cms_WV
Data source: Big Local News · About: big-local-datasette
36 rows where "inspection_date" is on date 2014-08-14
This data as json, copyable, CSV (advanced)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6010 | 6010 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 166 | D | 0 | 1 | K1XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, staff interview, resident interview, and family interview, the facility failed to ensure prompt efforts were made to resolve issues residents had, and also failed to keep resident and family members informed of progress toward resolution. This was found for two (2) of forty-six (46) residents reviewed and one (1) randomly reviewed resident. Resident identifiers: #103, #25, and #105. Facility census: 94. Findings include: a) Resident #103 Record review, beginning on 08/06/14 at 10:14 a.m., found this [AGE] year-old woman was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was sent out to an out of state behavioral health unit on 07/25/14 due to escalating behaviors. During investigation of the facility's care for the maintenance of her nutritional status, it was discovered staff identified she had lost her dentures. The review found an inventory of personal items completed upon admission, 03/21/14, documented Resident #103 had both upper and lower dentures. The registered dietitian's medical nutrition therapy assessment, dated 06/24/14, included the statement, (typed as written): CNA (certified nursing assistant) believes resident does wear upper dentures but her lower dentures are lost. The resident was receiving a regular diet for both nutrients and texture. The nursing assessment completed upon admission (on 03/21/14) documented Resident #103 had both upper and lower dentures. The nursing assessment completed 06/24/14 documented Resident #103 had no dentures. On 08/06/14 at 11:57 a.m., information was requested from the director of nursing (DON), Employee #17, regarding any staff awareness of the missing dentures prior to 06/24/14, and any documented attempts to locate them or inform anyone of the loss. On 08/06/14 at 2:47 p.m., the DON confirmed that the exact date the dentures went missing could not be determined, but was documented as at least as far back as 06/24/14. He presented a Grievance/C… | 2018-05-01 |
| 6011 | 6011 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 225 | F | 0 | 1 | K1XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on employee personnel file review, review of Chapter 514.4.1 of the Medicaid manual and a clarification memorandum from the Bureau for Medical Services (BMS) regarding the requirements for criminal background checks to meet the requirements of the Affordable Care Act, and staff interview, the facility failed to ensure individuals who had been employed more than three (3) years had had another criminal background check to determine whether the individuals had been found guilty of abuse, neglect, or mistreatment of [REDACTED]. This was not completed for seven (7) of fifteen (15) employees whose personnel files were reviewed. This practice had the potential to affect all residents. Employee identifiers: #20, #35, #45, #78, #79, #87, and #104. Additionally, the facility failed to ensure all allegations of mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, were reported immediately to the administrator of the facility and to other officials in accordance with State law. This was found for three (3) of forty-six (46) complaints reviewed, and had the potential to affect more than a limited number of residents. Resident identifiers: #42, #43, and #34. Facility census: 94. Findings include: a) On 08/06/14 at 11:05 a.m., a review of the personnel files for tenured employees was conducted with Employee #38, the payroll/human resources person. This review identified the following: 1. Employee #20 A review of the personnel file for Employee #20, a cook, who was hired on 06/09/11, revealed no evidence of an up to date statewide criminal background check completed since her hire date. 2. Employee #35 Upon a review of the personnel file for Employee #35, a NA, who was hired on 10/24/1994, revealed no evidence of an up to date statewide criminal background check was completed since her hire date. 3. Employee #45 Review of the personnel file for Employee #45, a nurse aide (NA) who was hired on… | 2018-05-01 |
| 6012 | 6012 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 241 | E | 0 | 1 | K1XR11 | , Based on observation and staff interview, the facility failed to ensure the dignity of the residents who required total feeding by staff as exhibited by staff members addressing residents with a label instead of their name in a hallway where others could overhear. Resident #24 was referred to as a Feed. This had the potential to affect more than an isolated number of residents. Resident identifier: #24. Facility census: 94. Findings include: a) Resident #24 During the observation of the medication pass at 8:30 a.m. on 08/06/14, an alert and oriented resident approached Employee #118 (nurse aide) in her wheelchair in the hallway and asked the nurse aide for assistance. In the immediate presence of Resident #24, Employee #42 (nurse administering medications), and the surveyor, the nurse aide answered the resident by saying she would assist her . as soon as I check on the Feeds. She then continued to the tray carts sitting in the hallway. During an interview with the Director of Nursing at 12:15 p.m. on 08/14/14, he was informed of the incident and told similar episodes had been observed during the survey. He stated this was not appropriate and he would address this with staff. | 2018-05-01 |
| 6013 | 6013 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 252 | E | 0 | 1 | K1XR12 | Based on observation and staff interview, the facility failed to ensure a homelike environment which de-emphasized the institutional character of the setting. The facility was not free, to the extent possible, of unpleasant odors. Urine odors from the laundry, odor of urine from a recognized resident source, and the odor of permanents from the beauty shop lingered and/or reoccurred throughout Hilltop unit. The facility had a cover-up deodorizer to use after the odors occurred; however, staff did not always use the deodorizer when needed. There was no evidence the facility attempted a preventative solution to eliminate the known odors. This had the potential to effect all (46) residents residing on Hilltop unit. Facility census: 83. Findings include: a) At 9:30 a.m. on 11/05/14, a strong odor of urine was noticed coming from room #149. It could be smelled beyond the nurses station at the end of the hall. Employee #91, a licensed practical nurse (LPN) stated a resident who resided in that room had become agitated and refused to allow staff to change her brief. She said this happened often and they would try again later. At 11:30 a.m., the strong urine odor was still present and could be detected throughout Hilltop hall, including the Solarium. The odor was present outside the main dining room, which was filling with residents for the noon meal, and became stronger at the entry to Hilltop hall. The Administrator (NHA) was approached in her office, at 11:30 a.m. on 11/05/14. She was told of the odor, and was asked what was done to dispel odors in the facility. The NHA immediately said she thought the odor was coming from the laundry. She added that there were odors into the hall from the laundry at times, and she went to check. The laundry was located between the dining room and Hilltop hall. The NHA returned and acknowledged the odor was from the laundry. She said she did not know know what had been done to dispel it. The NHA stated she would refer the answer to the housekeeping supervisor (Employee #59) when he ret… | 2018-05-01 |
