cms_WV
Data source: Big Local News · About: big-local-datasette
37 rows where "inspection_date" is on date 2012-04-26
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8527 | 8527 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 156 | E | 0 | 1 | JZJM11 | Based on observation and interview, the facility failed to post the names, addresses and telephone numbers of all pertinent client advocacy groups in a manner in which Residents can view them. The facility also failed to post contact numbers for the State Survey and Certification agency with a statement that a Resident may file a complaint in a manner that Residents can read them. This had the potential to affect any resident dependent on a wheel chair for ambulation. Findings include: a) Observations of the facility on 04/26/12, revealed a bulletin board located across from the social service office on the south side of the building. There was small poster board located on the top left hand side of the bulletin board. The poster board contained information concerning the State Survey and Certification agency and Medicaid and Medicare. The contact information for the agencies was small and difficult to read from a seated wheelchair position. Observations of the facility on 04/26/12, revealed a bulletin board located across from the south nurses' station. At the top right hand corner of the bulletin board was a small poster board which contained information about the Ombudsman including a contact number. The information was not easily accessible for residents. A nurse's treatment cart was located in front of the bulletin board preventing residents, staff and visitors from easily viewing the information. Observations of the facility on 04/26/12, revealed a bulletin board located across from the north nurses' station. There were no posted names, addresses and telephone numbers for pertinent client advocacy groups or contact numbers for the State Survey and Certification agency. During an interview with the facility Administrator, on 04/26/12 at 12:35 p.m., it was verified the required information of all State client advocacy groups was not easily accessible to all residents, staff, and visitors. | 2016-05-01 |
| 8528 | 8528 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 159 | E | 0 | 1 | JZJM11 | Based on resident interview and staff interviews, the facility failed to make resident funds available on an on-going basis. This had the potential to affect more than an isolated number of residents. Resident identifiers: #98, #90, #97, #112. Findings include: a) During interviews with residents, on 4/23/12, residents were asked whether the monies in their personal funds accounts were available to them when they wanted, including weekends. Four (4) residents had negative responses to the question: During an interview with Resident #98, on 04/23/12 at 01:48 p.m., he stated, Have to follow their hours. During an interview with Resident #90, on 04/23/12 at 12:01 p.m., he stated, Only when someone is in the office they have certain hours to give out money. Two (2) other residents, #97 and #112, were interviewed at 12:07 p.m. They just stated, No, without elaboration. During an interview with the Nursing Home Administrator (NHA), on 04/25/12 at 2:00 p.m., he stated the residents had access to their funds, 7 days a week, 7 a.m. - 7:30 p.m. Monday thru Friday and 8 a.m. - 4:30 p.m. on weekends. He continued that all the residents were aware of the times. He elaborated further that the facility once had a petty cash fund because they did not have a receptionist. Now we have a receptionist that works until 7:30 M-F and 8 - 4:30 Sat and Sun. It is a better safe-guard for the money and the nurses can attend to their nursing responsibilities without having to safeguard the cash box too. The NHA was asked how the younger residents living in the building could get a pizza on Saturday if they wanted one. He responded, If there was some pre-planning, they could get a pizza at 9 p.m. on Sat night. They also have a lock-box in their room where they can keep money if they want to. The NHA stated that when he saw how this evolved, I thought I evolved with it. I thought I was accommodating the weekend and evening hours. The NHA concluded, After hours I felt better that nursing didn't have a cash box in medication room. When I made t… | 2016-05-01 |
| 8529 | 8529 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 164 | E | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to provide privacy curtains that ensured full visual privacy for residents in 23 rooms. Room #s 6, 7, 9, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 48, 49, 53, 54, 56, 57, 59, 61, 62, and 64. Findings include: a) During tour of the South Unit of the facility, the following rooms were observed to have a privacy curtain hanging for bed A of each room that did not provide full visual privacy for the residents residing in rooms 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 48, 49, 53, 54, 56, 57, 59, 61, 62, 64. These observations were verified by the maintenance director at 12:30 p.m. on 04/26/12. b) Observation of room [ROOM NUMBER] bed A, on 04/23/12 at 2:50 p.m., and on 04/26/12 at 1:24 p.m., revealed the privacy curtain was not long enough to go entirely around the resident's bed to provide full visual privacy. c) Observation of room [ROOM NUMBER] bed A, on 04/23/2102 at 10:53 a.m., and on 4/26/12 at 1:24 p.m., and also room # 9 bed A, observed on 04/23/12 at 3:53 p.m. and 4/26/12 at 1:25 p.m., revealed these privacy curtains were also not long enough to go entirely around the resident's bed to provide full visual privacy. This was verified by maintenance director on 04/26/12 at 11:30 a.m | 2016-05-01 |
| 8530 | 8530 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 166 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interviews, and staff interviews, the facility failed to replace reported missing property after the resident was told the property would be replaced. This affected 1 of 3 sample residents reviewed out of the 6 residents who had reported missing property. (Sample resident #97) Findings include: a) Resident #97 Review of a Resident Missing Item Request form, dated 12/12/11, for Resident #97 noted Resident #97 had reported a box of 64 [MEDICATION NAME] and a box of 50 [MEDICATION NAME] pencils were missing. It was noted the Social Worker (SW) had completed the report portion of the form. Under Follow Up Required, the Housekeeping Supervisor (HS) wrote, Replace the [MEDICATION NAME] and pencil. The HS dated this part of the form 12/14/11. On 04/23/12 at 03:13 p.m., an interview was conducted with Resident #97. Resident #97 stated, Someone stole my new [MEDICATION NAME] and colored pencils about a month ago. She added she had reported the missing property to the staff. An interview was conducted with the SW at 2:44 p.m. on 04/23/12. The SW stated, if something is reported missing, they would come tell me or send an e-mail or leave me a note. I would fill out a missing item form. I would give it to laundry if it was for them. They would look, then give the form back indicating whether the item had been found. Around Christmas (the resident) was missing some [MEDICATION NAME]. We looked for them but couldn't find them. The HS wrote that we would replace them. Activities (staff) probably did that. An interview was conducted on 04/23/12 at 3:13 p.m. with the the HS. The HS said that reports of missing items were turned in to her; then, she and her staff would look for the item. We usually find everything within 2 weeks. If we can't find it, we will replace it. (Resident #97) has lost other stuff, but we found it. After reviewing the Missing Item form, HS said, I wrote on there we would replace the pencils, but I haven… | 2016-05-01 |
| 8531 | 8531 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 241 | E | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to maintain the dignity of residents who were dependent on staff for assistance in performing activities of daily living. This involved 1 (Resident #172) of 3 residents observed related to activities of daily living out of 41 residents sampled. The facility also failed to maintain the dignity of residents during meal services for 4 residents not served timely. (Residents #61, #131, #135 and #173.) Findings include: a) Review of the medical record for Resident #172 revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the most recent comprehensive assessment, dated 03/27/12, revealed Resident #172 was assessed to be totally dependent on staff for bed mobility, transfers, personal hygiene and bathing. The comprehensive assessment also revealed Resident #172 was assessed to sometimes understand others and as able to respond adequately to simple direct communication. Further review of the medical record revealed a care plan, dated 04/06/12, related to Resident #172's activities of daily living (ADL). The care plan identified the Resident required total care and assistance with grooming. A care plan developed by the facility for Resident #172 related to mouth care revealed interventions that direct nursing staff to brush the Resident's teeth and gums daily and to monitor Resident #172 for discomfort. On 04/25/12 at 10:22 a.m., Nurse Aide (NA) #3, was observed providing personal care to Resident #172. At 10:29 a.m., NA #3 was observed to adjust the resident's pillow with both hands. With her face close to that of Resident #172 the NA stated, We need to do mouth care 'cause your mouth smells like a potty. At 10:40 a.m., when NA #3 left the resident's room, mouth care had not been provided. During an interview, on 04/26/12, the Director of Nursing verified NA #3 had addressed Resident #172 in a manner that did not maintain the resident's dignity an… | 2016-05-01 |
