of twenty-one (21) sampled residents. A transcription error related to a medication order occurred for Resident #21. The medical records of Residents #81, #8, and #85 did not contain the amount of prescribed supplement those residents consumed. Failure to record the amount of supplement consumed rendered an inability to assess whether the intervention was effective in maintaining or improving the residents' weights. Resident identifiers: #81, #8, #85, #21. Facility census: 85. Findings include: a) Resident #8 Review of the medical record on 07/18/16 at 4:00 p.m. found a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no space provided in which to record the percentage consumed. On 07/18/16 at 4:30 p.m., the director of nursing (DON) provided a copy of the (MONTH) and (MONTH) (YEAR) MAR. Out of forty-seven (47) opportunities; the MAR indicated [REDACTED]. The DON said the amount of supplement the resident consumed should have been recorded daily, and it was not. b) Resident #85 Review of the medical record on 07/18/16 at 4:00 p.m. found a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no space provided in which to record the percentage consumed. The director of nursing (DON) provided a copy of the (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED]. Out of forty-seven (47) opportunities in (MONTH) and (MONTH) (YEAR), the MAR indicated [REDACTED]. The DON later clarified that the facility's house supplement was Ensure. c) Resident #81 Review of the medical record on 07/18/16 at 4:00 p.m. found a physician's orders [REDACTED]. Four (4) ounces equals 120 cubic centimeters (cc's). Review of the Medication Administration Record [REDACTED]. Spaces were provi… | 2020-04-01 |
| 3912 | 3912 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 159 | E | 0 | 1 | VTNG11 | Based on record review and staff interview, the facility failed to safeguard, manage, and account for the residents' personal funds deposited with the facility in accordance with regulations. The facility failed to ensure the resident/responsible party received quarterly notices for two (2) of three (3) reviewed, and/or failed to ensure residents who received Medicaid were notified the account reached $200 less than the Social Security Income (SSI) resource limit for four (4) of five (5) resident accounts reviewed. Resident identifiers: #59, #8, #109, #21, and 119. Facility Census: 109. a) Residents #109, #8, #119, #59 A financial record review, on 11/03/6 at 11:27 a.m., with Business Office Manager (BOM) #84, revealed the above residents received Medicaid services and had greater than $1800 in the Resident Funds account. The BOM reviewed the financial records and stated the accounts contained amounts greater than $1,800. b) Resident #59 The quarterly minimum data set (MDS) with an assessment reference date (ARD) of 08/08/16 noted a brief interview for mental status (BIMS) score of 14, which indicated Resident #59 was cognitively intact. The resident fund management statement noted account balances greater than $1,800 dollars for: --November (YEAR) for three (3) of three (3) days --October (YEAR) for thirty-one (31) of thirty-one (31) days --September (YEAR) for thirty (30) of thirty (30) --August (YEAR) for thirty-one of thirty-one days --July (YEAR) for twenty-three (23) of thirty-one (31) days BOM #84 provided a copy of a letter, dated 10/20/16 related to notification of funds. Both the signature of the facility representative and resident acknowledgement were blank. The acknowledgement of receipt of resident trust, dated 10/20/16 was also contained no signatures. c) Resident 8 Resident #8 ' s financial record indicated the resident's account contained greater than $1,800 dollars for: --November (YEAR) for three (3) of three (3) days --October (YEAR) for thirty-one (31) of thirty-one (31) days --September (YEA… | 2020-04-01 |
| 3913 | 3913 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 160 | D | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based record and staff interview the facility failed to convey personal funds in accordance with regulations upon death. This practice affected three (3) residents but had the potential to affect all residents who had a personal funds account upon death. Facility census: 109 Resident identifiers: Facility census: 109. Resident identifiers: Resident #13, #58 and #112. Findings include: a) Resident #13, #58 and #112 A financial record review, with Business Office Manager (BOM) #84, on [DATE] at 11:31 a.m., revealed the above residents had a Resident Funds Account with the facility, and had expired within the previous three (3) to six (6) months. The residents' accounts, reviewed with the BOM revealed the facility had not conveyed the deceased residents' personal funds and a final accounting to the individual or probate jurisdiction administering the individual's estate, within 30 days, as provided by State law. b) Resident #58 expired on [DATE] and the account noted a pending amount of $1,131.49. c) Resident #13 expired on [DATE] and had an account balance of $865.58. d) Resident #112 expired on [DATE] and a check in the amount of $36.01 was made payable to the facility on [DATE]. e) The BOM reviewed the financial records and medical record and voiced no information was present to indicate each resident's responsible party had been notified of the account balance, and acknowledged the accounts had not been conveyed to the responsible parties within thirty (30) days as required. | 2020-04-01 |
| 3914 | 3914 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 161 | E | 0 | 1 | VTNG11 | Based on financial record review and staff interview, the facility failed to purchase a Surety bond to ensure the security of all personal funds of residents deposited with the facility. Resident Funds accounts exceeded the amount of the surety bond. This practice had the potential to affect more than a limited number of residents. Facility census: 109. Findings include: a) The Surety bond, reviewed on 11/02/16, revealed a bond in the amount of one hundred twenty thousand dollars ($120,000). The bank statement daily balances, dated 07/01/16 through 10/31/16, reviewed on 11/03/16 at 8:55 a.m., noted balances in excess of the bond as follows: --$144,052.14 on 09/12/16 --$139,836.84 on 09/11/16, 09/10/16, and 09/09/16 --$140,068.84 on 09/08/16 --$140,168.84 on 09/07/16 --$141,794.92 on 09/06/16, 09/05/16, 09/04/16, 09/03/16, and 09/02/16 --$140,115.42 on 08/09/16 --$140,220.42 on 08/08/16 --$140,310.42 on 08/07/16, 08/06/16 and 08/05/16 --$139,880.50 on 08/04/16 and 08/03/16 --$128,339.92 on 07/06/16 --$128,150.22 on 07/05/16 --$126,230.47 on 07/04/16, 07/03/16, 07/02/16 and 07/01/16 The administrator acknowledged during an interview at about 10:30 a.m., the daily funds exceed the amount of the Surety bond. | 2020-04-01 |
| 3915 | 3915 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 223 | D | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, staff interview, and policy review, the facility failed to ensure one (1) of one (1) residents reviewed for abuse, were free from physical, emotional, mental and/or sexual abuse. A male resident allegedly grabbed Resident #164's arm and tried to push her hand down toward his private area. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #164. Facility census: 109. Findings include: a) Resident #164 During a Stage 1 interview with Resident #164 on 11/01/16 at 11:58 a.m., when asked the question: Has staff, a resident or anyone else here abused you, this includes verbal, physical or sexual abuse? She stated, Yes. She further stated, A gentleman here grabbed me on my arm either Friday or Saturday to put my hand on his privates, can't remember his name, but he was a friend of my husband. I told my speech therapist on Monday and she reported it. Upon further inquiry as to why she did not report it when it occurred, Resident #164 stated, Because it was embarrassing and it upset me because this gentleman used to be a friend of my husband. I was talking with my speech therapist on Monday and it just came out during our conversation. I should have told someone when it happened but it was just shocking and I could not believe it happened and he would do that. Speech Therapist (ST) #31 reported during an interview on 11/02/16 at 8:50 a.m., Resident name (Resident #164) reported the abuse to me on Monday 10/31/16 and I reported it to the social worker, for her (the social worker) to further investigate the reporting of abuse. Resident name (Resident #164) stated, He grabbed me. The resident stated she wasn't sure about reporting it because she had known him through her husband, but I explained that I needed to report this because it is considered abuse. The resident not seem upset about the incident and she had mentioned it during just our general … | 2020-04-01 |
| 3916 | 3916 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 225 | D | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, personnel record review, staff interview, and policy review, the facility failed to screen personnel for a background of abuse, neglect or mistreatment and investigate and report allegations of abuse. The facility failed to identify, thoroughly investigate and/or report timely allegations of physical, emotional, mental and/or sexual abuse to the appropriate State agencies. This practice has the potential to affect more than a limited number of residents. The facility also failed to operationalize policies and procedures related to completion of criminal background checks as required, for one (1) of ten (10) employees reviewed and failed to implement policies and procedures related to reporting and/or a thorough investigation of allegations of abuse. This practice affected one (1) of one (1) residents reviewed for abuse, and had the potential to affect more than a limited number of residents. Facility census: 109. Resident identifier: Resident #164. Employee identifier: Nurse Aide (NA) #20. Resident identifiers: #164. Facility census: 109. Findings include: a) Resident #164 During a Stage 1 interview with Resident #164 on 11/01/16 at 11:58 a.m., when asked the question: Has staff, a resident or anyone else here abused you, this includes verbal, physical or sexual abuse? She stated, Yes. She further stated, A gentleman here grabbed me on my arm either Friday or Saturday to put my hand on his privates, can't remember his name, but he was a friend of my husband. I told my speech therapist on Monday and she reported it. Upon further inquiry as to why she did not report it when it occurred, Resident #164 stated, Because it was embarrassing and it upset me because this gentleman used to be a friend of my husband. I was talking with my speech therapist on Monday and it just came out during our conversation. I should have told someone when it happened but it was just shocking and I could not believe … | 2020-04-01 |
