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50 rows where "inspection_date" is on date 2011-02-02
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9173 | 9173 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 221 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, policy review, and staff interview, the facility failed to ensure each resident was free from any physical restraints not required to treat the resident's medical symptoms. One (1) of thirty-six (36) Stage II sample residents was placed in a beanbag chair (which prevented him from rising) without a written physician's order for its use to treat a medical symptom. Resident identifier: #62. Facility census: 90. Findings include: a) Resident #62 1. At approximately 3:00 p.m. on 01/24/11, observation found Resident #62 to be sliding out of his positional chair while located in the living room area. Only one (1) aide was present in the room, and she placed a beanbag chair that had been positioned adjacent to his chair under him, so that he slid out of the positional chair and onto the beanbag chair. At 4:30 p.m. on 01/24/11, this surveyor observed the resident still reclining in the beanbag chair receiving one-on-one (1:1) supervision by a nursing assistant (Employee #80) while a licensed practical nurse (LPN - Employee #43) worked nearby. The resident was very confused, making snoring sounds, and hitting out (ineffectively) at staff. During an interview with Employee #43 at this time, she stated they use the beanbag chair when the resident is so agitated that they cannot get him in any other chair without fear that he will throw himself out or turn the chair over. A subsequent review of incident reports verified this behavior. The incident reports indicated the falls were usually from his positional chair with a safety belt harness in place. The resident was strong and would shift his weight to one (1) side and, then, upset chair. He had six (6) reported falls of this type in the last two (2) months (on 01/24/11, 01/18/11, 12/15/10, 12/13/10, 12/05/10, and 12/01/10). A follow-up visit, at 5:45 p.m., revealed Resident #62 was in a positional chair being fed by a nurse aide. When he had finished eating, he was m… | 2016-01-01 |
| 9174 | 9174 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 272 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the accuracy of an initial physical assessment and a minimum data set assessment (MDS) for two (2) of thirty-six (36) Stage II sample residents. Resident #109's admission nursing assessment was inaccurate related to the absence of skin breakdown, and two (2) of Resident #34's MDS assessments were inaccurate related to the absence of contractures. Resident identifiers: #109 and #34. Facility census: 90. Findings include: a) Resident #109 When reviewed on 01/31/11, the medical record of Resident #109 divulged the resident had been admitted to the facility from an acute care hospital on [DATE], following surgery for [REDACTED]. Assessment by a facility nurse on the day of admission (12/22/10) stated the resident has had no foot problems or care in past seven (7) days. Review of the resident's care plan revealed that, shortly after admission on 01/05/11, a problem statement was added to address the presence of stage II pressure areas. (A Stage II pressure area is described by the National Pressure Ulcer Advisory Panel at www.npuap.org as a partial thickness of dermis presenting as a shallow open ulcer with a pink wound bed, without slough. May also present as an intact or open / ruptured serum filled blister.) A facility nurse (Employee #135), when interviewed on 02/01/11 at approximately 10:00 a.m., was asked why this skin breakdown was not recognized prior to progressing to Stage II. Another facility nurse (Employee #139) presented a written document, which identified as having been acquired from the hospital from where the resident had been discharged immediately preceding his admission to the nursing home. Employee #139 stated the information had been received upon request by the facility on the previous evening (01/31/11). This document included an evaluation of the resident dated 12/22/10 at 7:50 a.m., which noted patient heels pink and spongy bilat (bilaterally). The… | 2016-01-01 |
| 9175 | 9175 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 279 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan that describes the services to be furnished to attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being, for two (2) of thirty-six (36) Stage II sample residents. One (1) resident (#109) had a [MEDICAL CONDITION] with no mention of this device and its associated care needs in the resident's care plan. Another resident (#97) acquired an eye infection that was not included in the care plan. Resident identifiers: #109 and #97. Facility census: 90. Findings include: a) Resident #109 When reviewed on 02/01/11, the medical record for Resident #109 divulged she had been admitted to the facility from an acute care hospital on [DATE], following surgery for [REDACTED]. Review of the resident's physician orders [REDACTED]. The resident's care plan, when reviewed on 02/01/11, contained no mention of the resident's [MEDICAL CONDITION] or care needs related to it. Employee #135, a facility nurse and assistant director of nurses, when interviewed related to the resident's care plan to address [MEDICAL CONDITION] care on 02/01/11 at 9:35 a.m., confirmed the [MEDICAL CONDITION] and its care needs were not included in the resident's plan of care. Employee #135, later on 02/01/11, provided evidence that, although the [MEDICAL CONDITION] and its care were not included on the resident's care plan, the information related to its care was available to facility nursing assistants by way of their kiosk (computer terminal) system. -- b) Resident #97 When reviewed on 01/31/11, the medical record of Resident #97 revealed a lab report dated (as reported to the facility) at 4:10 p.m. on 10/08/10. This lab report of a culture of the resident's eye identified the presence of [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA), scant growth. The resident's care plan in effect at that time (October 2010) was reviewed, and ther… | 2016-01-01 |
| 9176 | 9176 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 280 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the care plans for two (2) of thirty-six (36) Stage II sample residents when changes occurred in their healthcare status and/or service needs. Resident identifiers: #62 and #55. Facility census: 90. Findings include: a) Resident #62 1. At approximately 3:00 p.m. on 01/24/11, observation found Resident #62 to be sliding out of his positional chair while located in the living room area. Only one (1) aide was present in the room, and she placed a beanbag chair that had been positioned adjacent to his chair under him, so that he slid out of the positional chair and onto the beanbag chair. At 4:30 p.m. on 01/24/11, this surveyor observed the resident still reclining in the beanbag chair receiving one-on-one (1:1) supervision by a nursing assistant (Employee #80) while a licensed practical nurse (LPN - Employee #43) worked nearby. The resident was very confused, making snoring sounds, and hitting out (ineffectively) at staff. During an interview with Employee #43 at this time, she stated they use the beanbag chair when the resident is so agitated that they cannot get him in any other chair without fear that he will throw himself out or turn the chair over. A subsequent review of incident reports verified this behavior. The incident reports indicated the falls were usually from his positional chair with a safety belt harness in place. The resident was strong and would shift his weight to one (1) side and, then, upset chair. He had six (6) reported falls of this type in the last two (2) months (on 01/24/11, 01/18/11, 12/15/10, 12/13/10, 12/05/10, and 12/01/10). A follow-up visit, at 5:45 p.m., revealed Resident #62 was in a positional chair being fed by a nurse aide. When he had finished eating, he was moved away from the other residents and was provided a 1:1 caregiver (Employee #60). He was still very awake and trying to rise, although the nurse (Employee #43) stated he had r… | 2016-01-01 |
| 9177 | 9177 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 282 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to implement the plan of care for one (1) of thirty-six (36) Stage II sample residents, by failing to ensure staff applied a hand roll to the resident's hand and provided passive range of motion (PROM) exercises to the resident's knees and ankles in accordance with physician orders. Resident identifier: #55. Facility census: 90. Findings include: a) Resident #55 1. Observation, at 2:00 p.m. on 01/24/11, found Resident #55 sitting up in a chair in her room. There was no hand roll (foam or rolled washcloth) in either hand, nor was any hand roll observed to be present in her room. She was observed again at 10:00 a.m. on 01/25/11, at 4:15 p.m. on 01/25/11, and at 11:00 a.m. on 01/31/11, with no hand roll in place. A review of Resident #55's medical record revealed this [AGE] year old female had [DIAGNOSES REDACTED]. Further review of the medical record found the treatment administration records (TARs) for December 2010 and January 2011 were filled out daily indicating, by the nurse's initials, that a hand roll was applied to the resident's right hand on each shift. Review of the resident's therapy note, dated 01/11/11, revealed the following: Received a screen request from nursing to look at pt's (patient's) L (left) hand for contracture management and consider orthotic placement. Informed nursing that pt has been looked at twice in the past for same issue and that she will NOT leave any orthotic in that hand. She uses her other hand to remove it. Therefore, there is a recommendation still in pt.'s care plan to place hand rolls (or rolled gauze) in pt's hands AS SHE TOLERATES, which this therapist agrees with continuing. Review of the resident's physician orders [REDACTED]. If unable to put foam roll in hand you may use a rolled up washcloth. Review of the resident's current care plan found the following problem statement: Needs Total Assist with ADL's (activities of d… | 2016-01-01 |
| 9178 | 9178 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 309 | D | 0 | 1 | IEXL11 | Based on observation, record review, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care, by not consistently using hand rolls as specified in the resident's active care plan. This was found for one (1) of thirty-six (36) Stage II sample residents. Resident identifier: #34. Facility census: 90. Findings include: a) Resident #34 1. During daily observations of Resident #34 each morning and each afternoon on 01/24/11, 01/25/11, 01/26/11, and the morning of 01/27/11, there were no hand rolls or splints observed. Resident #34, when observed on 01/25/11 at 9:30 a.m., appeared to be unable to execute virtually any voluntary movement. During an interview with a facility registered nurse (RN - Employee #142) at 10:15 a.m. on 01/25/11, she was asked whether Resident #34 had any contractures. Employee #142 responded in the affirmative, stating she had contractures in both hands. When asked if hand rolls or splints were being used, she replied they were no longer, used because they were no longer helpful. She explained that the resident was nearly incapable of any voluntary movement and was totally dependant upon staff for all activities of daily living (ADLs) and movement. When observations were attempted on 01/31/11, it was found that resident was moved to another wing. Subsequent observation of the resident this revealed, again, no hand rolls or splints in place. On 01/31/11 at 4:20 p.m., a nursing assistant (Employee #143) was asked about use of splints or hand rolls for the resident. She stated she knew they sometimes used to use wash cloths. On 02/01/11 at 8:00 a.m., resident was observed in the dining room for breakfast with hand rolls in place. Observation of resident, on 02/01/11 at 9:45 a.m., revealed no breakdown on fingers or insides of hands. Resident #34 now had Posey hand rolls in place. -- The resident's MDS 3.0… | 2016-01-01 |