| 8532 | 8532 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 242 | D | 0 | 1 | JZJM11 | Based on resident interviews, staff interviews and record review, the facility failed to allow 1 of 3 sampled residents reviewed, out of 5 residents who reported not having choices, to determine her shower schedule. Resident identifier: #97 Findings include: a) Resident #97 Review of Resident #97's care plan, dated 03/20/12, noted a concern as Distressed mood-persistent anger and anxiety regarding care such as meds, meals, toileting, cleanliness, and bathing. Interventions included: allow to verbalize anger, attempt to resolve, encourage activities of choice, explore perception. During an interview on 04/23/12 at 02:56 p.m., Resident #97 stated that Unit Manager #1 (UM #1) changed her shower day from Friday to Saturday without involving the resident. Resident #97 stated that she did not like that change and the change had been made without asking her. A follow up interview was completed with Resident #97 at 9:15 a.m. on 04/24/12. Resident #97 said, UM #1 told me she changed me from Friday to Saturday recently. I don't know why. No one asked me first. On 04/24/12 at 4:16 p.m., an interview was conducted with UM #1. UM #1 said that when Resident #97 started going to a recurring out-of-facility appointment, the shower was moved from Tuesday morning to Tuesday evening. (Resident #97) was OK with that move. (The resident) may have been a Friday before but we changed the schedule at his/her request. UM #1 said that there wouldn't be any documentation of a request by Resident #97, or notification of Resident #97 for a change in the shower schedule. UM #1 reported that when the facility added Sunday to the schedule for resident showers, many of the residents' schedules had been moved. An interview was conducted with Nursing Assistant #1 (NA#1) at 9:35 a.m. on 04/25/12. NA # 1 stated that Resident #97's shower schedule had changed. (Resident #97) gets a shower on evenings (evening shift) one day a week and the day time on Saturday. The schedule was changed from Tuesday and Friday on the day shift to Tuesday evenings, and … | 2016-05-01 |
| 8533 | 8533 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 248 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide an activity programing for residents based on their comprehensive assessment. This involved 2 of 3 sampled residents. (Residents #22 and #172) Findings include: a) Resident #22 Review of Resident #22's Recreation Assessment, dated 10/11/11, revealed that Resident #22 cannot read due to [MEDICAL CONDITION]. The assessment also noted that Resident #22 liked blue grass and country music and reported that being around pets was very important, especially cats. The assessment also noted that her favorite activities were very important to Resident #22. The Activities Director (AD) noted on the assessment that Resident #22 states she is unable to do anything due to being bedfast. The assessment also indicated the resident was, Encouraged and invited to attend activities of her choice. Resident #22's care plan, dated 04/11/12, was reviewed. The focus was for Resident #22 to attend activities of her choice. Interventions included assist resident in attending and leaving activities, and introduce her to others. The intervention was dated 01/04/12. A form, supplied by the AD, contained daily activity participation from 01/15/12 through 05/05/12. The AD showed the form to the surveyor on 04/25/12. Every day, 7 days a week, the form showed that Resident #22 engaged in conversation and television. The form was filled out through 05/02/12. An interview was completed with Resident #22 at 8:51 a.m. on 04/23/12. Resident #22 reported the activities in the facility did not meet her interests. She stated she liked music, but did not have a way to listen to it. She stated she would like to have a radio or music compact discs (CDs). On 04/24/12 at 9:56 a.m., an interview was conducted with Nursing Assistant #2 (NA #2). NA #2 stated she was familiar with Resident #22 and that Resident #22 did not participate in activities. (Resident #22) used to participate. Now she never gets out of … | 2016-05-01 |
| 8534 | 8534 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 250 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure an ordered follow-up appointment was made and received for 1 of 1 sampled residents. (Resident #22) Findings include: Resident #22 was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of a Report of Consultation form for Resident #22 noted that she was evaluated by the psychologist on 10/12/11. The consultation recorded that Resident #22 was to have a follow up appointment in 2 weeks. There were no other consultation notes by the psychologist located for Resident #22. On 04/26/2012 at 9:00 a.m., an interview was completed with Unit Manager #1 (UM #1). UM #1 stated that Resident #22 was seen by the psychologist in October (2011) and that Social Worker (SW) would have scheduled the two week follow up appointment. After reviewing the record, UM #1 noted that Resident #22 had not been seen for the two week follow up. An interview was completed with the SW at 9:10 a.m. on 04/26/12. The SW stated, I write up the consults (consultations). All of the new and follow ups. Back then (October 2011) he (psychologist) was doing his own follow up scheduling and he missed some, so I took that over. When we found that he was missing them, we started doing them for him from that point. The SW said that no one went back to search for ones that the psychologist missed. When the SW took over the scheduling, it was only from that point forward. I started doing that after the first of the year. | 2016-05-01 |
| 8535 | 8535 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 253 | E | 0 | 1 | JZJM11 | Based on observation and staff interview, it was determined the facility failed to provide maintenance services necessary to maintain an orderly and comfortable interior environment for the residents residing on the North and South Units of the facility. Findings include: a) Observation during the environmental tour, on 4/26/12 at 10:40 a.m., revealed the toilet paper holder in room #3 on the North hall had become dislodged from the wall. No toilet paper could be placed on this holder for 4 residents who used this bathroom. On this date, at 10:47 a.m., the caulking around the sink in Room #4 was noted be be cracked and peeling away from the sink and the vanity. The wall around the air conditioner in Room 12 B was noted to be in need of painting. The bathroom doors in Room 23 and 26 were noted to have large gouges in them and required painting. These findings were verified with the maintained director at 11:02 a.m. on 04/26/12. b) During tour of the South Unit of the facility there were several gouges and scratches noted in the dry wall, door jams and interior doors leading to resident bathrooms. The following rooms were affected: 39, 48, 49, 54, 59, 61, 62, and 64. These observations were verified by the Maintenance Director at 12:10 p.m. on 04/26/12. | 2016-05-01 |
| 8536 | 8536 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 279 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interviews, and resident interviews, the facility failed to develop a care plan to address dental needs for 1 of 1 sampled resident who had dental problems. (Resident #112) Findings include: Resident #112 stated in interview that he did not have any teeth and wanted dentures, but there was no evidence that a dental care plan had been created. Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #112 was coded with a BIMS (Brief Interview for Mental Status) score of 15, indicating he was cognitively independent with decision-making. His dental status was coded as not having dentures or natural teeth. The MDS also marked the resident as having no difficulty with chewing. He was coded as a being totally dependent on staff to carry out ADL functions, including personal hygiene. Observation of Resident #112 on 04/22/12, 04/23/12, 04/24/12, 04/25/12, and 04/26/12 revealed he did not have any teeth. During an interview, on 04/23/12 at 12:08 p.m., Resident #112 stated he did not have any teeth or dentures, but wanted dentures. The resident continued, They tell me I need $350 to pay for them. The resident added that he was trying to save up money from a personal needs account to pay for them. Resident #112 also stated there were many foods he could not eat because he could not chew them - especially meat which he was unable to chew. Resident #112 stated again on 04/25/12 at noon, as he was served corn with the noon meal, I love corn but I can't chew it because I don't have any teeth! Review of the care plans (CP), dated 01/19/12, did not reveal a CP related to dental needs or services. The resident was identified at that time as a short-stay resident (expected to stay in the facility for less than 90 days). Review of the social service care plan, dated 04/17/12, also did not identify any dental needs or… | 2016-05-01 |