| 6014 | 6014 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 253 | E | 0 | 1 | K1XR11 | Based on observation and staff interview, the facility failed to provide to provide effective housekeeping and maintenance services in eleven (11) of thirty-five (35) rooms observed during Stage 1 and Stage 2 of the survey. Environmental issues included missing and peeling wallpaper, discolored and stained caulking around the toilet base, loose and missing baseboards, missing caulking around the sink counter top, stained and discolored baseboards under the sink, missing bathroom floor thresholds, rusted metal toilet paper holder, scratched door frames, scratched and discolored sink basin, cracked and missing floor tile in bathrooms and resident rooms, cracked and missing plaster near a sink and a gouged and scratched bathroom doors. This practice had the potential to affect more than an isolated number of residents. Room numbers: #101, #105, #106, #110, #136, #138, #143, #144, #145, #146, and #166. Facility census: 94 Findings include: a) On 08/12/14 at 2:30 p.m., accompanied by Employee #105, the Maintenance Director, a tour of the facility was conducted. The tour revealed the following issues: 1. Room #101: The wall plaster was cracked and had missing pieces near the sink located within the resident's room. The caulking located around the base of the toilet in the bathroom was stained and discolored. 2. Room #105: The floor tile in the resident room had multiple cracks. 3. Room #106: The floor tile in the room was stained and had multiple cracks. There was stained and discolored caulking around the base of the toilet in the bathroom. 4. Room #110: The heating/air conditioning unit located in the room under the window had wires visible and protruding from the base of the unit. The floor tile in the room had multiple cracks. The toilet located in the bathroom had stained and discolored caulking around the base. 5. Room #136: The sink counter located in the room had missing laminate measuring 3 inches by 4 inches on the left lower corner revealing the pressed fiberboard. Also the front lower lip of the sink counte… | 2018-05-01 |
| 6015 | 6015 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 272 | D | 0 | 1 | K1XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure the accuracy of the comprehensive minimum date set (MDS) assessment for one (1) of thirty-six (36) Stage 2 residents in the sample. A significant change in status assessment for Resident #85's indicated his care needs were less than actually required. Resident identifier: #85. Facility census: 94. Findings include: a) Resident #85 A review of the medical record revealed Resident #94 was a [AGE] year-old male with [DIAGNOSES REDACTED]. A review of the Admission MDS, with an assessment reference date (ARD) of 11/07/14, revealed in Section G, the resident was coded as requiring extensive assist to total care for all activities of daily living (ADLs). He was care planned to meet these needs. His needs assessments for the 60-day MDS of 12/26/13 and a Significant Change (SC) MDS of 02/04/14, both mirrored the Admission assessment of his needs. The SC MDS submitted on 05/07/14, indicated the resident went from total care (coded as 4) to supervision only (coded as 1) in locomotion and from total care to extensive assistance for toileting, personal hygiene, and bathing. The most recent MDS (a quarterly on 07/25/14) indicated the resident had returned to his prior status in all aspects. The resident was observed during the survey in bed at all times. He was on a turning schedule in an attempt to prevent pressure areas from developing and received one-on-one activities three (3) times weekly in his room. He was fed by staff. During an interview with Employee #98 (Social Worker) at 11:00 a.m. on 08/12/14, she stated Resident # 85 had remained in the same physical state since admission. She reviewed his care plan meeting notes and added her own memories of the meetings in her evaluations. During an interview with Employees #31 and #86 (nurses responsible for the MDSs) at 3:30 p.m. on 08/13/14, Employee #31 stated, after reviewing the data, the 05/07/14 MDS was incorrec… | 2018-05-01 |
| 6016 | 6016 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 280 | E | 0 | 1 | K1XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the care plans for three (3) of 36 Stage 2 sample residents (#103, #98, and #77) and four (4) randomly reviewed residents (#90, #104, #18, and #66) were revised as needed and/or were reviewed by an interdisciplinary team which included a registered nurse (RN) with responsibility for the residents. The care plan for Resident #103 was not revised when the resident's health status declined. The care plans for Residents #77, #98, #90, #104, #18, #66, who resided on the Alzheimer's unit, were not reviewed by an interdisciplinary team which included a RN with responsibilities in the care of the Alzheimer/Dementia resident. Resident identifiers: #77, #98, #90, #104, #18, #67, and #103. Facility census: 94. Findings include: a) Resident #77 A review of the medical record revealed Resident #77 was a [AGE] year old female admitted to the facility's Alzheimer's/Dementia Special Care Unit on 05/25/12. Her [DIAGNOSES REDACTED]. She had 37 reported falls within the past six (6) months. A review of the attendance roster of Care Plan meetings held on 10/03/13, 01/08/14, and 05/07/14, revealed the only professional nurses present were the Clinical Reimbursement Coordinator (Employee #31) and/or a Licensed Practical Nurse. Only the care plan meeting on 07/30/14 revealed attendance of an RN (Employee #7) with responsibilities in the care of the Alzheimer/Dementia resident. b) Resident #98 A review of the medical record revealed Resident #98 was a [AGE] year old male admitted to the Alzheimer's/Dementia Unit on 07/16/13. His [DIAGNOSES REDACTED]. His behaviors include refusing to bathe, wandering (walks almost continuously), verbal abuse, and socially inappropriate verbalization. A review of the attendance roster of Care Plan meetings held on 07/07/13, 10/31/13, and 01/20/14, revealed the only professional nurses present was the Clinical Reimbursement Coordinator (Employee #31) and/or a Li… | 2018-05-01 |
| 6017 | 6017 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 282 | D | 0 | 1 | K1XR11 | Based on record review, staff interview, and policy review, the facility failed to ensure direct care giving staff were knowledgeable of the care and services needed to care for a resident. This was found for one (1) of three (3) Stage 2 residents reviewed for accidents. Resident #32 experienced an unobserved fall in her room on 07/23/14. The revised care plan information was not transferred to the nurse aide Kardex (the method by which nursing assistants are notified of residents' care plans and needs), and direct care staff were unaware of the resident's recent fall. Resident identifier: #32. Facility census: 94. Findings include: a) Resident #32 Review of the medical record and the incident and accident log, on 08/06/14 at 3:06 p.m., revealed Resident #32 experienced an unobserved fall in her room on 07/23/14 at 10:15 p.m. She was found on the floor beside her bed. A fall mat was ordered and placed on the left side of the bed on 07/24/14 and the care plan was updated on 07/29/14. The nurse aide (NA) Kardex with a print date of 08/06/14, was blank in the section labeled Accidents - Fall Risk. The Kardex lacked any information regarding the resident's recent fall or the addition of the fall mat to the left side of the bed. During an interview on 08/07/14 at 8:35 a.m., Nurse Aide (NA) #54, reported Resident #32, required assistance with all care including repositioning every two (2) hours. The NA said the resident did not move so she could not have had a recent fall. The NA said residents were identified as being at risk for falls by a bracelet on their wrist, and Resident #32 did not have a fall bracelet on her wrist. NA #9, was interviewed on 08/07/14 at 8:45 a.m She was also unaware of Resident #32's recent fall. She reported residents were identified as at risk for falls on their Kardex and with a sticker above the bed. There was no sticker found above Resident #32's bed and the Accident - Fall Risk section of the Kardex was blank. The director of nursing (DON), Employee #17, was interviewed on 08/11/14 at 11… | 2018-05-01 |
| 6018 | 6018 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 309 | D | 0 | 1 | K1XR12 | Deficiency Text Not Available | 2018-05-01 |