| 3917 | 3917 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 226 | D | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, record review and policy/procedure review, the facility failed to implement its written policies and procedures to ensure one (1) of one (1) residents reviewed for abuse, were free from physical, emotional, mental and/or sexual abuse. A male resident allegedly grabbed Resident #164's arm and tried to push her hand down toward his private area. This practice has the potential to affect more than a limited number of residents. Resident identifiers: #164. Facility census: 109. Findings include: a) Resident #164 During a Stage 1 interview with Resident #164 on 11/01/16 at 11:58 a.m., when asked the question: Has staff, a resident or anyone else here abused you, this includes verbal, physical or sexual abuse? She stated, Yes. She further stated, A gentleman here grabbed me on my arm either Friday or Saturday to put my hand on his privates, can't remember his name, but he was a friend of my husband. I told my speech therapist on Monday and she reported it. Upon further inquiry as to why she did not report it when it occurred, Resident #164 stated, Because it was embarrassing and it upset me because this gentleman used to be a friend of my husband. I was talking with my speech therapist on Monday and it just came out during our conversation. I should have told someone when it happened but it was just shocking and I could not believe it happened and he would do that. Speech Therapist (ST) #31 reported during an interview on 11/02/16 at 8:50 a.m., Resident name (Resident #164) reported the abuse to me on Monday 10/31/16 and I reported it to the social worker, for her (the social worker) to further investigate the reporting of abuse. Resident name (Resident #164) stated, He grabbed me. The resident stated she wasn't sure about reporting it because she had known him through her husband, but I explained that I needed to report this because it is considered abuse. The resident not seem upset about the incident… | 2020-04-01 |
| 3918 | 3918 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 241 | D | 0 | 1 | VTNG11 | Based on observation, record review, resident interview and staff interview, the facility failed to promote care for residents in a manner that maintained each resident's dignity and respect in full recognition of their identity. Resident #68 experienced a prolonged wait time for lunch to be served. Resident #132 was transferred by the use of his armpits. This failed practice caused affected to two (2) of four (4) residents reviewed. Resident identifiers: #68 and #132. Facility census: 109. a) Resident #68 On 10/31/16 at 12:45 p.m. in the Fiesta Dining Room (Dining room A), observation revealed a refused meal for Resident #68. A resident seated at the table stated that Resident #68 waited over an hour for lunch, and said he was not waiting any longer and left the dining room. During an interview on 10/31/16 at 12:48 p.m., the Clinical Reimbursement Coordinator (CRC) #93 stated that Resident #68 did not eat lunch today. Review of Resident #68's medical record on 11/01/16 at 8:00 a.m., showed the activities of daily living (ADL) record dated 10/31/16 failed to reflect Resident #68's meal refusal. During a resident interview, on 11/01/2016 at 8:49 a.m., Resident #68 stated, I didn't like sitting there like a welfare case that lunch was going to be late. Why should you want to sit for an hour and five minutes for something to eat? I would never treat people like this. During a resident interview on 11/02/16 at 11:26 a.m., Resident #68 stated, It was an insult, I felt at their mercy. I don't expect luxury, but they should have had the courtesy to tell me it (lunch) was going to be late and by the time they served me, it was an hour. I feel like I have a boss. Review of Resident #68's medical record on 11/02/2016 at 10:50 a.m. showed a care plan stating that Resident #68 had potential for psycho social impairment due to difficulty adjusting to new environment. b) Resident #132 During a Stage 1 observation and interview on 11/01/16 at 9:48 a.m., observation revealed Resident #132 seated in a chair across from the reside… | 2020-04-01 |
| 3919 | 3919 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 242 | D | 0 | 1 | VTNG11 | Based on observation, resident interview and staff interview, the facility failed to demonstrate that the resident had the right to choose schedules consistent with their interests and make choices about aspects of their life that were significant to the resident. The facility failed to inform a resident of a prolonged wait during a meal service, prohibiting the resident to make an informed choice. This was a random observation affecting Resident #68. Facility census: 109. On 10/31/16 at 12:45 p.m. in the Fiesta Dining Room (Dining room A), observation revealed a refused meal for Resident #68. A resident seated at the table stated that Resident #68 waited over an hour for lunch, and said he was not waiting any longer and left the dining room. During an interview on 10/31/16 at 12:48 p.m., the Clinical Reimbursement Coordinator (CRC) #93 stated that Resident #68 did not eat lunch today. Review of Resident #68's medical record on 11/01/16 at 8:00 a.m., showed the activities of daily living (ADL) record dated 10/31/16 failed to reflect Resident #68's meal refusal. During a resident interview on 11/02/16 at 11:26 a.m., Resident #68 stated, It was an insult, I felt at their mercy. I don't expect luxury, but they should have had the courtesy to tell me it (lunch) was going to be late and by the time they served me, it was an hour. I feel like I have a boss. Review of Resident #68's medical record on 11/02/2016 at 10:50 a.m. showed a care plan stating that Resident #68 had potential for psycho social impairment due to difficulty adjusting to new environment. During a resident interview, on 11/01/2016 at 8:49 a.m., Resident #68 stated, I didn't like sitting there like a welfare case that lunch was going to be late. Why should you want to sit for an hour and five minutes for something to eat? I would never treat people like this. During a staff interview on 11/02/16 at 10:32 a.m. the Food Service Director (FSD), stated, Some residents are always served last. They (facility) needs to try to rotate the serving order if they… | 2020-04-01 |
| 3920 | 3920 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 250 | D | 0 | 1 | VTNG11 | Based on resident interview, medical record review, staff interview, and policy review, the facility failed to ensure the provision of medically related social services were sufficient and appropriate to meet resident needs. The facility failed to identify and thoroughly investigate an alleged allegations of physical, emotional, mental and/or sexual abuse. This practice affected one (1) of one (1) residents reviewed for abuse and has the potential to affect more than a limited number of residents. Resident identifiers: #164. Facility census: 109. Findings include: a) Resident #164 During a Stage 1 interview with Resident #164 on 11/01/16 at 11:58 a.m., when asked the question: Has staff, a resident or anyone else here abused you, this includes verbal, physical or sexual abuse? She stated, Yes. She further stated, A gentleman here grabbed me on my arm either Friday or Saturday to put my hand on his privates, can't remember his name, but he was a friend of my husband. I told my speech therapist on Monday and she reported it. Upon further inquiry as to why she did not report it when it occurred, Resident #164 stated, Because it was embarrassing and it upset me because this gentleman used to be a friend of my husband. I was talking with my speech therapist on Monday and it just came out during our conversation. I should have told someone when it happened but it was just shocking and I could not believe it happened and he would do that. Speech Therapist (ST) #31 reported during an interview on 11/02/16 at 8:50 a.m., Resident name (Resident #164) reported the abuse to me on Monday 10/31/16 and I reported it to the social worker, for her (the social worker) to further investigate the reporting of abuse. Resident name (Resident #164) stated, He grabbed me. The resident stated she wasn't sure about reporting it because she had known him through her husband, but I explained that I needed to report this because it is considered abuse. The resident not seem upset about the incident and she had mentioned it during just our ge… | 2020-04-01 |