| 9179 | 9179 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 314 | G | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed, for one (1) of thirty-six (36) Stage II sample residents, to provide care and services to prevent the development of pressure ulcers for a resident who entered the facility without pressure ulcers, but who was at risk of developing pressure ulcers. Resident #109 was admitted to the facility following hospitalization and surgery for [REDACTED]. This incorrect assessment delayed implementation of care to the areas which resulted in the development of Stage II pressure sores. These Stage II pressure sores subsequently worsened to Stage III pressure sores. Resident identifier: #109. Facility census: 90. Findings include: a) Resident #109 When reviewed on 01/31/11, the medical record for Resident #109 divulged this [AGE] year old male was admitted to the facility from an acute care hospital on [DATE], following surgery for [REDACTED]. Review of the discharge summary received at the facility from the acute care hospital revealed, under Discharge Disposition, We will have the patient up with assistance, weight bearing as tolerated, decubitus precautions up in chair at bedside, QPI's (unknown abbreviation) off bed and abduction pillows at all times. The resident's admission minimum data set assessment (MDS), with an assessment reference date (ARD) of 12/29/10, stated in the areas of Functional Status that the resident required the extensive physical assistance of two (2) or more persons for bed mobility and transferring to/from bed, chair, wheelchair, standing position. The resident had no ability to reposition himself. A nursing assessment completed on the day admission to the facility (dated 12/22/10 at 7:12 p.m.), stated the resident has had no foot problems or care in past seven (7) days. The resident's physician orders, when reviewed, disclosed orders for no pressure ulcer treatment or preventive measures at the time of admission. A nursing assessment entry, dated on 01/02/11 at 11… | 2016-01-01 |
| 9180 | 9180 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 318 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to provide physician-ordered therapeutic measures intended to prevent further decline in range of motion (ROM) and failed to periodically re-evaluate the resident's status and revise the plan of care as needed for one (1) of thirty-six (36) Stage II sample residents. Resident identifier: #55. Facility census: 90. Findings include: a) Resident #55 1. A review of Resident #55's medical record revealed this [AGE] year old female had [DIAGNOSES REDACTED]. The resident's annual minimum data set assessment (MDS), with an assessment reference date (ARD) of 08/31/10, stated the resident had limited ROM of all extremities and that this was no change from the previous MDS. The quarterly MDS, with an ARD of 11/14/10, indicated the resident had functional limitations of all extremities. The resident received therapy until 11/01/10, when she was discharged with a note stating, Discharge planned following completed staff education for restorative PROM (passive range of motion) program. -- 2. Review of the resident's therapy note, dated 01/11/11, revealed the following: Received a screen request from nursing to look at pt's (patient's) L (left) hand for contracture management and consider orthotic placement. Informed nursing that pt has been looked at twice in the past for same issue and that she will NOT leave any orthotic in that hand. She uses her other hand to remove it. Therefore, there is a recommendation still in pt.'s care plan to place hand rolls (or rolled gauze) in pt's hands AS SHE TOLERATES, which this therapist agrees with continuing. Review of the resident's physician orders [REDACTED]. If unable to put foam roll in hand you may use a rolled up washcloth. Review of the resident's current care plan found the following problem statement: Needs Total Assist with ADL's (activities of daily living). Has flexion contractures Rt (right) hand. The goal associated with this … | 2016-01-01 |
| 9181 | 9181 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 323 | E | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility incident and accident reports, and staff interview, the facility failed to provide an environment that was free from accident hazards over which the facility had control, by having room heating units in five (5) randomly observed resident rooms with surface temperatures exceeding 150 degrees Fahrenheit (F); by storing hazardous chemicals in an unlocked storage cabinet in the bathing room on the D Hall of the facility; and by failing to provide adequate supervision to one (1) of thirty-six (36) Stage II sample residents on B Hall of the facility to prevent reoccurring accidents. These practices had the potential to affect Residents #85, #69, #62, #70, and #65 (who had excessive heater temperatures), all cognitively impaired residents who wandered in the unsecured areas of the facility and had access to the unlocked chemicals on D Hall, and Resident #62 who was provided inadequate supervision to prevent reoccurring accidents. Facility census: 90. Findings include: a) Residents #85, #69, #62, #70 and #65 1. During an interview with Resident #85 in her room on D Hall at 5:30 p.m. on 01/24/11, testing found the surface temperature of the resident's heater, near the baseboard of her outside wall on the right side of her bed, was very hot to touch. The surface temperature, when measured with a thermometer, was found to be 162.9 degrees F. The resident, who currently occupied the bed nearest the heater, stated she knew it was hot and did not go over there. Observation found the thermostat which controls the heater in this room was set on 72 degrees F. This resident stated she did not adjust the thermostat herself. Following this observation, a random tour of the facility was conducted, and excessive surface temperatures were noted in rooms on each hallway of the facility as follows: 2. The heater in the room of Resident #69 (located on D Hall) was very warm to the touch. The surface temperature,… | 2016-01-01 |
| 9182 | 9182 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 329 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interview, the facility failed to ensure physician orders [REDACTED]. Resident identifier: #28. Facility census: 90. Findings include: a) Resident #28 1. A review of Resident #28's medical record revealed this [AGE] year old female had [DIAGNOSES REDACTED]. Her physician's orders [REDACTED].>- 04/07/10 - ([MEDICATION NAME]) [MEDICATION NAME] 2 mg/ml solution injection Dose Ordered: (0.5 ml/1 mg) intramuscular 1 mg q.6.h. (every 6 hours) p.r.n. first date 03/01/2010 FOR: Agitation. - 08/30/10 - ([MEDICATION NAME]) [MEDICATION NAME] 1 mg Tablet by mouth (1) 2 X wk. Sunday Wednesday 8:00 am first date: 09/01/2010 FOR: Agitation and restlessness due to dementia Notify Staff. - 09/14/10 - [MEDICATION NAME] 0.5 mg Tablet by mouth q.6.h. 8:00 am 2:00 pm 8:00 pm 2:00 am first date: 09/15/2010 FOR: Agitation and restlessness due to dementia Notify Staff. - 09/23/10 - ([MEDICATION NAME]) [MEDICATION NAME] 0.25 mg Tablet by mouth q.6.h. p.r.n. first date: 02/20/2010 FOR: Dementia-Related [MEDICAL CONDITION], organic mental syndrome, (Dementia-Related Psychoses) with behaviors of yelling out, spitting, screaming and resistive of personal care Notify staff. - 09/23/10 - ([MEDICATION NAME]) [MEDICATION NAME] 1 mg Tablet by mouth daily 8:00 am FOR: Dementia-Related [MEDICAL CONDITION] (Dementia-Related Psychoses) organic mental syndrome with psychotic or agitated behaviors first date: 07/01/2010. -- 2. The resident's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Also, there were no times or cumulative dosage limits set for giving either the PRN [MEDICATION NAME] or the PRN [MEDICATION NAME] along with the routine doses. -- 3. The facility policy entitled PRN MEDICATIONS, provided by the director of nurses at 8:00 a.m. on 02/02/11, stated: B. To assure the proper utilization of 'PRN' drug orders: 1. The frequency of normal use should be specified within the physician's … | 2016-01-01 |
| 9183 | 9183 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 371 | F | 0 | 1 | IEXL11 | Based upon observation, review of facility documents, and staff interview, the facility failed to store, prepare, distribute, and serve food under sanitary conditions, by not ensuring that staff was properly trained and equipped to monitor the sanitization process in the 3-compartment sink. This had the potential to affect all residents. Facility census: 90. Findings include: a) The clean-up of the morning meal was observed at 8:30 - 9:00 a.m. on 01/26/11. The facility's cook (Employee #157) was asked about procedure for test strips to test sanitizer levels in the 3-compartment sink, which was used for any manual dish washing. She stated she tests all three (3) sinks every time she washes. She indicated that she did not know what color the strips should be or what the acceptable values were following the test. She stated she will get the answer. When asked to demonstrate the procedure she follows, Employee #157 tested the third sink (sink containing sanitizing solution) by immersing a test strip for approximately 30 seconds in the hot water. (The heater had just been turned off.) The posting adjacent to the sink directed staff to allow the water to cool to 75 degrees Fahrenheit (room temperature) prior to testing. During an interview on 01/26/11 at 11:32 a.m., the dietary manager (Employee #16) was asked what the acceptable parts per million (PPM) concentration was for the sanitizer solution test. She did not know what the minimum acceptable levels were. She referred to the label on the jug of chemicals, which stated an acceptable range of 150 to 400 PPM. During an interview on 01/26/11 at 11:00 a.m., the dietary assistant (Employee #59) was asked about the correct procedure for testing the sanitizer solution in the 3-compartment sink. She stated she was not familiar with the use of the sinks or strips and that she had only been at the facility for about six (6) months. Observations also determined that the posted testing instructions located adjacent to the sink differed from the instructions found on the contai… | 2016-01-01 |