| 6019 | 6019 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 315 | D | 0 | 1 | K1XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to have evidence of an acceptable medical justification for the continued use of an indwelling urinary catheter for one (1) of three (3) residents reviewed for the care area of urinary catheters in Stage 2 of the survey. Resident identifier: #85. Facility census: 94. Findings include: a) Resident #85 A review of the medical record revealed Resident #85 was a [AGE] year old male with [DIAGNOSES REDACTED]. The resident was admitted to the facility with a urinary catheter in place on 01/23/14. The resident's care plan stated, Resident has a urinary obstruction due to hypertrophy of the Prostate, although all [DIAGNOSES REDACTED]. A review of the physician's progress notes failed to identify any medical reason for the catheter although the orders for maintenance of the catheter were continued monthly. Review of the record failed to show evidence the resident's retention of urine had ever been assessed or that a urinary consult had been done. In an interview with the Director of Nursing at 4:00 p.m. on 08/12/14, he stated he had reviewed the record and verified the urinary catheter had been in place since admission. He had not located documentation of an evaluation for [MEDICAL CONDITION] or any medical reason for the presence of the catheter. | 2018-05-01 |
| 6020 | 6020 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 323 | D | 0 | 1 | K1XR11 | Based on observation, record review, staff interview, and policy review, the facility failed to ensure one (1) of three (3) residents reviewed for falls was as free as possible from accident hazards over which the facility had control. The resident's care plan was revised after a fall. A new intervention to prevent injury was established, but the intervention was not transferred to the nurse aide (NA) Kardex, the method by which NAs are informed of residents' care plans, interventions, and individual needs. Direct care staff were unaware of the resident's recent fall. Resident identifier: #32. Facility census: 94. Findings include: a) Resident #32 Review of the resident's medical record and review of the incident and accident log, on 08/06/14 at 3:06 p.m., revealed Resident #32 experienced an unobserved fall in her room on 07/23/14 at 10:15 p.m. She was found on the floor beside her bed. A fall mat was ordered and placed on the left side of the bed on 07/24/14. The care plan was updated on 07/29/14. The nurse aide (NA) Kardex with a print date of 08/06/14, was blank in the section labeled Accidents - Fall Risk. The Kardex lacked any information regarding the resident's recent fall or the addition of an intervention for a fall mat to the left side of the bed. During an interview, on 08/07/14 at 8:35 a.m., Nurse aide (NA) #54, reported Resident #32, required assistance with all care including repositioning every two (2) hours. The NA said the resident did not move, so she could not have had a recent fall. According to the NA, residents were identified as being at risk for falls by a bracelet on their wrist, and Resident #32 did not have a fall bracelet on her wrist. NA #9 was interviewed on 08/07/14 at 8:45 a.m. She was also unaware of Resident #32's recent fall. She reported residents who were at risk for falls were identified on their Kardex and with a sticker above the bed. There was no sticker found above Resident #32's bed and the Accident - Fall Risk section of the Kardex was blank. The director of nursing (D… | 2018-05-01 |
| 6021 | 6021 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 325 | D | 0 | 1 | K1XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for nutrition maintained, to the extent possible, acceptable parameters of nutritional status. The resident had a significant weight loss. The facility did not recognize and address the loss of her dentures as a potential contributing factor for the weight loss. Resident identifier: #103. Facility census: 94. Findings include: a) Resident #103 This resident triggered for a Stage 2 investigation during the Quality Indicator Survey due to a 7.4% weight loss. Review of the resident's medical record, beginning on 08/06/14 at 10:14 a.m., found this [AGE] year-old resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review found her weight record as documented since admission, found the following weights were recorded. -- 03/22/14 - 122.4 pounds (admitted [DATE]) -- 03/24/14 - 113.4 pounds -- 03/25/14 - 117.0 pounds -- 03/31/14 - 114.0 pounds -- 04/01/14 - 114.0 pounds -- 04/25/14 - 115.6 pounds -- 05/01/14 - 109.6 pounds -- 05/06/14 - 108.0 pounds -- 05/12/14 - 109.0 pounds -- 05/19/14 - 112.8 pounds -- 05/26/14 - 108.0 pounds -- 06/02/14 - 112.2 pounds -- 07/01/14 - 108.6 pounds -- 07/02/14 - 110.6 pounds The review found an inventory of personal items, completed upon admission (on 03/21/14), documented Resident #103 had both upper and lower dentures. The nursing assessment, also completed upon admission on 03/21/14, documented Resident #103 had both upper and lower dentures. The nursing assessment, completed 06/24/14, documented Resident #103 had no dentures. On 06/24/14, the registered dietitian's medical nutrition therapy assessment included the statement, (typed as written) CNA (certified nursing assistant) believes resident does wear upper dentures but her lower dentures are lost. The resident was receiving a regular texture diet for nutrients. On 08/06/14 at 11:57 a.m., information was requested from the d… | 2018-05-01 |
| 6022 | 6022 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 329 | D | 0 | 1 | K1XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure one (1) of five residents reviewed for unnecessary medications was free of unnecessary medications. A resident receiving the antipsychotic medication [MEDICATION NAME], had no gradual dose reduction (GDR) or a documented clinical rationale for the continuance of the medication by the physician, and in the presence of adverse consequences potentially related to the medication. Resident identifier: #77. Facility census: 94. Findings include: a) Resident #77 A review of the medical record revealed Resident #77 was an [AGE] year old female admitted to the Alzheimer's/Dementia special care unit on 05/25/12. Her [DIAGNOSES REDACTED]. A review of the medical record revealed a pharmacist's recommendation for Resident #77 on 10/31/13. At that time the resident was receiving [MEDICATION NAME] 2.5 mg (milligrams) po (by mouth) Qhs (at bedtime). The pharmacist notified the physician the [MEDICATION NAME] was due for a GDR. The physician responded by declining to change the dosage and stated the resident, Failed in the past with (sign indicating 'lower') dose. The [MEDICATION NAME] was increased to 5 mg daily at bedtime on 02/06/14, related to dementia with behavioral disorder as evidenced by pacing to the point of exhaustion. The physician stated in the progress notes the resident had an increase in behaviors. A pharmacy review on 02/27/14, resulted in a recommendation to the physician for laboratory work to evaluate the resident's lipid levels as she was due for an annual check because of the [MEDICATION NAME] use. The physician complied and ordered the testing. On 03/30/14, the physician discontinued the [MEDICATION NAME] and [MEDICATION NAME] and ordered [MEDICATION NAME] 20mg po Qd (by mouth daily), but the order was canceled the same day and the resident continued on the [MEDICATION NAME] 5 mg po at bedtime. There was no reason for these changes documented in either th… | 2018-05-01 |
| 6023 | 6023 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 353 | E | 0 | 1 | K1XR11 | Based on observation, review of a facility generated Resident Census and Conditions of Residents, and staff interview, the facility failed to deploy sufficient nursing staff to meet the residents' needs at meal time. Meals were not served in a timely manner on the Hilltop front and back halls. This was found for one (1) of six (6) residents dependent on staff for eating, but had the potential to affect more than an isolated number of residents. Resident identifier: #57. Facility census: 94. Findings include: a) Resident #57 The lunch meal tray pass was observed on the Hilltop front and back halls on 08/04/14. The first unheated meal cart arrived at 12:00 p.m. Two (2) nursing assistants (NA) were observed passing meal trays from four (4) unheated meal trucks. Resident #57's lunch tray was removed from the cart at 12:40 p.m., forty (40) minutes after the unheated meal cart arrived on the hall. Upon request NA #44, immediately carried the covered tray to the kitchen. The cook, Employee #33, checked the food temperatures, and reported the following temperatures in degrees Fahrenheit: potatoes were 110 degrees, beef was 100 degrees, corn was 95 degrees, pudding was 50 degrees, and milk was 45 degrees. He stated he would have to make a new tray for the resident. b) According to the facility generated CMS (Centers for Medicare and Medicaid Services)-672 (Resident Census and Conditions of Residents) nine (9) residents on Hilltop front and back halls were dependent on staff for nutrition intake. The meal service location seating list indicated five (5) of these residents were fed in their rooms and twenty-five (25) additional residents were served lunches in their rooms. c) Nurse aide (NA) #89 was interviewed on 08/07/14 at 9:30 a.m. She reported there were currently six (6) residents on Hilltop front and back that ate lunch in their rooms and were dependent on staff for eating. There were four (4) NAs on the schedule, two (2) reported to the dining room for lunch and two (2) remained on the hall to pass thirty (30) trays… | 2018-05-01 |