| 8537 | 8537 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 280 | E | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and resident interviews, the facility failed to revise care plans for 4 of 23 sampled residents. (Residents #22, #51, #112, and #187) Findings include: a) Resident #22 This resident was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of Resident #22's Recreation Assessment, dated 10/11/11, revealed Resident #22 cannot read due to [MEDICAL CONDITION]. The assessment also noted that Resident #22 liked blue grass and country music and reported that being around pets was very important, especially cats. The assessment also noted that favorite activities were very important to Resident #22. The Activities Director (AD) noted on the assessment that Resident #22 stated she was unable to do anything due to being bedfast. The resident should be encouraged and invited to attend activities of her choice. Resident #22's care plan, dated 04/11/12, was reviewed. The focus was for Resident #22 to, attend activities of his/ her choice. Interventions included assist him/her in attending and leaving activities, and, introduce him/her to others. The intervention was dated 01/04/12. The only intervention dated after 01/04/12 was dated 04/24/12, noting that in room supplies would be provided to Resident #22. A form supplied by the AD contained daily activity participation from 01/15/12 through 05/05/12. The AD showed the form to the surveyor on 04/25/12. Every day, 7 days a week, the form showed that Resident #22 engaged in conversation and television. The form was filled out through 05/02/12. On 04/24/12 at 9:56 a.m., an interview was completed with Nursing Assistant #2 (NA #2). NA #2 stated that she was familiar with Resident #22 and that Resident #22 did not participate in activities. (Resident #22) used to. Now she doesn't get out of bed. I don't know why. We use the (mechanical) lift on her. She refuses to go to the shower, just gets a bed bath. I don't know if anyone has talked to her. NA … | 2016-05-01 |
| 8538 | 8538 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 282 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to provide care for 2 of 41 sampled residents as directed by the Residents' plan of care. (Residents #172 and #174) Findings include: 1. Review of the medical record for Resident #172 revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the most recent comprehensive assessment dated [DATE] revealed Resident #172 was assessed to be totally dependent on staff for bed mobility, transfers, personal hygiene and bathing. The comprehensive assessment also revealed Resident #172 was assessed to sometimes understand others and is able to respond adequately to simple direct communication. Further review of the medical record revealed a plan of care dated 04/06/12 related to Resident #172's activities of daily living (ADL). The plan of care identified that the Resident required total care and assistance with grooming. A plan of care developed by the facility for Resident #172 related to mouth care revealed interventions that direct nursing staff to brush the Resident's teeth and gums daily and to monitor Resident #172 for discomfort. Review of document titled Visual/Bedside Kardex Report, identified by Unit Manager #2 as being a guide for staff to provide care for Resident #172, revealed the Resident's teeth are to be brushed with a soft tooth brush daily. On 04/25/12 at 10:22 A.M., Certified Nurse Aide (CNA) # 3 was observed providing personal care to Resident #172. At 10:29 A.M., CNA #3 was observed to adjust the Resident's pillow with both hands and with her face close to that of Resident #172 stated, we need to do mouth care cause your mouth smells like a potty. At 10:40 A.M., when CNA #3 left the Resident's room and mouth care had not been provided. The drawers holding Resident #172's personal care items were observed to be absent any items used to provide mouth care such as a tooth brush and tooth paste. There were 2 small, store bought disposable … | 2016-05-01 |
| 8539 | 8539 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 309 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure one (1) resident received the necessary care and services to maintain good body alignment while in bed in accordance with his comprehensive assessment and care plan. (Resident #47) Findings include: a) Resident #47 This resident was admitted to the facility on [DATE] with senile dementia and left sided [MEDICAL CONDITION]. Review of his most recent Minimum (MDS) data set [DATE] found he required the extensive assistance of one staff member for bed mobility. The Activity of Daily Living Plan of Care, dated 11/23/12, identified the resident was dependent on staff for bed mobility and staff should ensure the resident maintained good body alignment while in bed. The physical therapy notes, documented on 11/15/11, noted the resident required maximal assistance from staff for bed mobility. When the resident was discharged from physical therapy on 12/30/11, he was documented to require minimal assistance from staff for bed mobility. Observation of Resident #47, on 04/24/12 at 7:55 a.m., revealed he was in bed with his legs hanging out the right side of the bed and his head was leaning up against the wall to the left. He was also noted to be scooted way down in the bed. At 8:22 a.m. he was in the same position and his breakfast tray was in front of him and was empty. He had eaten his meal while positioned as stated above. On 04/24/12 at 9:42 a.m., the resident remained in the same position. On 04/24/12 at 10:30 a.m., the resident was re-positioned by staff, but there was no attempt to place any support devices beside the resident to assist in maintaining good body alignment. On 4/25/12 at 12:31 p.m., Resident #47 was observed in bed with his lunch tray beside him. The head of his bed was elevated, but he was scooted down in the bed and leaning to the left. During interview with Nurse Aide #7, on 04/25/12, the nurse aide revealed she tries to straighten the residen… | 2016-05-01 |
| 8540 | 8540 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 311 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, the facility failed to provide activities of daily living, specifically personal hygiene, for 1 of 8 residents with observed concerns of the 40 residents who were observed on the sample. (Resident #112) Findings include a) Resident #112 This resident stated in an interview he had not had some care provided related to personal hygiene. Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #112 was coded with a BIMS score of 15, indicating he was independent in his cognitive ability for daily decision-making. He was coded as being totally dependent on staff to carry out ADL functions, including personal hygiene. During an interview, on 04/23/12 at 12:08, Resident #112 stated his fingernails were too long. They (staff) have clipped them once, but they need to be clipped again. The resident was asked if he was growing a beard? He responded, They have not shaved me for a couple of weeks -- I would like to be shaved! The resident was asked why they hadn't shaved him? He responded, They keep forgetting to take razors with them when they shower me. He stated further that he thought he could shave himself if he had an electric razor. Observations of Resident #112 on 04/22, 04/23, 04/24 and 04/25 revealed the resident had a short beard. Observation on 04/26/12 revealed he had been shaved. Observation of Resident #112's nails, on 04/22, 04/23 and 04/24/12, revealed they were long and jagged. During the dressing change observation on 04/24/12 at 9:30 a.m., the LPN informed the resident she would be back later to trim his fingernails. Observation of his nails at 5:00 p.m. revealed his nails had been trimmed. Review of the care plan, dated 01/17/12, revealed: Resident demonstrates capacity and motivation to improve function but exhibits or is at risk for decreasing ability to… | 2016-05-01 |