| 9184 | 9184 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 428 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to ensure one (1) of thirty-six (36) Stage II sample residents was free of the potential for excessive dosages of psychoactive medications due to duplicate therapy, when the pharmacist failed to recognize irregularities in his physician's orders [REDACTED]. Resident identifier: #28. Facility census: 90. Findings include: a) Resident #28 1. A review of Resident #28's medical record revealed this [AGE] year old female had [DIAGNOSES REDACTED]. Her physician's orders [REDACTED].>- 04/07/10 - (Ativan) Lorazepam 2 mg/ml solution injection Dose Ordered: (0.5 ml/1 mg) intramuscular 1 mg q.6.h. (every 6 hours) p.r.n. first date 03/01/2010 FOR: Agitation. - 08/30/10 - (Ativan) Lorazepam 1 mg Tablet by mouth (1) 2 X wk. Sunday Wednesday 8:00 am first date: 09/01/2010 FOR: Agitation and restlessness due to dementia Notify Staff. - 09/14/10 - Lorazepam 0.5 mg Tablet by mouth q.6.h. 8:00 am 2:00 pm 8:00 pm 2:00 am first date: 09/15/2010 FOR: Agitation and restlessness due to dementia Notify Staff. - 09/23/10 - (Risperdal) Risperidone 0.25 mg Tablet by mouth q.6.h. p.r.n. first date: 02/20/2010 FOR: Dementia-Related Psychosis, organic mental syndrome, (Dementia-Related Psychoses) with behaviors of yelling out, spitting, screaming and resistive of personal care Notify staff. - 09/23/10 - (Risperdal) Risperidone 1 mg Tablet by mouth daily 8:00 am FOR: Dementia-Related Psychosis (Dementia-Related Psychoses) organic mental syndrome with psychotic or agitated behaviors first date: 07/01/2010. -- 2. The resident's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Also, there were no times or cumulative dosage limits set for giving either the PRN Ativan or the PRN Risperdal along with the routine doses. -- 3. The facility policy entitled PRN MEDICATIONS, provided by the director of nurses at 8:00 a.m. on 02/02/11, stated: B. To assure the proper utilization of… | 2016-01-01 |
| 9185 | 9185 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 502 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed, for one (1) of thirty-six (36) Stage II sample residents, to obtain a physician-ordered laboratory procedure. Resident identifier: #32. Facility census: 90. Findings include: a) Resident #32 When reviewed on 01/26/11, the medical record of Resident #32 divulged the resident was receiving the medication [MEDICATION NAME] (an anti-platelet drug that helps to prevent the formation of blood clots). The record further disclosed a physician's orders [REDACTED]. The results of these lab tests, when reviewed, revealed they were provided to the facility on [DATE]. The report stated the quantity of the specimen was not sufficient for analysis of the CBC with diff and platelets. There was no evidence that a specimen had been resubmitted to carry out the physician's orders [REDACTED].>A facility nurse (Employee #28), when interviewed on 01/26/11 at approximately 2:00 p.m., confirmed staff had not resubmitted a sample in an attempt to carry out the physician's orders [REDACTED].> | 2016-01-01 |
| 9186 | 9186 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2011-02-02 | 514 | D | 0 | 1 | IEXL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate clinical information in each resident's medical record, as evidenced by incorrectly recording nursing interventions in the care plan that differed from the physician's orders [REDACTED]. Resident identifiers: #55 and #62. Facility census: 90. Findings include: a) Resident #55 A review of Resident #55's medical record revealed an [AGE] year old female with [DIAGNOSES REDACTED]. Review of the resident's care plan found the following problem statement established 07/17/09: Needs Total Assist with ADL's (activities of daily living). Has flexion contractures Rt (right) hand. The nursing intervention stated: Wash / dry hands daily, apply foam roll to Rt hand, leave in hand until bedtime or as long as resident tolerates. The physician's orders [REDACTED]. The physician's orders [REDACTED]. During an interview with the administrator, director of nursing (DON), and a nurse (Employee #28) at 4:30 p.m. on 02/01/11, they acknowledged there was a difference in the wording of the care plan intervention versus the actual physician's orders [REDACTED]. -- b) Resident #62 A review of Resident #62's monthly recapitulation of the physician orders [REDACTED]. Notify Staff. This order was written on 04/09/10, when the resident was receiving physical therapy services. Further record review revealed Resident #62 had not been ambulatory or used a Merry Walker since at least August 2010, although the order continued to be recorded on the monthly recapitulations for the physician to sign. A review of the record revealed documentation by nursing assistants on the Activities of Daily Living forms, indicating the resident walk(ed) in room daily from 12/01/10 through 02/02/11 and required the assistance of one (1) person on eight (8) occasions. The physical therapist (Employee #17), stated in her documentation on 09/29/10: (Resident #62) is no longer able to ambulate. (mobility) Total Ass… | 2016-01-01 |
| 9467 | 9467 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2011-02-02 | 157 | D | 0 | 1 | U0V411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the attending physician and/or responsible party of when two (2) of thirty-seven (37) Stage II sample residents experienced significant weight losses. Resident #44 experienced an 11 pound (#) unplanned weight loss in a 10-day period, and Resident #26 experienced a 12# (12.5%) unplanned weight loss in a 3-month period. There was a lack of evidence to reflect staff notified each resident ' s attending physician and/or responsible party of the significant weight loss. Facility census: 63. Findings include: a) Resident #44 1. Record review revealed this [AGE] year old female resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was recently hospitalized from [DATE] through 01/13/11 for an irregular heart rate. Resident #44, when readmitted to the facility on [DATE], weighed 94#. On 01/22/11, she again weighed 94#. On 01/28/11, the resident weighed 86#; this represents an 8# weight loss over a 6-day period. On 01/29/11, the resident weighed 84#. On 02/01/11, the resident was weighed at the surveyor's request, and the resident's weight was 82.8#. -- 2. Review of the resident's nursing notes revealed the following entries: - On 01/14/11 at 8:34 p.m. - . ate poorly at dinner - took evening snack. - On 01/19/11 at 11:58 a.m. - . Of her 1800 ADA pureed with nectar liquid diet res (resident) ate an average of only 20.1% over last 7 days. Does not take supplements well. Weight on 1/14/11 was 93.4 lbs. - On 01/20/11 at 11:06 a.m. - . Taken to dining room to eat - encouraged to feed self - declined. Assist x 1 for feeding. - On 01/26/11 at 11:11 a.m. - . of her 1800 CAL pureed with nectar liquid diet Res ate ave (average) of 27%. Weight on 1-22-11 was 94%. - On 01/28/11 at 1:45 p.m. - Skilled for PT/OT. Wt 86 lbs. No s/s (signs / symptoms) distress noted. Continues to have poor PO (oral) intake. Up in w/c (wheelchair) for meals in dr (dining… | 2015-11-01 |
| 9468 | 9468 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2011-02-02 | 161 | B | 0 | 1 | U0V411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's continuation certificate and staff interview, the facility failed to provide evidence that the facility's surety bond had been reviewed (for sufficiency of form and amount) and approved by the Attorney General's Office for the funds of eleven (11) residents that were being managed by the facility. Review of the continuation certificate found it had not been submitted for review and approval by the Attorney General's Office; therefore, this facility was managing residents' personal funds without an approved surety bond. Facility census: 63. Findings include: a) Review of the facility's surety bond continuation certificate revealed a lack of evidence that it had been reviewed, for sufficiency of form and amount, by the West Virginia Attorney General's Office. Review of the facility's surety bond, held by the Office of Health Facility Licensure and Certification (OHFLAC), found the last surety bond that had been approved through the Attorney General's Office (#B 895) had expired on [DATE]. During a telephone interview on [DATE] at 2:00 p.m., the facility's office manager (Employee #31) confirmed the facility had not submitted the continuation certificate to OHFLAC for review and approval by the Attorney General's Office. Facility records revealed the facility managed funds for eleven (11) residents, and their current high balance for the month of January, 2011 was $1,300.00. Review of the continuation certificate noted the amount of the bond was for $20,000.00. | 2015-11-01 |
| 9469 | 9469 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2011-02-02 | 225 | D | 0 | 1 | U0V411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review and staff interview, the facility failed to screen applicants for negative findings on the West Virginia Nurse Aide Registry prior to hire, to ensure they did not had a finding entered into the Registry concerning abuse, neglect, mistreatment of [REDACTED]. This occurred for one (1) of five (5) new employees whose personnel records were reviewed. Employee identifier: #32. Facility census: 63. Findings include: a) Employee #33 Review of sampled personnel records found no evidence to reflect the facility had checked the State Nurse Aide registry prior to hiring Employee #32, to ensure this individual had no negative findings entered into Registry concerning abuse, neglect, mistreatment of [REDACTED]. An interview with the facility's human resources, on the mid-afternoon of 01/31/11, confirmed there was no evidence to verify the facility had checked with the Registry prior to hiring Employee #32. | 2015-11-01 |
| 9470 | 9470 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2011-02-02 | 226 | D | 0 | 1 | U0V411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review, facility policy review, and staff interview, the facility failed to effectively implement its abuse prohibition policies and procedures to include checking the West Virginia Nurse Aide Registry prior hiring new employees, to verify they did not had a negative finding entered into the Registry concerning abuse, neglect, mistreatment of [REDACTED]. This occurred for one (1) of five (5) new employees whose personnel records were reviewed. Employee identifier: #32. Facility census: 63. Findings include: a) Employee #33 Review of sampled personnel records found no evidence to reflect the facility had checked the State Nurse Aide registry prior to hiring Employee #32, to ensure this individual had no negative findings entered into Registry concerning abuse, neglect, mistreatment of [REDACTED]. An interview with the facility's human resources, on the mid-afternoon of 01/31/11, confirmed there was no evidence to verify the facility had checked with the Registry prior to hiring Employee #32. Review of the facility's policy titled Abuse: Screening Policy (no revision date) found the facility was supposed to check with the State Nurse Aide Registry in order to screen new employees for possible findings entered into the Registry concerning abuse, neglect, mistreatment of [REDACTED]. | 2015-11-01 |