| 6024 | 6024 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 356 | C | 0 | 1 | K1XR11 | Based on observation and staff interview, the facility failed to ensure the residents and/or public were informed on a daily basis of the nurse staffing data as required by 42 CFR 483.30(e). The failed to include the actual hours worked by the direct care staff and failed to use a print size that enabled easy reading of the posting. This had the potential to affect all residents and/or the public. Facility census: 94 Findings include: a) At 1:30 p.m. on 05/15/14, Review of the POS [REDACTED]. The form in use did not require inclusion of the hours worked for registered nurses), licensed practical nurses, and nurse aides. The missing actual hours worked and the size of the wording on the posting making it very difficult to read, were pointed out to the Administrator and the Director of Nurses at 3:00 p.m. on 08/06/14. The Director of Nurses stated he would have this corrected. | 2018-05-01 |
| 6025 | 6025 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 371 | E | 0 | 1 | K1XR11 | Based on observation and staff interview, the facility failed to store food in a manner to ensure sanitary conditions were maintained. Uncovered, unlabeled, and partially ingested foods were found in the residents' nutrition refrigerator/freezer on the Woodside Hall. This practice had the potential to affect all residents who consumed food from the nutrition refrigerator/freezer on the Woodside Hall. Facility census: 94. Findings include: a) The nutrition refrigerator/freezer on Woodside Hall was inspected on 08/05/14 at 3:30 p.m., with the assistant director of nursing (ADON) Employee #7. The refrigerator/freezer contained -- an opened and partially consumed bottle of water, -- an opened and partially consumed bottle of Coke, -- an uncovered plastic cup of frozen juice, and -- an uncovered partially eaten bowl of sherbet with the spoon in place. All of these items were unlabeled. There were no resident names on the items and no dates to identify when they were placed in the freezer. The ADON stated these items should not have been in the freezer and removed them immediately. The kitchen staff was responsible for stocking the refrigerator daily and removing any outdated or improperly labeled foods. During an interview with the food service supervisor (Employee #82) on 08/05/14 at 3:45 p.m., he confirmed the kitchen was responsible for checking the refrigerators daily. All foods were to be dated the day they were placed in the refrigerator and discarded three (3) days later. | 2018-05-01 |
| 6026 | 6026 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 425 | E | 0 | 1 | K1XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility, in collaboration with the pharmacist, failed to ensure pharmaceutical services to meet the needs of each resident. The facility did not have an accurate accounting of controlled substances to ensure these medications were accurately accounted for and correct at the end and beginning of each nurse's shift. In addition, the facility had no system in place to review the pharmacist's recommendations and/or to verify the physician acted upon identified irregularities. These deficits were not identified and/or addressed by the pharmacist or the facility. The practices had the potential to affect more than an isolated number of residents. Facility census: 94 Findings include: a) On 08/05/14 at 4:20 p.m., a review of the controlled substances shift count book on the Hilltop back unit shift count book revealed it was not consistently signed by the nurse coming on duty and the nurse going off duty to ensure controlled medications were accurately accounted for and correct at the end and beginning of each nurse's shift. There was no evidence this problem was identified and addressed during the pharmacist's review for the months of May, June, or July 2014. The blank signature spaces, for the months of May 2014 and July 2014 were reviewed with Employee #23, a licensed practical nurse (LPN). The LPN verified the shift count book was missing signatures for the verification of the shift count. (The counts were correct at the time of the interview.) An interview was conducted, on 08/06/14 at 8:35 a.m., with Employee #17, the director of nursing (DON). He commented there should not be any blanks in the shift count book. The DON said the off going duty nurse and the on coming duty nurse should sign their names at the end of each count of the controlled medications to verify the count was correct. He also stated, The Pharmacist should have caught that there were missing signatures in the narc… | 2018-05-01 |
| 6027 | 6027 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 428 | D | 0 | 1 | K1XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a medication irregularity, for one (1) of five (5) Stage 2 residents reviewed for unnecessary medication use, was acted upon timely. The pharmacist identified an antipsychotic medication, Zyprexa, was ordered for hallucinations, which was not an approved medical [DIAGNOSES REDACTED]. The facility failed to act upon the identified irregularity until after the pharmacist repeated the recommendation two (2) months later. An investigation of the issue also revealed the facility had no system in place to ensure the pharmacist's recommendations were addressed by the physician and/or the director of nursing. Resident identifier: #57. Facility census: 94. Findings include: a) Resident #57 Review of the medical record, on 08/06/14 at 8:45 a.m., revealed Resident #57 was admitted on [DATE] with an order for [REDACTED]. On 04/23/14, the pharmacist completed the monthly medication regimen review (MRR) and identified an improper order for the antipsychotic, Zyprexa. The pharmacist noted the medication was ordered for hallucinogenic behaviors and lacked an approved medical diagnosis. The facility did not act on the identified irregularity, and did not provide an approved [DIAGNOSES REDACTED]. An interview was conducted with the director of nursing (DON), Employee #17, on 08/06/14 at 10:30 a.m. He reported the facility had no system in place to review the pharmacist's MRR recommendations and/or to verify the physician addressed any identified concerns. The DON printed and signed the MRRs and forwarded the forms to the medical records department. He did not review the MRRs or track the recommendations to verify they were acted upon. The medical records clerk, Employee #18, was interviewed on 08/06/14 at 11:10 a.m. She stated she received the signed MRR recommendations from the DON and placed them on a shelf in the medical records room. Employee #18 said she did not track or log the rep… | 2018-05-01 |
| 6028 | 6028 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 431 | F | 0 | 1 | K1XR11 | Based on observation, record review, policy review, and staff interview, the facility failed to ensure the secure storage of a medication subject to abuse (Ativan), failed to maintain accurate labeling to facilitate safe administration of medications, and failed to maintain a system of medication records which enabled accurate reconciliation of all controlled medications. This had the potential to affect all residents due to the locations of the units involved. Facility census: 94. Findings include: a) An observation of the medication storage area located on the Alzheimer's unit was completed at 10:00 a.m. on 08/06/14, in the company of Employee #79 licensed practical nurse (LPN). Multiple ampoules of injectable Ativan were stored in a plastic lock-box inside a locked refrigerator. Employee #79 stated that the refrigerator was used for storage of medications for both the Alzheimer's unit and the unit called Hilltop - back. The plastic container was secured to a removable shelf rack and both the rack and the container were demonstrated to be easily removable from the refrigerator. This observation was immediately conveyed to the Alzheimer's Director, who stated she would contact maintenance to have the container secured correctly. b) On 08/05/14 at 4:20 p.m. a review of the controlled medication shift count book revealed blank signature spaces during the month of May and July 2014 for the nurse going off duty and the nurse coming on duty. Employee #23, a licensed practical nurse (LPN), reviewed and verified the shift count book contained missing signatures for the verification of the shift count. (The count was correct at the time of the interview.) An interview was conducted on 08/06/14 at 8:35 a.m. with Employee #17, the director of nursing (DON). He commented there should not be any blanks in the shift count book. The off going duty nurse and the on coming duty nurse should sign their names at the end of each count to verify the count was correct. Also the DON stated, the Pharmacist should have caught that ther… | 2018-05-01 |