| 3921 | 3921 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 253 | E | 0 | 1 | VTNG11 | Based on observation, facility guidelines and staff interviews, the facility to provide housekeeping and maintenance services necessary to ensure an orderly, sanitary, and comfortable environment by not performing routine and/or preventative maintenance services on oxygen concentrators and resident rooms and/or bathrooms. This affected more than a limited number of residents. Resident room identifiers: #170, #173, #175, #181, #236, #237 and #347. Resident identifiers for the concentrators: #162, #64, #114, #143 and #29. Facility census 109. Findings include: a) Cosmetic imperfections On 11/02/16 observations began at 11:00 a.m., with the Maintenance Supervisor, found the following cosmetic imperfections. --The bathroom commode in Room #170 had yellow, brown discoloration around the base of commode. There were caulking missing from the molding on the top right back side of the bathroom wall. --The bathroom in between Rooms #173 and #175, had the caulking missing and a dark brown discoloration at the doorway entrance of the bathroom. The paint was peeling from the right lower corner of the wall, and on the right side of the wall facing the commode. The caulking was no longer present and the molding is pulled away on the right side behind the commode. --The bathroom entrance in Room #181 had the caulking missing and a dark brown discoloration. The molding along the back wall behind the commode was pulled away and the caulking missing from the bottom of the molding along the wall to the right upon entering the bathroom. --The bathroom heater located along the bottom of the bathroom in Room #236 had brown color rust in the corner and top, and bottom of the heater. The thermostat knob on the heater was missing. --In Room 237 tile was missing under the sink in the right back corner along the wall. The beside stand was covered in a thick layer of dust with fingerprint smudges near the front on 11/01/16 at 1: 59 p.m., the assistant director of nursing (ADON) #87 said, Yeah, that's pretty bad. --In Room #347 entrance to th… | 2020-04-01 |
| 3922 | 3922 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 272 | D | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to conduct an accurate comprehensive assessment for one (1) of one (1) Stage 2 sample residents reviewed for Hospice services. Resident #26's assessment did not identify receiving Hospice services. Resident identifier: #26. Facility census: 109. Findings include: a) Resident #26 On 11/03/2016 at 11:51 a.m. review of the resident's medical record revealed [REDACTED]. The significant change minimum data set (MDS) with an assessment reference date (ARD) of 09/30/16 did not identify the resident as receiving Hospice services in section O0100. Clinical Reimbursement Coordinator (CRC) #11 reviewed this MDS with an ARD of 09/30/16 during an interview on 11/03/16 at 12:38 p.m. and confirmed the MDS was coded incorrectly and did not reflect Resident #26 as receiving Hospice services. | 2020-04-01 |
| 3923 | 3923 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 279 | D | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews the facility failed to develop a comprehensive care plan for three (3) of twenty-three (23) Stage 2 residents related to [MEDICAL CONDITION] (GI bleed), ,[MEDICAL CONDITION]. difficle (C. Diff), isolation for the [DIAGNOSES REDACTED], and dental care. Resident Identifiers: #147, #139, #37. Facility census 109. Findings include: a) Resident #147 1) [MEDICAL CONDITION] Record review for Resident #147, on 11/02/16 at 11:50 a.m., found a note dated 05/07/16 from an acute care facility. This note indicated the resident had occasional blood in her stool and she was on Xarelto (a blood thinner) due to a [MEDICAL CONDITION] embolism. The physician for Resident #147 wrote in the admission history and physical, recent GI bleed. diagnosed with [REDACTED]. The admission minimum data set (MDS) with an assessment reference date (ARD) of 05/30/16 was reviewed on 11/02/16 at 12:57 p.m. for Resident #147. This MDS revealed the resident had the [DIAGNOSES REDACTED]. A review of the physician order [REDACTED]. A review of a lab test, complete blood count (CBC), for Resident #147 on 05/30/16 revealed the following results: --[NAME] blood count (WBC) was 13.5 (high); --Hemoglobin (HGB) level of 11.3 (low) with normal noted as 12.0 -16.0 gram/deciliter; and --Hematocrit (HCT) was 34.7 (low) with normal level noted as 37 - 47 percent. The HGB, and HCT is an indicator of [MEDICAL CONDITION] (too few red blood cells). Written on the lab test result was a note stating (typed as written), active GI (gastrointestinal) bleed, loose bm's (bowel movement) with sticky clay color noted. not black, but red visible blood with clots. Resident #147 had a progress note on 06/08/16 revealing a new order to obtain a CBC in the morning. Written on the note said due to active GI bleed/ recent hospitalization . On 06/27/16 the resident was sent to the acute care facility for the GI bleed. 2) ,[MEDICAL CONDITION]. Difficle and co… | 2020-04-01 |
| 3924 | 3924 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 280 | D | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise a care plan for one (1) of twenty-three (23) Stage 2 residents reviewed during the annual quality indicator survey. Resident #143's care plan did not identify a decline in urinary incontinence after hospitalization . Resident identifier: #143. Facility Census: 109. Findings include: a) Resident #143 Review of the medical record on 11/03/16 at 9:51 a.m., revealed Resident #143 was admitted to the facility on [DATE]. The three-day continence management diary initiated on 06/29/16 noted Resident #143 was incontinent three (3) out of twenty-eight (28) checks on 07/01/16, 07/02/16, and 07/06/16. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/04/16 noted the resident was always continent of urine under section H0300. Resident #143 was admitted to the hospital on [DATE] and returned to the facility on [DATE]. The activity of daily living forms dated (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) identify Resident #143 as always incontinent of urine since 07/22/16. The quarterly MDS with an ARD of 10/03/16 noted the resident was always incontinent of urine and indicated a toileting program was not attempted. The Clinical Records Coordinator (CRC) #93 reviewed the records during an interview on 11/03/16 at 12:11 p.m. and confirmed Resident #143 was initially occasionally incontinent of urine and is now always incontinent. CRC #93 reviewed the current care plan and acknowledged the care plan lacked a focus, goal or any interventions for urinary incontinence. Nurse Aide (NA) #75 confirmed Resident #143 is always incontinent of urine during an interview on 11/03/16 at 1:42 p.m. | 2020-04-01 |
| 3925 | 3925 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 309 | E | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to follow physician orders for three (3) of twenty-three (23) Stage 2 residents. The facility failed to follow a physician order for [REDACTED]. Resident Identifiers: #40, #136, and #139. Facility census 109. Findings include: a) Resident #40 Review of Resident #40's pharmacy consultant report dated 09/20/16 was reviewed on 11/03/16 at 12:30 p.m., revealed the resident received Quetiapine ([MEDICATION NAME]) 50 milligram (mg) daily for behavioral or psychological symptoms of dementia since 03/24/16 and [MEDICATION NAME] (Klonopin) 0.5 mg twice a day. The consultant report indicated both were due for a gradual dose reduction (GDR). The pharmacy consultant made the recommendation for a GDR of the resident's Quetiapine 50 mg to 25 mg at night with the end goal of discontinuation of the medication. If medication is to continue at this dose, the prescriber must document a clinical contraindication, defined as a patient-specific rational including, 1) documentation that a target symptom(s) returned or worsened during a dose reduction attempted during the most recent facility admission, and 2) why additional attempted dose reduction would be likely to impair the resident's function or increase distressed behavior. The physician accepted the recommendations with the following modifications to reduce [MEDICATION NAME] to 0.25 mg in the morning, and 0.5 mg in the evening. The physician signed the recommendations on 10/04/16. A review of Resident #40's physician orders on 11/03/16 at 12:35 p.m., found a physician order was written on 10/04/16 for the GDR for the [MEDICATION NAME], but no physician order was written for the Quetiapine. A review of Resident #40's Medication Administration Record [REDACTED]. From 10/10/16 through 10/31/16 there was no documentation the resident received the medication at all. A review of the Resident #40's physician order for [REDACTED]. The (MONTH) (YEAR) MA… | 2020-04-01 |
| 3926 | 3926 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 315 | D | 0 | 1 | VTNG11 | **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 three (3) residents incontinent of bladder receives the appropriate treatment and services to restore normal bladder function to the extent possible. Resident #143's increase in urinary incontinence was not assessed after each admission and interventions were not put into place to address the decline in bladder control. Resident identifier: #143. Facility census: 109. Findings include: a) Resident #143 Review of the medical record on 11/03/16 at 9:51 a.m., revealed Resident #143 was initially admitted to the facility on [DATE]. She was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Resident #143 returned to the hospital on [DATE] and was readmitted to the facility on [DATE]. The three-day continence management diary initiated on 06/29/16 noted Resident #143 was incontinent three (3) out of twenty-eight (28) checks on 07/01/16, 07/02/16, and 07/06/16. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/04/16 noted the resident was always continent of urine under section H0300. The activity of daily living forms dated (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) identified Resident #143 as always incontinent of urine since 07/22/16. The quarterly MDS with an ARD of 10/03/16 noted the resident as always incontinent of urine and is marked No under section H0200 indicating a toileting program was not attempted. The medical record was silent in regards to any toileting assessments. The Clinical Records Coordinator (CRC) #93 reviewed the records during an interview on 11/03/16 at 12:11 p.m., confirmed Resident #143 was initially occasionally incontinent of urine and is now always incontinent. She acknowledged the urinary incontinence was not identified during Resident #143's recent quarterly assessment and a plan was not put into place to address this concern. CRC #93 stated it is the restorative nurs… | 2020-04-01 |