| 9471 | 9471 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2011-02-02 | 241 | E | 0 | 1 | U0V411 | Based on observation and staff interview, the facility failed to feed dependent residents in a dignified manner as evidenced by staff standing over residents in the dining room while assisting them to eat. This was evident for ten (10) residents during random observations of various meals served. Resident identifiers: #63, #18, #11, #14, #33, #23, #5, #36, #52, and #22. Facility census: 63. Findings include: a) Resident #63 Observation, on 01/25/11 at 5:15 p.m., found restorative staff (Employee #77) standing over this resident while feeding the evening meal in the dining room. On 01/31/11 at 12:50 p.m., observation found Employee #77 again standing over this resident while feeding lunch in the dining room. Observation, on 02/01/11 at 5:30 p.m., found a nurse (Employee #45) standing over this resident while feeding the evening meal in the dining room. b) Resident #18 Observation, on 01/31/11 at 12:50 p.m., found a nursing assistant (Employee #51) standing over this resident while feeding the noon meal in the dining room. c) Resident #11 Observation, on 01/31/11 at 12:50 p.m., found a nursing assistant (Employee #55) standing over this resident while feeding the noon meal in the dining room. d) Resident #14 Observation, on 01/25/11 at 8:30 a.m., found a nursing assistant (Employee #65) standing across the table while feeding this resident breakfast in the dining room. e) Resident #33 Observation, on 01/25/11 at 12:00 p.m., found restorative staff (Employee #78) standing across the table while feeding this resident the noon meal in the dining room. f) Resident #23 Observation, on 01/31/11 at 12:30 p.m., found a nursing assistant (Employee #55) standing over this resident while feeding the noon meal in the dining room. On 02/01/11 at 5:30 p.m., observation again found Employee #55 standing over this resident while feeding the evening meal in the dining room. g) Resident #5 Observation, on 01/25/11 at 5:15 p.m., found Employee #77 standing over this resident while feeding the evening meal in the dining room. h) Resid… | 2015-11-01 |
| 9472 | 9472 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2011-02-02 | 248 | E | 0 | 1 | U0V411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview, family interview, and resident interview, the facility failed to provide an activity program to meet the needs of cognitively impaired, visually impaired, and/or bed bound residents in accordance with their comprehensive care plans, to address individual interests and preferences and to promote the mental and psychosocial well-being of six (6) of thirty-seven (37) Stage II sampled residents who were reviewed for activities. Resident identifiers: #1, #5, #44, #66, #58, and #49. Facility census: 63. Findings include: a) Resident #1 Observations of this resident, from 01/24/11 to 01/27/11, found she remained in her room and in bed during the day. The resident was verbal but made only noises and gestures. This resident was non-ambulatory and required staff assistance to transfer from bed to a transport chair to attend organized activities. Further observations found this resident was not assisted to attend an organized activity, nor were any in-room activities provided. Review of the resident's comprehensive care plan, dated 11/16/11 to 02/17/11, found a goal for the resident to participate in a minimum of two (2) small group activities of her choice each week as tolerated. Interview with the activity director (Employee #79), on 01/27/11 at 9:15 a.m., revealed unscheduled room visits, [MEDICATION NAME] approximately fifteen (15) minutes each, were to be provided to Resident #1 two (2) times a week. The activity director also reported this resident enjoyed the music entertainment provided by local groups. Review of the resident's participation schedule on the recreation detail therapy reports for December 2010 and January 2011 (month-to-date), provided by the activity director on 01/27/11 at 10:50 a.m., found no evidence this resident had attended any type of out-of-room activity in facility during December 2010 or January 2011, and there was no evidence any in-room activity having bee… | 2015-11-01 |
| 9473 | 9473 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2011-02-02 | 279 | D | 0 | 1 | U0V411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, observation, family interview, resident comments, and staff interview, the facility failed, for two (2) of thirty-seven (37) Stage II sample residents, to use the results of the assessment to develop the comprehensive plan of care, with goals and interventions to attain or maintain each resident's highest practicable mental and psychosocial well-being. The care plan of Resident #49, who was nearly blind, failed to address accommodations to enable him to participate in activities of his choice / preference. The care plan for Resident #58 failed to addresses his difficulty in accessing and using his call light, nor did it address his known activity interests, strengths, and level of cognitive impairment. Resident identifiers: #49 and #58. Facility census: 63. Findings include: a) Resident #49 During an interview in his room on 01/25/11 at 10:45 a.m., Resident #49 said he liked to watch television but can only see 2 or 3 feet away, and his television was mounted on the wall above the sink - too far away for him to see anything. He also reported having DVDs, but he could not see to watch them. He said he would also like to play bingo if they had cards large enough for him to see. When asked, he stated he had resided in the facility for four (4) months. Review of his minimum data set (MDS), with an assessment reference date (ARD) of 09/23/10, found in Section N that Resident #49's activity preferences included watching television and sports and playing cards or games. The assessor also encoded the MDS to reflect he was highly impaired visually. Review of his current care plan revealed the identification of depression and anxiety [DIAGNOSES REDACTED]. Another intervention identified in his care plan was that he enjoyed sports, especially West Virginia University and Ohio State University football. Further review of the care plan revealed the identification of his need for continued stimulation and sociali… | 2015-11-01 |
| 9474 | 9474 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2011-02-02 | 280 | D | 0 | 1 | U0V411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to revise the care plans of two (2) of thirty-seven (37) Stage II sample residents when changes occurred in their condition and/or when previously developed interventions proved to be ineffective or inappropriate to address each resident's needs. Resident #44 experienced a significant weight loss in a short period of time with no review or revision of her care plan to address this. Resident #66's care plan was not reviewed / revised to include interventions specific to her individual activity needs. Resident identifiers: #44 and #66. Facility census: 63. Findings include: a) Resident #44 1. Record review revealed this [AGE] year old female resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was recently hospitalized from [DATE] through 01/13/11 for an irregular heart rate. Resident #44, when readmitted to the facility on [DATE], weighed 94#. On 01/22/11, she again weighed 94#. On 01/28/11, the resident weighed 86#; this represents an 8# weight loss over a 6-day period. On 01/29/11, the resident weighed 84#. On 02/01/11, the resident was weighed at the surveyor's request, and the resident's weight was 82.8#. Review of the resident's most recent care plan for nutrition, dated 01/05/11, identified the following problem statement: Needs Low concentrated sweet NAS (no added salt) puree diet with nectar fluids. Was pocketing food on previous consistency. Diet snack tid. Able to make food preferences know if asked. Needs seated at supervised table to assist with eating needs encouraged. Wt. loss in past 180 days. The goal associated with this problem stated: Resident will try to consume at least 50% of meals and take snacks tid to try to help bs (blood sugar) be wnl (within normal limits) and try to prevent wt loss by next quarter. Interventions included: Offer Diabetic snack tid as ordered; Monitor weight; Monitor food intakes … | 2015-11-01 |
| 9475 | 9475 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2011-02-02 | 309 | D | 0 | 1 | U0V411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of the facility's weight policy, the facility failed to provide care and services to attain or maintain the highest practicable physical well-being for one (1) of thirty-seven (37) Stage II sample residents. Resident #44 had a significant change in condition for which there was no evidence to reflect facility staff identified this change and/or notified the resident's attending physician and/or responsible party. The resident experienced an eleven (11) pound unplanned weight loss, representing a loss of 11.7% of her total body weight, in a 10-day period. There was no evidence of review of existing weight loss interventions and/or new interventions by the physician and/or other members of the interdisciplinary team to address this change in condition. Resident identifier: #44. Facility census: 63. Findings include: a) Resident #44 1. Record review revealed this [AGE] year old female resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was recently hospitalized from [DATE] through 01/13/11 for an irregular heart rate. Resident #44, when readmitted to the facility on [DATE], weighed 94#. On 01/22/11, she again weighed 94#. On 01/28/11, the resident weighed 86#; this represented an 8# (8.5%) weight loss over a 6-day period. On 01/29/11, the resident weighed 84#, representing a 10.6% weight loss in seven (7) days. On 02/01/11, the resident was weighed at the surveyor's request, and the resident's weight was 82.8#, a loss of 11.7% in a ten (10) day period. -- 2. Review of the resident's nursing notes revealed the following entries: - On 01/14/11 at 8:34 p.m. - . ate poorly at dinner - took evening snack. - On 01/19/11 at 11:58 a.m. - . Of her 1800 ADA pureed with nectar liquid diet res (resident) ate an average of only 20.1% over last 7 days. Does not take supplements well. Weight on 1/14/11 was 93.4 lbs. - On 01/20/11 at 11:06 a.m. - . Take… | 2015-11-01 |
| 9476 | 9476 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2011-02-02 | 371 | F | 0 | 1 | U0V411 | Based on observation and staff interview, the facility failed to store foods under sanitary conditions. This was evident by the presence of canned goods in the emergency food supply being kept past their expiration dates and with other canned goods having no expiration date nor evidence of when those canned goods were stocked on the shelf, to ensure older stock was rotated out and used first. Facility census: 63. Findings include: a) Observation of the emergency food supply room, on 01/31/11 at 3:15 p.m., found four (4) 46-ounce cans of tomato juice with an expiration date of 12/04/10; three (3) 6 pound, 1 ounce cans of mandarin oranges with no expiration date on the cans and no date of when those cans were stocked on the shelf; and three (3) 6 pound 15 ounce cans of three-bean salad with no expiration date on the cans and no date of when those cans were stocked on the shelf. During interview with the dietary manager on 01/31/11 at 3:15 p.m., she acknowledged the cans of tomato juice were beyond the expiration date and she discarded them immediately. She also acknowledged the cans of mandarin oranges and three-bean salad (which had no expiration dates on them) should have been dated when they were placed on the shelves and were not. She said the cans without stock dates were probably supplied in October 2010 when the shelves were last restocked, but staff failed to date them as they should have. | 2015-11-01 |
| 9477 | 9477 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2011-02-02 | 441 | E | 0 | 1 | U0V411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policies on handwashing and glove use, and staff interview, the facility failed to ensure the appropriate handwashing procedure and glove use was followed by two (2) of five (5) nurses observed during medication pass. This practice has the potential to affect more than an isolated number of residents, as it promotes the development and transmission of disease and infection. Employee identifiers: #83 and 34. Facility census: 63. Findings include: a) Employee #83 During medication administration pass observation on 01/24/11 at 4:24 p.m., this nurse applied an oral ointment (using an applicator) to a resident. The nurse was then observed rinsing her hands briefly under running water (using no soap), then turning off the water, and drying her hands on a paper towel. Review of the facility's handwashing procedure revealed the proper procedure should have been to apply a generous amount of soap and wash hands for at least 20 seconds, rinse with hands down, dry with paper towels, then use a towel to turn the water off. An interview with the director of nursing (DON - Employee #27), at 4:00 p.m. on 02/01/11, confirmed this nurse failed to use the proper handwashing procedure to prevent the spread of disease causing organisms. -- b) Employee #34 During the medication pass observation on 01/26/11 at 7:30 a.m., this nurse assisted a resident to clean his nose after applying gloves and before giving his medications. The nurse then left the resident's room with the gloves on and prepared the resident's medications on the medication cart. The nurse also handling a stock bottle of [MEDICATION NAME]. Review of the facility's policy on personal protective equipment found, in Section IV. B., that the gloves should have been removed before the nurse left the resident's room and appropriate handwashing procedure should have been done. An interview with the DON, at 4:00 p.m. on 02/01/11, confirmed this nurse failed to use … | 2015-11-01 |
| 9478 | 9478 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 156 | D | 0 | 1 | SJCY11 | Based on medical record review, review of information provided to residents upon admission, and staff interview, the facility failed to inform one (1) of thirty-two (32) Stage II sample residents, both orally and in writing, of all the rules and regulations governing resident conduct and responsibilities during the stay in the facility. There was no evidence and/or acknowledgement in writing the resident was notified of the facility's smoking policy prior to or upon admission to the facility. Resident identifier: #109. Facility census: 84. Findings include: a) Resident #109 Closed record review, on 01/26/11, revealed this resident was admitted from the hospital to the facility for rehabilitation services on 12/16/10. The resident had been determined to possess the capacity to understand and make informed making health care decisions. Further review revealed the resident left the facility against medical advice (AMA) on 01/24/11. Interview with the director of nursing (DON - Employee #1), at 10:00 a.m. on 02/01/11, revealed the resident left AMA because he wanted to smoke and the facility was a non-smoking facility. Additional medical record review revealed no evidence the resident was informed, prior or at the time admission, that he would not be able to smoke at the facility. There was no discussion in the record that the resident had been informed of this rule, and there was nothing within the record which the resident had signed acknowledging his understanding of this facility rule. Review of the facility's admission contract revealed it did not contain information relative to the facility's smoke-free status. Additionally, the facility had no formal means of assuring residents were made aware of this facility policy prior to or upon admission. On 02/02/11 at 12:00 p.m., an interview was conducted with one (1) of the facility's social workers (Employee #51). Employee #51 confirmed the facility had not provided Resident #109 with written information regarding the facility's smoking policy. At that time, Employe… | 2015-11-01 |
| 9479 | 9479 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 164 | D | 0 | 1 | SJCY11 | Based on observation and staff interview, the facility failed to ensure each resident has the right to confidentiality of his or her clinical records, as evidenced by staff leaving confidential clinical records unattended / open to public view during medication administration. This affected two (2) residents of random observation. Facility census: 84. Findings include: a) An observation made during medication administration, on 01/25/11 at 8:40 a.m., found a registered nurse (RN - Employee #2) left the medication cart unattended in the hallway with the Medication Administration Record [REDACTED]. An observation made during medication administration, on 02/02/11 at 7:40 a.m., found Employee #2 again left the medication cart unattended in the hallway with the MAR indicated [REDACTED]. On 02/02/11 at 1:00 p.m., an interview with the director of nursing (DON - Employee #1) revealed it was a violation of a resident's privacy for the MAR indicated [REDACTED]. | 2015-11-01 |
| 9480 | 9480 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 241 | E | 0 | 1 | SJCY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and medical record review, the facility failed to provide residents with a dining experience that promoted independence and dignity. The facility used plastic cutlery and paper dishware for three (3) of thirty-two (32) Stage II sample residents (#111, #55, and #98) who were on contact precautions, and these disposable products were also used for one (1) of thirty-two (32) Stage II sample residents who engaged in socially unacceptable behavior (#74). In addition, staff did not encourage and assist Resident #111 to dress in her own clothes appropriate to the time of day and her individual preference (rather than in hospital gowns). Resident identifiers: #111, #55, #98, and #74. Facility census: 84. Findings include: a) Residents #111, #55, and #98 During meal times on 01/24/11 and 02/01/11, residents in contact isolation precautions for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) and/or [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) were served meals in paper dishware and with plastic cutlery. Residents #111, #55, and #98 all received the disposable products. When interviewed on 01/25/11 at approximately 8:45 a.m., Resident #111 reported she did not know why she had plastic cutlery and paper dishware; however, she said she thought it had to do with her infection. On 01/27/11 at approximately 3:00 p.m., the infection control registered nurse (Employee #8) indicated she did not know these three (3) residents did not need to be served with plastic cutlery and paper dishware. She said she thought they needed these products due to their infection. Employee #8 was informed that all dishes, glasses, and trays are cleaned and disinfected by using hot water and detergent and by drying at high temperature; this process kills the bacteria. Therefore, the facility did not need to use paper plates or plastic silverware for these residents. The residents continued to receive the p… | 2015-11-01 |
| 9481 | 9481 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 272 | E | 0 | 1 | SJCY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to conduct a comprehensive assessment for the dental needs of one (1) of thirty-two (32) Stage II sample residents and the nutritional needs for five (5) of thirty-two (32) Stage II sample residents, resulting in a failure to address in an individualized care plan the services necessary to meet these residents' needs. Resident identifiers: #7, #37, #84, #31, #35, and #28. Facility census: 84. Findings include: a) Resident #7 During a Stage I interview on 01/26/11 at 8:55 a.m., observation revealed Resident #7's natural teeth were in very poor condition, and many were missing. When the resident was asked the interview questions about dental condition, she stated her teeth were half gone. review of the resident's medical record revealed [REDACTED]. This assessment was not accurate, as it was the resident's natural teeth which were in poor condition. There was no further assessment, evaluation, or plan to address the resident's dental needs. This was brought to the attention of the director of nursing (DON - Employee #1) at 10:00 a.m. on 02/01/11. When asked to provide any additional information regarding an assessment of the resident's dental needs; however, Employee #1 was unable to locate any additional information. -- b) Resident #37 Observation of the preparation of this resident's meal, at noon on 01/27/11, revealed dietary staff was adding water to portions of pureed foods and was attempting to push the foods through a small strainer. A small amount of thin liquid came through the strainer. Staff then added more water and pushed it through. This continued until a portion of watery food substance was acquired for each food item. At 12:00 p.m. on 01/27/11, this was discussed with the dietary manager (DM - Employee #61), who stated the resident's family wanted the resident to be able to drink his meal through a straw. When the nutritiona… | 2015-11-01 |
| 9482 | 9482 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 279 | E | 0 | 1 | SJCY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to develop a comprehensive plan of care for seven (7) of thirty-two (32) Stage II sample residents. There were no care plans to address the dental needs for two (2) residents or the nutritional needs for five (5) residents. Resident identifiers: #7, #37, #84, #31, #35, #28, and #79. Facility census: 84. Findings include: a) Resident #7 During a Stage I interview on 01/26/11 at 8:55 a.m., observation revealed Resident #7's natural teeth were in very poor condition, and many were missing. When the resident was asked the interview questions about dental condition, she stated her teeth were half gone. review of the resident's medical record revealed [REDACTED]. This assessment was not accurate, as it was the resident's natural teeth which were in poor condition. There was no further assessment, evaluation, or plan to address the resident's dental needs. This was brought to the attention of the director of nursing (DON - Employee #1) at 10:00 a.m. on 02/01/11, at which time the DON confirmed the resident should have a care plan if she had dental needs. -- b) Resident #37 Observation of the preparation of this resident's meal, at noon on 01/27/11, revealed dietary staff were adding water to portions of pureed foods and were attempting to push the foods through a small strainer. A small amount of thin liquid came through the strainer. Staff then added more water and pushed it through. This continued until a portion of watery food substance was acquired for each food item. At 12:00 p.m. on 01/27/11, this was discussed with the dietary manager (DM - Employee #61), who stated the resident's family wanted the resident to be able to drink his meal through a straw. When the nutritional content of the meal as prepared was discussed, the DM confirmed the manner dietary staff were preparing this resident's meals was not a method which assured the provisi… | 2015-11-01 |