| 8541 | 8541 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 312 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, family interview, and staff interview, the facility failed to provide mouth care for a resident dependent on staff for activities of daily living. This involved 1 of 3 sampled residents investigated related to concerns in the Care Area of Activities of Daily Living. (Resident #172) Findings include: a) Resident #172 Review of the medical record for Resident #172 revealed an admission date of [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the most recent comprehensive assessment, dated 03/27/12, revealed Resident #172 was assessed to be totally dependent on staff for bed mobility, transfers, personal hygiene and bathing. The comprehensive assessment also revealed Resident #172 was assessed to sometimes understand others and as able to respond adequately to simple direct communication. Further review of the medical record revealed a care plan, dated 04/06/12, related to Resident #172's activities of daily living (ADLs). The care plan identified the resident required total care and assistance with grooming. A care plan developed by the facility for Resident #172 related to mouth care revealed interventions that direct nursing staff to brush the resident's teeth and gums daily and to monitor Resident #172 for discomfort. Review of document titled Visual/Bedside Kardex Report, identified by Unit Manager #2 as being a guide for staff to provide care for Resident #172, revealed the resident's teeth were to be brushed with a soft toothbrush daily. On 04/25/12 at 10:22 a.m., Nurse Aide (NA) #3 was observed providing personal care to Resident #172. At 10:29 a.m., NA #3 was observed to adjust the resident's pillow with both hands and with her face close to that of the resident. The NA stated, we need to do mouth care 'cause your mouth smells like a potty. At 10:40 a.m., NA #3 left the resident's room and mouth care had not been provided. The drawers holding Resident #172's personal care items were observed to … | 2016-05-01 |
| 8542 | 8542 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 323 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to implement interventions to protect two (2) residents with a history of falls. (Residents #51 and #28) 1. The facility failed in multiple areas, specifically: A. Therapy did not evaluate Resident #51's functional abilities after either the first fall or the second. B. Environmental services had arranged the resident's room for safety, however observations revealed both sides of the bed remained cluttered with equipment, even on the fall mats. C. The care plan had not been updated to include the fall on 03/17/12, thereby preventing the facility from providing interventions which might have prevented the second fall where the resident experienced head and facial injuries. D. Food products were kept on the nightstand, but not within reach of the resident, thereby creating a potential for additional falls should the resident reach for a food product that was out of reach. The findings were: a) Resident #51 This resident was re-admitted to the facility on [DATE]. Review of the 11/07/11 MDS revealed sample Resident #51 was [AGE] years old and had [DIAGNOSES REDACTED]. Resident #51's functional status was coded as requiring extensive assistance for ADLs and total assistance required for toileting, hygiene and bathing. She was coded as unsteady with transfers, had range of motion impairments, and was incontinent of bladder and bowel. Resident #51 was 66 inches tall and weighed 155 pounds. Further review of the MDS identified that the resident had experienced no falls since readmission to the facility on [DATE]. The most current MDS, dated [DATE], identified no falls since admission. During the staff interview, on 04/23/2012 at 10:32 a.m., staff identified that Resident #51 had experienced a fall on 04/16/12. The nurse being interviewed identified that the resident had fallen out of bed on the evening of 04/17/12 with resulting bruising to the face. The nursing note indi… | 2016-05-01 |
| 8543 | 8543 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 325 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and resident observations, it was determined the facility failed to maintain acceptable parameters of nutrition for 1 of 3 residents reviewed in Stage 2 for the care area of nutrition. Sample Resident #174 experienced a significant weight loss. Findings include: a) Resident #174 This resident was admitted to the facility 12/30/11. Resident #174 was noted to have a [DIAGNOSES REDACTED]. The resident received speech and occupational therapy from 01/04/12 through 03/22/12 related to dysphagia and inability to feed himself. The most recent dietary assessment, dated 04/05/12, revealed documentation of the diet order for a mechanically altered diet with nectar thick liquids. The resident also received enteral feedings of [MEDICATION NAME] 200 cc three times a day due to [MEDICAL CONDITION]. The dietary notes documented inconsistent oral intake and the resident's weight was down 6 pounds during this review. The most recent Minimum Data Set, dated dated [DATE], documented that Resident #174 required the extensive assist of one staff member for eating and the resident consumed 26-50% of his meals. The care plan, dated 01/10/12 documented the resident required extensive assist of one with eating, would consume 75% of meals, and staff were to monitor the resident's intake and weight changes. Review of Resident #174's weight history revealed the following: Date: 12/30/2011; Weight: 253 Date: 01/16/2012; Weight: 251 Date: 02/03/2012; Weight: 248 Date: 02/24/2012; Weight: 240 Date: 03/22/2012; Weight: 240 Date: 04/20/2012; Weight: 233 These weights reflect a 20 pound weight loss in 4 months. On 04/05/12, the dietitian made a note in the record of no concerns noted. Her notes state the resident has inconsistent oral intake and must be encouraged by staff to eat and feed himself. The notes speak to the resident's weight loss, but documented the resident's weight fluctuated and no further interventions were needed at … | 2016-05-01 |
| 8544 | 8544 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 329 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure 1 of 10 residents reviewed did not receive unnecessary medication. (Resident #22) Findings include: a) Resident #22 This resident was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of Resident #22's Medication Administration Record [REDACTED]. Review of Resident #22's medical record noted a [DIAGNOSES REDACTED]. A review of the monthly pharmacy consultant notes from 10/2011 through 04/2012 found no mention of Resident #22 being on [MEDICATION NAME]. An interview was completed with Resident #22's physician (Physician #1) on 04/25/12 at 2:20 p.m. (Physician #1) said, I noticed today that (Resident #22) was on [MEDICATION NAME]. The reason on the record mentions [MEDICAL CONDITION]. If she isn't compromised and she has genital [MEDICAL CONDITION], we would make that a daily dose. I am having (Unit Manager #1) check on that. The physician noted that if Resident #22 did not have a history of genital [MEDICAL CONDITION], then the use of [MEDICATION NAME] would be time limited. On 4/25/12 at 3:30 p.m., an interview was completed with the facility pharmacy consultant (PC). PC reported that she visits the facility every month and looks at every chart. I thought I asked about the [MEDICATION NAME], but I don't see where I wrote anything. I think I looked up the drug to verify the dose. If I was concerned about it, I would have sent it to the physician. If there is a [MEDICAL CONDITION] infection that is chronic the dose would continue if it was active. It would be up to the doctor to continue (the drug treatment) if it (infection) isn't active. When we go in and review a resident we make sure doses and indications are appropriate. We make sure they (residents) aren't allergic (to any of the medications), make sure lab (laboratory) work is done. We look at physician's orders [REDACTED]. I don't do a 100% MAR indicated [REDACTED]. Sometimes I do look at… | 2016-05-01 |