| 3927 | 3927 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 371 | F | 0 | 1 | VTNG11 | Based on observation, staff interviews and policy review, the facility failed to store and serve food in a safe and sanitary manner. Food in the cooler was exposed to air and undated, and food in the nourishment refrigerator rooms was unlabeled and undated. The staff were serving food with contaminated gloves, and touching food items with their bare hands. This has the potential to affect more than a limited number of residents. Facility census 109. Findings include: a) Cooler and nourishment room refrigerator 1. During the initial tour of the kitchen, on 10/31/16 at 11:50 a.m., with food service director, observation of the cooler found fourteen (14) large carrots open, undated and exposed to the air. The food service director acknowledge the need for the carrots to be covered and dated when they were open. Observed the cooler on 11/02/16 at 2:00 p.m., found the fourteen (14) carrots continue to be open and exposed to air and undated. Observation of the cooler on 11/03/16 at 9:40 a.m., found fourteen (14) carrots continued to be opened and exposed to air and undated. 2. Observation and interview with clinical reimbursement coordinator (CRC) #93, on 11/02/16 at 4:45 p.m., found the (a) side of the nourishment room refrigerator with 21 slices of American cheese in a clear plastic zip lock bag, half a gallon (1/8th full) of two (2) percent milk (with a best used by date of 11/01/16), a plastic pitcher full of orange juice, another half a gallon of two (2) percent milk (3/4th full), and a half a gallon of Tru Moo milk (1/3rd full). These items were undated and/or unlabeled. The (b) side of the nourishment room refrigerator was observed with CRC #93, on 11/02/16 at 4:49 p.m., with a half a gallon of 2% milk (1/2 full was open and undated). During the two (2) observations of the nourishment refrigerator with CRC #93, she confirmed someone should have thrown away the milk that was already passed the used by date, and put the date they opened the other milk. The CRC said the orange juice should have had a date on the to… | 2020-04-01 |
| 3928 | 3928 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 411 | D | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure dental services were obtained for one (1) of three (3) residents reviewed. The facility failed to obtain a surgical consultation with an oral surgeon as directed by the dentist, for a resident who received Medicare services. Resident identifier: #139. Facility census: 109. Findings include: b) Resident #139 During a Stage 1 observation, on 11/01/16 at 8:36 a.m., Resident #139 opened her mouth widely, as though trying to communicate. Observation revealed missing teeth. The minimum data set (MDS) with an assessment reference date (ARD) of 07/26/16, noted obvious or likely cavity or broken natural teeth. Further review of the medical record revealed an order, dated 04/25/16, for a consult with an oral surgeon for extraction of teeth, as recommended by the dentist. The physician services nursing facility subsequent visit form, dated 03/08/16, had noted the chief complaint/history record many damaged and non-restorable teeth. A physician's orders [REDACTED]. The dentist' assessment/plan included a referral to an oral surgeon for a full mouth extraction due to many damaged and non-restorable teeth, and was noted on 04/25/16. The medical record, reviewed from date of admission through 11/03/16 revealed a progress note dated 04/25/16 which noted the dentist assessed Resident #139 and the facility received an order to refer the resident to an oral surgeon for full mouth extraction. --04/28/16 - the resident saw the dentist and a recommendation was made to do a full mouth extraction; --04/30/16 - spoon feed all meals; --05/05/16 - waiting for an appointment for full mouth extraction; --06/30/16 - continue on [MEDICATION NAME] for mouth, resident is very hard to feed meals due to continually closing mouth; --07/07/16 - continue [MEDICATION NAME] to gums of mouth provided, when resident eating lunch because staff noticed resident crunching teeth, face getting r… | 2020-04-01 |
| 3929 | 3929 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 412 | D | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure dental services were obtained for one (1) of three (3) residents reviewed. The facility failed to obtain a surgical consultation with an oral surgeon as directed by the dentist, for a resident who received Medicaid services. Facility census: 109. Resident identifier: #139. Findings include: b) Resident #139 During a Stage 1 observation, on 11/01/16 at 8:36 a.m., Resident #139 opened her mouth widely, as though trying to communicate. Observation revealed missing teeth. The minimum data set (MDS) with an assessment reference date (ARD) of 07/26/16, noted obvious or likely cavity or broken natural teeth. Further review of the medical record revealed an order, dated 04/25/16, for a consult with an oral surgeon for extraction of teeth, as recommended by the dentist. The physician services nursing facility subsequent visit form, dated 03/08/16, had noted the chief complaint/history record many damaged and non-restorable teeth. A physician's orders [REDACTED]. The dentist' assessment/plan included a referral to an oral surgeon for a full mouth extraction due to many damaged and non-restorable teeth, and was noted on 04/25/16. The medical record, reviewed from date of admission through 11/03/16 revealed a progress note dated 04/25/16 which noted the dentist assessed Resident #139 and the facility received an order to refer the resident to an oral surgeon for full mouth extraction. --04/28/16 - the resident saw the dentist and a recommendation was made to do a full mouth extraction; --04/30/16 - spoon feed all meals; --05/05/16 - waiting for an appointment for full mouth extraction; --06/30/16 - continue on [MEDICATION NAME] for mouth, resident is very hard to feed meals due to continually closing mouth; --07/07/16 - continue [MEDICATION NAME] to gums of mouth provided, when resident eating lunch because staff noticed resident crunching teeth, face getting r… | 2020-04-01 |
| 3930 | 3930 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 428 | E | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews the facility failed to ensure a pharmacist recommendation was acted upon by failing to ensure an order was written to implement the gradual dose reduction (GDR) for one (1) of five (5) Stage 2 residents for a GDR. Resident Identifiers: #40. Facility census 109. Findings include: a) Resident #40 Review of Resident #40's pharmacy consultant report dated 09/20/16 was reviewed on 11/03/16 at 12:30 p.m., revealed the resident received Quetiapine (Seroquel) 50 milligram (mg) daily for behavioral or psychological symptoms of dementia since 03/24/16 and Clonazepam (Klonopin) 0.5 mg twice a day. The consultant report indicated both were due for a gradual dose reduction (GDR). The pharmacy consultant made the recommendation for a GDR of the resident's Quetiapine 50 mg to 25 mg at night with the end goal of discontinuation of the medication. If medication is to continue at this dose, the prescriber must document a clinical contraindication, defined as a patient-specific rational including, 1) documentation that a target symptom(s) returned or worsened during a dose reduction attempted during the most recent facility admission, and 2) why additional attempted dose reduction would be likely to impair the resident's function or increase distressed behavior. The physician accepted the recommendations with the following modifications to reduce Clonazepam to 0.25 mg in the morning, and 0.5 mg in the evening. The physician signed the recommendations on 10/04/16. A review of Resident #40's physician orders on 11/03/16 at 12:35 p.m., found a physician order was written on 10/04/16 for the GDR for the Clonazepam, but no physician order was written for the Quetiapine. A review of Resident #40's Medication Administration Record [REDACTED]. From 10/10/16 through 10/31/16 there was no documentation the resident received the medication at all. A review of the Resident #40's physician order for [REDACTED]. The (MONTH)… | 2020-04-01 |
| 3931 | 3931 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 441 | F | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, medical record review and policy review, and Centers for Disease Control and Prevention guidelines, the facility failed to maintain an infection control program to prevent the spread of disease and infection to the extent possible. The facility failed to implement contact precautions for a resident with suspected shingles, soiled linens were handled improperly, and staff failed to utilize proper hand hygiene and/or personal protective equipment (PPE) when handling items contaminated with nasal secretions. This practice affected three (3) residents, but had the potential to affect all residents. Resident identifier: Resident #139, #97, and #57. Findings include: a) Resident #97 During a Stage 1 interview, on 10/31/16 at 3:18 p.m., Resident #97 voiced she had shingles, and pulled up her shirt exposing fluid filled blisters in large patches in a stripe across her abdomen from her left side to her right side. The resident said the areas were painful and she had eaten in her room that date due to the shingles. Shingles is caused by the reactivation of the [MEDICATION NAME]-[MEDICATION NAME] virus (VZV), the same virus that causes chicken pox. Observation revealed no signage on the door or personal protective equipment (PPE) such as gowns, masks, disposable vital signs equipment upon entry of the room. Upon inquiry, Nurse Aide (NA) #22, said the resident required no special precautions. Immediately after the resident interview, during a conversation with Licensed Practical Nurse (LPN) #64 she said the resident did not require precautions because she did not yet have a diagnosis. The nurse said the physician wanted to wait and see if it was a rash. The nurse said staff were using gloves, washing hand and the resident was staying in her room. When asked how long the resident had the areas, the nurse said they were found during the resident's shower on 10/30/16. When asked about the resident's… | 2020-04-01 |