| 9483 | 9483 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 280 | E | 0 | 1 | SJCY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, and care plan review, the facility failed to revise the activity care plans for three (3) of thirty-two (32) Stage II sample residents (#111, #55, and #98) who were in contact isolation. In addition, the facility failed to ensure two (2) of thirty-two (32) Stage II sample residents (#28 and #7) were invited to their quarterly care plan meetings. Resident identifiers: #111, #55, #98, #28, and #7. Facility census: 84. Findings include: a) Residents #111, #55, and #98 A review of Resident #111, #55, and #98's medical records, on 01/25/11, revealed all three (3) were currently in contact isolation precautions due to having [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) and/or [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE). Resident #111 was diagnosed with [REDACTED]. Resident #98 was diagnosed with [REDACTED]. Resident #55 was diagnosed with [REDACTED]. The care plans for the three (3) residents were revised to address the provision of contact isolation precautions after these [DIAGNOSES REDACTED]. On 01/25/11 at 3:00 p.m., a licensed practical nurse (LPN - Employee #11) reported that, since these residents were in contact isolation, they could not come out of their rooms. On 01/27/11 at approximately 2:00 p.m., the activity director (Employee #54) reported these residents could not participate in out of room activities, because they were in contact isolation. She also stated she had particular concerns about residents on contact isolation attending food-related activity programs. She said she had ensured these residents had things in their rooms they enjoyed doing. She also said her staff provided one-on-one visits for these residents. On 02/02/11 at approximately 3:00 p.m., the activity director indicated she had not updated the three (3) residents' care plans after they were placed on contact isolation. She agreed these updates were important to ensure the re… | 2015-11-01 |
| 9484 | 9484 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 282 | D | 0 | 1 | SJCY11 | Based on medical record review and staff interview, the facility failed to assure the care plans for oral care and hydration were implemented for one (1) of thirty-two (32) Stage II sample residents. Resident identifier: #37. Facility census: 84. Findings include: a) Resident #37 Review of Resident #37's care plan, on 02/01/11, noted the resident was to be provided 30 cc of fluid every hour, and his mouth was to be wiped with swabs every hour. Review of the February 2011 nursing assistant flow sheets revealed no directives to offer 30 cc fluids every hour, and the directives for mouth care stated the resident's mouth was to be swabbed in the morning and the evening (and not hourly). The medication administration records (MARs) were also reviewed for the provision of these services. There was nothing relative to the provision of 30 cc fluids hourly or swabbing of the mouth hourly in the February MARs. According to the director of nursing (DON - Employee #1), at 12:30 p.m. on 02/02/11, the nursing assistant flow sheets were where staff was to find the resident-specific directives regarding the provision of care. When asked, the DON was unable to provide any evidence to support the care plan interventions (for 30 cc fluids every hour and mouth to be wiped with swabs every hour) were being implemented. | 2015-11-01 |
| 9485 | 9485 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 312 | D | 0 | 1 | SJCY11 | Based on resident interview, record review, and staff interview, the facility failed to ensure two (2) of thirty-two (32) Stage II sample residents, who were dependent in the areas of oral care and bathing, received necessary services to maintain good grooming and personal and oral hygiene. Resident identifiers: #111 and #37. Facility census: 84. Findings include: a) Resident #111 During an interview on 01/25/11 at approximately 10:15 a.m., Resident #111 reported she had not had a shower since her admission (on 01/11/11). She stated she would like to have a shower. At approximately 10:30 a.m. on 01/25/11, nurse aides came in to give the resident a shower. Review of the resident's plan of care kardex revealed she received her first shower on 01/25/11. Further review of her kardex revealed staff had recorded B to indicate the resident received a bath on 01/12/11, 01/13/11, 01/14/11, 01/15/11, and 01/16/11. On 01/17/11 and 01/18/11, there was no documentation to indicate what kind of bathing the resident received. On 01/19/11, 01/20/11, 01/21/11, 01/22/11, 01/23/11, and 01/24/11, staff again recorded B to indicate the resident received a bath on these dates. When interviewed, Employee #18 (a licensed practical nurse - LPN) reported all residents receive one (1) shower per week. Employee #13 (an LPN) indicated Resident #111 had refused her showers; however, the documentation did not reflect the resident had refused any showers. The resident also did not have a care plan for refusing showers. -- b) Resident #37 Review of the resident's current care plan noted he was to be provided 30 cc of fluid every hour, and his mouth was supposed to be wiped with swabs every hour. Review of the February 2011 nursing assistant flow sheets revealed no directives to offer 30 cc fluids every hour, and the directives for mouth care stated the resident's mouth was to be swabbed in the morning and the evening (and not hourly). The medication administration records (MARs) were also reviewed for the provision of these services. There was n… | 2015-11-01 |
| 9486 | 9486 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 318 | D | 0 | 1 | SJCY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observation, medical record review, and staff interview, the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM, as evidenced failure of the staff to apply a palm protector with finger separators to the resident's left hand in accordance with physician orders [REDACTED]. Resident identifier: #22. Facility census: 84. Findings include: a) Resident #22 On 01/31/11 at 3:05 p.m., observation found Resident #22 had contractures of both hands and arms. She had a rolled washcloth in her right hand, but there was no device in her left hand. On 01/31/11 at 3:45 p.m., an interview with a licensed practical nurse (LPN - Employee #9) confirmed Resident #22 had contractures of bilateral hands, arms, and legs. According to Employee #9, Resident #22 was supposed to have rolled washcloths rolls in both hands; she did not use splints due to swelling. Review of the physician's orders [REDACTED]. Remove for bathing and hygiene. On 02/01/11 at 9:15 a.m., the resident was observed in the dining room with no palm protector in her left hand. On 02/02/11 at 8:30 a.m., the resident was again observed in the dining room; she was sitting up in her chair with rolled washcloths in both hands, but there was no palm protector in her left hand. On 02/02/11 at 11:55 a.m., the resident was again observed sitting up in a chair in the dining room, with no palm protector in her left hand. On 02/02/11 at 12:00 p.m., an interview with another LPN (Employee #19) revealed the resident was to be wearing a palm protector in her left hand, and she was unsure why the resident would not be wearing it. It may be in the laundry. She also observed, with this surveyor, that Resident #22 was not wearing a palm protector in her left hand. | 2015-11-01 |
| 9487 | 9487 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 323 | E | 0 | 1 | SJCY11 | Based on observation and staff interview, the facility failed to ensure the resident environment remains as free of accident hazards as is possible, as evidenced by staff leaving a medication cart unlocked while unattended, leaving a medication drawer open, and leaving medications on top of the cart while unattended. These practices have the potential to affect more than an isolated number of residents. Facility census: 84. Findings include: a) An observation made during medication administration, on 01/25/11 at 8:40 a.m., found a registered nurse (Employee #2) left the medication cart unattended in the hallway unlocked and with a medication drawer open. An observation made during medication administration, on 02/02/11 at 7:40 a.m., found Employee #2 left medication on top of the medication cart while the cart was unattended. An observation made during medication administration, on 02/02/11 at 8:00 a.m., revealed Employee #2 left medication on top of the medication cart and left a medication drawer open while the cart was unattended. On 02/02/11 at 1:00 p.m., an interview with the director of nursing (DON - Employee #1) confirmed that leaving a medication cart unlocked while unattended, leaving a medication drawer open, and leaving medications on top of the cart while unattended were unsafe practices. | 2015-11-01 |
| 9488 | 9488 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 329 | D | 0 | 1 | SJCY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs, as evidenced by continuing to administer a steroid medication to a resident who had an allergy to that steroid medication. One (1) of thirty-two (32) residents in the Stage II sample was affected. Resident identifier: #79. Facility census: 84. Findings include: a) Resident #79 Review of Resident #79's physician's orders [REDACTED]. Review of Resident #79's admission nursing assessment, dated 11/23/10, revealed she was allergic to steroids. Review of Resident #79's admission orders [REDACTED]vision problems. On 02/01/11 at 2:05 p.m., an interview with the director of nursing (DON - Employee #1) revealed the staff should have clarified the order for the [MEDICATION NAME] with the resident's attending physician due to the steroid allergy. | 2015-11-01 |
| 9489 | 9489 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 353 | C | 0 | 1 | SJCY11 | Based on review of the nursing staffing schedule and staff interview, the facility failed to designate a licensed nurse to serve as a charge nurse on each tour of duty. This had the potential to affect all residents in the facility. Facility census: 84. Findings include: a) Review of the nursing staffing schedule for 02/01/11 revealed no licensed nurse had been designated to serve as charge nurse for each shift. On 02/01/11 at 9:35 a.m., interview with a registered nurse (Employee #8) revealed that each nurse was in charge of there own hallway, but we do not have one specific nurse designated as a charge nurse on the schedule each shift. | 2015-11-01 |