| 8545 | 8545 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 371 | D | 0 | 1 | JZJM11 | Based on observation, record reviews, and staff interview, it was determined the facility failed to monitor temperatures of the refrigerator on the North hall. Failing to monitor food storage temperatures where resident food is stored creates the potential for foodborne illness for the residents on this Unit. Findings include: a) Observation of the clean utility area, on 04/26/12 at 10:30 a.m., revealed a refrigerator with several small bowls of applesauce, white milk, chocolate milk, and 2 take-out food bags containing resident food items. The temperature log on the door of the refrigerator documented temperatures logged for only two days in April, 04/24/12 and 04/25/12. All other dates for the month of April were blank. An interview with the charge nurse indicated this refrigerator was used for resident food items brought in from outside the facility. There was a sign on the outside of the door that documented that temperatures were to be taken and logged by housekeeping staff, but the charge nurse indicated the monitoring was supposed to be completed by the dietary staff. During an interview with the dietary manager, on 04/26/12 at 11:00 a.m., she indicated her staff were responsible for taking and logging the temperatures in this refrigerator. She stated the staff were very nervous when the survey team entered the building and they had removed the log from the door of the refrigerator. She stated they had replaced the old one with a new one on 04/24/12, so that was why there were only 2 dates logged on the new form. The dietary manager then supplied a log that she stated had been taken down right after the survey team entered the building. This form contained all the dates and temperatures logged since April 1, 2012. The temperature log had been observed by the surveyor doing the initial tour of the facility on 04/22/12 at 4:20 p.m., and the log on the refrigerator door for April had been completely blank. The log on the door during this observation for March was also only sporadically completed with a date a… | 2016-05-01 |
| 8546 | 8546 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 373 | E | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure its paid feeding assistants did not feed residents with complicated feeding problems. This affected 1 resident (Resident #127) and the potential to affect 8 additional residents identified by the facility as having swallowing problems. Findings include: a) Resident #127 Review of the clinical record for Resident #127 revealed a [DIAGNOSES REDACTED]. The diet order was last revised on 12/05/11. Review of the Speech Therapy discharge summary, dated 09/30/11, revealed Resident #127 was seen for 9 days from 09/18/11- 09/30/11. The discharge notes confirmed the resident's [DIAGNOSES REDACTED].#127 had demonstrated the ability to safely tolerate pureed food with thin liquids as the least restrictive diet and that the resident would continue to require assistance with all meals. During an interview with the Unit Manager, on 04/23/12 at 5:03 p.m., the Unit Manager stated Resident #127 was changed to thickened liquids at the request of the family because the resident had been coughing when drinking thin liquids. There was no speech evaluation done at that time and the resident's trouble with coughing had stopped since the physician ordered thickened liquids. During observations, on 04/24/12, of the noon meal being served in the dining room (identified by the facility as the cafe), six (6) residents were being fed by different staff members. Paid Feeding Assistant #9 was observed to be feeding Resident #127. The Feeding Assistant was observed placing a cup of thickened fluids to the resident's mouth so that she might drink. There was a sippy cup observed next to the resident's plate. During an interview with Feeding Assistant #9, at the time of the observation, it was stated she did not know why Resident #127 had a sippy cup, but she did fine without it. The Feeding Assistant was observed feeding Resident #127 her noon meal which was pureed pizza and vegetables. Feeding A… | 2016-05-01 |
| 8547 | 8547 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 412 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interviews, the facility failed to provide dental care and a dental evaluation for a resident with no teeth who wanted dentures. (Resident #112) Findings include: a) Resident #112 This resident stated in interview that he did not have any teeth and wanted dentures. Resident # 112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed resident #112 was coded with a BIMS score of 15. His dental status was assessed as not having dentures or natural teeth. The MDS also marked the resident as having no difficulty with chewing. He was coded as a being totally dependent on staff to carry out ADL functions, including personal hygiene. During an interview, on 4/23/12 at 12:08 p.m., Resident #112 stated he did not have any teeth or dentures, but wanted dentures. He continued, They tell me I need $315 or $350 to pay for them. The resident stated that he was trying to save up money from his personal needs account to pay for them. Resident #112 also stated there were many foods he could not eat because he could not chew them, specifically, meat. Resident #112 stated again, on 04/25/12 at noon, as he was served corn with his noon meal, I love corn but I can't chew it because I don't have any teeth! Review of the care plan, dated 1/19/12 did not reveal a care plan related to dental needs or services. Resident was identified in January 2012 as a short-stay resident, i.e. expected to be in the facility for a short period of time, less than 90 days. Review of the Social Service Care Plan, dated 04/17/12, also did not reveal any dental needs or services. The Social Services Care Plan again identified the resident as short term stay less than 90 days, even though the resident had been admitted on [DATE] and had already exceeded the 90 day mark. Social Services (SS) was interviewed at 11:20 a.m. on 04/25/12. She stated residents g… | 2016-05-01 |
| 8548 | 8548 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 428 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure that medication potentially being used for an excessive period of time was reported to the physician by the consultant pharmacist for 1 of 10 sampled residents. (Resident #22) Finding include: a) Resident #22 This resident was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of Resident #22's Medication Administration Record [REDACTED]. Review of Resident #22's medical record noted a [DIAGNOSES REDACTED]. A review of the monthly pharmacy consultant notes from 10/2011 through 04/2012 found no mention of Resident #22 being on Valtrex. An interview was conducted with Resident #22's physician (Physician #1) on 04/25/12 at 2:20 p.m (Physician #1) said, I noticed today that (Resident #22) was on Valtrex. The reason on the record mentions dermatitis. If she isn't compromised and she has genital herpes, we would make that a daily dose. I am having (Unit Manager #1) check on that. The physician noted that if Resident #22 did not have a history of genital herpes, then the use of Valtrex would be time limited. On 4/25/12 at 3:30 p.m., an interview was completed with the facility pharmacy consultant (PC). The PC reported that she visits the facility every month and looks at every chart. I thought I asked about the Valtrex, but I don't see where I wrote anything. I think I looked up the drug to verify the dose. If I was concerned about it, I would have sent it to the physician. If there is a herpes infection that is chronic, the dose would continue if it was active. It would be up to the doctor to continue (the drug treatment) if it (infection) isn't active. When we go in and review a resident we make sure doses and indications are appropriate. We make sure they (residents) aren't allergic (to any of the medications), make sure lab (laboratory) work is done. We look at physician's orders [REDACTED]. I don't do a 100% MAR indicated [REDACTED]. Sometimes I d… | 2016-05-01 |
| 8549 | 8549 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2012-04-26 | 514 | D | 0 | 1 | JZJM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to maintain accurate Medication Administration Records for 3 of 10 sampled residents. (Residents #180, #22, and #187) Findings include: a) Resident #180 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of Resident #180's Medication Administration Record [REDACTED]. An observation of Resident #180's medication stock noted [MEDICATION NAME] 250 mcg (micrograms) in single dose packs. On 4/25/2012 at 3:30 p.m., an interview was completed with the Pharmacy Consultant (PC). The PC stated, When we go in and review a resident, we make sure doses and indications are appropriate. We look at physician's orders [REDACTED]. I don't do a 100% MAR indicated [REDACTED]. Sometimes I do look at MARs, but not routinely. I have caught errors on the MARs, but if the order was correct, I might not see it on the MARs. On 04/26/12 at 9:45 AM, an interview was completed with Nurse #2. Nurse #2 acknowledged that the MAR indicated [REDACTED]. She said that she would get a clarification order and change the MAR. 2. Resident #22 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of Resident #22's Medication Administration Record [REDACTED]. An interview was completed with Nurse #1 on 4/25/2012 at 2:50 PM. Nurse #1 said that the K-dur should be 20 mEq instead of 20 mg and the [MEDICATION NAME] is 2 sprays in each nostril. The packages are correct. I will write a clarification order. Resident #22's medication was observed in the mediation cart on 4/25/2012 at 3:00 PM. The Kdur is packaged at 20 mEq and the [MEDICATION NAME] box label reads 2 sprays in each nostril. On 4/25/2012 at 3:30 PM, an interview was completed with the Pharmacy Consultant (PC). When we go in and review a resident, we make sure doses and indications are appropriate. We look at physician's orders [REDACTED]. I don't do a 100% MAR indicated [REDACTED]. Sometimes I do look at MARs, … | 2016-05-01 |