| 6029 | 6029 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 441 | E | 0 | 1 | K1XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection. Two (2) of four (4) medication carts were not maintained in a sanitary condition. Also, the facility failed to ensure an isolation cart was not located directly on the floor in the main hallway outside the room of a resident who was in isolation. This practice had the potential to affect more than an isolated number of residents. Facility census: 94. Findings include: a) On 08/05/14 at 4:00 p.m. an observation of the medication cart on the Hilltop front unit was conducted with Employee # 41, a licensed practical nurse (LPN). The drawer containing multi-dose plastic bottles, was found with a reddish pink liquid covering the entire bottom of the drawer. Also, plastic bottles had liquid running down the sides of the bottles. Upon lifting the plastic bottles, the liquid was transferred all over the surveyor's hands. When Employee #41 witnessed this, she stated, The liquid was cough syrup and it should have been cleaned up. She commented this was the medication cart she utilized to dispense medication to the residents on the Hilltop front unit since she came on duty at 7:00 a.m. that morning. Employee #41 further stated, I have no idea how long it has been in this condition and it is an infection control issue since it is dirty, it is supposed to be cleaned every day or when it is necessary. The medication cart on the Hilltop back unit was observed on 08/05/14 at 4:10 p.m. with Employee #23, a LPN. Both drawers on the right side of the medication cart had a sticky reddish pink liquid-like substance that coated the bottom of both drawers when the multi-dose plastic bottles were lifted up. One (1) of the drawers also contained a small white tablet and crushed white powder near the back of the drawer. This discovery was witnessed by Employee #23 and also Emp… | 2018-05-01 |
| 6030 | 6030 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 490 | F | 0 | 1 | K1XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility personal files, staff interview, and facility policy review, the facility failed be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility failed to comply with Federal and State regulations, codes, and guidelines and/or facility policy. he mandated deadline for West Virginia statewide criminal background checks was not implemented for any employee. Seven (7) of fifteen (15) employees (#20, #35, #45, #78, #79, #87, and #104) whose personnel files were reviewed,did not have evidence of a current criminal background check. Facility administration also failed to ensure annual [MEDICAL CONDITION] (TB) screenings and/or skin testing were conducted for employees in accordance with State guidelines and/or facility policy. Nine (9) of fifteen (15) employees whose personnel files were reviewed did not have evidence of TB screenings. This practice had the potential to affect all residents. Employee identifiers: #7, #20, #35, #45, #50, #78, #79, #87, and #104. Facility census: 94. Findings include: a) On 08/06/14 at 11:05 a.m., a review of the personnel files for tenured employees was conducted with Employee #38, the payroll/human resources person. The following was identified: 1. Employee #7 A personnel file review was conducted for Employee #7, a registered nurse (RN)/assistant director of nursing (ADON), who was hired by the facility on 06/14/12. This review revealed found no evidence a [MEDICAL CONDITION] annual skin test and/or screening tool was completed on a yearly basis. 2. Employee#20 A review of the personnel file for Employee #20, a cook, who was hired on 06/09/11, revealed no evidence of up to date statewide criminal background check was completed since her hire date. Also, there was no evidence a [MEDICAL CONDITION] annual skin test and/or screening tool was… | 2018-05-01 |
| 6031 | 6031 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 492 | F | 0 | 1 | K1XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review, policy review, and staff interview, the facility failed to comply with Federal, State, and local laws, regulations, and/or codes relating to health, safety, and/or sanitation by: a) failing to ensure the training requirements in section 4.1.c and 4.1.d of Series 85 of the Title 64 legislative rule for Alzheimer's/Dementia Special Care Units and Programs; b) failing to ensure WV statewide criminal background checks were completed per the timetable set by the Bureau for Medical Services (BMS) policy; c) failing to ensure [MEDICAL CONDITION] Screening was completed as outlined by the [MEDICAL CONDITION] Program for WV, based on the recommendation of the Center for Disease Control (CDC); and d) failing to ensure dietary employees maintained a valid food handler's permit as required by county regulations. This had the potential to affect all residents, employees, and/or visitors of the facility. Facility census: 94. Findings include: a) Section 4.1.c of Series 85 of the Title 64 legislative rule for Alzheimer's/Dementia Special Care Units and Programs requires 30 hours of documented training on the care of residents with [MEDICAL CONDITION] and related dementia for all employees prior to working in the unit; and section 4.1.d requires 8 hours of documented annual training to all staff. A review of the personnel files of 11 employees of the Alzheimer's/ Dementia Unit revealed Employees #56, #65, #104, and #112 had no evidence in their files of the required 30 hours of training. Five (5) of the employees (Employees #104, #7, #35, #79, and #87) had no evidence of the annual 8 hours of training for the previous year. b) The WV Bureau for Medical Services (BMS) policy required an up to date statewide criminal background check be completed for all current employees by March 1, 2014. Seven (7) of fifteen (15) employees reviewed had worked in the facility for more than three (3) years and did not have a current criminal ba… | 2018-05-01 |
| 6032 | 6032 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 502 | D | 0 | 1 | K1XR12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a physician ordered laboratory (lab) test for one (1) of twenty-one (21) sample residents was obtained. Resident identifier: #101. Facility census: 83 Findings include: a) Resident #101 Review of medical records, on 11/05/14 at 10:45 a.m., revealed Resident #101 had a physician's orders [REDACTED]. A lab result, dated 09/09/14 revealed the Vitamin D level was completed with a value of 17.84 ng/ml (nanograms per milliliter). The lab results also noted the level for Vitamin D (25-OH) by many experts was recommended to be greater than 30 ng/ml. The ordering physician signed the lab results and wrote a note for the lab to be repeated in thirty (30) days, which would have been during the first full week of October 2014. On 11/05/14 at 1:30 p.m., upon inquiry, the director of nursing stated there was no evidence the repeat lab value had been completed. | 2018-05-01 |
| 6033 | 6033 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 520 | F | 0 | 1 | K1XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review and staff interview, the facility failed to maintain an effective Quality Assessment and Assurance (QAA) Committee. The QAA committee failed to identify and act upon quality deficiencies in the daily operation of the facility in which it did have, or should have had knowledge. Criminal background investigations were not completed for all employees, [MEDICAL CONDITION] (TB) screenings were not completed, food service workers did not have approved food handlers permits as required by the Health Department of the county in which the facility was located, allegations of abuse or misappropriation of property were not immediately reported, and staff of the Alzheimer's/Dementia special care unit did not receive the required thirty (30) hours of training on the care of residents with [MEDICAL CONDITION] and other dementias, and the required eight (8) hours of annual training. These quality deficiencies have the potential to affect all residents residing in the facility. Facility census: 94. Findings include: a) During the annual survey there were five (5) deficient practices identified that should have been identified by the QAA committee, and plans of action implemented to correct these deficiencies. These were: 1. Criminal background checks were not completed for seven (7) of fifteen (15) employees whose files were reviewed. There was no evidence of the requisite fingerprinting, as required for a statewide criminal background check in West Virginia. Employees #20, #35, #45, #78, #79, #87, and #104. -- The Bureau for medical service manual includes: 514.4.1 Employment Restrictions. Criminal Investigation Background Check (CBI) results which may place a member at risk of personal health and safety or have evidence of a history for Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to a member. At a minimum, a fingerprint-based State level cr… | 2018-05-01 |
| 6238 | 6238 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 161 | E | 0 | 1 | EXXT11 | Based on financial 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 total amount of residents' funds as of the most recent quarter. This had the potential to affect all residents with a resident trust fund account with the facility. Fifty (50)residents had a personal funds account with the facility. Facility census: 50. Findings include: a) On 08/12/14 at 10:00 a.m. a review of the resident funds on deposit revealed the most recent quarterly balance, according to the Account Summary, was April 2014: $16,595.24; May 2014: $15,030.23; and June 2014: $16,655.19. The facility's current surety bond was for $10,000.00. The bond was insufficient to cover the resident trust fund accounts of the fifty (50) residents who had a trust fund account with the facility. b) On 08/12/14 at 10:30 a.m., an interview was conducted with Employee #100 (Business Office staff). Employee #100 acknowledged the account summary balances for the most recent quarter had exceeded the amount of the current surety bond. | 2018-04-01 |
| 6239 | 6239 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 253 | E | 0 | 1 | EXXT11 | Based on observation and staff interview, the facility failed to ensure effective housekeeping and maintenance services to maintain a sanitary, orderly, comfortable interior which was free from esthetic imperfections. Observations of resident rooms found multiple pieces of spackling was missing and broken, entrance doors had multiple scratches or mars or chipped wood, dresser finishes were scratched and sometimes down to the bare wood, knobs were missing on dressers, wooden bed rails were scratched and marred, a closet door had a hole through the wood, shower floor tiles contained a black substance, shower wall tiles contained a black substance, tile and caulking was discolored around a commode, and a rusted and dirty heating and cooling unit was observed. These findings were observed in thirteen (13) of twenty-four (24) resident rooms in Stage I of the Quality Indicator Survey. Room numbers: A100, A102, A107, A108, B100, B101, B103, B105, B107, B108, B109, C102 and C108. Resident census: 50. Findings include: a) A Hall A tour was conducted with Environmental Employees #98 and #96 on 08/11/14 between 11:00 a.m. and 12:00 p.m. The findings for esthetic imperfections were as follows: - Room 100. The closet door contained multiple scratches. - Room 102. The finish of the entrance door had deep scrapes down into the wood. There were multiple scrapes on the wooden part of the bed side rails. - Room 107. The white paint was scraped off the inner and outer bathroom door trim in several areas. It had black/brown discoloration in place of the white paint. Two (2) knobs were missing from a dresser in the room. - Room 108. Two (2) knobs were missing from a dresser in the room. b) B Hall A tour was conducted with Environmental Employees #98 and #96 on 08/11/14 between 11:00 a.m. and 12:00 p.m. The findings for esthetic imperfections and areas of uncleanliness were as follows: - Room 100. A dresser in the room was scratched down to the bare wood, and one (1) knob was missing. The closet door contained a hole broken through th… | 2018-04-01 |
| 6240 | 6240 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 256 | D | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview and medical record review, the facility failed to ensure the provision of adequate and comfortable lighting for one (1) of twenty-four (24) residents observed in Stage I of the Quality Indicator Survey. A resident with known visual impairment lacked the necessary lighting she felt she needed in order to see and read more easily while in bed. Resident identifier: #2. Facility census: 50. Findings include: a) Resident #2 During an interview on 08/05/14 at 4:22 p.m., Resident #2 stated, I like to read and the light is not bright enough. Told the nurse. An observation of the resident's room, during the environmental tour on 08/11/14, at approximately 11:00 a.m., revealed the light over her bed was on and put off a fair amount of light. Resident #2 said she preferred more light. She told the maintenance crew during this environmental tour she would like to have more light to read by. She also said she told a nurse about it, but could not remember the nurse's name. She said she told everyone. The resident's medical record was reviewed on 08/12/14 at 10:00 a.m. The most recent minimum data set (MDS), with an assessment reference date (ARD) of 07/07/14, assessed this resident had a [DIAGNOSES REDACTED]. A leisure interest assessment, dated 04/03/14, assessed the resident did in room activities (reading, radio, television) with the comment, can't see well to read. The MDS nurse, Employee #15, was interviewed on 08/12/14 at 11:45 a.m. She said she had not heard this resident ask or say anything about her lighting. She was aware this resident had a history of [REDACTED]. An interview was conducted with the Person in Charge, Employee #31, on 08/12/14 at 2:15 p.m. She said it would help if the resident would allow the staff to draw her curtains, but she generally did not want the curtains opened. Employee #31 said she would see about getting a separate light for Resident #2's room. | 2018-04-01 |
| 6241 | 6241 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 279 | D | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview, the facility failed to develop a care plan based on the comprehensive assessment for one (1) of fourteen (14) Stage 2 sampled residents. A resident who had a [DIAGNOSES REDACTED]. Resident identifier: #2. Facility census: 50. Findings include: a) Resident #2 During an interview on 08/05/14 at 4:22 p.m., Resident #2 stated, I like to read and the light is not bright enough. Told the nurse. Observations were made during the environmental tour on 08/11/14 at approximately 11:00 a.m. The light over her bed was on and put off a fair amount of light, but she said she preferred more light. She told the maintenance crew during the environmental tour she would like to have more light to read by. She said she told a nurse about it, but could not remember the nurse's name. She said she told everyone. The resident's medical record was reviewed on 08/12/14 at 10:00 a.m. The most recent minimum data set (MDS), with an assessment reference date (ARD) of 07/07/14, assessed this resident had a [DIAGNOSES REDACTED]. A leisure interest assessment, dated 04/03/14, assessed that the resident did in room activities (reading, radio, television), with the comment, can't see well to read. The MDS nurse, Employee #15, was interviewed on 08/12/14 at 11:45 a.m. She said she had not heard this resident ask or say anything about her lighting. She was aware this resident had a history of [REDACTED]. The MDS nurse printed off a quarterly nurse assessment. Quarterly assessments included side rail, dental, vision, pain, and various types of assessments the facility completed quarterly on each resident. The vision assessment, dated 07/04/14, addressed the resident had vision problems and wore glasses. It noted her pupils were equal but slow to react, and that the resident reported a history of cataract surgeries on both eyes. The care plan was reviewed. It contained nothing about her vision problems. Ther… | 2018-04-01 |
| 6242 | 6242 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 323 | K | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and a review of the Centers for Medicare and Medicaid (CMS) State Operations Manual, the facility failed to provide an environment that was as free as possible from accident hazards over which it had control. Water temperatures in the public restrooms, that could be accessed by more than an isolated number of residents, were too high for safety. The public restrooms, for men and women, registered 160 degrees Fahrenheit (F) on 08/13/14. Those restrooms were unlocked and could be accessed by mobile residents. Also, water temperatures were high in two (2) resident common use restrooms, registering 120 degrees (F) on 08/13/14. Those restrooms were unlocked and could be accessed by mobile residents. These situations created a potential for serious injury to residents. Affected areas included the men's and women's public restrooms that were located in the corridor between the front hall and back hall resident living quarters, and the two (2) common use restrooms located at the entrance to the C hall resident living quarters. The former resulted in a determination of immediate jeopardy (IJ). A facility maintenance employee verbally reported that they check the water temperatures in all the resident areas once per month. However, they do not keep a log, or records, of when the water temperatures were tested , and/or the results of the testing. There was no evidence the facility monitored and/or used the results of the monitoring of hot water temperatures to ensure resident safety. On 08/13/14 at 1:02 p.m., the State office directed to call an immediate jeopardy (IJ) related to the hot water temperatures of the men's and women's restrooms located in the corridor between the front and back halls. Employee #31, the Person in Charge (PIC), was notified immediately. On 08/13/14 at 1:50 p.m., Employee #31 provided a plan of correction. The correction was that the bathrooms had been locked, and were out of working orde… | 2018-04-01 |
| 6243 | 6243 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 329 | D | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the Center for Medicare and Medicaid Services (CMS) State Operations Manual (SOM) guidelines for unnecessary medication, the facility failed to ensure one (1) of five (5) residents reviewed for unnecessary medications, during Stage 2 of the Quality Indicator Survey (QIS), was free from unnecessary medications. There was no evidence of a gradual dose reduction (GDR) for Resident #46 for a psychopharmacological medication (any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders) used for depression, anxiety and/or sleep induction. The resident received [MEDICATION NAME] (antidepressant) for over one (1) year without evidence of an attempted GDR. Resident identifier: #46. Facility census: 50. Findings include: a) Resident #46 A review of Resident #46's medical record, on 08/11/14 at 10:50 a.m., revealed [DIAGNOSES REDACTED]. The record revealed the resident had received [MEDICATION NAME] (antidepressant), 20 milligrams (mg) since 03/25/13. The [MEDICATION NAME] was ordered for depression with specific behaviors of withdrawn and tearfulness. A concurrent review of this resident's behavior sheets found no behaviors of being withdrawn and/or tearfulness for the past four (4) months. On 08/12/14 at 9:30 a.m., a confidential interview was conducted with a licensed practical nurse. This employee stated the resident had had no behaviors for months. On 08/12/14 at 10:18 a.m., a review of the monthly drug regimen review (DRR), from 03/25/13 through the current DRR, found no recommendations for a dosage reduction of the [MEDICATION NAME] from the consulting pharmacist. On 08/12/14 at 4:00 p.m., in an interview with the Person in Charge (PIC), she said she did not know if Resident #46 had had an attempted dose reduction of the ordered antidepressant. She stated it might be in the thinned records and she would attempt to find the information An interview wi… | 2018-04-01 |
| 6244 | 6244 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 371 | F | 0 | 1 | EXXT11 | Based on observation and staff interview, the facility failed to ensure food was served in a safe and sanitary manner for seven (7) residents identified during a random opportunity for discovery. Observation found that nursing staff touched the residents' food with their bare hands, touched an unsanitary inanimate object, then immediately touched food contact surfaces. In addition, foods were not stored in a safe and sanitary manner. Food items in the freezer were found undated when opened and/or outdated. Opened foods in the freezer were also not securely re-closed to prevent potential contamination. These practices had the potential to affect all residents who received nourishment from the dietary kitchen. Resident identifiers: #46, #49, #56, #41, #20, #57, and #8. Facility census: 50. Findings include: a) During the noon meal on 08/05/14, between 11:35 a.m. and 12:00 p.m., the foods of several residents were touched by the bare hands of facility staff. - Employee #4 (nursing assistant) touched Resident #46's bread with her bare hands. - Employee #4 touched Resident #49's bread with her bare hands. - Employee #4 touched Resident #56's bread with her bare hands. - Employee #46 (nursing assistant) touched Resident #41's corn muffin with her bare hands. - After touching and positioning an unclean object (geri-chair of Resident #30), and without first sanitizing her hands, Employee #46 touched the spoon and bowl of beans of Resident #20. She then placed the bowl of beans and spoon into the hands of Resident #20 to begin feeding herself. - Resident #57. Employee #46 touched her corn muffin with her bare hands. - Resident #8. Employee #7 touched her bread with her bare hands. She also peeled the banana removed the banana from the peel with her bare hands and gave it to the resident. An interview was conducted with the certified dietary manager (CDM) and the registered dietitian on 08/06/14 at 12:00 p.m. They agreed staff were not allowed to have direct contact with residents' food. They also said staff must first san… | 2018-04-01 |
| 6245 | 6245 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 428 | D | 0 | 1 | EXXT11 | Based on medical record review, staff interview, and the State Operations Manual (SOM) Appendix PP, the consulting pharmacist failed to identify and report a medication irregularity for one (1) of five (5) residents reviewed for unnecessary medications in Stage II of the Quality Indicator Survey (QIS). The resident had not had a gradual dose reduction (GDR) for Celexa, a psychopharmacological medication (any mediation used for managing behavior, stabilizing mood, or treating psychiatric disorders), used by a resident for depression. The pharmacist failed to identify and report this irregularity. Resident identifier: #46. Facility census: 50. Findings include: a) Resident #46 Review of the medical record, on 08/11/14 at 10:50 a.m., found the resident was prescribed Celexa (antidepressant) 20 mg (milligrams) by mouth every day at 2000 (10:00 p.m.) due to depression. The beginning date for this medication was 03/25/13. On 08/12/14 at 10:18 a.m., a review of the monthly drug regimen review (DRR), from 03/25/13 through the most current DRR, found no recommendations for a dosage reduction for Celexa from the consulting pharmacist. An interview was conducted with the consultant pharmacist, on 08/14/14 at 9:30 a.m. The consultant pharmacist stated he did not recommend a dosage reduction for any resident receiving an antidepressant unless the dosage was above the maximum recommended dosage. If a resident was receiving an antidepressant above the recommend maximum dosage, he would make a recommendation to the physician for a dosage reduction. He further stated Resident #46 was not receiving a dosage above the maximum recommended dosage, so he had made no recommendations for a dosage reduction. In addition, he stated he did not agree with dosage reductions for antidepressants even though he knew the regulation and had received a citation before. A review of the Centers for Medicare and Medicaid Services SOM guidelines at 483.25 (l) Unnecessary Drugs: .when monitoring all psychopharmacological medications and sedative/hypnot… | 2018-04-01 |