| 9490 | 9490 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 364 | F | 0 | 1 | SJCY11 | Based on observation, medical record review, menu review, and staff interview, the facility failed to provide food prepared by methods that conserved nutritive value, flavor, and appearance. One (1) resident (#37) was provided a thinned diet which contained very little nutritive value; residents on pureed diets were provided foods which were too thin and ran onto each other when plated; and spaghetti was not portioned in a manner which assured portions as directed by the menu. Resident #37 was affected, as were all other residents who received nourishment from the dietary department. Resident identifier: #37. Facility census: 84. Findings include: a) Resident #37 Observation of the preparation of this resident's meal, at noon on 01/27/11, revealed dietary staff was adding water to portions of pureed foods and was attempting to push the foods through a small strainer. A small amount of thin liquid came through the strainer. Staff then added more water and pushed it through. This continued until a portion of watery food substance was acquired for each food item. At 12:00 p.m. on 01/27/11, this was discussed with the dietary manager (DM - Employee #61), who stated the resident's family wanted the resident to be able to drink his meal through a straw. When the nutritional content of the meal as prepared was discussed, the DM confirmed the manner dietary staff were preparing this resident's meals was not a method which assured the provision of adequate nutrition. When asked if this had been assessed by the consultant registered dietitian (RD), the DM was unsure. Review of the resident's dietary assessments revealed no evidence the RD had assessed how this resident's meals should be provided and/or if the manner they were provided was meeting the resident's nutritional needs. -- b) Residents who required pureed foods Observation of the portioning of these residents' meals, at noon on 01/27/11, revealed the spaghetti and other foods placed on the plates ran together, creating an unattractive presentation for these resid… | 2015-11-01 |
| 9491 | 9491 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 371 | F | 0 | 1 | SJCY11 | Based on observations and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices had the potential to affect all facility residents who received nourishment from the dietary department. Facility census: 84 Findings include: a) Employee #63 (dietary personnel) accompanied the tour of the kitchen at approximately 2:30 p.m. on 01/24/11. The facility had an insulated cooler in the walk-in refrigerator, in which were stored individual pats of butter. On 01/25/11 at approximately 11:00 a.m., the surveyor checked the temperature of the individual pats of butter while they were stored in the cooler located inside the refrigerator; the temperature registered at 45 degrees Fahrenheit (F). The surveyor explained to the dietary manager (DM - Employee #61) that the insulation in the cooler prevented the cool air from the refrigerator from reaching the products stored inside. An acceptable cool temperature for these pats of butter would register at 41 degrees F or cooler. The DM acknowledged the 45 degree F temperature was too warm. b) At 11:00 a.m. on 01/25/11, a walk through of the kitchen was completed with the dietary manager (DM). The following sanitation infractions were identified: 1. A dietary staff member was washing pots and pans in the 3-compartment sink. She was asked to test the chlorine solution in the sanitizing sink. A test strip was inserted, but there was no color chart accessible to use to check the chlorine test strips for adequate concentration of chlorine. 2. Cups, bowls, plate bottoms and lids were observed stacked and/or inverted on trays prior to air drying. This created a medium for bacterial growth. 3. Peeling plastic, with exposed metal, was observed on the dish washer racks for the pellet system. 4. The handwashing sink in the dish room was very soiled. Additionally, a broom and dus… | 2015-11-01 |
| 9492 | 9492 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 411 | D | 0 | 1 | SJCY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to provide routine dental services to meet the needs of each resident, as evidenced by failing to arrange for routine dental services after two (2) residents' assessments revealed poor dental status. Two (2) of thirty-two (32) residents on the Stage II sample were affected. Resident identifiers: #79 and #7. Facility census: 84. Findings include: a) Resident #79 On 02/01/11 at 3:05 p.m., review of the resident's admission nursing assessment, dated 11/23/10, revealed the resident wore a partial, had obvious or likely cavity or broken natural teeth, and her remaining teeth were in poor shape. Review of the resident's initial social review revealed the resident had natural teeth, but they were in poor condition. No further information given. On 02/01/11 at 3:50 p.m., an interview with a licensed practical nurse (LPN - Employee #11) revealed she was not aware whether the resident had had a dental appointment since admission, and the resident had not mentioned any gum soreness to Employee #11 Review of the resident's care plan found no plan to address dental problems. On 02/01/11 at 4:10 p.m., a follow-up interview with the director of nursing (DON - Employee #1) revealed Resident #79 had not had a dental appointment since admission nor any further intervention. -- b) Resident #7 During a Stage I interview on 01/26/11 at 8:55 a.m., observation revealed Resident #7's natural teeth were in very poor condition, and many were missing. When the resident was asked the interview questions about dental condition, she stated her teeth were half gone. review of the resident's medical record revealed [REDACTED]. This assessment was not accurate, as it was the resident's natural teeth which were in poor condition. There was no further assessment, evaluation, or plan to address the resident's dental needs. This was brought to the attention of the DON at 10:00 a.m. on 02… | 2015-11-01 |
| 9493 | 9493 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 428 | D | 0 | 1 | SJCY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the pharmacist identified and reported an irregularity in the medical regimen of one (1) of thirty-two (32) Stage II residents. Resident #79 was known to have an allergy to steroid medications. Facility staff continued to administer a steroid medication to this resident after the allergy was made known to staff, and the pharmacist failed to identify and report this irregularity to the attending physician and the director of nursing (DON). Resident identifier: #79. Facility census: 84. Findings include: a) Resident #79 Review of Resident #79's physician's orders [REDACTED]. Review of Resident #79's admission nursing assessment, dated 11/23/10, revealed she was allergic to steroids. Review of Resident #79's admission orders [REDACTED]vision problems. On 02/01/11 at 2:05 p.m., an interview with the DON (Employee #1) revealed the staff should have clarified the order for the Prednisone with the resident's attending physician due to the steroid allergy. Further record review revealed the pharmacist reviewed the resident's medication regimen on 01/22/11 and made no recommendations regarding the use of steroids. | 2015-11-01 |
| 9494 | 9494 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 431 | E | 0 | 1 | SJCY11 | Based on observation, staff interview, and review of facility policy and procedure, the facility failed to appropriately manage and store drugs and biologicals used in the facility, as evidenced by not ensuring drugs and biologicals were labeled in accordance with currently accepted professional principles (including labeling with expiration dates when applicable) and by storing outdated medications on medication carts. This has the potential to affect more than a isolated number of residents. Facility census: 84. Findings include: a) On 01/26/11 at 10:00 a.m., an observation of the 1st floor medication storage room revealed, on the short hall medication cart, Milk of Magnesia with an expiration date of 12/09 and Calcium Carbonate with an expiration date of 05/10. Observation of the long hall medication cart revealed Pepto Bismol with an expiration date of 10/10. Also observed in the medication refrigerator were thirteen (13) vials of insulin without labeling to indicate on what date the vials were opened and Phenergan Suppositories with an expiration date of 04/09. b) On 01/26/11 at 10:45 a.m., an observation of the 2nd floor medication storage room revealed, on the short hall medication cart, Vegetable Laxative with an expiration date of 06/08. Also observed in the medication refrigerator were twelve (12) vials of insulin that were not dated after opening. c) On 01/26/11 at 12:00 p.m., an interview with the director of nursing (DON - Employee #1) revealed these medications should have not been left on the cart after their expiration dates had passed, and all insulin vials should be dated immediately after opening. d) Review of the facility policy and procedure regarding Vials and Ampules of Injectable Medications revealed: The date opened and the initials of the first person to use the vial are recorded on the multidose vial (on the vial label or an accessory label affixed for that purpose). | 2015-11-01 |
| 9495 | 9495 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2011-02-02 | 441 | F | 0 | 1 | SJCY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, review of recommendations made by the Centers for Disease Control and Prevention (CDC), and review of the facility's transmission-based precautions policy, the facility failed to establish and maintain an infection control program in accordance with current accepted standards and practices. Three (3) of thirty-two (32) Stage II sample residents (#111, #98, and #55) were currently placed in contact isolation due to Methicillin-resistant Staphylococcus aureus(MRSA) and/or [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) infections. There was no signage at the entrance to these residents' rooms to alert visitors of the need to take special precautions when interacting with them, and these residents were isolated in excess of what is required (according to CDC guidelines) to maintain contact isolation in a nursing home, by being prevented from attending out-of-room activities and being served meals using disposable paper dishware and plastic cutlery. In addition, the facility's dietary department allowed a staff member to work in the kitchen while displaying an open wound resulting from spider bite to the forearm. The staff member prepared food for resident consumption as well as handled various equipment used for food preparation in the kitchen area. This practice had the potential to affect all residents who consumed an oral diet in the facility. Facility census: 84. Findings include: a) Residents #111, #55, and #98 1. On 01/24/11 at approximately 2:30 p.m., observation found three (3) resident rooms with carts sitting outside their doors; each cart contained gowns, gloves and other personal protective equipment. These rooms were occupied by Residents #111, #98, and #55. However, there was no signage posted at the entrances of any of the three (3) rooms to alert visitors of the need to don any of the protective coverings prior to entering the rooms. These residents were later identif… | 2015-11-01 |