| 3932 | 3932 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 490 | F | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review, staff interview, medical record review, resident interview and policy review, the facility was not administered in a manner which utilized its resources effectively and efficiently to maintain the highest practicable physical, mental and psychosocial well-being of each resident. The administration failed to ensure the safety of residents after an allegation of sexual abuse, failed to ensure allegations of abuse were thoroughly investigated and/or reported to the appropriate State agencies, failed to ensure the provision of medically related social services, and failed to ensure criminal background checks were completed as required. This practice affected one (1) of one (1) resident reviewed for abuse, and had the potential to affect all residents. Resident identifier: Resident #164. Employee Identifier: Nurse Aide (NA) #20. Findings include: a) Criminal background checks During a personnel record review related to criminal background checks, with the Human Resources Regional Director (HRRD) #150, on 11/02/16 at 2:30 p.m., the director provided a copy of a State police background check, dated 12/07/15 for Nurse Aide (NA) #20, who was hired on 11/19/15. Upon inquiry, the director related no information was present to indicate the facility had entered the NA into the West Virginia (WV) Cares system. The administrator, interviewed at 2:40 p.m., said the WV Cares form was completed on paper on 11/11/15 and submitted, and was informed at a later time that he had to submit it electronically. The administrator provided a copy of the bill from Morphotrust, which noted a payment in the amount required for only a State background check. He confirmed a federal background check had not been completed. The SAFRAN MorphoTrust USA guideline, with a revision date of Sept (YEAR) (September (YEAR)) was currently doing the fingerprinting for WV CARES for both a West Virginia (WV) and Federal Bureau of Investigation (FBI) backgro… | 2020-04-01 |
| 3933 | 3933 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 510 | D | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain a physician's order [REDACTED]. Resident identifier: Resident #136. Facility census: 109. Findings include: a) Resident #136 A medical record review, on 11/03/16, revealed a radiology report dated 10/17/16. The report indicated Resident #136 had an x-ray of the left shoulder and ribs. Further review of the electronic and paper medical record revealed no evidence of a physician's orders [REDACTED].>The interim director of nursing, interviewed at 3:30 p.m., reviewed the medical record and confirmed she was unable to find a physician's orders [REDACTED]. | 2020-04-01 |
| 3934 | 3934 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 513 | D | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure x-rays and/or diagnostic reports were signed and dated for two (2) of twenty-two (22) Stage 2 residents. Resident identifiers: Resident #37 and #136. Facility census: 109. Findings include: a) Resident #37 and #136 A medical record review on 11/03/16, revealed chest X-ray reports for Resident #37 dated 08/19/16 and 08/10/16 which had not been signed by the physician. A laboratory report dated 10/10/16 for a hemoglobin A1c lab, basic metabolic panel, complete blood count with differential, and [MEDICAL CONDITION] stimulating hormone had not been signed by the physician. Another laboratory report, dated 08/19/16 for laboratory work which included an hepatic function panel and complete blood count did not have a physician's signature. The medical record for Resident #136, reviewed on 11/03/16, contained X-ray reports of the left shoulder and ribs dated 08/02/16 and 10/17/16. The reports did not contain a physician's signature. The assistant director of nursing (ADON), interviewed at 3:30 p.m., confirmed the reports had been flagged for the physician, but had not yet been signed. Upon inquiry, the ADON stated the physician was in the building frequently. | 2020-04-01 |
| 3935 | 3935 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 514 | E | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review and staff interview, the facility failed to complete and accurately document in the medical record for four (4) of twenty- six (26) residents related to what behavior symptom(s) the staff is to monitor on the behavior monitoring forms, incomplete and inaccurate documentation for meal/fluid percentages, bedtime snack, and facility did not fill out a liability notice correctly. This had the potential to affect a limited number of residents. Resident identifiers: #40, #37, #150 and #68. Facility census 109. Findings include: a) Resident #40. A review of the (MONTH) (YEAR) behavior monitoring and intervention form, on 11/03/16 at 1:00 p.m., for Resident #40, found there was no behavior symptoms on the form in order for the staff to know what behaviors they are to be monitoring. The form revealed the resident is on [MEDICATION NAME] and [MEDICATION NAME]. The medication Quetiapine [MEDICATION NAME] ([MEDICATION NAME]) has a marked through the name. A review of Resident #40's physician order [REDACTED]. A review of the psychotherapeutic medication use evaluation form dated 10/04/16, revealed Resident #40 had behaviors of grabbing, repetition, and refusing care. On 11/03/16 at 1:34 p.m., Resident #40's behavior monitoring and intervention form was reviewed by employee #35 licensed practical nurse (LPN), and she confirmed the staff should have written the resident's behavior on the (MONTH) (YEAR)'s form in order to know what behaviors to monitor. She said at one time it was hitting and grabbing, but the forms had changed to rejection of care, and grabbing. The LPN stated, I do not know why the [MEDICATION NAME] was marked through (resident's name) has been receiving the medication. b) Resident #40 A review of Resident #40's Medication Administration Record [REDACTED]. In an interview on 11/03/16 at 1:23 p.m. with licensed practical nurse (LPN) #35, she reviewed the (MONTH) (YEAR) MAR indicated [REDACTED]. The LPN said she did … | 2020-04-01 |
| 3936 | 3936 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2016-11-04 | 520 | F | 0 | 1 | VTNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel records, resident and staff interviews, and policy review, the quality assessment and assurance (QAA) committee failed to identify and/or act upon a quality deficiency within the facility's operations of which it did have (or should have had) knowledge, and implement plans of action to correct these deficiencies, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. The facility failed to ensure the safety of residents after an allegation of sexual abuse, failed to ensure allegations of abuse were thoroughly investigated and/or reported to the appropriate State agencies, failed to ensure the provision of medically related social services, and failed to ensure criminal background checks were completed as required. This practice affected one (1) of one (1) resident reviewed for abuse, and had the potential to affect all residents. Resident identifier: Resident #164. Employee Identifier: Nurse Aide (NA) #20. Findings include: a) Criminal background checks During a personnel record review related to criminal background checks, with the Human Resources Regional Director (HRRD) #150, on 11/02/16 at 2:30 p.m., the director provided a copy of a State police background check, dated 12/07/15 for Nurse Aide (NA) #20, who was hired on 11/19/15. Upon inquiry, the director related no information was present to indicate the facility had entered the NA into the West Virginia (WV) Cares system. The administrator, interviewed at 2:40 p.m., said the WV Cares form was completed on paper on 11/11/15 and submitted, and was informed at a later time that he had to submit it electronically. The administrator provided a copy of the bill from Morphotrust, which noted a payment in the amount required for only a State background check. He confirmed a federal background check had not been completed. The SAFRAN MorphoTrust USA guideline, with a revision date of Sept (YEAR… | 2020-04-01 |
| 3937 | 3937 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2017-01-19 | 253 | E | 0 | 1 | E2UQ11 | Based on observation and staff interview the facility failed to ensure the floor perimeter of resident rooms and linen closet floors were clean. This had the potential to affect more than a limited number of residents. Facility identifiers: East Hall, West Hall. Census: 52. Findings include: a) East Hall --Room #11 floor perimeter soiled --Room #18 bathroom floor perimeter soiled --Room #21 floor perimeter under sink soiled --Room #22 bathroom floor perimeter soiled --Room #23 floor perimeter under sink soiled --Room #25 bathroom floor perimeter soiled --Linen closet floor soiled and a brief was on floor b) West Hall --Room #32 floor perimeter soiled --Room #33 floor perimeter including between television stands and along wall under heating and cooling unit soiled --Room #34 bathroom floor perimeter including perimeter of closet soiled --Room #35 floor perimeter under bathroom sink, and under TV stand around closet soiled --Room #36 bathroom floor perimeter under sink soiled --Room #38 floor perimeter soiled under sink soiled --Room #40 bathroom floor perimeter and behind toilet, and room entry soiled --Room #39 floor perimeter adjacent to closet wall, including room entry floor perimeter soiled --Room #42 bathroom floor perimeter soiled --Room #44 floor perimeter between TV stands, and perimeter of wall behind air concentrator soiled --Room #45 floor perimeter behind chair, behind toilet, behind closet door soiled --Linen closet floor soiled and trash noted on floor On 01/18/17 at 9:30 a.m. an environmental tour occured with the Maintenance supervisor who verified the findings of a dirty and soiled floor area in resident rooms, resident bathrooms, and linen closets on East and West Halls. The Maintenance supervisor stated that he expects floors to be cleaned up to and including the floor perimeter. He further stated housekeeping needs oversight and these findings do not reflect the company's expectations. | 2020-04-01 |
| 3938 | 3938 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2017-01-19 | 309 | E | 0 | 1 | E2UQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to follow physician's orders to hold antihypertensive medications when indicated. The physician ordered certain antihypertensive medications held whenever the blood pressure readings were lower than a set parameter. This was evident for one (1) of five (5) residents reviewed for unnecessary medications. Resident #84 received six (6) doses of antihypertensive medications after her systolic blood pressure readings were lower than the parameters set by the physician. Resident identifier: #84. Facility census: 52. Findings include: a) Resident #84 Review of the medical record on 01/18/17 revealed this resident received three (3) antihypertensive medications each day. The physician ordered Losartan 25 milligrams (mg) by mouth once daily to treat hypertension. The physician instructed on 12/09/16 to hold (not administer) this medication if the systolic blood pressure was less than 100 millimeters of hemoglobin (mm/hg). Review of the Medication Administration Record [REDACTED]. to Resident #84 on the following dates and times: --On 12/20/16 at 8:00 a.m., blood pressure reading was 93/63 mm/hg. --On 12/27/16 at 8:00 a.m., blood pressure reading was 96/63 mm/hg. --On 12/28/16 at 8:00 a.m., blood pressure reading was 96/73 mm/hg. Further review of the medical record found the physician also ordered [MEDICATION NAME] XL 50 mg. twice daily to treat hypertension. The physician instructed on 12/09/16 to hold (not administer) this medication if the systolic blood pressure was less than 110 mm/hg. However, staff still administered [MEDICATION NAME] XL 50 mg. to Resident #84 when this parameter was not met, on the following dates and times: --On 01/04/17 at 8:00 p.m., blood pressure reading was 104/48. --On 01/16/17 at 8:00 p.m., blood pressure reading was 104/64. --On 01/17/17 at 8:00 p.m., blood pressure reading was 105/51. During an interview with the director of nursing (DON) on 01/18… | 2020-04-01 |
| 3939 | 3939 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2017-01-19 | 323 | E | 0 | 1 | E2UQ11 | Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. The West Wing Shower Room contained chemical substances and uncapped razors accessible to residents. This practice had the potential to affect more than a limited number of residents. Facility census: 52. Findings include: a) Observations Observation of the West Wing on 01/17/17 at 10:30 a.m., revealed the Shower Room was unlocked and contained the following products in an unsecured cabinet: --One (1) container of Neutra Stat TB Disinfectant with the warning, Hazardous to humans and domestic animals. Keep out of reach of children. Causes moderate eye irritation. Avoid contact with eyes or clothing. Wash thoroughly with soap and water after handling and before eating, drinking, chewing gum or using tobacco. --Six (6) containers of Aplicare Antiseptic Perineal Wash with the warning, Keep out of reach of children. -One (1) container of Lucky For Men Shave Cream with the warning, Keep out of reach of children. -Four (4) containers of Suave Extreme Hold with the warning. Keep out of reach of children. -Three (3) containers of McKesson Mouthwash with the warning, Keep out of reach of children. In case of accidental ingestion seek professional assistance or call a Poison Control Center. -Two (2) uncapped razors. b) Interview An interview with Licensed Practical Nurse (LPN) #83 on 01/17/17 at 10:35 a.m., revealed all chemical substances should be locked away from any resident access. The LPN stated the cabinet in the West Wing Shower Room should always be locked. | 2020-04-01 |
| 3940 | 3940 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2017-01-19 | 329 | D | 0 | 1 | E2UQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to discontinue a medication as ordered. Three (3) doses of UTI STAT was administered past prescribed time frame. Resident identifier: #18. Facility census: 52. Findings include: a) Record review On 01/18/17 at 12:14 p.m. a medical record review revealed a physician order [REDACTED]. Review of medication administration records revelaed the medication UTI STAT was administered longer than the order for 2 week on 01/5/17, 01/16/17 and 01/17/17. b) Staff interview An interview on 01/18/17 at 1:34 p.m. with licensed practical nurse (LPN) #113 revealed medication UTI STAT should have been discontinued. LPN #113 stated that the medication should have had a stop date when the order was transcribed but the order did not include a stop date. She stated the resident did receive three (3) extra doses, and it needs to be discontinued. | 2020-04-01 |
| 3941 | 3941 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2017-01-19 | 371 | E | 0 | 1 | E2UQ11 | Based on observation, staff interview and policy review the facility failed to store foods in a safe and sanitary manner. Expired food items were observed in the kitchen and nourishment refrigerators. The nourishment refrigerator and freezer were unclean. The dishwash machine did not reach a minimum wash cycle temperature of 120 degrees. These findings had the potential to affect all residents. Facility census: 52. Findings include: a) Kitchen refrigerator On 01/16/17 at 10:58 a.m. a tour of the kitchen was conducted. The refrigerator was observed to contain a bag of pepperoni dated 01/07/17. Re-packaged sliced cheese dated 12/31/16 was observed. On 01/16/17 at 11:14 a.m. the Food Service Supervisor stated that according to policy, the findings including the cheese and pepperoni could be refrigerated for up to 7 days. On 01/16/17 at 12:36 p.m. a review of the facility's Food Storage policy states leftover food is to be used within 3 days or discarded. b) Nourishment Refrigerator On 01/18/17 at 11:07 a.m. the nourishment refrigerator located near an activity room was inspected. Observations included, multiple opened bottles of undated soda, a bottle of soda dated 1/10, undated opened apple juice, undated chocolate milk, soiled interior door compartments, soiled interior bottom shelf floor of refrigerator and soiled interior freezer shelf floor. On 01/18/17 a review of the temperature monitoring record revealed an incomplete record. Temperature recording for the dates of 01/04/17, 01/05/17, 01/06/17, 01/08/17, 01/09/17, and 01/10/17 were omitted. On 01/18/17 at 11:37 a.m. an observation of the nourishment refrigerator and the refrigerator temperature record conducted with the Food Service Supervisor revealed collaborative staff monitoring of the refrigerator temperature log is a problem and the nourishment refrigerator is supposed to be cleaned on specific days. c) Dishwashing System On 01/17/17 at 12:53 p.m., the dishwashing machine cycle was observed in operation by Staff #26. Staff #26 performed one full wash an… | 2020-04-01 |
| 3942 | 3942 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2017-01-19 | 441 | E | 0 | 1 | E2UQ11 | Based on observation, medical record review, staff interview, and policy review, the facility failed to maintain an effective infection control program designed to help prevent the development and/or transmission of disease and infection. Residents #58, #5, #4, #64, and #41 had no signage at their doors to caution that those residents were in isolation, or to communicate the type of isolation required, and/or the need to see the nurse prior to entering the room in order to receive specific instructions. An employee was observed going from one room to a second room re-filling residents' ice water pitchers for residents who resided on the East wing, while wearing the same pair of disposable gloves. Although this had the potential to affect any of the residents on the East wing, it most directly affected Residents #25 and #94. A housekeeping employee was observed as she emptied a dust pan into a trashbin next to residents who were eating their lunch. Also, a nurse aide was observed carrying unbagged, dirty linens down the East wing hallway to the soiled utility room. Resident identifiers: #25, #94, #58, #5, #4, #64, #41. Facility census: 52. Findings include: a) Resident #25 Observation on 01/17/17 at 1:35 p.m. found unit nurse aide (NA) #112 passing fresh ice water to residents on the East wing. This wing is currently quarantined because four (4) of their residents on this wing tested positive for type A influenza in the past few days. This employee wore disposable gloves and obtained fresh ice water for Resident #26. Without changing gloves or sanitizing her hands, she then picked up the plastic, pink water pitcher of Resident #25 (room-mate of Resident #26), and brought it out into the hall beside the portable ice chest. Using a metal scoop, she then filled this pitcher with ice. She returned the pitcher to Resident #25. b) Resident #94 Observation on 01/17/17 at 1:35 p.m. found unit aide #112 entered this room to give the resident fresh ice from the ice chest parked in the hallway. This employee wore disposable … | 2020-04-01 |
| 3943 | 3943 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2017-01-19 | 465 | E | 0 | 1 | E2UQ11 | Based on observation and staff interview the facility failed to ensure a safe, functional sanitary, and comfortable environment for residents. The floor and wall tiles in the East hall shower room were cracked and in disrepair. This has the potential to affect all residents on the East hall that use this shower room. Facility census: 52. Findings include: a) An observation of the East hall shower room on 01/16/17 at 10:55 a.m. revealed the following: --multiple cracked and unrepaired floor tile in the center of the shower room --cracked and chipped tiles on the lower external corners of the shower walls --a dark mold like stain in the shower corners These observations were confirmed by housekeeper #67 at 11:00 a.m. on 01/16/17. During an interview on 01/17/17 at 8:30 a.m. the Maintenance Supervisor acknowledged the East shower room was in disrepair. He stated the facility had consulted one (1) company in regards to repairing the shower and they were told all of the tiles needed to be replaced. No plans were put into place to repair and/or replace the shower room tiles. | 2020-04-01 |
| 3944 | 3944 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2017-01-19 | 514 | B | 0 | 1 | E2UQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure complete and accurately documented clinical records. The facility transcribed a medication dosage incorrectly onto the physician's orders [REDACTED]. Nursing staff documented they administered this incorrectly transcribed physician's orders [REDACTED]. Resident identifier: #84. Facility census: 52. Findings include: a) Resident #84 Review of the medical record on 01/18/17 found physician's orders [REDACTED]. The medication ordered was [MEDICATION NAME] 30 milligrams (mg) per 0.3 milliliter (ml). [MEDICATION NAME] is a blood thinner used to aid in the prevention of [MEDICAL CONDITION] (blood clots), and [MEDICAL CONDITION] embolism. The physician's orders [REDACTED]. subcutaneously once daily for [MEDICAL CONDITION], until the resident was consistently ambulating. This dose amounted to one-thirtieth of three (3) tenths of a milliliter, which is so minuscule it could not be measured accurately in a syringe. Review of the MAR found that nursing staff initialed that they gave that dosage as written on seven (7) consecutive days at 8:00 a.m. on 11/26/16, 11/27/16, 11/28/16, 11/29/16, 11/30/16, 12/01/16, and 12/02/16, without seeking clarification of the order. Further review of the medical record found the order was changed on the afternoon of 12/02/16 to inject 0.3 ml. one time daily of a 30 mg/0.3 ml solution. An interview was conducted with licensed practical nurse #114 on 01/18/17 at 9:25 a.m. He said [MEDICATION NAME] comes from the pharmacy in a prepackaged syringe. He said one (1) mg. of [MEDICATION NAME] could not possibly be correct, and that the order should have been clarified right from the start. He said that on 12/03/16 he gave the full 0.3 mg. dose of [MEDICATION NAME] as the new order specified. He said he did not recall how this order became corrected. An interview was completed with the director of nursing (DON) on 01/18/17 at 9:35 a.m. She said the… | 2020-04-01 |
| 3945 | 3945 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2017-01-19 | 520 | E | 0 | 1 | E2UQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility's Quality Assessment and Assurance (QAA) Committee failed to address previously identified quality issues. The facility failed to maintain an infection control program to help prevent the development and transmission of disease and infection. Isolation precautions were not implemented for five (5) residents according to the facility's isolation precaution policy. Resident identifiers: #4, #5, #41, #58, and #64. Additionally, the facility failed to store food in a safe and sanitary manner. The kitchen and nourishment refrigerator contained outdated and undated food. These practices had the potential to affect more than a limited number of residents. Facility census: 52. Findings include: a) Infection control 1. Resident #25 Observation on 01/17/17 at 1:35 p.m. found unit nurse aide (NA) #112 passing fresh ice water to residents on the East wing. This wing is currently quarantined because four (4) of their residents on this wing tested positive for type A influenza in the past few days. This employee wore disposable gloves and obtained fresh ice water for Resident #26. Without changing gloves or sanitizing her hands, she then picked up the plastic, pink water pitcher of Resident #25 (room-mate of Resident #26), and brought it out into the hall beside the portable ice chest. Using a metal scoop, she then filled this pitcher with ice. She returned the pitcher to Resident #25. 2. Resident #94 Observation on 01/17/17 at 1:35 p.m. found unit aide #112 entered this room to give the resident fresh ice from the ice chest parked in the hallway. This employee wore disposable gloves, but did not change the gloves after having had direct contact with water pitchers which belonged to Residents #25 and #26 who resided together in a room across the hall from Resident #94. Residents #25 and #26 had not tested positive for influenza type [NAME] Employee #112 brought Resident #94's water pitc… | 2020-04-01 |
| 3946 | 3946 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2016-05-26 | 157 | D | 0 | 1 | ULQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, the facility failed to notify the responsible party of one (1) of 24 residents reviewed in Stage 2 for a change of status. Resident identifier: #68. Facility census: 99. Findings include: a) Resident #68 Review of the quarterly Minimum Data Set (MDS) review dated 07/03/15 for Resident #68 on 05/24/16, revealed the resident was always continent. The next MDS dated [DATE] noted Resident #68 was frequently incontinent. Interview On 05/24/2016 at 10:09 a.m. with Nurse Aide (NA) #106 stated Resident #68 is incontinent. NA #106 stated, He gradually became incontinent. That happened months ago. On 05/24/16, a review of Resident #68's progress notes for 07/01/15 through 10/07/15 had no mention of Resident #68 being incontinent. A review of Activities of Daily Living (ADL) sheets for (MONTH) (YEAR) noted Resident #68 was continent each shift. The ADL sheets for (MONTH) showed Resident #68 was frequently incontinent. The ADL sheets for (MONTH) (YEAR), showed nearly every shift Resident #68 was incontinent. An interview completed with Social Worker #45 on 05/24/2016 at 3:17 p.m., revealed she had not talked with the responsible party about Resident #68's incontinence. During an interview with the Director of Nurse (DON) #84 on 05/24/2016 at 3:28 p.m., she said, We would notify the responsible party about any changes in the plan of care. Medication changes, falls and any change in condition. DON #84 said she had not discussed any changes concerning Resident #68 with the responsible party. DON #84 stated notification made to the responsible party the resident was using a wheelchair more, but could find no documentation she informed the legal party Resident #68 had become incontinent. | 2020-04-01 |
| 3947 | 3947 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2016-05-26 | 160 | D | 0 | 1 | ULQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personal funds record review and staff interview, the facility failed to close the trust fund within 30 days after a resident expired for one (1) of one (1) fund account reviewed. Resident identifier: #62. Facility census: 99. Findings include: a) Resident #62 Review of records on [DATE] noted Resident #62 died on [DATE]. A check closing the resident's trust fund account was generated on [DATE]. During an interview on [DATE] at 1:12 p.m., the Business Office Manager #80 stated, I must have been looking at the date I closed the account, [DATE] instead of the date the resident died . The checks are supposed to go out within 30 days. | 2020-04-01 |
| 3948 | 3948 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2016-05-26 | 225 | D | 0 | 1 | ULQ211 | Based on review of allegations of abuse and staff interviews, a staff member failed to report an allegation of abuse immediately to the facility. This affected one (1) resident of three (3) reviewed for abuse allegations. Resident identifier: #10. Facility census: 99. Findings include: a) Resident #10 Review of Resident #10 ' s abuse allegation on 05/25/16 revealed an investigation dated 04/18/16. The investigation indicated the incident occurred on 04/10/16, but was not reported until 04/18/16. Two housekeepers (#27 and #28) reported the abuse allegation to the Environmental Service Director #22. The investigation of the allegation indicated housekeeper #87 was near the resident's room on 04/11/16 and heard Nurse Aide (NA) #38 tell the resident to stop that and then heard a slapping noise. The documentation from employee statements #27, 28, 81 and #87 indicated during a break on 04/17/16 the four employees had a conversation about the incident that occurred on 04/11/16. The statements indicated housekeeper #87 mentioned to the other housekeeper's #27, 28 and 81 what she heard on 04/11/16 involving NA #38 and Resident #10, but had never reported it. During an interview with Housekeeper #87 on 05/25/2016 at 1:44 p.m., she stated she failed to report the alleged abuse that happened on 04/11/16. She stated she did not witness abuse, but did hear a noise that sounded like a slap, but since she didn't see anything she didn't know if it was just a noise or if the NA slapped the resident or if the resident slapped the N[NAME] During an interview with Housekeeper #28 on 05/25/16 at 2:00 p.m. stated the housekeepers were taking a break on Sunday 04/17/16. She stated Housekeeper #87 told them she thought that NA #38 slapped Resident #10 on 04/11/16, but was not sure if it happened or not. The housekeepers told her even if she was not sure she needed to report it. During an interview with Housekeeper #27 on 05/25/16 at 2:05 p.m., she stated during a break on 04/17/16 housekeeper #87 told her and the other housekeepers #28 a… | 2020-04-01 |
| 3949 | 3949 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2016-05-26 | 226 | D | 0 | 1 | ULQ211 | Based on review of abuse allegations, staff interviews and review of the facility's policy and procedure, the facility failed to implement the Abuse/Neglect/Misappropriation of Property Policy by not reporting an allegation of abuse timely. This affected one (1) resident of three (3) reviewed for abuse allegations. Resident identifier: #10. Facility census: 99. Findings include: a) Resident #10 Review of Resident #10 ' s abuse allegation on 05/25/16 revealed an investigation dated 04/18/16. The investigation indicated the incident occurred on 04/10/16, but was not reported until 04/18/16. Two housekeepers (#27 and #28) reported the abuse allegation to the Environmental Service Director #22. The investigation of the allegation indicated housekeeper #87 was near the resident's room on 04/11/16 and heard Nurse Aide (NA) #38 tell the resident to stop that and then heard a slapping noise. The documentation from employee statements #27, 28, 81 and #87 indicated during a break on 04/17/16 the four employees had a conversation about the incident that occurred on 04/11/16. The statements indicated housekeeper #87 mentioned to the other housekeeper's #27, 28 and 81 what she heard on 04/11/16 involving NA #38 and Resident #10, but had never reported it. During an interview with Housekeeper #87 on 05/25/2016 at 1:44 p.m., she stated she failed to report the alleged abuse that happened on 04/11/16. She stated she did not witness abuse, but did hear a noise that sounded like a slap, but since she didn't see anything she didn't know if it was just a noise or if the NA slapped the resident or if the resident slapped the N[NAME] During an interview with Housekeeper #28 on 05/25/16 at 2:00 p.m. stated the housekeepers were taking a break on Sunday 04/17/16. She stated Housekeeper #87 told them she thought that NA #38 slapped Resident #10 on 04/11/16, but was not sure if it happened or not. The housekeepers told her even if she was not sure she needed to report it. During an interview with Housekeeper #27 on 05/25/16 at 2:05 p.m., … | 2020-04-01 |
| 3950 | 3950 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2016-05-26 | 242 | D | 0 | 1 | ULQ211 | Based on record review and staff and resident interviews, the facility failed to ensure three (3) of three (3) sampled residents were offered choices. Residents #5, 83 and 67 did not have bathing choices, and Resident #67 did not have a choice in getting out of bed. Resident identifiers: #5, #83, and #67. Facility census: 99. Findings include: a) Resident #5 During an interview on 05/24/16 at 08:27 a.m., Resident #5 said, I have a schedule (for getting showered). They told me I have to have a schedule so they get to everyone. I go Monday, Wednesday and Friday. Review of Resident #5's care plan on 05/24/16, noted the following entry dated 02/10/2016, Residents bathing preference will be honored at each bathing opportunity. During an interview on 05/24/16 at 10:13 a.m., Nurse Aide (NA) #106 stated, For shower days, we look at the book. When a resident comes in they take an empty spot on the schedule. Review of the bathing schedule on 05/24/16, was a grid with room numbers and x's indicating days of the week a resident would receive a shower. During an interview on 05/24/16 at 10:48 a.m., the Director of Nursing (DON) #84 said, We have shower schedules preset based on the room. If they tell us they have a preference for a different day or time we adjust the schedule. b) Resident #83 During an interview on 05/23/16 at 12:46 p.m., Resident #83 stated, she used to shower twice a week and now it's once week. They have a schedule at the desk. Review of Resident #83's care plan on 05/24/16 revealed the following entry dated 01/22/16, (Resident #83's) bathing preference will be honored at each bathing opportunity. During an interview on 05/24/16 at 10:13 a.m., NA #106 stated, For shower days, we look at the book. When a resident comes in they take an empty spot on the schedule. c) Resident #67 During an interview on 05/23/16 at 2:10 p.m., a family member for Resident #67 said, (Resident #67) has to be transferred by two people with the hoyer (mechanical lift). Sometimes there isn't enough staff to do it. I have complained … | 2020-04-01 |
| 3951 | 3951 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2016-05-26 | 246 | D | 0 | 1 | ULQ211 | Based on record review family interviews and staff interviews, the facility failed to accommodate the needs for one (1) of one (1) residents who needed assistance getting out of bed. Resident identifier: #67. Facility census: 99. Findings include: a) Resident #67 During an interview on 05/23/16 at 2:10 p.m., a family member for Resident #67 said, (Resident #67) has to be transferred by two people with the hoyer (mechanical lift). Sometimes there isn't enough staff to do it. I have complained to the administrator and others. There were times he missed his shower because there no aide on shift. The last time it was last week. Review of Resident #67's care plan on 05/24/16, revealed a noted that Resident #67 required two (2) people to assist using a mechanical lift for transfers. During an interview on 05/24/16 at 10:13 a.m., NA #106 stated, There has been times when (Resident #67) didn't get out of bed because it takes two people to transfer him and there was only one person. During an interview on 05/25/2016 at 8:06 a.m., Nurse #107 stated he was the normal day nurse on Station 4. He said sometimes, infrequently, he works on the unit with no aide. He said, I'm sure it has happened that someone didn't get showered when I didn't have an aide. It probably happened that (Resident #67) was not gotten up some days. I do the best I can with the resources I have. | 2020-04-01 |
| 3952 | 3952 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2016-05-26 | 279 | D | 0 | 1 | ULQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the their visual needs. This involved two (2) of three (3) residents investigated in Stage 2 for vision. Resident identifiers: #85 and #125. Facility census: 99. Findings include: a) Resident #85 Review of the most recent Minimum Data Set ((MDS) dated [DATE], revealed Resident #85 had moderate visual impairment. The MDS documented Resident #85 had limited vision and was not able to see the newspaper headlines but can identify objects. This MDS also documented the resident had no corrective lenses. Further review of the clinical record revealed the care plan dated 04/29/16 was silent to a care plan to address Resident #85's visual impairment. Review of the activity care plan dated 04/29/16, directed the staff to encourage the resident's participation in reading the bible, listening to music and to socialize with residents staff. The activity care plan also included an intervention that the staff should provide leisure supplies to include paper, pen, magazines, and newspapers. Review of an activity note on 05/02/16 revealed Resident #85 is alert and verbally able to make needs and wants known. The note also indicated in the resident ' s leisure time he enjoys listening to music, wheeling around unit, and reading the bible. During an interview on 05/24/16 at 12:59 p.m., the Minimum Data Set (MDS)/RN #18 revealed she conducts the MDS assessment for vision and she was aware Resident #85 has visual impairment and does not wear glasses. She verified that a comprehensive care plan for Resident #85's moderately impaired vision was not developed and she would be have been responsible for the care plan development. b) Resident #127 Record review for Resident #127 on 05/25/16, revealed an admission date of [DATE] with the following relevant Diagnoses: [REDACTED]. Revi… | 2020-04-01 |
| 3953 | 3953 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2016-05-26 | 313 | D | 0 | 1 | ULQ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide one (1) of three (3) residents reviewed in Stage 2 for vision concern with devices to maintain vision. Resident identifier: #85. Facility census: 99. Findings include: a) Resident #85 Review of the most recent Minimum Data Set ((MDS) dated [DATE], revealed Resident #85 had moderate visual impairment. The MDS documented Resident #85 had limited vision and was not able to see the newspaper headlines but can identify objects. This MDS also documented the resident had no corrective lenses. Further review of the clinical record revealed the care plan dated 04/29/16 was silent to a care plan to address Resident #85's visual impairment. Review of the activity care plan dated 04/29/16, directed the staff to encourage the resident's participation in reading the bible, listening to music and to socialize with residents staff. The activity care plan also included an intervention that the staff should provide leisure supplies to include paper, pen, magazines, and newspapers. Review of an activity note on 05/02/16 revealed Resident #85 is alert and verbally able to make needs and wants known. The note also indicated in the resident ' s leisure time he enjoys listening to music, wheeling around unit, and reading the bible. During an Interview with Resident #85 on 05/24/2016 at 11:11 AM revealed he does not currently have glasses. He stated he an not do that without glasses. He stated he like to read the bible and bible verses but he cant right now since he does not have any glasses. He stated he was able to read things far away and he was able to read two signs posted on his wall. This surveyor ask Resident #85 if he would read if he had glasses and he said yes he would love to be able to read the bible and maybe a magazine. During an interview with Social Service Personnel # 45 on 05/24/16 at 12:53 p.m., she stated she was not aware if Resident #85 had ever seen an eye … | 2020-04-01 |
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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 );