cms_WV
Data source: Big Local News · About: big-local-datasette
48 rows where "inspection_date" is on date 2014-03-27
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Suggested facets: facility_name, facility_id, address, city, zip, deficiency_tag, scope_severity, eventid, filedate, filedate (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6042 | 6042 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 161 | E | 0 | 1 | R3PM11 | Based on record review and staff interview, the facility failed to guarantee the security of all personal funds deposited with the facility. The facility did not have a surety bond of sufficient value to cover the highest daily balance of the resident trust fund for February 2014. This had the potential to affect all 117 residents with a resident trust fund account. Facility census: 135. Findings include: a) On 03/24/14 at 3:00 p.m., review of the resident funds on deposit found the highest daily balance, according to the Account Summary for February 2014, balance was $69,988.73 on 02/07/14. The facility's current surety bond was for $60,000.00. The bond was insufficient to cover the resident trust fund accounts of the one hundred seventeen (117) residents who had a trust account with the facility. b) On 03/24/14 at 3:30 p.m., an interview was completed with Employee #152 (Business Office Manager), she acknowledged the daily balance on 02/07/14 of $69,988.73 had exceeded the amount of the current surety bond. | 2018-05-01 |
| 6043 | 6043 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 272 | D | 0 | 1 | R3PM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident's comprehensive assessment accurately reflect the resident's medications, one of the required elements for the comprehensive assessment. Resident #46's comprehensive minimum data set (MDS) assessment did not identify the resident was receiving an antidepressant. This was found for one (1) of nineteen (19) Stage 2 residents. Resident identifier: #46. Facility census: 135. Findings include: a) Resident #46 During record review, on 03/18/14 at 1:30 p.m., it was revealed that Resident #46 had an order dated 01/31/14, for [MEDICATION NAME], an antidepressant, 30 milligrams (mg) orally each day. The last comprehensive assessment, with an assessment reference date (ARD) of 02/06/14, made no reference to the use of the antidepressant ([MEDICATION NAME]). On 03/26/14 at 4:00 p.m., the director of nursing (DON) reviewed the January and February 2014 physician's orders [REDACTED].#46 had a physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The DON verified an antidepressant should have been coded on the MDS, with an ARD of 02/06/14. A correction MDS was completed. | 2018-05-01 |
| 6044 | 6044 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 279 | D | 0 | 1 | R3PM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop care plans based on assessments of the resident's condition in regard to [DIAGNOSES REDACTED].#46 and urinary incontinence for Resident #234. This was true for two (2) of nineteen (19) Stage 2 residents. Resident identifiers: #46 and #234. Facility census: 135. Findings include: a) Resident #46 A record review, performed on 03/18/14 at 1:30 p.m., found current MEDICATION ORDERS FOR [REDACTED]. On 03/26/14 at 3:30 p.m., review of the resident's care plan found it did not address the resident's needs associated with these conditions. There were no plans developed for the issues associated with diabetes, anxiety, or [MEDICAL CONDITION]. The care plan also did not address the potential adverse effects of the medications used to treat the [DIAGNOSES REDACTED]. At 3:40 p.m. on 03/26/14, this was discussed with the director of nursing who agreed the issues associated with the [DIAGNOSES REDACTED]. b) Resident #234 Medical record review, completed on 03/26/14 at 3:45 p.m., revealed the minimum data set (MDS), with an assessment reference date (ARD) of 12/19/13, reflected the resident was occasionally incontinent. The MDS, with an ARD of 02/12/14 indicated the resident's urinary continence had changed to frequently incontinent. The care plan, developed on 12/19/13 and revised on 02/19/14, did not address urinary continence. The care plan did not provide any interventions to prevent further decline in urinary continence for this resident. In an interview with Employee #75 (registered nurse/assessment coordinator), on 03/26/14 at 5:25 p.m., she verified bladder incontinence had not been addressed on the current care plan. | 2018-05-01 |
| 6045 | 6045 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 309 | D | 0 | 1 | R3PM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the necessary care and services to attain or maintain the highest practicable physical well-being for one (1) of three (3) Stage 2 residents reviewed for hospitalization after admission. The facility failed to obtain physician ordered laboratory work required to monitor the resident's use of antocoagulant medication. The resident subsequently required hospitalization due to [MEDICAL CONDITION] of the left lower extremity. Resident identifier: #31. Facility census: 135. Findings include: a) Resident #31 A review of the medical record, on 03/24/14 at 4:00 p.m., revealed this [AGE] year old resident was admitted to the facility on [DATE] from an acute care hospital. The hospital's admission history and physical (H&P), dated 12/06/13, revealed Resident #31 had slight weakness on the left side, and a possible [MEDICAL CONDITION]. The resident also had chronic venous stasis and [MEDICAL CONDITION] of her left lower extremity. The H&P also noted the resident was on [MEDICATION NAME] with a therapeutic INR. The INR result was 2.89 on 12/06/14. (PT/INR ([MEDICATION NAME] time and international normalized ratio) is a lab test used to monitor bleeding and clotting time for those who are on anticoagulation therapy, such as with [MEDICATION NAME]. The therapeutic range of the INR is between 2.0 and 3.0.) The hospital's discharge summary, dated 12/10/14, indicated the primary [DIAGNOSES REDACTED]. Another discharge [DIAGNOSES REDACTED]. A PT/INR at the hospital on [DATE] showed an INR value of 1.69. Initial physician's orders [REDACTED]. A registered nurse completed a situation background assessment recommendation (SBAR) on 12/29/14 at 1:45 p.m. The nurse stated (typed as written) Resident d/t (due to) have PT/INR on 12/17/13. Lab slip not filled out and lab was not drawn. Resident on ATB (antibiotic) therapy. She notified the physician who then gave orders for an immediate PT/INR. T… | 2018-05-01 |
| 6046 | 6046 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 332 | D | 0 | 1 | R3PM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, pharmacist interview, review of Centers for Medicare Services (CMS) guidance to surveyors, information from the Federal Drug Administration (FDA), and information from the National Institutes of Health (NIH), the facility failed to ensure it was free of a medication error rate of five (5) percent or greater. The facility had a medication error rate of 5%. Resident #11 received antibiotic eye drops without sufficient contact time allowed between drops. Resident #114 was not instructed to rinse her mouth after receiving an inhaler. Two (2) of nine (9) residents were affected. Resident identifiers: #11 and #114. Facility census: 135. Findings include: a) Observation of medication administration pass, on 03/17/14 at 4:00 p.m., 03/19/14 at 8:00 a.m., and 03/20/14 at 7:00 a.m., identified 36 opportunities for medication errors. There were two (2) medication errors observed in the thirty-six (36) opportunities for error. b) Resident #11 On 03/17/14 at 4:10 p.m. a licensed nurse Employee #2 was observed as she administered two (2) drops of an antibiotic eye medication ([MEDICATION NAME]) into each of Resident #11's eyes. She administered the drops in quick succession, with only a few seconds between each instilled eye drop. An interview was conducted with the director of nursing (DON) on 03/25/14 at 12:20 p.m. She said there should be a timed interval between a first and a second dose of an eye drop. She said the drops were not to be given in quick succession, although she was unsure of the exact time interval involved. Later, at 3:10 p.m., she said she was unable to find a policy regarding how close to space two (2) eye drops if they were the same medication. The pharmacist was interviewed on 03/25/14 at 12:30 p.m. He provided his pharmacy's policy guideline related to instillation of eye drops. His interpretation of the guideline was that three (3) to five (5) minutes must elapse between each ey… | 2018-05-01 |
| 6047 | 6047 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 356 | B | 0 | 1 | R3PM11 | The facility failed to ensure the posted nurse staffing data was completed and available for viewing by the residents and/or visitors. The total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift were not posted for day shift in Building 1. This had the potential to affect more than a limited number of residents and/or visitors. Facility census: 135. Findings include: a) The completion of the initial tour of building one (1) of the facility took place on 03/17/14 at 12:15 p.m. Observations at and near the nurses' station revealed the facility had not posted the staffing numbers for day shift on 03/17/14. An interview with Employee #119 (nursing supervisor) and Employee #25 (assistant director of nursing) revealed the facility had not posted the required staff posting for 03/17/14 day shift. They said the employee who normally completed the posting was not working on 03/17/14. The nurses went on to say that no other employee had completed this posting on 03/17/14. | 2018-05-01 |
| 6048 | 6048 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 371 | E | 0 | 1 | R3PM11 | Based on observation, staff interview, and policy review, the facility failed to store food in a sanitary manner in the clean utility room refrigerator in Building 2. This practice had to potential to affect more than a limited number of residents. Facility census: 135. Findings include: a) A tour was conducted of the facility on 03/17/14 at 1:15 p.m. At 1:30 p.m. the refrigerator was examined in Building 2's clean utility room. There was a piece of cake wrapped in foil with a label on it stating (Resident name) 1-19-14 and a soggy sandwich wrapped in cellophane and in a brown paper bag that was unlabeled. Employee #42 (registered nurse) stated the facility practice was to throw the residents' food away after one (1) week. She discarded both items at 2:00 p.m. She also said the nurse supervisors on the afternoon shift were in charge of monitoring food dates in the resident refrigerators. This matter was discussed with the dietary manager at 10:30 a.m. on 03/19/14. She said nursing was responsible for all resident personal food items in the clean utility refrigerators. During an interview with the director of nursing (DON), at 4:39 p.m. on 03/19/14, she agreed the food needed to be discarded and provided a policy for Storage of Food dated 04/07/06. This policy included, Store potentially hazardous foods under refrigeration . for a maximum of 7 days and discard food when use-by date is unclear. The DON also said the facility practice was for nurses to monitor refrigerators with resident food items in the facility. | 2018-05-01 |