| 9652 | 9652 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2011-02-02 | 156 | C | 0 | 1 | 860Y11 | Based on observation and staff interview, the facility failed to ensure the names, addresses and phone numbers of advocacy groups remained posted and accessible at all times to residents and members of the general public. This practice had the potential to affect all residents. Facility census: 59. Findings include: a) Surveyors were unable to find the posted information related to advocacy groups as is required by regulation. Observations, made on 02/01/11, found a bulletin board where other information was located; however, there was no information regarding the names, addresses and phone numbers for all advocacy groups. The surveyor, on 02/01/11 at 10:36 a.m., then questioned the director of nursing (DON - Employee #15) and the administrator (Employee #25) as to where this information might be. After searching for the missing data, the administrator informed the surveyor that it had been found in a notebook that a confused resident (#61) had been given to put paperwork in. This resident had been known to remove posted items from bulletin boards, and staff would be unable to locate them. The facility provided her with a notebook, which would give staff some idea where to begin looking when things were missing. According to the administrator, this happened frequently, and staff would look once a week to see things were posted as necessary. If not, they would search the notebook. | 2015-10-01 |
| 9653 | 9653 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2011-02-02 | 279 | D | 0 | 1 | 860Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan for the use of an antipsychotic medication for one (1) of twenty-eight (28) Stage II sample residents. Resident #56 was prescribed [MEDICATION NAME] on 10/11/10 for a [DIAGNOSES REDACTED].#56. The facility must develop a comprehensive care plan for each resident that includes measurable objectives to meet a residents medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. Resident identifier: #56. Facility census: 59. Findings include: a) Resident #56 Record review revealed Resident #56 was sent to a psychiatrist on 10/11/10 for evaluation. The psychiatrist diagnosed the resident with depression, rule out dementia, and anxiety. [MEDICATION NAME] is an antipsychotic used to treat [MEDICAL CONDITION], schizo-affective disorder, and mood disorders (e.g. mania, [MEDICAL CONDITION] disorder, and depression with psychotic features). Resident #56 was prescribed 0.5 mg of [MEDICATION NAME] to be given at bedtime on 10/11/10. Resident #56 returned to the psychiatrist on 12/06/10, and the [MEDICATION NAME] was increased to 1 mg at bedtime. Review of the medical record revealed no comprehensive care plan to identify the use of the [MEDICATION NAME]. This information was brought to the attention of the director of nursing (DON - Employee #15) at 1:30 p.m. on 01/31/11. | 2015-10-01 |
| 9654 | 9654 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2011-02-02 | 281 | D | 0 | 1 | 860Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of Criteria for Determining Scope of Practice for Licensed Nurses and Guidelines for Determining Acts That May Be Delegated or Assigned by Licensed Nurses (Delegation Guidelines), the facility failed to provide services in accordance with accepted standards of clinical practice. Review of Resident #26's medication administration records (MARs) revealed the orders that offered the option to the licensed practical nurse (LPN) of administering by mouth or via enteral tube, with no parameters to guide the LPN's decision-making process. This practice allows an LPN to act outside his or her scope of practice as established by the WV Boards of Nursing. Resident identifier: #26. Facility census: 59. Findings include: a) Review of Resident #26's MARs found orders that offered the option to the LPNs of administering medications by mouth or through the resident's enteral feeding tube, with no parameters to guide a LPN's decision-making process. Review of the Delegation Guidelines, revised by the West Virginia Board of Examiners for Registered Professional Nurses and the West Virginia State Board of Examiners for Licensed Practical Nurses on 06/17/09, found the following information on Page 13: ACTIVITIES THAT MAY BE DELEGATED TO THE LPN Activities appropriate for delegation to the LPN should be those that, after careful evaluation by the supervising RN, are expected to contain only one option. That is, the LPN is expected to be able to proceed through the established steps or an activity without encountering an unexpected response or reaction and competence in performance of the activity has been demonstrated. ACTIVITIES THAT SHOULD NOT BE DELEGATED TO THE LPN Activities that are NOT appropriate for delegation to an LPN are those that are likely to present decision making options, requiring in depth assessment and professional judgment in determining the next step to take as the provider proceeds throu… | 2015-10-01 |
| 9655 | 9655 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2011-02-02 | 329 | D | 0 | 1 | 860Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medication regimen of one (1) of twenty-eight (28) Stage II sample residents was free from unnecessary drugs. Resident #56 was ordered [MEDICATION NAME] (an antipsychotic medication) on 10/11/10 for the [DIAGNOSES REDACTED].#56 had an appropriate [DIAGNOSES REDACTED]. Resident identifier: #56. Facility census: 59. Findings include: a) Resident #56 Record review revealed Resident #56 was sent to a psychiatrist on 10/11/10 for evaluation. The psychiatrist diagnosed the resident with depression, rule out dementia, and anxiety. [MEDICATION NAME] is an antipsychotic used to treat [MEDICAL CONDITION], schizo-affective disorder, and mood disorders (e.g. mania, [MEDICAL CONDITION] disorder, and depression with psychotic features). Resident #56 was prescribed 0.5 mg of [MEDICATION NAME] to be given at bedtime on 10/11/10. Resident #56 returned to the psychiatrist on 12/06/10, and the [MEDICATION NAME] was increased to 1 mg at bedtime. Further review of the medical record found the consulting pharmacist had reported to the physician and the facility, on 10/18/10, that Resident #56 did not have an appropriate [DIAGNOSES REDACTED]. In addition, the clinical condition being treated did not meet the criteria for the use of [MEDICATION NAME]. The physician responded to the pharmacist's recommendation by stating, Still (symbol for 'with') repetitive health related complaints. GDR (gradual dose recommendation) not appropriate. This information was brought to the attention of the director of nursing (DON - Employee #15) at 1:30 p.m. on 01/31/11. | 2015-10-01 |
| 9656 | 9656 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2011-02-02 | 425 | D | 0 | 1 | 860Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide medications as prescribed for one (1) of twenty-eight (28) Stage II sample residents. Resident #80 was admitted to the facility on [DATE], for rehabilitation after surgery requiring cemented left triathlon total knee arthroplasty. A dose of routine pain medication was not given as prescribed at 9:00 a.m. on 10/30/10. According to staff interview, the medication was not available for administration at that time. Resident identifier: #80. Facility census: 59. Findings include: a) Resident #80 Record review revealed Resident #80 was admitted to the facility on [DATE], for rehabilitation services related to a total knee replacement. The resident was ordered Morphine Sulfate ER 30 mg twice a day for pain related to the knee surgery. Review of the Medication Administration Record [REDACTED]. During a telephone interview with a nurse (Employee #16) confirmed the medication was not available to give to the resident that morning. She further stated she called the physician at approximately 10:30 a.m. on 10/30/10 to report the medication was not in the facility. The physician discontinued the morphine at this time. During an interview with the director of nursing (DON - Employee #15 on 02/01/11 at 12:35 p.m., she verified the medication was not available for administration to Resident #80 at that time. | 2015-10-01 |
| 9657 | 9657 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2011-02-02 | 428 | D | 0 | 1 | 860Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed, for one (1) of twenty-eight (28) Stage II sample residents, to ensure the physician acted upon reports of irregularities in a resident's medication regimen. Resident #56 was ordered Risperdal (an antipsychotic medication) on 10/11/10 for the [DIAGNOSES REDACTED].#56 had an appropriate [DIAGNOSES REDACTED]. The consulting pharmacist identified and reported to the facility and the physician that Resident #56 did not have an appropriate [DIAGNOSES REDACTED]. Resident identifier: #56. Facility census: 59. Findings include: a) Resident #56 Record review revealed Resident #56 was sent to a psychiatrist on 10/11/10 for evaluation. The psychiatrist diagnosed the resident with depression, rule out dementia, and anxiety. Risperdal is an antipsychotic used to treat schizophrenia, schizo-affective disorder, and mood disorders (e.g. mania, bipolar disorder, and depression with psychotic features). Resident #56 was prescribed 0.5 mg of Risperdal to be given at bedtime on 10/11/10. Resident #56 returned to the psychiatrist on 12/06/10, and the Risperdal was increased to 1 mg at bedtime. Further review of the medical record found the consulting pharmacist had reported to the physician and the facility, on 10/18/10, that Resident #56 did not have an appropriate [DIAGNOSES REDACTED]. In addition, he reported the clinical condition being treated did not meet the criteria for the use of Risperdal. The physician responded to the pharmacist's recommendation on 11/05/10, by stating, Still (symbol for 'with') repetitive health related complaints. GDR (gradual dose recommendation) not appropriate. However, the physician did not provide documentation of the clinical rationale for using this antipsychotic medication to treat this behavior (repetitive health complaints). This information was brought to the attention of the director of nursing (DON - Employee #15) at 1:30 p.m. on 01/31/11. | 2015-10-01 |
| 9658 | 9658 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2011-02-02 | 441 | D | 0 | 1 | 860Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's listing of residents with histories of Methicillin-resistant Staphylococcus aureus (MRSA), observation, and staff interview, the facility failed to assure Resident #49 was appropriately cohorted with roommates to prevent the potential spread of infection. The facility placed Resident #74 in a four-bed ward with Resident #49, when Resident #74 was receiving treatment for [REDACTED].#74 at risk of contracting a MRSA infection to her open wounds. This deficient practice affected one (1) of twenty-eight (28) residents in the Stage II sample. Resident identifiers: #74. Facility census: 59. Findings include: a) Resident #74 Review of the facility's listing of residents with a history of MRSA infection, on 01/27/11, found Resident #49 had a history of [REDACTED]. Review of Resident #74's medical record found she was receiving treatment for [REDACTED]. Observation of the facility found Resident #74 had been placed in the same room as Resident #49. When this issue was brought to the facility's attention, Resident #49 was moved to a private room. An interview with the director of nursing (DON - Employee #15), on the afternoon of 02/02/11, revealed Resident #49 was moved to a private room for infection control purposes on 01/31/11. | 2015-10-01 |
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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 );