| 6246 | 6246 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 431 | E | 0 | 1 | EXXT11 | Based on observation and staff interview, the facility failed to provide safe and secure storage of medications. Controlled medications and other medications subject to abuse were not stored in a separately locked, permanently affixed compartment as required for medications listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976. The emergency medication supply box (labeled as narcotics) containing these medications, was observed locked and sitting on the counter top in the Hall B and C medication room. The box was not affixed to a secure location. This practice had the potential to affect more than a limited number of residents. Facility census 50. Findings Include: a) Observation of the B and C hall medication room, at 3:35 p.m., on 08/11/14, revealed a locked box marked narcotics. The box was not permanently affixed to a surface. Licensed Practical Nurse (LPN) #27 was present during the observation and said this was the emergency supply box of medications. The situation was reported to the Person in Charge (PIC). On 08/14/14 at 11:55 a.m., the emergency medication supply box was observed locked, but still was not permanently affixed. At that time, the PIC stated she had already ordered a box that could be permanently affixed. The contents of the emergency medication supply box were counted by the PIC. It contained the following: -- Hydrocodone with Tylenol 5/325 mg (milligrams) - two (2) tabs, -- Hydrocodone with Tylenol 10/325 mg - eight (8) tabs, -- Hydrocodone with Tylenol 10/500 mg - two (2) tabs, -- Ativan 0.5 mg - four (4) tabs, -- Phenergan 125 mg - seventeen (17) tabs, -- Oxycodone 5 mg - ten (10) tabs, -- Oxycodone with Tylenol 5/325 mg - nineteen (19) tabs, -- Valium 5 mg - three (3) tabs, -- Tylenol with Codeine 300/30 mg - three (3) tabs, -- Fentanyl Patch 25 mch, (micrograms) - three (3), -- Fentanyl Patch 75 mch - three (3), -- Morphine Sulfate 10 mg per 5 ml (millimeters), five (5) containers, -- Demerol 25 mg - nine (9) injections, -- Valium Injectable 10 mg/2 m… | 2018-04-01 |
| 6247 | 6247 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 441 | E | 0 | 1 | EXXT11 | Based on observation and staff interview, the facility failed to maintain an effective infection control program to prevent and control, to the extent possible, the onset and spread of infection within the facility. During a meal served in the fine dining room, employees touched residents' food items with bare hands. In addition, a nursing assistant (NA) touched an inanimate unclean object, then immediately served food to a resident without first completing hand sanitation. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: #46, #49, #56, #41, #20, #57, #8. Facility census: 50. Findings include: a) During the noon meal on 08/05/14, between 11:35 a.m. and 12:00 p.m., the food of several residents was touched by the bare hands of facility staff: - Employee #4 (NA) touched Resident #46's bread with her bare hands. - Employee #4 touched Resident #49's bread with her bare hands. - Employee #4 touched Resident #56's bread with her bare hands. - Employee #46 (NA) touched Resident #41's corn muffin with her bare hands. - Employee #46, after touching and positioning an unclean object (geri-chair of Resident #30), and without first sanitizing her hands, touched the spoon and bowl of beans of Resident #20. She then placed the bowl of beans and spoon into the hands of Resident #20 to begin feeding herself. - Employee #46 touched Resident #57's corn muffin with her bare hands. - Employee #7 touched Resident #8's bread with her bare hands. She also peeled the banana removed the banana from the peel with her bare hands and gave it to the resident. An interview was conducted with the certified dietary manager (CDM) and the registered dietitian on 08/06/14 at 12:00 p.m. They agreed staff members are not allowed to have direct contact with residents' food. Also, staff must first sanitize their hands before coming into contact with food and eating utensils belonging to the residents. An interview was conducted with the Person in Charge, Employee #31, on 08/12/14 at 8:00 a.m. S… | 2018-04-01 |
| 6248 | 6248 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 490 | E | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and a review of the Centers for Medicare and Medicaid (CMS) State Operations Manual, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Facility administration failed to ensure residents were as free as possible from accident hazards over which it had control. Water temperatures in the public restrooms, that could be accessed by more than an isolated number of residents, were too high for safety. The public restrooms, for men and women, registered 160 degrees Fahrenheit (F) on 08/13/14. Those restrooms were unlocked, and could be accessed by mobile residents. Also, water temperatures were high in two (2) resident common use restrooms, registering 120 degrees (F) on 08/13/14. Those restrooms were unlocked, and could be accessed by mobile residents. These situations created a potential for serious injury to more than an isolated number of residents. Affected areas included the men's and women's public restrooms that were located in the corridor between the front hall and back hall resident living quarters, and the two (2) common use restrooms located at the entrance to the C hall resident living quarters. A facility maintenance employee verbally reported that they check the water temperatures in all the resident areas once per month. However, they do not keep a log, or records, of when the water temperatures were tested , and/or the results of the testing. There was no evidence the facility monitored and/or used the results of the monitoring of hot water temperatures to ensure resident safety. Census: 50. Findings include: a) Men and Women public restrooms between the front and back resident halls While completing the survey, it was noticed that the water temperature of the sink in the female public restroom seemed hot to touch. This prompted further investiga… | 2018-04-01 |
| 6249 | 6249 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 520 | E | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and a review of the Centers for Medicare and Medicaid (CMS) State Operations Manual, the quality and assessment (QA) committee failed to identify and implement a plan of action to correct a quality deficiency over which it had knowledge, or should have had knowledge. Water temperatures in the public restrooms, that could be accessed by more than an isolated number of residents, were too high for safety. The public restrooms, for men and women, registered 160 degrees Fahrenheit (F) on 08/13/14. Those restrooms were unlocked, and could be accessed by mobile residents. Also, water temperatures were high in two (2) resident common use restrooms, registering 120 degrees (F) on 08/13/14. Those restrooms were unlocked, and could be accessed by mobile residents. These situations created a potential for serious injury to more than an isolated number of residents. Affected areas included the men's and women's public restrooms that were located in the corridor between the front hall and back hall resident living quarters, and the two (2) common use restrooms located at the entrance to the C hall resident living quarters. A facility maintenance employee verbally reported that they check the water temperatures in all the resident areas once per month. However, they do not keep a log, or records, of when the water temperatures were tested , and/or the results of the testing. There was no evidence the facility monitored and/or used the results of the monitoring of hot water temperatures to ensure resident safety. Facility census: 50 Findings include: a) Men and Women public restrooms between the front and back resident halls While completing the survey, it was noticed that the water temperature of the sink in the female public restroom seemed hot to touch. This prompted further investigation of water temperatures in public and common use restrooms. An interview was conducted with Maintenance Employee #99 on 08/13/14 at… | 2018-04-01 |
Advanced export
JSON shape: default, array, newline-delimited
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 );