| 6049 | 6049 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 425 | E | 0 | 1 | R3PM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Centers for Disease Control guidelines, and staff interview, the facility failed to implement procedures for the disposition of expired medications. Observation of the medication storage areas revealed vials of expired tuberculin testing serum, insulin and influenza vaccine. This had the potential to affect more than an isolated number of residents. Resident identifier: #45. Facility census: 135. a) Resident #45 During an observation of the A Wing medication cart, on 03/17/14 at 1:05 p.m., one (1) partially used vial of Humalog insulin was found for Resident #45. The vial contained a date to discard on 01/25/14. It was nearly empty, and had not been discarded. A licensed nurse (Employee #80) acknowledged that all multi-dose vials must be dated when first opened, and discarded according to facility policy. b) Aplisol tuberculin testing serum At 1:22 p.m. on 03/17/14, the medication storage refrigerator for Building 1 was observed with Employee #119, a licensed nurse. An opened and partially used fifty (50) test vial of Aplisol was dated as having been opened on 01/30/14. This tuberculin testing serum is injected beneath the skin of residents and employees, and used as a screening test for the presence of [DIAGNOSES REDACTED]. Employee #119 said she would check to see when this vial should be discarded. The director of nursing (DON) produced storage recommendations for Aplisol on 03/19/14 at 4:30 p.m. According to the facility's policy, vials of Aplisol must be dated when opened, and any unused portion discarded after thirty (30) days. c) Flulaval influenza vaccine On 03/17/14 at 1:22 p.m., the medication storage refrigerator for Building 1 was observed with a nurse, Employee #119. An opened and partially used five (5) milliliter (ml) vial of Flulaval influenza vaccine was dated as having been initially opened on 12/31/13. This vial can provide influenza vaccinations for ten (10) people. Employee #119 said she would check … | 2018-05-01 |
| 6050 | 6050 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 431 | E | 0 | 1 | R3PM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of recommendations from the Centers for Disease Control (CDC), policy review, and staff interview, the facility failed to ensure medications were labeled and dated properly. Vials of insulin did not contain expiration dates. Two (2) of eight (8) medication carts contained expired vials of insulin. Resident identifiers: #274 and #45. Facility census: 135. Findings include: a) Resident #274 Observation of the B Wing medication cart, on [DATE] at 1:00 p.m., revealed a partially used vial of Novolog insulin. There was no date on the vial, or on the box it came in, to indicate when the insulin vial had initially been opened. Upon inquiry, registered nurse (Employee #68) said the vial should have been dated when it was first opened for use, and it had not been dated. Employee #68 said the insulin must be discarded after twenty-eight (28) days of opening. Without a date inscribed, it would not be known when this vial should be discarded. The director of nursing (DON) produced insulin storage recommendations on [DATE] at 4:30 p.m. According to the facility's policy, vials of Novolog insulin may only be used for 28 days after having been initially opened. b) Resident #45 During an observation of the A Wing medication cart, on [DATE] at 1:05 p.m., one (1) partially used vials of Humalog insulin was found for Resident #45. A partially used vial of Humalog insulin contained no date to indicate when it had first been opened. A licensed nurse (Employee #80) acknowledged that all multi-dose vials must be dated when first opened, and discarded according to facility policy. Without a date inscribed, it would not be known when this vial should be discarded. The DON produced insulin storage recommendations on [DATE] at 4:30 p.m. According to the facility's policy, vials of Humalog insulin may only be used for twenty-eight (28) days after having been initially opened. | 2018-05-01 |
| 6051 | 6051 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 441 | E | 0 | 1 | R3PM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain an effective infection control program designed to provide a sanitary environment. Nursing staff did not demonstrate safe infection control techniques when using a glucometer. Nursing staff also did not properly use personal protective equipment when caring for a resident who had an infection with multi-drug resistant organism. These practices had the potential to transmit microorganisms and infection, and could potentially affect more than a limited number of residents. Resident identifiers: #11 and #96. Facility census: 135. Findings include: a) Resident #11 On 03/17/14 at 4:07 p.m., licensed nurse (Employee #2) cleaned the hand-held, blood sugar testing machine after completing a blood sugar test on Resident #69. She cleaned the machine with a disinfectant wipe, then placed the machine directly onto the resident's bed. It laid on the bed for several minutes. The nurse picked the machine up from the resident's bed and placed it back onto the medication cart with no further cleaning. The nurse then entered the room of Resident #11. At 4:14 p.m. on 03/17/14, Employee #2 completed a blood sugar test on Resident #11 without first disinfecting the testing machine that had lain on the bed of Resident #69. This practice had the potential to transmit microorganisms from one resident to another. On 03/27/14 at 11:00 a.m., during an interview with the administrator (Employee #185) and DON, they were informed of the inadequate cleaning of a glucometer between each resident used. The DON was in agreement the nurse did not follow infection control facility practice to prevent cross contamination between each use of the glucometer. b) Resident #96 On 3/17/14 at 4:35 p.m., a nurse (Employee #176) was observed in the room of Resident #96. A sign on the resident's door alerted those who entered this resident was on contact precautions. The directions on the sign instructed those who e… | 2018-05-01 |
| 6052 | 6052 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 469 | D | 0 | 1 | R3PM11 | Based on observation and staff interview, the facility failed to maintain an effective pest control program. During an observation, there was evidence of pest infestation in room C-9. This had the potential to affect more than a limited number of rooms. Facility census: 135. Findings include: a) Room C-9 On 03/27/14 at 2:15 p.m., the director of maintenance and the nursing home administrator verified the presence of ants in room C-9 near the heating/air unit located under the window. The director of maintenance also provided the most recent pest control log, which indicated a building perimeter spray had been completed on 02/24/14. | 2018-05-01 |
| 6053 | 6053 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 520 | E | 0 | 1 | R3PM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and medical record review, it was determined the facility's quality assessment and assurance (QA&A) committee failed to identify and/or develop an effective plan of action to correct quality deficiencies in the facility's daily operations in which it did have or should have had knowledge. During the survey, from 03/17/14 through 03/27/14, it was identified the facility had an issue with infection control practices. The facility had already identified infection control issues in their QA&A committee, prior to the issues discovered during the survey. In addition, after the facility became aware critical laboratory work was not obtained for a resident. The QA&A committee failed to implement corrective actions to ensure this situation did not reoccur. Residents #96 and #31 were affected; however, the practices had the potential to affect more than an isolated number of residents. Facility census: 135. Findings include: a) Infection Control On 3/17/14 at 4:07 p.m., a licensed practical nurse (LPN - Employee #2) was observed cleaning a glucometer after completing a blood sugar test. Employee #2 laid the glucometer on a resident's bed, then picked up the glucometer and placed on the medication cart with no further cleaning. The employee then used the glucometer with another resident without cleaning the glucometer. This practice had a potential for cross contamination of the glucometer. At 11:00 a.m. on 03/27/14, during an interview with the administrator and director of nursing (DON), the DON was informed of the failure to adequately clean a glucometer between each resident. The DON was in agreement the nurse did not follow infection control practices to prevent cross contamination between each use of the glucometer. In addition, the DON stated infection control issues and monitoring of staff infection control practices was presented during the QA&A meetings. b) Resident #96 On 3/17/14 at 4:35 p.m. a nurse (E… | 2018-05-01 |
| 6484 | 6484 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2014-03-27 | 159 | D | 0 | 1 | TPO611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide one resident (#16) with a quarterly statement of his personal funds account out of four residents with concerns regarding personal funds. Findings include: Resident #16 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the clinical record for resident #16 revealed that he was assessed to be cognitively intact with a Brief Interview of Mental Status score of 12 on a quarterly MDS (Minimum Data Set) assessment dated [DATE]. Further review of the clinical record revealed that resident #16 did not have capacity to make his own decisions. During an interview with resident #16 on 3/25/14 at 9:01 AM, the resident stated that he is not given a quarterly statement of his personal funds account, though occasionally the facility does tell him how much money he has in his account. He further stated that he would like to receive a copy of his quarterly statement. During an interview conducted with Business Office Assistant staff #13 on 3/26/14 at 3:01 PM, staff produced the most recent quarterly statement of the resident's personal funds account. The statement had been signed by the facility's administrator. There was no evidence that the resident had also been provided a copy of his personal funds account statement. During an interview conducted with Nursing Home Administrator staff #94 on 3/26/14 at 3:18 PM, staff stated that as the facility is the Representative Payee for the resident's finances, the administrator signs the quarterly statement on behalf of the resident. Staff stated that they would in the future provide a copy to residents for whom the facility is Representative Payee, but that they do not currently do so. | 2018-03-01 |