| 8687 | 8687 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2012-04-26 | 253 | B | 0 | 1 | S35H11 | Based on observation and staff interview, it was determined maintenance and housekeeping services had not ensured doors to resident bathrooms were free from scratches and gouges, walls were not marred and scuffed, and doorframes did not have chipped paint. This affected nine (9) resident rooms in the facility. Room numbers: 99, 110, 111, 112, 113, 221, 224, 226 and 227. Census: 64. Findings include: a) Resident room #s 99, 110, 111, 112, 113, 221, 224, 226 and 227 Observations of the facility, during Stage I of the quality indicator survey process, revealed doors and walls that were scratched, marred, and/or scuffed. Door frames to bathrooms and to the hallways had paint chipped off of the door frames. This was discussed with the maintenance director, Employee #63, as part of the environmental component of the survey process. It was also made known to the administrator, Employee #55, on the afternoon of 04/25/12. | 2016-04-01 |
| 8688 | 8688 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2012-04-26 | 312 | D | 0 | 1 | S35H11 | Based on observation, staff interview, and medical record review, the facility failed to ensure one (1) of thirty (30) Stage 2 sampled residents, dependent on staff for grooming needs, received necessary care and services to ensure the residents' hands and fingernails were cleaned prior to dining. Resident identifier: #70. Facility census: 64. Findings include: a) Resident #70 During random observations of the noon meal service in the main dining room, on 04/24/12 at 12:30 p.m., Resident #70 sat and ate her lunch at a table with other residents. It was noted a brownish colored substance was packed beneath all the resident's fingernails. The director of nursing (DON), Employee #57 was notified of the condition of the resident's fingernails. Employee #57 assisted the resident to a restroom and cleaned Resident #70's hands and fingernails. The brownish colored substance was no longer present beneath the resident's fingernails following the hand hygiene assistance provided by the DON. Review of the medical record found the minimum data set (MDS), with an assessment reference date (ARD) of 02/29/12, identified the resident required the extensive assistance of one (1) staff member for grooming needs, including washing of hands. Review of the current care plan, with a target date of 05/31/12, found nursing staff were to, Ensure and assist with grooming needs, comb hair, wash face, hands, and oral hygiene as needed. | 2016-04-01 |
| 8689 | 8689 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2012-04-26 | 323 | G | 0 | 1 | S35H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, review of facility documents, medical record review, and mechanical lift manufacturer representative interview, the facility failed to ensure one (1) of thirty (30) Stage 2 sampled residents was transferred in a manner to prevent injury. Facility staff utilized a lift pad (sling) not designed for use with the facility's mechanical lift to transfer Resident #77 from a wheelchair to her bed. The resident fell out of the lift pad (sling) while suspended in the air and struck the floor. The resident sustained [REDACTED]. The facility failed to ensure lift pads (slings), not intended for use with their current mechanical lifts, were removed from the facility's inventory. The facility failed to ensure facility staff were adequately trained in the use and operation of mechanical lifts and lift slings. These deficient practices resulted in harm to Resident #77, and placed all residents who required transfers with a mechanical lift at risk of injury. Resident identifier: #77. Facility census: 64. Findings include: a) Resident #77 - Licensed practical nurse (LPN), Employee #15, was interviewed on 04/23/12 at 2:13 p.m. as part of the Stage 1 Quality Indicator Survey (QIS). When asked whether Resident #77 had any falls or fractures in the previous 30 days, Employee #15 stated the resident fell from a mechanical lift on 04/18/12 and sustained a fracture of her left humerus. - Review of facility documents found at 7:30 p.m. on 04/18/12, nursing assistants (NA), Employees #35 and #33 were transferring Resident #77 from the wheelchair to the bed using a mechanical lift. The report documented, Resident in Hoyer lift & (and) fell out. The report documented the resident complained of pain to her left shoulder, left hip, and right foot. - Review of the medical record found the minimum data set (MDS), with an assessment reference date (ARD) of 02/01/12, Section G, found the resident required the total assistance of two (2) or more staff … | 2016-04-01 |
| 8690 | 8690 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2012-04-26 | 441 | F | 0 | 1 | S35H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, record review, and staff interview, it was determined the facility's Infection Control Program had not ensured five (5) of ten (10) sampled employees were free of communicable disease prior to direct resident contact, which could potentially expose more than a limited number of residents, and had not ensured an employee washed her hands and donned gloves prior to the instillation of eye drops to one (1) of thirty (30) sampled residents. Employee identifiers: #13, #5, #41, #54, and #38. Resident identifier: #38. Facility census: 64. Findings include: a) Employees During the review of personnel files, at 11:30 a.m. on 04/25/12, it was determined by the absence of a completed physical form signed by the appropriate medical professional, that two (2) employees hired in 2012 (Nurses' Aides #38 and #54) had not had their pre-employment physicals prior to performing direct resident care. This was confirmed by the Employee Health Nurse (Employee #1) at 1:30 p.m. the same day, when she reviewed the blank forms in the personnel files. Further, there was no evidence in the files of three (3) long - term employees (Registered Nurse #13, Dietary aide #5, and Nurses' Aide #41) to indicate they had obtained their annual physical in the previous 12 months. This was confirmed by the Employee Health Nurse (Employee #1), at 1:30 p.m. the same day, when she reviewed the blank forms in the personnel files. During an interview with the Administrator, at 2:45 p.m. on 04/25/12, she acknowledged the facility does require these physicals. b) Resident #38 During random observations of the medication administration pass, on 04/25/12 at 8:04 a.m., licensed practical nurse (LPN), Employee #15 gave Resident #38 oral medications while the resident was seated in a wheelchair in the resident hallway. Employee #15 removed a hand wipe from a container on her medication cart and wiped her hands. She then picked up a bottle of [MEDICATION NAME… | 2016-04-01 |
| 9140 | 9140 | CAREHAVEN OF PLEASANTS | 515191 | PO BOX 625 | BELMONT | WV | 26134 | 2012-04-26 | 151 | D | 0 | 1 | JRXZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and record review, the facility failed to allow one (1) of thirty-three (33) residents the opportunity to exercise his resident rights, and gave the resident a thirty (30) day notice for refusing care and treatment. Resident identifier: #78. Facility census: 61. Findings include: a) Resident #78. Review of the medical record found several occasions when Resident #78 had refused care and treatment. No evidence could be found the facility investigated why the resident refused care and treatment. Resident #78 was admitted to the facility on [DATE]. The admission [DIAGNOSES REDACTED]. During an interview with the resident, on 04/23/12 at 3:00 p.m., it was learned the resident did not like the type of solution used to treat his wounds. The resident stated, It's a bleach solution and [MEDICAL CONDITION] nose. The treatment was ordered twice a day. The resident stated he was not going to let the facility use Dakins solution twice a day. According to Employee #97, the treatment nurse, in an interview on 04/25/12 at 9:14 a.m., Resident #78 had voiced his opinion of the Dakins solution to her. She stated, He is non-compliant with a twice a day treatment. She further added she contacted the wound care center, but they would not change the treatment. Employee #97 was asked whether she had contacted the attending physician to get the treatment changed. She stated, He will not go against the wound care center. She stated at one time they had used a patch which only had to be changed every three (3) days, and the resident was more compliant with this treatment. No evidence could be found the physician was aware of Resident #78 having difficulty with the current treatment. No evidence could be found the facility alerted the physician to why Resident #78 was refusing treatments. The resident further stated, he had friends who worked at the facility, and he did not want them to provide his care. The resident stated… | 2016-02-01 |
| 9141 | 9141 | CAREHAVEN OF PLEASANTS | 515191 | PO BOX 625 | BELMONT | WV | 26134 | 2012-04-26 | 155 | D | 0 | 1 | JRXZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and record review, the facility failed to ensure one (1) of thirty-three (33) residents was provided the opportunity to exercise his right to refuse treatment. The resident was given a thirty (30) day notice for refusing care and treatment without evidence the facility assessed the reason's for the refusals and without evidence alternative treatments and/or times for treatments were offered. Resident identifier: #78. Facility census: 61. Findings include: a) Resident #78. Review of the medical record found several occasions when Resident #78 refused care and treatment. No evidence could be found the facility investigated why the resident refused care and treatment. Resident #78 was admitted to the facility on [DATE]. The admission [DIAGNOSES REDACTED]. During an interview with the resident, on 04/23/12 at 3:00 p.m., it was learned the resident did not like the type of solution used to treat his wounds. The resident stated, It's a bleach solution and [MEDICAL CONDITION] nose. The treatment was ordered twice a day. The resident stated he was not going to let the facility use Dakins solution twice a day. According to Employee #97 (treatment nurse), during an interview on 04/25/12 at 9:14 a.m., Resident #78 had voiced his opinion of the Dakins solution to her. She stated, He is non-compliant with a twice a day treatment. She further added she contacted the wound care center, but they would not change the treatment. Employee #97 was asked whether she had contacted the attending physician to get the treatment changed. She stated, He will not go against the wound care center. She stated at one time they had used a patch which only had to be changed every three (3) days, and the resident was more compliant with this treatment. No evidence could be found the physician was aware of Resident #78 having difficulty with the current treatment. Additionally, no evidence could be found the facility alerted the ph… | 2016-02-01 |
| 9142 | 9142 | CAREHAVEN OF PLEASANTS | 515191 | PO BOX 625 | BELMONT | WV | 26134 | 2012-04-26 | 242 | D | 0 | 1 | JRXZ11 | Based on record review, staff interview, and resident interview, the facility failed to allow one (1) of thirty-three (33) sample residents the right to make choices regarding who would provide his care. The resident did not want his care provided by his acquaintances who worked at the facility. This aspect of care was significant to the resident. Resident identifier: #78. Facility census: 61. Findings include. a) Resident #78 During and interview with the resident, on 04/23/12 at 3:00 p.m., he stated he had friends who worked at the facility, and he did not want them to provide his care. He stated, I went to school with some of them and some of them date my friends. On 04/25/12, in the afternoon, an interview was conducted Employee #83, the evening shift nurse. At that time she said she was aware Resident #78 had acquaintances who worked at the facility. She stated He does not want particular people taking care of him because he knew them. Medical record review and staff interview revealed no evidence the facility made any attempts to maintain this resident's dignity by honoring his request to not be provided care by his acquaintances who worked at the facility. | 2016-02-01 |
| 9143 | 9143 | CAREHAVEN OF PLEASANTS | 515191 | PO BOX 625 | BELMONT | WV | 26134 | 2012-04-26 | 247 | D | 0 | 1 | JRXZ11 | Based on resident interview, medical record review, policy review, and staff interview, the facility failed to notify residents before room changes were made due to construction in the facility. One (1) of thirty-three (33) sample residents was affected; however, the practice had the potential to affect more than an isolated number of residents. Resident identifier: #37. Facility census: 61. a) Resident #37 In an interview, on 04/24/12 at 8:54 a.m., Resident #37 stated she was moved to another room without prior notice. She stated, They just came in and moved me. Review of the medical record, on 04/25/12 at 1:30 p.m., revealed no evidence the resident was notified of this room change. The administrator (Employee #100) was informed of this finding. A request for the facility's policy and procedure for room transfers was made at that time. At 5:00 p.m., a form entitled Notification of Room/Roommate Change was provided by Employee #100. This employee stated he did not have a policy/procedure, just the form. On 04/25/12 at 8:00 a.m., Employee #100 stated he had obtained the policy entitled Room to Room Transfers from corporate headquarters. A review of this policy revealed the following: Policy Interpretation and Implementation 1. The facility reserves . 2. Unless medically necessary . 3. Prior to the room transfer, the resident, his or her roommate (if any), and the resident's representative will be provided with information concerning the decision to make the room transfer. 4. A roommate will . 5. Room transfers are not . 6. Documentation of a room transfer shall be recorded in the resident's medical record. On 04/26/12 at 9:50 a.m., an interview was conducted with the administrator (Employee #100) and the social worker (Employee #78). Employee #78 was asked if he had information regarding Resident #37's room change on 04/18/12. He stated he would investigate the matter. Employee #100 stated he had sent a letter to all residents, family members, and responsible parties on 04/13/12 explaining new construction in the… | 2016-02-01 |
| 9144 | 9144 | CAREHAVEN OF PLEASANTS | 515191 | PO BOX 625 | BELMONT | WV | 26134 | 2012-04-26 | 250 | D | 0 | 1 | JRXZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to provide medically-related social services which addressed the needs of three (3) of thirty-three (33) stage II sample residents. There was no evidence Resident #73 was provided medically-related social services when she made comments about hurting herself prior to sending her out of the facility for psychiatric treatment. Additionally, there was no evidence of non-pharmacological interventions in her care when she returned to the facility. Resident #78, who had capacity to make his own medical decisions, did not receive assistance when he attempted to exercise his right to refuse treatment, in coping with his disabling medical condition, his individual preferences related to care, or before and after he was given a 30 day discharge notice. The facility also failed to provide medically-related social services for Resident #8, who required assistance with financial and legal matters. The facility did not ensure proper referrals and notifications were made in this matter. Resident identifiers: #73, #78, and #8. Facility Census: 61. Finding Include: a) Resident #73 This resident was admitted to the facility on ,[DATE] from another facility. Her social service assessment was completed on 01/23/12. At that time, the resident's mood and behavior was described as confused, content and satisfied, cooperative, trusting, cheerful, and relaxed. The assessment also identified her as being a wanderer. She had a [DIAGNOSES REDACTED]. The resident was identified with exit seeking behaviors. According to social service notes, she could make her basic needs known and could understand and follow directions. The resident's previous occupation was a registered nurse and she loved dogs. She moved to this facility to be closer to her family. Shortly after admission, nursing notes described the resident was exhibiting signs of depression. She was also noted with sad facial expres… | 2016-02-01 |
| 9145 | 9145 | CAREHAVEN OF PLEASANTS | 515191 | PO BOX 625 | BELMONT | WV | 26134 | 2012-04-26 | 279 | D | 0 | 1 | JRXZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and resident interview, the facility failed, to develop a care plan which addressed the individual needs and preferences for one (1) of thirty-three (33) stage 2 sample residents. The resident did not want acquaintances to provide personal care, had specific requests regarding treatments, and was depressed. Resident identifier: #78. Facility census: 61. Findings include: a) Resident #78 During an interview with Resident #78, on 04/24/12 at 3:00 p.m., he stated he only wanted certain people to provide his care. The resident said said he had friends at the facility and was not comfortable with them providing his care. Employee #83 (an evening shift nurse) confirmed this statement on the evening of 04/25/12. Review of the care plan found no interventions in place to honor the resident's preference in the provision of care. The care plan identified the resident was at risk for altered body image related to a [MEDICAL CONDITION], Foley catheter, impaired mobility, and wounds. No evidence was found the facility provided interventions to focus on the resident's choices and preferences to maintain his dignity related to the focus statement. Interventions on the current care plan included allowing the resident to make decisions about his treatment regimen and to provide the resident a sense of control. During an interview with Employee #97 (treatment nurse) on 04/25/12 at 9:14 a.m., she stated Resident #78 told her he did not like the treatment of [REDACTED]. Employee #97 stated, I contacted the wound care center, but they would not change the treatment. When asked if she talked with the attending physician, she stated, He will not go against the treatment center. No evidence could be found Resident #78 was permitted to make choices regarding his treatments, even though there was a care plan to this effect. During an interview, on 04/24/12 at 5:57 p.m., with Employee #100 (the administrator), he stated, The fam… | 2016-02-01 |