| 6485 | 6485 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2014-03-27 | 253 | D | 0 | 1 | TPO611 | Based on observations and staff interviews, the facility failed to maintain a sanitary and orderly environment with regards to resident privacy curtains and resident room sinks. Findings Include: On 3/27/2014 at 9:10 AM an observation was completed with Environmental Supervisor #7 (ES #7) in room C6. The privacy curtain was noted to have multiple brown stains during observation on 3/24/2014 that had remained. ES #7 said that housekeeping staff would normally look at privacy curtains and clean them as necessary. Observations of sinks in resident rooms D7 and D11 were noted to be loose and easily movable. ES #7 said that he would tighten the brackets holding the sink against the wall. A follow up observation was made of both sinks on 3/27/2014 at 12:10 PM. New caulking had been placed around the sink in room D11, but the sink remained easily moveable. | 2018-03-01 |
| 6486 | 6486 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2014-03-27 | 272 | D | 0 | 1 | TPO611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to comprehensively assess 1 resident (#124) with regards to side rails out of 3 residents reviewed for potential physical restraints out of 13 residents with observed with potential physical restraints in place. Findings include: Resident #124 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A side rail assessment dated [DATE] noted that Resident #124 independently uses side rails and expressed a desire for a side rail to assist with bed mobility and transfers. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] noted that Resident #124's bed rail was not used as a restraint. On 03/25/2014 at 1:22 PM, an interview was completed with Nursing Assistant #25 (NA #25) NA #25 stated that Resident #124 turns herself using the side rail. I stand beside her when she transfers out of the bed. On 03/25/2014 at 1:40 PM, an interview was completed with Nurse #70. Nurse #70 stated that Resident #124 did not have an assessment of her side rails as a potential restraint. If the IDT (interdisciplinary team) determines the resident needs a restraint, they would do the initial assessment to determine what was appropriate. Quarterly, I would review the restraint. I'm not sure who would review a restraint if it came from the hospital. The IDT reviews residents after admission for an interim care plan. An interview was completed with Nurse #97 on 03/25/2014 at 2:05 PM. Nurse #97 is a Clinical Care Supervisor (CCS). Nurse #97 said, After admission, IDT reviews the resident. If the floor nurse feels like they need a restraint, IDT reviews it. On admission, the unit charge nurse reviews the resident for restraints. The (staff) nurse fills out a nursing assessment that the RN (Registered Nurse) will complete that reviews for devices. Side rails would be reviewed on the initial assessment. There is no assessment for side rails to see if they are restraints. An inte… | 2018-03-01 |
| 6487 | 6487 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2014-03-27 | 280 | E | 0 | 1 | TPO611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews, and record review, the facility failed to ensure that 3 residents (#8, 33, 90) out of 3 residents reviewed for participation in care planning were informed of scheduled appointments and medication changes. Findings include: Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On an annual MDS (Minimum Date Set) assessment dated [DATE], the resident scored a 13 on the Brief Interview of Mental Status which indicated the resident was cognitively intact. During interviews conducted with resident #90 on 3/24/14 and on 3/26/14, the resident stated that he is not informed of medication changes nor is he made aware of upcoming appointments. Resident #90 stated that recently he went to an appointment to get his teeth extracted and he did not know that he was going to have his teeth extracted. He added, They just yanked them out! The resident was also not aware of recent medication changes nor was he aware of ongoing treatments to his leg/foot. During an interview with licensed nursing staff #1 on 3/26/14 at 11:41 AM, staff stated that she informs the resident's daughter of medication changes and of appointments. She stated that she would not inform the resident of upcoming appointments more that 1 day in advance because the resident would forget. During an interview with certified nursing assistant staff #12 on 3/26/14 at 1:58 PM, staff stated that the resident is not forgetful with her and that he does remember what they talk about from day to day. During an interview with medical records staff #39 on 3/26/14 at 2:18 PM, staff stated that she schedules appointments with the residents but she informs the resident of the appointment on the day before the appointment but does not document this anywhere. During an interview conducted with Director of Nursing (DON) staff #92 on 3/26/14, staff stated that the facility had identified that residents were not being informed of upcoming… | 2018-03-01 |
| 6488 | 6488 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2014-03-27 | 282 | D | 0 | 1 | TPO611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement the accidents care plan for 2 residents (#124, 20) out of 22 residents whose care plans were reviewed. Findings include: Resident #124 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of Resident #124's medical record revealed a physician's orders [REDACTED].#124 was to be transferred with the assistance of 2 staff. Review of progress notes for Resident #124 dated 3/12/2014 revealed that a nursing assistant observed resident #124 attempting an unassisted transfer from the wheelchair to the bed. Resident #124 slide to the floor on her knees. Resident #124 was documented as saying I thought I could do it myself, but I got weak. A care plan dated 3/20/2014, noted that Resident #124 was a fall risk. Interventions included: Ask resident to demonstrate the operation of the call light q (every) shift. Alarm to chair at all times. Transfer bed to chair 2 person physical assist. On 3/25/2014 at 1:22 PM, an interview was completed with Nursing Assistant #25 (NA #25). NA #25 stated, I don't let her up by herself. I stand by when she gets up. NA#25 said that she was not aware of Resident #124 having any falls. She also stated that she can tell who needs transfer assistance by the way they sit up in bed. She said that she could also look in the electronic kiosk to see how residents are to be transferred or if the resident ever had a fall. The kiosk was reviewed with NA # 25. She found no documentation of a fall for Resident #124. I think there is a way to look at the history. I'm not sure. NA #25 reported that Resident #124 does use her call bell, but that she was not asked to demonstrate the use of the call bell each shift. On 3/26/2014 at 9:02 AM, an interview was completed with Resident #124. Resident #124 denied every having a fall. She reported that she gets out of bed with assistance. An interview was completed with NA #75 on 3/27/2014 at 8:3… | 2018-03-01 |
| 6489 | 6489 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2014-03-27 | 315 | D | 0 | 1 | TPO611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observations, and record review, the facility failed to ensure that there was a medically justified use of a catheter for 1 resident (#124) out of 3 residents reviewed for catheters out 4 residents identified with catheters in stage 1. Findings include: Resident #124 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #124's medical record revealed a physician's orders [REDACTED]. Resident #124's care plan dated 3/20/2014 noted that she had an indwelling urinary catheter for [MEDICAL CONDITION]. Review of Resident #124's quarterly Minimum Data Set (MDS) assessment dated [DATE] noted no urinary toileting program has been tried since admission. An interview was completed with Nurse #97 on 3/25/2014 at 2:30 PM. Nurse #97 stated she was familiar with Resident #124 and that Resident #124 was not on a toileting program. On 3/25/2014 at 2:55 PM, an interview was completed with Resident #124's physician. The physician stated, We spent a month working on an incisional abscess. We thought she was going to die. In the last 5 weeks, she is better. We should have been doing more to try and get it (urinary catheter) out. We wanted to keep the wounds on her buttocks healed. She hasn't had a (Stage) 3 or 4 (pressure ulcer). Her nutritional status was so bad, I was worried about them getting worse. We should have done more to get the urologist to see about getting it out. When she came back in January, she had a residual volume of over 300 cc (cubic centimeters). She also went to the hospital in February for the abscess. An observation was completed on Resident #124 on 3/26/2014 at 12:00 PM. Resident #124 was noted to have an indwelling urinary catheter. On 03/26/2014 at 12:40 PM, an interview was completed with the Director of Nurses (DON). The DON stated that an appointment has been made for Resident #124 to see a urologist to evaluate for the need of the catheter. | 2018-03-01 |
| 6490 | 6490 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2014-03-27 | 371 | E | 0 | 1 | TPO611 | Based on interviews and observations, the facility failed to appropriately maintain food items to prevent potential food borne illness. Findings include: On 3/26/2014 at 10:50 AM, an observation of the dry storage area of the kitchen was completed. One bag of pasta and one bag of potato chips noted to be opened but not dated. There was also one bag of lasagna noodles left open to air; not resealed. On 3/26/2014 at 10:52 AM, an interview was completed with Dietary Supervisor #5 (DS #5). DS #5 said the pasta was just opened yesterday. He was observed to put the date on the bag and he threw away the potato chips. He folded the bag of lasagna noodles over to close them and left them on the shelf. On 3/26/2014 at 12:25 PM, the lasagna noodles were still noted on the shelf. | 2018-03-01 |
| 6491 | 6491 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2014-03-27 | 460 | E | 0 | 1 | TPO611 | , Based on observations and interviews, the facility failed to ensure that bed privacy curtains provided full visual privacy. Findings Include: On 3/24/2014 at 9:45 AM observations of rooms were completed with Environmental Supervisor #7 (ES #7). Sampled rooms A3, A6, A13, C16, D7 and D13 noted that privacy curtains would only enclose one resident at a time for privacy. ES #7 said that he would order and install extra curtain panels to cover both residents. | 2018-03-01 |
| 6564 | 6564 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 253 | E | 0 | 1 | BWIF11 | Based on observation, resident interview, and staff interview, the facility failed to provide effective housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable interior. The floor tiles had cracks that were filled with dirt/debris, screens on sliding glass doors were loose, draperies were not hanging properly, and tiles in one room were uneven. This had the potential to affect more than a limited number of residents. Facility census: 105. Findings include: a) A tour of the 300 hall at 10:30 a.m. on 03/19/14, revealed the following observations: -- Rooms #322 and #323 had sliding glass doors opening to an enclosed yard. The screens on the doors were hanging loose from their frames on the outside of the glass. The screens banged on the doors when the wind blew. -- Rooms #310 and #328 had curtains on the sliding doors which were hanging loose in places where they had come loose from the rail. Resident #34 in room #328, stated the drapes had been like this a long time. -- Rooms #310, #326, #335, and #328 had floor tiles with many cracks running the width of the room. The cracks were blackened, which revealed an inability to remove all soil from the cracks. In room #335 the crack in the floor tile was wider and raised on one side and spanned the width of the room. The difference in the height of the flooring had the potential to cause a person to stumble when crossing the area. These observations were relayed to Employee #117 (Maintenance worker) at 11:00 a.m. on 03/19/14. He acknowledged the floors were in bad shape and he would check room #335 and have housekeeping look at the drapes. During an interview with the Administrator at 11:10 a.m. on 03/24/14, she added the facility was in the planning stages of replacing the flooring, and acknowledged the floors posing a hazard should be repaired first. | 2018-01-01 |
| 6565 | 6565 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 272 | D | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to conduct a comprehensive assessment accurately reflecting the status of the individual resident. Resident #76's minimum data set (MDS) assessment did not identify he had no natural teeth and no dentures. Resident #132's assessment indicated the resident was on a physician prescribe weight loss program, which was incorrect. Inaccuracies of the MDSs were identified for two (2) of thirty-seven (37) sample residents reviewed during Stage 2 of the Quality Indicator Survey. Resident identifiers: #76 and #132. Facility census: 105. Findings include: a) Resident #76 On 03/18/14 at 11:30 a.m., an observation of the resident revealed this resident was edentulous (no natural teeth). The resident was unable to be interviewed due to his cognitive status. An interview was conducted with the resident's daughter by telephone on 03/18/14 at 11:45 a.m. During the interview, his daughter commented her father had dementia and had lost his dentures at home prior to his admission to the facility. On 03/26/14 at 8:30 a.m. a medical record review for Resident #76 found he was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment, dated 11/09/13, noted the resident had no dentures present and he was edentulous. Review of the significant change MDS, with an assessment reference date (ARD) of 02/28/14, found Item L0200 - Dental was not checked for B. No natural teeth or tooth fragment(s) (edentulous). Instead, L0200 was checked as Z. None of the above were present. An interview was conducted with Employee #109, the MDS Coordinator, on 03/26/14 at 12:20 p.m. After reviewing the resident's MDS, she agreed it was an incorrect assessment for the resident's dental status. She commented it should have been coded as B in L0200 for edentulous. She corrected the assessment immediately. b) Resident #132 Review of the resident's medical record, on 03/25/14 at 10:00 a.m., … | 2018-01-01 |
| 6566 | 6566 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 278 | D | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the individual completing and certifying the accuracy of the assessments for two (2) of thirty-seven (37) Stage 2 sampled residents coded the assessments accurately. The minimum data set (MDS) assessment did not accurately reflect Resident #76's dental status. Resident #132's MDS was coded inaccurately for weight loss. Resident identifiers: #132 and #76. Facility census: 105. Findings include: a) Resident #132 Review of the resident's medical record on 03/25/14 at 10:00 a.m., found the resident's weight had decreased forty-six (46) pounds (or 36.3%) between 12/09/13 and 02/26/14. The physician's progress note, dated 02/28/14, stated Resident #132's current weight loss was related to his recent leg amputation, depression, and a loss of appetite. The dietary note, dated 03/07/14, stated the resident's weight had declined 12.2%, because of a decrease in intake, his recent leg amputation and a wound infection. The significant change minimum data set (MDS) assessment, with an assessment reference date of 01/27/14, was coded 1 for item K0300, which indicated the resident was on a physician prescribed weight-loss regimen. An interview was conducted with Employee #109 (MDS coordinator), on 03/25/14 at 11:30 a.m. She confirmed the MDS assessment had been coded inaccurately. Item K0300, should have been coded 2 to indicate the resident was not on a physician-prescribed weight-loss regimen. The MDS was corrected after this interview. b) Resident #76 On 03/18/14 at 11:30 a.m. an observation of the resident revealed he was edentulous. The resident was unable to be interviewed due to his cognitive status. A family interview was conducted with his daughter by telephone on 03/18/14 at 11:45 a.m. During the interview, his daughter commented he had dementia and had lost his dentures at home prior to his admission to the facility. On 03/26/14 at 8:30 a.m., review of the resident's medical… | 2018-01-01 |
| 6567 | 6567 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 279 | E | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to ensure the care plans for five (5) of thirty-seven (37) residents reviewed in the sample had measurable goals and interventions developed to enable the residents to achieve the highest level of well-being the resident might be expected to attain. Resident #140 did not have a care plan established relative to his multiple contractures and his activities of daily living (ADL) needs. Residents #113, #97, and #24, did not have care plans developed when isolation precautions were implemented and/or the plan was not established timely. Resident #132's care plan did not identify the need for a specialized utensil to improve the resident's abilities to feed himself. Resident identifiers: #140, #113, #97, #24, and #132. Facility census 105. Findings include: a) Resident #140 A review of the medical record revealed Resident #140 was admitted on [DATE] after hospitalization for [MEDICAL CONDITION]. His [DIAGNOSES REDACTED]. 1) Observation of this non-verbal resident, at 3:30 p.m. on 03/17/14, revealed he was very small in stature and thin (weight: 98 pounds). He was lying in bed on a concave mattress with his legs crossed and drawn up to his body. His movements were jerky and random. During an interview with Employee #16, a licensed practical nurse (LPN) who was also a direct care giver, at 10:00 a.m. on 03/18/14, she was asked if the resident had any contractures, She replied he did, although he received no therapy and used no splints at the present time. A review of the Physical Therapy evaluation, completed on 01/06/14, revealed the resident was assessed with [REDACTED]. This was confirmed by Employee #125 (Rehabilitation Manager) at 9:45 a.m. on 03/20/14. According to the resident's comprehensive minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/08/14, the resident was identified in item G0400 as having limited functional range of motion … | 2018-01-01 |
| 6568 | 6568 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 280 | E | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to periodically evaluate and revise the care plan based on changes in health care status and/or physician's orders [REDACTED]. Resident #112's and #87's care plans had interventions that were no longer appropriate due to changes in condition. Resident #132's care plan was not revised when she no longer received therapy. Resident #112's care plan was not revised to reflect isolation precautions were no long in effect. Lack of care plan revision was identified for four (4) of thirty-seven (37) Stage 2 sample residents. Resident identifiers: #112, #87, #12, and #132. Facility census: 105. Findings include: a) Resident #112 1) A review of the resident's care plan revealed an identified focus for Restorative Ambulation initiated on 06/13/13. A measurable goal was established: Patient will participate in the walk to dine program X 90 days. The 90 day evaluation would have been due 09/13/13. As of 03/25/14, there was no evidence of a 90 day evaluation. In addition, the seven (7) interventions in the active care plan were no longer applicable to the resident. All seven (7) of the interventions were directed towards ambulation. The medical record, including the comprehensive assessments, indicated the resident had been non-ambulatory since 01/25/14. All of the interventions were assigned to Restorative Nursing. There was no evidence the resident was receiving services from Restorative Nursing. When interviewed at 12:40 p.m. on 03/25/14, Employee #39 (Nurse responsible for Restorative Care) confirmed restorative care was not currently being provided to Resident #112. She could not state when it had ceased. She was aware the resident no longer ambulated, but was not sure whose responsibility it was to update the care plan or contact the physician to update the care orders. 2) The resident's care plan for activities was also reviewed. The focus of the plan was to encourage and … | 2018-01-01 |
| 6569 | 6569 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 282 | E | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure interventions ordered by the physician, and planned in the care plan, were provided for four (4) of thirty-seven (37) residents reviewed for range of motion. Resident identifiers: #56, #12, #14, and #1. Facility census: 105. Findings include: a) Resident #56 During an interview with Employee #93, a licensed practical nurse (LPN), on 03/17/14 at 2:37 p.m., she related Resident #56 had a contracture of her knees. Review of the resident's medical record found current physician's orders [REDACTED]. The restorative notes were reviewed on 03/25/14 at 1:49 p.m. They indicated no services were provided for the month of March 2014. Employee #39 (LPN), restorative nursing supervisor, confirmed the resident had not received ROM due to staffing issues. An interview with the administrator,on 03/25/14 at 3:11 p.m., confirmed, due to staffing issues, restorative nursing had not been provided in accordance with the resident's written plan of care. b) Resident #12 A review of the medical record revealed Resident #12 was an [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He had three (3) falls within the previous two (2) months. On 06/12/13, the attending physician ordered RNP (Restorative Nursing Program): AROM (active range of motion) to BLE's (bilateral lower extremities) and Ambulation with rolling walker min (minimum) assist of 1. These orders were reflected in the resident's active care plan as interventions for the focus problem related to activities of daily living. There was no evidence the resident received these services in February or March 2014. The Restorative Care forms used to record the care were blank. During an interview with Employee # 39 (Nurse in charge of Restorative Care) at 8:50 a.m. on 03/25/14, she acknowledged the resident had not received the restorative care services as ordered and planned for in the care plan. She attributed… | 2018-01-01 |
| 6570 | 6570 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 311 | D | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to ensure two (2) of the thirty-seven (37) sample residents received restorative services as ordered by the physician and planned in the care plan to maintain and/or improve the resident's functional abilities. Resident identifiers: #27 and #14. Facility census 105. Findings include: a) Resident #27 A review of the medical record revealed Resident #27 was admitted to the facility on [DATE], after an extended illness in an acute care facility left her very weak. Prior to her illness she was planning orthopedic surgery to correct a lower extremity deformity. She recently received her right lower extremity ankle brace and wore a modified left shoe for comfort. She was not able to ambulate without a brace. The resident had limited range of motion (contractures) in her right shoulder, left shoulder, right ankle, and left ankle. The resident was admitted for physical therapy to improve ambulation with her new brace and to increase strength and coordination, to reach her maximum potential in preparation for surgery and return home. Her assessment stated, Patient demonstrates good rehab potential for stated goals as evidenced by prior level of function, motivation to participate, motivation to return to PLOF (prior level of function) and support systems in place. Her physical therapy continued from 01/07/14 - 02/16/14. She was discharged from physical therapy on 02/16/14, with the following goal: Restorative nursing program to be established prior to discharge in order to help pt. (patient) maintain gains achieved during physical therapy services. There was no evidence the resident received restorative nursing care, although the physician also ordered the service. When interviewed at 12:40 p.m. on 03/25/14, Employee #39, the nurse responsible for Restorative Care, confirmed restorative care was not presently being given to Resident #27. She could not state when it had cease… | 2018-01-01 |
| 6571 | 6571 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 318 | E | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident interview, and staff interview, the facility failed to ensure five (5) residents with limited range of motion, of the thirty-seven (37) residents in the Stage 2 sample, received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion in an attempt to maintain their highest level of function. Resident identifiers: #140, #87, #13, #56, and #1. Facility census: 105. Findings include: a) Resident #140 A review of the medical record revealed Resident #140 was admitted on [DATE], after hospitalization for [MEDICAL CONDITION]. His [DIAGNOSES REDACTED]. Observation of the resident at 3:30 p.m. on 03/17/14, revealed he was very small in stature and thin (weight: 98 pounds) and was non-verbal. Observation revealed he was lying in bed on a concave mattress with his legs crossed and drawn up to his body. His movements were jerky and random. During an interview with Employee #16 (LPN, direct care giver) at 10:00 a.m. on 03/18/14, the employee was asked if the resident had any contractures. The nurse replied the resident had contractures, although he received no therapy and used no splints at the present time. A review of the Physical Therapy evaluation completed on 01/06/14, revealed the resident was assessed with [REDACTED]. This was confirmed by Employee #125 (Rehabilitation Manager) at 9:45 a.m. on 03/20/14. A review of the care plan for Resident #140 failed to reveal a focus identified for limited range of motion or contractures. There was a focus item for assistance with activities of daily living (ADL) care, but it only listed each function and stated the resident required total care. There was no indication of the location of the contractures. No measurable goal was established to enable evaluation of progress or decline. There were no interventions regarding care to be provided relative to the resident's contractures. Resident #140 received phy… | 2018-01-01 |
| 6572 | 6572 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 323 | D | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to maintain an environment as free as possible from accident hazards over which the facility had control. Two (2) rooms were found with trip hazards. Resident #12's room had a length of drapery cord lying on the floor. Another room had a crack in the flooring tile resulting in a variance in floor height creating a trip hazard. In addition, an assistance device in a resident bathroom was in poor repair and was not secured properly. The identified issues had a potential to affect more than a limited number of residents. Resident identifier: #12. Facility census: 105. Findings include: a) Resident #12 A review of the medical record revealed Resident #12 was an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The resident was alert and verbal, but very confused and had poor safety awareness. He had experience three (3) falls within the previous two (2) months. During the initial tour observation, at 2:30 p.m. on 03/17/14, the resident's room was entered while he was out of the room attending an activity. The resident's room had sliding glass doors opening to an enclosed grassed area. The drapes on the doors had a long cord which was not anchored. It was lying on the floor in a large loop (approximately 3-4 feet) in an area between the bed and the patio doors. After the environmental tour, at 11:00 a.m. on 03/19/14, the above observation was related to Employee #117, a maintenance worker, who said he would check the drapery cord. During an interview with the Administrator and Employee #116 (Director of Nursing) at 10:45 a.m. on 03/20/14, they acknowledged the resident was more ambulatory when admitted , but both agreed he wandered through the halls propelling himself in his wheelchair. At 11:10 am on 03/24/14, the Administrator stated she had spoken to the maintenance supervisor, who said he installed a new curtain cord guide in the resid… | 2018-01-01 |
| 6573 | 6573 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 332 | E | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, family interview, review of medication information on the Food and Drug Administration website, staff interview, and medical record review, the facility failed to ensure the medication error rate did not exceed 5%. Four (4) errors occurred in twenty-eight (28) opportunities, resulting in a medication error rate of 14.28%. Medications were not administered according to physician's orders [REDACTED]. Resident #94's insulin was ordered to be administered before meals, but was administered after lunch. Resident #54 did not receive nasal sprays as ordered. A nurse crushed a delayed release medication for Resident #30. Facility census: 105. Resident identifiers: Resident #94, #54, and #30. Findings include: a) Resident #94 During a medication administration observation, on 03/19/14 at 12:50 p.m., Resident #94 received a dose of [MEDICATION NAME] three (3) units subcutaneously. This was after the resident had eaten lunch. Employee #125, a licensed practical nurse (LPN) said the resident often took the medication after lunch, according to his preference. Employee #125 further added the resident was on his way to lunch, and she did not want to administer the medication in the hallway. Review of the physician's orders [REDACTED]. During an interview with the resident, on 03/19/14 at 12:50 p.m., a family member stated [MEDICATION NAME] was usually taken before meals. The information about this medication on the Food and Drug Administration (FDA) website includes, WARNINGS [MEDICATION NAME] differs from regular human insulin by a more rapid onset and a shorter duration of activity. Because of the fast onset of action, the injection of [MEDICATION NAME] should immediately be followed by a meal, and DOSAGE AND ADMINISTRATION [MEDICATION NAME] should generally be given immediately before a meal (start of meal within 5 to 10 minutes after injection) because of its fast onset of action. The dosage of [MEDICATION NAME]… | 2018-01-01 |
| 6574 | 6574 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 353 | E | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview the facility failed to ensure sufficient nursing staff to meet each resident's needs and to assist each resident to attain or maintain the highest practicable physical well-being, as determined by individual assessments and plans of care. The facility failed to provide restorative nursing services, as ordered by the attending physician, for twenty-one (21) of forty-five (45) Stage 2 sample residents. The facility utilized restorative staff to cover the provision of routine care instead of restorative services, due to insufficient staffing. Resident identifiers: #1, #2, #4, #12, #14, #20, #50, #53, #54, #56, #59, #60, #66, #75, #87, #89, #94, #100, #132, #138, and #140. Facility census: 105 Findings included: a) Resident #1 On 03/25/14 at 2:10 p.m., an interview was conducted with Resident #1 after she requested to talk with someone from the state. She stated I have only received three (3) days of restorative therapy in the month of March because of the restorative staff being pulled to work the floor and this has been going on since December. Resident #1 further stated This is hindering me and I have gotten worse by not getting restorative therapy. She also stated the restorative Nursing Aides (NA) are always pulled to the floor to work because of short staffing. At 3:10 p.m. on 03/25/14 an interview was conducted with Employee #32, the Administrator and the survey team. She stated the facility was aware of the staffing problems and had utilized traveling nurses to assist with facility staffing. She said was also aware restorative services staff were utilized frequently to assist with staffing on the units since November 2013. An interview was conducted with Employee #39, a Licensed Practical Nurse (LPN), on 03/26/14 at 10:00 a.m. She introduced herself as the restorative services nurse. During the interview, when asked about Resident #1 receiving restorative services only three … | 2018-01-01 |
| 6575 | 6575 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 428 | D | 0 | 1 | BWIF11 | Based on record review and staff interview, the pharmacist failed to identify a medication irregularity during monthly medication reviews for one (1) of six (6) Stage 2 sample residents. A hand written order for insulin did not contain a route of administration. When the order was transcribed into the computer and the medication administration record (MAR), a route was added; however the route was inaccurate. Resident identifier: #66. Facility census: 105. Findings include: a) Resident #66 The medical record was reviewed on 03/19/14 at 11:00 a.m. Resident #66 was a seventy-nine (79) year old male with uncontrolled diabetes who required an Accu-chek instant glucose tests four (4) times a day to monitor his blood glucose level. Review of the resident's medical record found a medication order was handwritten in the chart on 08/06/13. The order was, HumaLOG twelve (12) units before meals. The order did not include a route of administration. The order was put into the computer system as: HumaLOG Solution injection 12 unit intramuscularly before meals related to diabetes. It had a start date of 08/07/13. The medication administration record (MAR) also had, HumaLOG Solution (Insulin Lispro (Human)) Inject 12 unit intramuscularly before meals related to diabetes . It had a start date of 08/07/13. (Note: Humalog is a rapid acting insulin. Insulin injected into a muscle is absorbed more rapidly than when injected into subcutaneous tissue.) The pharmacist's monthly medication regimen review summary indicated Pharmacist #129 reviewed the resident's medications monthly between 09/05/13 and 03/04/14. The pharmacist documented no irregularities and made no recommendations during these six (6)months. The pharmacist did not identify and report the order and MAR indicated the insulin was to be administered intramuscularly instead of subcutaneously. During an interview, on 03/19/14 at 4:30 p.m., registered nurse (RN), Employee #4, reviewed Resident #66's MAR and active orders. The nurse confirmed the insulin order contained an inco… | 2018-01-01 |
| 6576 | 6576 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 431 | D | 0 | 1 | BWIF11 | Based on observation, staff interview, and policy review, the facility failed to ensure medications were labeled in accordance with acceptable professional principles. An inhaler was stored with no label containing dispensing orders or to identify the resident to whom it belonged. Facility census: 105. Findings include: a) A220 medication cart An observation of the A220 medication cart on 03/17/14 at 4:00 p.m., found a Ventolin inhaler that was not labeled with a resident's name and was not stored in its original container. There was no label reflecting the dosage and frequency of administration. Upon inquiry, Employee #39, a licensed practical nurse (LPN), said she could not verify to whom it belonged. She said she believed it belonged to Resident #50. The facility's medication storage policy included, Medications designed for multiple administrations (e.g., inhalers, eye drops), the label is affixed in a manner to promote administration to the resident for whom it was prescribed. The LPN confirmed the medication was stored improperly. | 2018-01-01 |
| 6577 | 6577 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 441 | F | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, information obtained from the Wound, Ostomy Continence Nurses Society, and policy review, the facility failed to develop, implement, and maintain an infection prevention and control program to help prevent the onset and spread of infection. An isolation cart had no wheels and sat directly on the carpet in the hall and eye wash stations were dirty and/or in disrepair. The facility's policy did not identify who could place residents on isolation precautions or who could discontinue the precautions. In addition, the policy did not provide criteria for discontinuing isolation. Surveillance data did not identify when residents were placed on, or taken off of, isolation precautions. Staff did not employ infection control techniques to prevent transmission of microorganisms from resident to resident and/or from the environment to the resident. A glucose meter was not cleaned prior to, or after, use on a resident. Items dropped on the floor were not disposed of properly. A nurse did not wash her hands after removing gloves and accessing the treatment cart. Soiled tape was left on a hand rail. These issues had the potential to affect all residents. Resident identifiers: #56, #12, #112, #97, and #24. Facility census: 105. Findings include: a) Resident #56 Wound dressing changes were observed for Resident #56, on 03/19/14 at 3:30 p.m. Employee #88, a registered nurse (RN), entered the room and washed her hands. Wound care supplies were already on the over-bed table. The RN donned gloves and initiated care of the resident's fourth inner toe. The table was on the opposite side of the bed, away from the nurse's reach. The nurse obtained saline spray and placed it on the resident's mattress without a barrier. After cleansing the wound, she related she needed a measuring grid. The nurse removed her gloves, but did not sanitize her hands before obtaining the grid from the treatment cart, which was located in the hallway… | 2018-01-01 |
| 6578 | 6578 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 465 | D | 0 | 1 | BWIF11 | Based on a random observation and staff interview, the facility failed to ensure a sanitary and comfortable environment. Wet linens were not removed from a resident's bed prior to the bed being made. Resident identifier: #68. Facility census: 105. Findings include: a) Resident #68 While conducting an environmental tour of the facility, at 10:30 a.m. on 03/19/14, room 314 was entered. Resident #68 was out of the room at the time. There was a strong odor of urine noted upon entering the room. It was determined the odor was not emanating from the bathroom or the bed/resident near the door. Employee #9 (Patient Care Aide) was directly outside the room and entered, when requested to do so. The aide turned down the covers of the bed near the window (Resident #68's bed), which had already been made. Employee #9 confirmed the bed was wet with urine, but stated she had not been the one who made it. She sought the assistance of Employee #21 (Housekeeper) and they stripped and changed the bed. The incident was reported to the DON during an interview at 2:45 p.m. on 03/19/14. He stated he had already been made aware and was looking into the matter. | 2018-01-01 |
| 6579 | 6579 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 490 | F | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, observations, and staff interviews, the facility was not administered in a manner which ensured each resident attained or maintained his/her highest practicable well-being. Needed environmental repairs were not addressed and/or prioritized for repair according to potential for harm. Thirty-eight (38) residents were not provided restorative nursing services as ordered and/or care planned due to insufficient staffing. Administration was aware of these issues, but failed to ensure they were promptly addressed. This practice had the potential to affect all residents. Facility census: Findings include: a) Environment Observations, resident interview, and staff interview revealed the facility failed to provide effective housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable interior. Floor tiles had cracks that were filled with dirt/debris, screens on sliding glass doors were loose, draperies were not hanging properly, and tiles in one room were uneven. 1) A tour of the 300 hall at 10:30 a.m. on 03/19/14, revealed the following observations: -- Rooms #322 and #323 had sliding glass doors opening to an enclosed yard. The screens on the doors were hanging loose from their frames on the outside of the glass. The screens banged on the doors when the wind blew. -- Rooms #310 and #328 had curtains on the sliding doors which were hanging loose in places where they had come loose from the rail. Resident #34 in room [ROOM NUMBER], stated the drapes had been like this a long time. -- Rooms #310, #326, #335, and #328 had floor tiles with many cracks running the width of the room. The cracks were blackened, which revealed an inability to remove all soil from the cracks. In room [ROOM NUMBER] the crack in the floor tile was wider and raised on one side and spanned the width of the room. The difference in the height of the flooring had the potential to cause a person to stumble when crossing the area… | 2018-01-01 |
| 6580 | 6580 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 514 | D | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the accuracy of the medical record for one (1) of six (6) Stage 2 sampled residents. an order for [REDACTED]. When the order was transcribed into the computer and the medication administration record (MAR), a route was added; however the route was inaccurate. Resident identifier: #66. Facility census: 105. Findings include: a) Resident #66 Review of the resident's medical record on 03/19/14 at 11:00 a.m., found on 08/06/13, a medication order was handwritten in the chart. The order was, HumaLOG twelve (12) units before meals. The order was written into the computer system as: HumaLOG Solution injection 12 unit intramuscularly before meals related to diabetes. with a start date of 08/07/13. The order on the medication administration record (MAR) was written as: Humalog Solution Insulin [MEDICATION NAME] (Human) Inject 12 unit intramuscularly before meals related to diabetes. with a start date of 08/07/13. On 03/19/14 at 4:10 p.m., licensed practical nurse (LPN), LPN #93, reported an order can be written by a nurse, physician, or nurse practitioner. The order was reviewed by the nurse and transcribed to the MAR. The order slip was sent to the medical records department and was transcribed into the computer system within twenty-four (24) hours. During an interview on 03/19/14 at 4:30 p.m., a registered nurse (RN), RN #4, reviewed the original handwritten insulin order dated 08/06/13. The nurse agreed the handwritten order was incomplete. RN #4 reviewed the MAR and active orders and confirmed the insulin order contained an incorrect route. Humalog insulin is not given intramuscularly. ( Humalog is a rapid acting insulin. Insulin injected into a muscle is absorbed more rapidly than when injected into subcutaneous tissue.) At 4:38 p.m., RN #4 presented an in-service training sheet with the topic Order transcription and clarification. Six rights of medication administr… | 2018-01-01 |
| 6581 | 6581 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2014-03-27 | 520 | F | 0 | 1 | BWIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, observations, and staff interviews, the facility's quality assurance (QA) program failed to develop and implement appropriate plans of action to correct quality deficiencies of which it had, or should have had knowledge. Needed environmental repairs were not addressed and/or prioritized for repair according to potential for harm. Thirty-eight (38) residents were not provided restorative nursing services as ordered and/or care planned due to insufficient staffing. The QA committee was aware the services were not being provided. There was no evidence the QA committee took prompt action to address these quality deficiencies. These quality deficiencies had the potential to affect all residents. Facility census: 105 Findings include: a) Environment Observations, resident interview, and staff interview revealed the facility failed to provide effective housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable interior. Floor tiles had cracks that were filled with dirt/debris, screens on sliding glass doors were loose, draperies were not hanging properly, and tiles in one room were uneven. 1) A tour of the 300 hall at 10:30 a.m. on 03/19/14, revealed the following observations: -- Rooms #322 and #323 had sliding glass doors opening to an enclosed yard. The screens on the doors were hanging loose from their frames on the outside of the glass. The screens banged on the doors when the wind blew. -- Rooms #310 and #328 had curtains on the sliding doors which were hanging loose in places where they had come loose from the rail. Resident #34 in room [ROOM NUMBER], stated the drapes had been like this a long time. -- Rooms #310, #326, #335, and #328 had floor tiles with many cracks running the width of the room. The cracks were blackened, which revealed an inability to remove all soil from the cracks. In room [ROOM NUMBER] the crack in the floor tile was wider and raised on one side and spanned the… | 2018-01-01 |
| 6583 | 6583 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 278 | D | 0 | 1 | WK5211 | Based on record review and staff interview, the facility failed to complete a Minimum Data Set (MDS) discharge tracking assessment for one (1) of twenty-six (26) resident admission records reviewed in Stage 1 of the Quality Indicator Survey (QIS). Resident identifier: #119. Facility census: 95. Findings include: a) Resident #119 During Stage 1 admission record review of the QIS, Resident #119's medical record was reviewed on 03/25/14 at 10:00 a.m. The review revealed the resident was discharged to another long term care facility on 02/24/14. Review of the MDS tracking found no evidence a MDS discharge tracking form was completed. Interview with Employee #2, director of nursing, on 03/26/14 at 1:15 p.m., confirmed a MDS tracking form was not completed. | 2018-01-01 |
| 6584 | 6584 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 279 | D | 0 | 1 | WK5211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observations, the facility failed to develop a comprehensive care plan for two (2) of nineteen (19) residents whose care plans were reviewed during Stage 2 of the quality indicator survey. Resident #95 was receiving hospice services. The care plan did not address the coordination of responsibilities between hospice staff and facility staff. Accident hazards were not addressed in the care plan for Residents #67 who spilled hot coffee on himself. Resident Identifiers: #95 and #67. Facility Census: 95 Findings Include: a) Resident #95 Resident #95's medical record was reviewed at 6:22 p.m. on 03/26/14. This review revealed Resident #95 had been receiving hospice services since 02/03/14. Review of the care plan, initiated on 02/03/14, revealed a care plan for hospice which was not individualized for Resident #95. The focus statement was, Palliative Care due to disease process under hospice services. Review of the care plan revealed the following interventions: Hospice CNA to visit and Hospice nurse to visit. The interventions did not specify when the CNA or Nurse would visit, nor did they specify what care each would provide during their visits to the facility. Employee #4, Registered Nurse Assessment Coordinator, RNAC, was interviewed at 10:04 a.m. on 03/27/14. Employee #4 stated she was the RNAC who completed Resident #95's care plan. She reviewed the care plan and stated she was not sure why this care plan was not specific related to the days of the week the Hospice CNA was coming to the building and what the CNA would do for the resident while at the facility. The RNAC also confirmed the specific tasks for the hospice nurse were not included in the care plan. b) Resident #67 Review of the facility's incident / accident reports, at 8:56 a.m. on 03/26/14, found on two (2) occasions the resident spilled hot coffee on himself. On 03/01/13 at 8:11 a.m., the resident spilled a cup of hot coffee on his le… | 2018-01-01 |
| 6585 | 6585 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 280 | D | 0 | 1 | WK5211 | **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 three (3) of nineteen (19) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The care plans / interventions were not revised after Resident #26 no longer required bed rest. The care plan was not updated to reflect the addition of a lower extremity orthotic device ordered for Resident #117. The care plan for Resident #20 was not revised after a dental consult. Resident identifiers: #26, #117 and #20. Facility census: 95. Findings include: a) Resident #26 Review of the medical record on 03/25/14 found the resident had a history of [REDACTED]. The care plan contained a focus problem, updated on 12/02/13: (name of resident) experienced an actual fall and has a history of falls while out with family and in her room, she is at risk for further falls. On 01/07/14, an intervention was initiated for prevention of falls. It included Bedrest for 2 to 3 days. The resident's nursing assistant, Employee #102, was interviewed at 4:00 p.m. on 03/25/14. Employee #102 stated the resident was no longer on bed rest. Employee #4, the registered nurse assessment coordinator (RNAC), was interviewed on 03/25/14 at 4:11 p.m. Employee #4 stated the bed rest was initiated after a fall which occurred on 01/05/14. She verified the resident was no longer on bed rest, and the intervention should have been removed from the care plan. b) Resident #117 Medical record review on 03/26/14 found the resident currently had a Stage III pressure area to the left outer ankle, and an unstageable pressure area to the left lateral foot. The physician's orders [REDACTED]. Review of the current care plan, revised on 03/26/14, found a focus problem: (Name of resident) has a pressure ulcer upon return from hospital to left outer ankle. Currently has excoriation to buttocks. Pressure ulcer to left lateral foot. The 03/26/14 care plan did not include the orthotic device which wa… | 2018-01-01 |
| 6586 | 6586 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 323 | D | 0 | 1 | WK5211 | Based on observation, staff interview, and record review, the facility failed to ensure an environment which was as free as possible from accident hazards over which the facility had control. The facility failed to implement interventions, including adequate supervision, which was consistent with the needs for one (1) of three (3) residents reviewed who had accidents with spilled hot liquids. Resident identifier #67. Facility census: 95. Findings include: a) Resident #67 Review of incident/accident reports, at 8:56 a.m. on 03/26/14, revealed the resident spilled hot coffee on himself on 03/01/13. A reddened area, measuring seven (7) centimeters (cm) X four (4) cm., was noted on his left side and back area. The follow-up documentation was for staff to cool Resident #67's coffee prior to service. Another incident, dated 09/13/13 at 12:48 p.m., revealed Resident #67 again spilled hot coffee on himself. This time he sustained a reddened area to his right anterior forearm near the elbow. Review of the facility follow-up notes, dated 09/14/13 to 09/16/13, under the section titled, interventions put in place to prevent reoccurrence, the only intervention was to monitor the area. The interventions did not describe how the facility would prevent the same accident in the future. At 9:50 a.m. on 03/26/14, Employee #9, the dietary manager (DM), was interviewed. The DM stated kitchen staff provided a pitcher of ice cubes with the coffee, and staff were instructed to cool the coffee of residents at the time of service. At 10:45 a.m. on 03/26/14, the care plan for Resident #67 was reviewed. The care plan did not address safety issues or a plan to protect the resident from burns related to hot coffee. The previous two (2) burns, and the potential for burns related to hot coffee, were not addressed in the care plan. Observation of the noon meal, which began at 12:16 p.m. on 3/26/14, found Resident #67 was provided with a cup of coffee. Although there was an intervention to cool the resident's coffee after the incident on 03/01/13… | 2018-01-01 |
| 6587 | 6587 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 329 | D | 0 | 1 | WK5211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident's medication regimen was free from unnecessary medications for three (3) of five (5) residents reviewed for unnecessary medication during Stage 2 of the Quality Indicator Survey. The facility failed to monitor an apical pulse prior to the administration of [MEDICATION NAME] (a heart medication) for Resident #13. For Resident #80, the facility failed to attempt a gradual dose reduction for the use [MEDICATION NAME](a hypnotic). Resident #45 was receiving [MEDICATION NAME] (a [MEDICAL CONDITION] medication) without monitoring of identified behaviors. Resident identifiers: #13, #80 and #45. Facility census: 95. Findings include: a) Resident #13 The medical record for Resident #13 was reviewed on 03/26/14 at 2:15 p.m. Resident #13's [DIAGNOSES REDACTED]. The March 2014 physician's orders [REDACTED]. The Nursing 2014 Drug Handbook, the medication reference book used by the facility's licensed nurses, was reviewed on 03/26/14. The directions for oral administration for [MEDICATION NAME] (on page 442) instructed an apical pulse should be taken for one (1) minute before administering [MEDICATION NAME]. This information was to be recorded, and the prescriber notified of significant changes in the pulse. Review of the Medication Administration Record [REDACTED]. Interview with Employee #2, the director of nursing (DON), on 03/26/14 at 4:00 p.m., confirmed an apical pulse was to be obtained prior to the administration of [MEDICATION NAME]. She further confirmed Resident #13 received the medication without monitoring of the apical pulse. On 03/26/14 at 5:15 p.m., a telephone interview was conducted with Employee #142, the consultant pharmacist. He confirmed the medication, [MEDICATION NAME], required an apical pulse to be obtained prior to the administration of the medication. b) Resident #80.Resident #80's medical record was reviewed on 03/26/14 at 1:00 p.m. The resid… | 2018-01-01 |
| 6588 | 6588 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 364 | E | 0 | 1 | WK5211 | Based on resident interview, staff interview, observation, and food temperature assessment, the facility failed to ensure hot food items were served at the temperature satisfactory to the residents. Four (4) of twelve (12) residents interviewed during Stage 1 of the Quality Indicator Survey (QIS) voiced complaints about food temperatures. Resident identifiers: #12, #92, #37, and #52. Facility census: 95. Findings include: a) Resident interviews During Stage 1 of the QIS, the following interviewable residents were asked, Is the food served at the proper temperature? 1. Resident #12 Resident #12 was interviewed at 4:37 p.m. on 03/24/14. The resident stated the food was cold, and he could not eat it. 2. Resident #92 Resident #92 was interviewed at 1:51 p.m. on 03/25/14. The resident stated sometimes the food was cold. 3. Resident #37 The resident was interviewed at 11:08 a.m. on 03/25/14. She complained of receiving cold food. 4. Resident #52 The resident was interviewed at 4:33 on 03/24/14. She stated the breakfast meal was usually cold, especially the eggs and coffee. b) On 03/06/14 at 8:15 a.m., food temperatures were obtained at the time of service on B-hall by Employee #9, the dietary manager. According to professional standards of practice, hot foods should be served at or above 120 degrees Fahrenheit. The scrambled eggs were 103 degrees Fahrenheit and the bacon was 89 degrees Fahrenheit. c) On 03/06/14 at 8:20 a.m., observation of the food temperature log with Employee #91, the cook and Employee #9, the dietary manager, found the temperature of the eggs was recorded as 182.2 degrees Fahrenheit before leaving the kitchen. The temperature of the bacon was not recorded on the food temperature log before leaving the kitchen. The dietary manager confirmed the temperature of the eggs and bacon at the time of service was not acceptable. | 2018-01-01 |
| 6589 | 6589 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 371 | F | 0 | 1 | WK5211 | Based on observation and staff interview, the facility failed to ensure foods were stored in a manner which maintained sanitary conditions. Food items found in the reach-in refrigerator were without labels and/or dates. Food items were not dated to indicate when they were opened or prepared and/or when they should be discarded. This had the potential to affect all residents who received nourishment from the dietary department. Facility census: 95. Findings include: a) During the initial tour of the kitchen with Employee #93, the dietary services assistant, at 2:45 p.m. on 3/24/14 the following unlabeled and/or undated food items were found in the reach-in refrigerator: -- a Styrofoam container of ribs -- a stick of butter in a storage bag -- several slices of cheese in a storage bag -- a serving tray containing various food items in bowls -- several glasses of beverages and two (2) sandwiches. Employee #93 stated she would discard the food items. The above observations were discussed with Employee #9, the dietary manager, at 10:00 a.m. on 03/25/14. | 2018-01-01 |
| 6590 | 6590 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 428 | D | 0 | 1 | WK5211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the identification of medication irregularities and/or act on identified irregularities for two (2) of six (6) residents reviewed. Resident #80 had a physician's orders [REDACTED]. The pharmacist failed to identify the facility was not obtaining an apical pulse prior to the administration of the medication. In addition, the pharmacist recommended Resident #13 have a gradual dose reduction of Ambien. This was not acted upon by the physician. Resident identifier: #13 and 80. Facility census: 95.Findings include: a) Resident #13A medical record review was completed at 2:30 p.m. on 03/26/14. This review revealed the resident had a physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. This review revealed the resident had not had an apical pulse recorded during this time frame. The medical record revealed a chronological record of medication regimen reviews for Resident #13. The pharmacist reviewed the resident's drug regimen on 01/07/14, 02/03/14 and 03/06/14. The pharmacist failed to identify an apical pulse was not being obtained prior to the administration of Digoxin. Employee #2, Director of Nursing (DON), was interviewed at 3:00 p.m. on 03/26/14. She confirmed the pharmacist had failed to identify the need for an apical pulse prior to the administration of Digoxin. On 03/26/14 at 5:15 p.m. an interview by phone was conducted with Employee #142, consultant pharmacist. He confirmed the medication, Digoxin, required an apical pulse to be obtained prior to the administration of the medication. He further confirmed he failed to identify the need for an apical pulse prior to the administration of Digoxin.b) Resident #80Medical record review, on 03/26/14 at 10:30 a.m., revealed on 02/03/14, the pharmacist had made a recommendation for a gradual dose reduction (GDR) for Ambien. The physician had declined the recommendation, noting doing well o… | 2018-01-01 |
| 6591 | 6591 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 441 | E | 0 | 1 | WK5211 | Based on observations and staff interview, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of disease and infection. The staff placed a contaminated tray on a meal cart containing a clean tray. This had the potential to affect more than a isolated number of residents. Facility census: 95. Findings include: a) Observation of the breakfast meal cart on B-hall at 8:15 a.m. on 03/26/14 with the dietary manager (DM), Employee #9, found the contaminated meal tray of Resident #116 was placed in the cart containing a clean meal tray. Several nursing assistants were present in the hallway when the observation was made with Employee #9. At the time of discovery, only one (1) tray, belonging to Resident #81, remained on the meal cart. When questioned, facility staff members were unable to state who placed the meal tray in the meal cart, or how long the meal tray had been on the cart. For this reason, it could not be determined if other residents' meal trays were contaminated by Resident #116's meal tray. The DM confirmed this practice was not acceptable and he ordered another tray for Resident #81. | 2018-01-01 |
| 6592 | 6592 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2014-03-27 | 514 | D | 0 | 1 | WK5211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the medical record for one (1) of six (6) residents reviewed during Stage 2 of the Quality Indicator Survey was accurate and complete. A physician ordered laboratory service was not provided. The medical record contained no documentation regarding why the laboratory service was not obtained for the resident. Resident identifier: #94. Facility census: 95. Findings include: a) Resident #94 Medical record review, on 03/26/14, found a nurse's note, dated 01/14/14, Daughter visiting and concerned that patient is weak and not eating well. Patient had poor po ( by mouth) intake for breakfast and lunch. Skin warm and dry. Skin turgor good. No signs of dehydration at this time. Per (Name of physician) ordered Align one daily and UA (urinalysis) and C & S (culture and sensitivity) if indicated. Further review of the medical record found no evidence the urinalysis was obtained as ordered. The medical record had no physician's order which rescinded the UA and C & S orders. The director of nursing (DON) was interviewed at 5:52 p.m. on 03/26/14. She was asked if the urinalysis was obtained. During an interview at 6:00 p.m. on 03/26/14, the DON stated the physician came in the following day (01/16/14) to visit the resident before the urinalysis was obtained. She said the physician decided the urinalysis was not needed because the resident was on [MEDICATION NAME] for [MEDICAL CONDITIONS]. The DON was unable to provide documentation regarding this statement, or other verification the order was discontinued. On 03/26/14, after intervention during the survey, the physician entered a late entry, note for 01/15/14. The noted stated: . Advised staff urinalysis would likely not be necessary to obtain, as her symptoms were related to recurrent [MEDICAL CONDITION] infection of the stool | 2018-01-01 |
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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 );