| 9146 | 9146 | CAREHAVEN OF PLEASANTS | 515191 | PO BOX 625 | BELMONT | WV | 26134 | 2012-04-26 | 280 | D | 0 | 1 | JRXZ11 | Based on record review and staff interview, the facility failed to ensure one (1) of thirty-three (33) stage 2 sample residents was afforded the opportunity to participate in care planning related to discharge plans. Additionally, the facility failed to revise the care plan when a determination was made that the resident was not going to be discharged . Resident identifier: #8. Facility census: 61. Findings include: a) Resident #8 On 04/24/12 at 3:00 p.m., a medical record review was conducted. The pre-admission screening and resident review (PASRR) dated 10/26/11 indicated Resident #8 would not be able to be discharged or return home. The minimum data set (MDS) with an assessment review date (ARD) of 11/08/11 (admission) and 02/18/12 (quarterly) was marked as no discharge in section Q0400.A. The care plan, initiated on 11/17/11 by the social worker (Employee #78), under section titled Focus stated, The resident wishes to return/be discharged back to the community. The goal stated, The resident will verbalize/communicate an understanding of her discharge plan back to the community and describe the desired outcome by the review date. The last care plan review was completed on 02/10/12 with no changes made in the focus or goals of the care plan. In an interview, on 04/26/12 at 9:50 a.m., Employee #78 agreed Resident #8's care plan had not been revised to reflect there were no plans for discharge. He further agreed this resident had not been informed there were no longer plans for a discharge back to the community. | 2016-02-01 |
| 9147 | 9147 | CAREHAVEN OF PLEASANTS | 515191 | PO BOX 625 | BELMONT | WV | 26134 | 2012-04-26 | 309 | D | 0 | 1 | JRXZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review, review of the facility's 2012 drug handbook, and staff interview, the facility failed to provide care and services to ensure one (1) of ten (10) sample residents attained or maintained the highest practicable physical well-being. The resident's inhaled respiratory medications were not administered in a manner which ensured the resident achieved optimal benefits and minimal risk for systemic side effects. Resident identifier: #38. Facility census: 61. Findings include: a) Resident #38 Observation of a medication pass, on 04/24/12 at 8:44 a.m., found Resident #38 received three (3) different inhalant medications, administered successively in less than a two (2) minute span of time. Review of the facility policy revealed directives to wait at least two (2) minutes between administering each of the three (3) medications. The policy also described, when administering more than one inhalation of the same type of medication, a space of one (1) minute should lapse between each inhaled dose. According to the facility's 2012 drug handbook, failure to follow these procedures could potentially prevent the optimal absorption by the lung of each inhaled medication. Further review of the facility's 2012 drug handbook revealed when [MEDICATION NAME][MEDICATION NAME] and corticosteroids were administered at the same time, the [MEDICATION NAME][MEDICATION NAME] should be administered first to open the air passages to allow for maximal effectiveness of the corticosteroid. None of these procedures were followed during the administration of these medications. Observation also revealed this resident was not asked, by the nurse, to rinse her mouth and spit; therefore, the resident did not rinse her mouth and spit after inhaling any of the prescribed respiratory medications. Physician's orders and the Medication Administration Record [REDACTED]. Observation further revealed the third inhalant medication req… | 2016-02-01 |
| 9148 | 9148 | CAREHAVEN OF PLEASANTS | 515191 | PO BOX 625 | BELMONT | WV | 26134 | 2012-04-26 | 363 | E | 0 | 1 | JRXZ11 | Based on observation, review of the facility's planned menu, and staff interview, the facility failed to follow its planned menu to ensure residents on pureed diets received correct meat portions at each meal. Dietary personnel used the wrong size scoop to portion pureed beef, resulting in a serving which was less than that planned on the menu. This practice affected one (1) resident, but had the potential to affect sixteen (16) of sixteen (16) residents who were ordered pureed diets. Resident identifier: #49. Facility census: 61. Findings include: a) Resident #49 Observation of the facility's kitchen, on 04/25/12, at approximately 11:45 a.m., revealed a dietary staff member, Employee #16, placed serving utensils in all the pans of food on the steam table. A #8 scoop was placed in the pan of pureed beef. Review of the daily menu revealed residents on pureed diets were to receive a #6 scoop of pureed beef, not a #8 scoop. A #6 scoop is a larger portion than a #8 scoop. Continued observation of the kitchen's tray line service, on 04/25/12, at approximately 12:00 p.m., revealed Employee #16 served a portion of pureed beef to Resident #49, who resided on the Red Hall, using a #8 scoop. After all the trays were loaded onto the cart ready for distribution on the Red Hall, including the tray of Resident #49, Employee #16 was asked about the scoop sizes for each dish. Employee #16 stated the pureed beef was served with a #8 scoop. At that time, it was pointed out that the menu called for a #6 scoop. To correct the error, after surveyor intervention, Employee #16 switched the incorrect #8 scoop with the correct #6 scoop, then finished the tray service. During an interview with the dietary manager (DM), on 04/26/12, at approximately 10:00 a.m., she stated there were fifteen (15) more residents who would have received the incorrect amount of pureed beef during the lunch meal on 04/25/12, had the scoop size not been corrected. The DM agreed the wrong scoop was used to serve the pureed beef, providing less beef than planned o… | 2016-02-01 |
| 9149 | 9149 | CAREHAVEN OF PLEASANTS | 515191 | PO BOX 625 | BELMONT | WV | 26134 | 2012-04-26 | 371 | F | 0 | 1 | JRXZ11 | Based on observation, policy review, and staff interview, the facility failed to ensure foods were prepared and served under sanitary conditions. Three (3) dietary staff members failed to use correct handwashing techniques and/or contaminated clean hands by touching surfaces which were not sanitary. Food and/or food service items were then handled with contaminated hands, creating a potential for cross contamination. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 61. Findings include: a) Employee #53 Observation of the kitchen, on 04/25/12 at 11:30 a.m., revealed a dietary staff member, Employee #53, turned off the water faucet with a paper towel after washing and drying her hands. She then dried her hands some more, using the contaminated paper towel she had used to touch the water faucet when turning off the water. At 11:47 a.m. on 04/25/12, Employee #53 was again observed washing her hands. She turned off the water faucet with a paper towel after washing and drying her hands. Again, she dried her hands some more, using the contaminated paper towel she had used when turning off the water. b) Employee #9 Observation of the kitchen, on 04/25/12 at 11:35 a.m., revealed a dietary staff member, Employee #9, turned off the water faucet with a paper towel after washing and drying her hands. She then dried her hands some more, using the dirty paper towel she had used to touch the water faucet when turning off the water. Employee #9 then further contaminated her hands by touching the door handle of the walk-in refrigerator and a plastic bread holder prior to donning gloves to put slices of bread in plastic bags for the meal. c) Employee #16 Observation of the kitchen, on 04/25/12 at 11:45 a.m., revealed a dietary staff member, Employee #16, washed and dried her hands appropriately, then touched the trash can lid while disposing of the paper towel she used during handwashing. She then poured and covered a bowl of noodles, wrote a resident's n… | 2016-02-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );