cms_WV
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38 rows where "inspection_date" is on date 2017-06-30
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2435 | 2435 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2017-06-30 | 155 | D | 1 | 1 | 45HC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure Resident #133 was afforded the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive. Resident #133 was determined to have capacity to make medical decisions, however; his caregiver had signed all his admission paperwork for admission and treatment at the facility. This was true for one (1) of one (4) residents reviewed for the care area of Choices during Stage 2 of the Quality Indicator Survey. Resident identifier: #133. Facility census: 76. Findings include: a) Resident #133 A review of Resident #133's medical record, at 1:12 p.m. on 06/28/17, found the resident was [AGE] year old resident with an admission date of [DATE]. Consent for treatment and release of information found in medical records was signed by Resident #133's Medical Power of Attorney (MPOA) on 04/07/17. Review of the record found a Physician's Determination of Capacity dated 04/08/17 which indicated Resident #133 was capacitated to make medical decisions. Contained in Resident #133's medical record was a form titled, Resident Representative Designation which allows the representative on behalf of patient to sign the for purposes of nursing facility admission. This form was signed by Resident #133's MPOA on 04/11/17. Resident #133 did not sign this form. Review of Resident #133's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/12/17, found Resident #133's Brief Interview of Mental Status (BIMS) score was 14. This score indicates Resident #133 was cognitively intact. Further review of the record found no evidence to suggest the decisions made by Resident #133's MPOA were ever discussed with Resident #133. An interview with the Admission Director, at 10:26 a.m. on 06/29/17, confirmed she completed the admission form with Resident #133's MPOA on 04/07/17 and 04/08/17. She stated, what typically happens we have an admission meeting an… | 2020-09-01 |
| 2436 | 2436 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2017-06-30 | 157 | D | 1 | 1 | 45HC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to inform the responsible party of one (1) of three (3) residents reviewed for the care area of Nutritional status when a significant weight loss occurred. Resident #75 experienced a 5.5% weight loss fifteen (15) days after admission to the facility. Resident identifier: #75. Facility census 76. Findings include: a) Resident #75 Record review, at 10:56 a.m. on 06/27/17, found the resident triggered the care area of nutritional status due to a 5.5% weight loss fifteen (15) days after his original admission to the facility. The resident was admitted to the facility on [DATE] and was discharged from the facility to his home on 03/10/17. The following weights were available in the resident's electronic medical record: --02/16/17 - 181.6 pounds (lbs) --02/21/17 - 176.6 lbs. --02/28/17 - 173.6 lbs. --03/07/17 - 171.8 lbs. The resident did not have a terminal diagnosis. He was admitted to the facility after a hospital stay where he was treated for [REDACTED]. The resident planned to receive rehabilitation and return to his home. On 02/26/17, the resident was deemed to lack capacity to make medical decisions. The incapacity was expected to be long term due to cognitive loss. Further review of the medical record found no evidence the resident's responsible party had been informed of the weight loss. The Director of Nursing (DON) was interviewed, on 06/28/17 at 2:45 p.m., regarding the resident's weight loss and notification of his responsible party. The DON concluded the electronic medical record only alerts the facility of weight loss after 30 days. The DON said since the resident was here less than 30 days, and his weight loss did not show up on the computer. The DON was unable to provide evidence the resident's responsible party was aware of the weight loss when the facility should have known about the weight loss on 03/07/17. | 2020-09-01 |
| 2437 | 2437 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2017-06-30 | 272 | D | 1 | 1 | 45HC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessments accurately reflected each residents' status. Resident #133's MDS was inaccurate in the area of Prognosis (life expectancy of six months or less). For Resident #47, the MDS was inaccurate in the area of Vision. This was true for two (2) of twenty-one (21) residents reviewed for accuracy of comprehensive assessments during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #133 and #47. Facility Census: 76. Findings include: a) Resident #133 Resident #133 was admitted on [DATE] with pertinent [DIAGNOSES REDACTED]. This resident had multiple admissions over the last two (2) years and had been released the day before ([DATE]) from another acute care hospital prior to his admission on [DATE] to another acute care facility. During his eight (8) day stay in the acute care hospital Resident #133 showed little to no improvement and as documented in the discharge summary dated [DATE], the hospital physician spoke with the resident concerning his grave condition and poor prognosis and Hospice services was consulted to see him in the nursing home. According to the medical record, the resident expired at the local emergency roiagnom on [DATE]. On [DATE], the attending physician also spoke with Resident #133 concerning his grave condition and poor prognosis. He agreed he wanted Hospice services consulted. Further review of the medical records indicated the resident refused hospice services on [DATE]. The admission MDS with an ARD of [DATE], did not indicate the resident had a condition or terminal illness which would result in a life expectancy of less than six (6) months. An interview, on [DATE] at 11:00 a.m., with the MDS coordinator. She verified the MDS with ARD date [DATE] was inaccurate. She confirmed the resident had a terminal illness that may result in a life expectancy of less than six (6) mont… | 2020-09-01 |
| 2438 | 2438 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2017-06-30 | 278 | D | 1 | 1 | 45HC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility failed to ensure a complete and accurate Minimum Data Set (MDS) for two (2) of twenty-one (21) residents whose MDS's were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #75's MDS was incorrect for the care area of Swallowing/Nutritional Status and Resident #26's MDS was incorrect in the care area of Medications. Resident identifiers: #75 and #26. Facility census: 76. Findings include: a) Resident #75 Record review, at 10:56 a.m. on 06/27/17, found the resident triggered the care area of nutritional status due to a 5.5% weight loss fifteen (15) days after his original admission to the facility. The resident was admitted to the facility on [DATE], and was discharged from the facility to his home on 03/10/17. The following weights were available in the resident's electronic medical record: --02/16/17 - 181.6 pounds (lbs) --02/21/17 - 176.6 lbs --02/28/17 - 173.6 lbs --03/07/17 - 171.8 lbs The following formula determines percentage of weight loss: % of body weight loss = (usual weight -181.6) - actual weight- 171.8) / (usual weight-181.6) x 100. Review of the resident's discharge MDS with an assessment reference date (ARD) of 03/10/17 found Section K, did not code the resident as having a loss of 5% or more in the last month or loss of 10% or more in the last 6 months. At 12:01 p.m. on 06/27/17, the dietary manager (DM) #10 said she did not complete the discharge MDS because she was not employed at the time of completion. DM #10 said the MDS was completed by the dietician who is not at the facility, at this time, for interview. At 12:10 p.m. on 06/27/17 DM #10 and the facility's chef, #17 confirmed the discharge MDS was incorrect. Both employees verified the resident had a 5.5% weight loss which was not captured on the discharge MDS. b) Resident #26 A review of Resident #26's medical record, on 06/29/17 at 8:30 a.m., found a quarterly MDS with an assessment refere… | 2020-09-01 |
| 2439 | 2439 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2017-06-30 | 279 | D | 1 | 1 | 45HC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to develop a care plan for a resident who declined in urinary continence status. This was evident for one (1) of three (3) residents reviewed for urinary incontinence. Resident identifier: #84. Facility census: 76. Findings include: a) Resident #84 Review of the medical record for this discharged resident began on 06/27/17 at 10:57 a.m. [DIAGNOSES REDACTED]. She resided on the facility's Alzheimer's unit. Review of the 5-day admission MDS with assessment reference date (ARD) 11/24/16, and the 14-day MDS with ARD 12/01/16, assessed that she was always continent of urine. A significant change MDS with ARD 02/15/17, assessed that she was frequently incontinent of urine. Another significant change MDS with ARD 04/11/7, assessed that she was always incontinent of urine. Review of the care plan found it was not developed to include the assessed decline in urinary continence. An individualized goal related to urinary incontinence was not developed until 04/12/17. An interview was conducted with MDS registered nurse #40 on 06/27/17 at 11:58 a.m. She said this resident resided in the facility's Alzheimer's unit. However, due to an overall decline in her [MEDICAL CONDITION], she no longer met the criteria for the locked unit. She transferred to another facility closer to her family on 04/14/17. She explained that a significant change MDS was completed in (MONTH) (YEAR) by a nurse who formerly worked at the facility. She said at that time, the resident sustained [REDACTED]. After first reviewing the care plan, she agreed that the care plan was not developed with measurable goals related to the decline in urinary incontinence until 04/12/17. She agreed that it should have been done at the time of the 02/15/17 significant change MDS, and it was not. | 2020-09-01 |
| 2440 | 2440 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2017-06-30 | 280 | D | 1 | 1 | 45HC11 | > Based on observation, record review and staff interview, the facility failed to ensure the resident's care plan was revised to reflect the information on the most recent Minimum Data Set (MDS) for one (1) of three (3) residents reviewed for the care area of Vision during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #22. Facility census: 76. Findings include: a) Resident #22 Review of the residents last minimum data set (MDS), a significant change, with an assessment reference date (ARD) of 4/7/17 found Section B, entitled vision, coded the resident as having impaired vision but no corrective lenses. Observation of resident at 12:15 p.m. on 06/27/17, found she was not wearing glasses. At 12:35 p.m. on 06/27/17, the residents Nurse Aide (NA) #65 said, I have been here for 3 years and she doesn't wear glasses or have any glasses. NA #65 searched the resident's room and found no glasses, only an empty glasses case in the night stand drawer. Review of the resident's current care plan found the problem: --(Name of resident) has vision impairment: wears eyeglasses. The goal associated with the problem was: --(Name of resident) will remain free from falls without major injury requiring hospitalization through next review. Interventions included: --Encourage resident to utilize her eyeglasses, resident frequently refuses to wear glasses. At 9:45 a.m. on 6/28/17, the Registered Nurse (RN), clinical reimburse coordination (CRC), #40 accompanied the surveyor to the resident's room. CRC #40 was also unable to find any glasses in the resident's room. CRC #40 verified the resident was care planned to wear glasses and the significant change MDS completed on 04/07/17 noted the resident did not have any glasses. | 2020-09-01 |
| 2441 | 2441 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2017-06-30 | 282 | D | 1 | 1 | 45HC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to implement the care plan for one (1) of three (3) residents reviewed for the care area of Nutritional status. Resident #75 experienced a 5.5% weight loss within fifteen (15) days after being admitted to the facility. The care plan directed the facility to monitor the resident's intake at all meals. The resident was ordered a nutritional supplement to be provided at all meals. The facility did not record the amount of the nutritional supplement consumed by the resident during meal times to determine if the supplement was effective for the resident's weight loss. Resident identifier: #75. Facility census: 76. Findings include: a) Resident #75 Record review at 10:56 a.m. on 06/27/17, found the resident triggered the care area of nutritional status due to a 5.5% weight loss fifteen (15) days after his original admission to the facility. The resident was admitted to the facility on [DATE] and was discharged from the facility to his home on 03/10/17. The following weights were available in the resident's electronic medical record: --02/16/17 - 181.6 pounds (lbs) --02/21/17 - 176.6 lbs --02/28/17 - 173.6 lbs --03/07/17 - 171.8 lbs The following formula determines percentage of weight loss: % of body weight loss = (usual weight -181.6) - actual weight- 171.8) / (usual weight-181.6) x 100 The resident did not have a terminal diagnosis. He was admitted to the facility after a hospital stay where he was treated for [REDACTED]. The resident planned to receive rehabilitation and return to his home. Review of the current care plan, dated 02/21/17, noted the following problem: --(Name of resident) is at nutritional risk: related to requires mechanically altered diet, skin breakdown present, and [DIAGNOSES REDACTED]. The goal associated with this problem was: --The resident will have no significant changes thru next review date. Interventions included: --Monitor intake at all meals, offer al… | 2020-09-01 |
| 2442 | 2442 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2017-06-30 | 309 | E | 1 | 1 | 45HC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview, observation, physician interview and policy review, the faciliy failed to ensure it had accurate and clear physician orders [REDACTED]. This was evident for one (1) of five (5) residents observed during mediction pass observation. Resident identifier: #33. Facility census: 76. Findings include: a) Resident #33 On 06/27/17 at 9:15 a.m., Licensed Practical Nurse (LPN) #54 said she went on lunch break at 11:30 a.m. today, but would be back at noon or shortly after noon to do a fingerstick blood sugar check and administration of insulin for Resident #33. During medication pass observation, on 06/27/17 at 12:22 p.m., LPN #54 administered twelve (12) units of [MEDICATION NAME]subcutaneously following a fingerstick blood glucose result of 401 milligrams per deciliters (mg/dl). The resident's lunch tray which he had finished eating, sat on his overbed tray. According to the medication administration record (MAR), the sliding scale insulin coverage with [MEDICATION NAME]was scheduled daily at 7:00 a.m., 11:00 a.m., 5:00 p.m., and 9:00 p.m. daily. Upon inquiry as to whether the physician wanted to do the fingerstick blood sugar and insulin coverage prior to meals, she replied in the negative. The nurse said the lunch trays do not arrive on this hall until noon. She said he receives the insulin coverage after he eats in order to bring down the blood sugar. She said his blood sugars are like a roller coaster. A physician's orders [REDACTED]. The order gave directives of how much insulin to give for certain blood sugar parameters. However, the order did not direct the number of times per day to obtain the blood sugar readings and insulin coverage. The order also did not specify the timing of the blood sugars and insulin coverage as related to the meals serves. The physician signed the telephone order on 06/21/17. Review of the MAR found his fingerstick blood sugars were tested daily at 7:00 a.m., 11:00 a.… | 2020-09-01 |
| 2443 | 2443 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2017-06-30 | 313 | E | 1 | 1 | 45HC11 | > Based on record review, observation and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for the care area of Vision during Stage 2 of the Quality Indicator Survey (QIS) received assistive devices to maintain vision. The resident's glasses were not available for use. Resident identifier: #22. Facility census: 76. Findings include: a) Resident #22 Review of the residents last Minimum Data Set (MDS), a significant change, with an assessment reference date (ARD) of 04/07/17 found Section B, entitled vision, coded the resident as having impaired vision but no corrective lenses. Observation of resident, at 12:15 p.m. on 06/27/17, found she was not wearing glasses. At 12:35 p.m. on 06/27/17, the residents Nurse Aide (NA) #65 said, I have been here for 3 years and she doesn't wear glasses or have any glasses. NA #65 searched the resident's room and found no glasses, only an empty glasses case in the night stand drawer. Review of the resident's current care plan found the problem: --(Name of resident) has vision impairment: wears eyeglasses. The goal associated with the problem was: --(Name of resident) will remain free from falls without major injury requiring hospitalization through next review. Interventions included: --Encourage resident to utilize her eyeglasses, resident frequently refuses to wear glasses. At 9:45 a.m. on 6/28/17, the Registered Nurse (RN), clinical reimburse coordination (CRC), #40 accompanied the surveyor to the resident's room. CRC #40 was also unable to find any glasses in the residents room. At 12:10 p.m. on 06/28/17, the social worker (SW), #96 said she talked to the residents son who said the glasses have been missing for 2 or 3 months. At approximately 3:00 p.m. on 06/28/17, SW #96 said she had located the resident's glasses in a drawer at the nurses station and she would be returning them to the resident. | 2020-09-01 |
| 2444 | 2444 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2017-06-30 | 333 | E | 1 | 1 | 45HC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, medical record review, staff interview, physician interview, and policy review, the facility failed to ensure that it was free of any significant medication errors. The facility administered sliding scale insulin coverage four (4) times daily for seven (7) days in the absence of physician's orders [REDACTED]. This was evident for one of five (5) residents observed during medication pass administration. Resident identifier: #33. Facility census: 76. Findings include: a) Resident #33 During medication pass observation, on 06/27/17 at 12:22 p.m., Licensed Practical Nurse (LPN) #54 administered twelve (12) units of [MEDICATION NAME]subcutaneously following a fingerstick blood glucose result of 401 milligrams per deciliters (mg/dl). The resident's lunch tray which he had finished eating, sat on his overbed tray. According to the medication administration record (MAR), the sliding scale insulin coverage with [MEDICATION NAME]was scheduled daily at 7:00 a.m., 11:00 a.m., 5:00 p.m., and 9:00 p.m daily. Upon inquiry as to whether the physician wanted to do the fingerstick blood sugar and insulin coverage prior to meals, she replied in the negative. The nurse said the lunch trays do not arrive on this hall until noon. She said he receives the insulin coverage after he eats in order to bring down the blood sugar. She said his blood sugars are like a roller coaster. A physician's orders [REDACTED]. The order gave directives of how much insulin to give for certain blood sugar parameters. However, the order did not direct the number of times per day to obtain the blood sugar readings and insulin coverage. The order also did not specify the timing of the blood sugars and insulin coverage as related to the meals serves. The physician signed the telephone order on 06/21/17. Review of the MAR found that his fingerstick blood sugars were documented as tested daily at 7:00 a.m., 11:00 a.m., 5:00 p.m., and 9:00 p.m. from 11:00 a.m. on 06/2… | 2020-09-01 |
| 2445 | 2445 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2017-06-30 | 371 | E | 0 | 1 | 45HC11 | Based on observation and staff interview the facility failed to ensure food was stored in a safe and sanitary manner to prevent the spread of food borne illnesses. In the walk in cooler there was opened and undated cheese and Opened and dated cheese which should discarded, but was still available for use. In the A - Hall nutrition pantry there was opened and undated thickened liquids. This practice had the potential to affect more than an isolated number of residents. Facility Census: 76. Findings Include: a) Kitchen An initial tour of the kitchen at 8:45 a.m. on 06/26/17 with the Certified Dietary Manager (CDM) found the following concerns in the walk in cooler: --Sliced American Cheese which was opened and not dated. --Shredded Mozzarella Cheese 5 lb bag which was opened and not dated. --Two bags of Grated Parmesan Cheese. One bag was dated 06/15/17 and one bag was dated 05/2(illegible)/17 (the number behind the 2 was illegible). The CDM stated someone had to date that wrong there is no way we have had that in there that long. When asked how long to keep cheese after it is opened she stated it should be 7 days. b) A - Hall Nutrition Pantry Tour of the A hall Nutrition pantry with the CDM at approximately 9:00 a.m. on 06/26/17 found the following concerns in the refrigerator: --A 46 ounce container of thickened apple juice which was opened and not dated. --A 48 ounce container of Hydralyte Thickened water was opened and not dated. The CDM stated, I even put a place on there for them to put the date they opened it and they did not do it. | 2020-09-01 |
| 2446 | 2446 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2017-06-30 | 431 | D | 1 | 1 | 45HC11 | > Based on observation, policy review and staff interview, the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. Two (2) multi-dose vials of insulin on the A hall medication cart contained opened and partially used vials of insulin which contained no date to indicate when they had first been opened. This had the potential to negatively impact the safety and/or potency of the medication. This was found for one (1) of two (2) medication carts checked, and most directly affected Residents #145 and #68. Resident identifiers: #145, #68. Facility census: 76. Findings include: a) Observation of the A hall medication cart on 06/28/17 at 7:56 a.m., accompanied by licensed nurse #51, found two (2) opened and partially used vials of insulin. A three (3) milliliter (ml) vial of Humulin-R insulin for Resident #145 was opened and over half gone. A three (3) ml. vial of Humulin-R insulin for Resident #68 was opened and over half gone. Neither vial, or their storage boxes, contained the dates they were initially opened for use. Nurse #51 said both of the vials should have been dated when initially opened. She produced, and reviewed, the facility's insulin storage policy at this time, which stated that all insulin vials must be dated when first opened. It further stated that Humulin-R insulin may be used for only thirty-one (31) days after initially opened. She agreed that by not knowing the initial date of opening, it could not be determined when to discard the vial at thirty-one (31) days. She discarded those two (2) vials in question. On 06/30/17 at 8:08 a.m., an interview was conducted with the director of nursing (DON). She said staff informed her of those two (2) insulin vials which were not dated when initially opened. She said their policy dictates that staff must date the vials when initially opened for the first time, and discard the vials at times prescribed by the manufacturer. | 2020-09-01 |
| 2447 | 2447 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2017-06-30 | 441 | F | 1 | 1 | 45HC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to ensure soiled linens/laundry were handled properly to prevent the spread of infection. The facility failed to ensure proper cleaning and sanitizing supplies were available for staff usage in a room identified as an isolation room for Resident #127. In addition, an ice scoop was not sanitized after touching the rim of Resident #80's personal drinking glass. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: #127 and #80. Facility census: 76. Findings include: a) Resident #127 Resident #127 was admitted to the facility on [DATE] at 10:29 p.m. The resident's hospital discharge summary noted the final [DIAGNOSES REDACTED]. At 2:01 p.m. on 06/27/17, observation found two (2) housekeeping carts parked in the hallway outside Resident #127's room. Signage on the resident's door instructed visitors to please see the nurse before entering the room. A three drawer cart, containing personal equipment (PPE), and other items was also parked outside the residents room door, in the hallway. Employee #24, a housekeeper, was inside the residents room, wearing gloves and a gown. She was cleaning the resident's floor with a mop. Employee #23, also a housekeeper, was standing outside the resident's room when [NAME] #24 rolled a covered laundry cart outside the door of the resident's room to [NAME] #23. [NAME] #23's only PPE was gloves. Continued observation, found [NAME] #23 took the cart down the hallway to the laundry room. When asked what she intended to do with the soiled laundry, she stated, the laundry is in a disintegrating bag and it needed to be washed alone. She stated, I am working second shift as the laundry person so I am going to go ahead and start the washer. [NAME] #23 opened the cart and said, Someone put this stuff in a garbage bag, not a disintegrating laundry bag. [NAME] #23 opened the washing machine door and dumped the l… | 2020-09-01 |
| 2448 | 2448 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2017-06-30 | 514 | E | 0 | 1 | 45HC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #138's medical record was accurate. This was true for one (1) of one (1) residents reviewed for the care area of [MEDICAL TREATMENT] during Stage 2 of the Quality Indicator Survey. Resident Identifier: #138. Facility Census: 76. Findings Include: a) Resident #138 A review of Resident #138's medical record at 10:36 a.m. on 06/27/17, found Resident #138 had an arteriovenous (AV) graft for [MEDICAL TREATMENT] access in his left upper arm. Review of Resident #138's physician orders [REDACTED]. A review of Resident #138's Blood Pressure Summary in the electronic medical record found on the following dates and times Resident #138's blood pressure was documented as being obtained in his left arm: --05/13/17 at 12:33 p.m. --05/14/17 at 12:40 p.m. --05/18/17 at 7:53 a.m. --05/24/17 at 3:00 a.m. --05/28/17 at 8:06 a.m. --06/03/17 at 3:20 p.m. --06/04/17 at 3:29 p.m. --06/06/17 at 4:31 a.m. --06/07/17 at 3:01 a.m. --06/09/17 at 10:13 a.m. --06/21/17 at 5:41 p.m. --06/22/17 at 12:49 p.m. --06/24/17 at 12:42 p.m. --06/26/17 at 12:07 a.m. --06/26/17 at 1:09 p.m. During an interview with Resident #138 at 1:30 p.m. on 06/27/17, he stated that staff never takes his blood pressure in his left arm. He stated, They know not to take my blood pressure in my left arm they always use my right arm. He further stated if they tried to take it in my left arm I would not let them. An interview with Licensed Practical Nurse (LPN) #56 at 2:46 p.m. on 06/27/17, confirmed that on the above mentioned dates the residents blood pressure was documented as being obtained in the his left arm. He confirmed the record must be inaccurate based on what Resident #138 stated during his interview. | 2020-09-01 |
| 3434 | 3434 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 166 | E | 1 | 0 | 25Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, concern/grievance form review, policy review, family interview and staff interview, the facility failed to ensure prompt efforts to address and resolve concerns/grievances from residents and their families in a timely manner. The facility did not resolve expressed concerns about hydration and a clean comfortable homelike environment for Resident #1, as documented in the Resident Council's group meeting minutes, and expressed concerns regarding missing glasses for Resident #52. Resident identifiers: #1 and #52. Facility census: 115. Findings include: a) Resident #1 The review of Resident #1's record began on 06/21/17 at 10:04 a.m. Resident #1 is [AGE] years of age. She was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was determined by a physician to lack the capacity to make informed medical decisions. A family member was acting as her responsible party. Resident #1 had a care plan in place for nutrition, hydration, elimination related to weight loss, and consistency of food and liquids. She had a care plan for multiple signs in her room as reminders for resident/staff per the family's request. One of the reminders was for two (2) large insulated cups of ice and water to be within her reach at all times. On 06/22/17 at 11:38 a.m., the resident's responsible party was interviewed in the resident's room. She was surprised her mother was still in bed. She had the two large cups for the resident's water, which were not filled. She was taking the cups to the administrator to make a complaint. Updated complaint/grievance forms were requested regularly as the survey progressed. As of the final day of the survey on 06/30/17, there was no complaint form regarding the lack of water for hydration. On 06/27/17 at 9:10 a.m., a visit was again made to Resident #1's room. Nurse Aide #64 was in the room cleaning an area of the floor between the bed and the bathroom door. She said she had been called … | 2020-09-01 |
| 3435 | 3435 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 313 | D | 1 | 0 | 25Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family interview, record review, concern/grievance form review, and staff interview, the facility failed to ensure that a resident with impaired vision was provided with the care and services to maintain the resident's optimal vision. This affected one (1) of twenty-eight (28) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #52. Facility census: 115 Findings include: a) Resident #52 Resident #52's daughter reported during a Stage 1 family interview on 06/26/17 at 12:16, that her Mother had poor vision and wore glasses, but the facility lost them two (2) months ago. On 06/28/17 at 10:31 a.m., medical record review revealed Resident #52 had [DIAGNOSES REDACTED]. Review of the resident's minimum data set (MDS) with an assessment reference date of (ARD) of 09/09/16 , found her vision assessed as impaired. The quarterly MDS with an ARD of 12/09/16 identified her vision as impaired. Review of the care plan revealed, Has impaired vision was circled indicating this was a problem. Other problems marked with an x include [MEDICAL CONDITION] repaired and dry eyes. Interventions marked with an x include, Vision consult as needed. A review of the concern/grievance reports on 06//28/17 at 2:30 p.m. found a concern/grievance report dated 04/04/17 by Resident #52's daughter that was reported to Referral Manager/Social Worker (SW) #143. Under Documentation of Grievance/Complaint, the concern was described as (typed as written), Said her mothers glasses have been missing and no one followed up with her about this . On 06/28/17 at 3:42 p.m. after reviewing the concern/grievance form for Resident #52, the administrator agreed that it was not resolved. She stated, I just spoke with the daughter about this and she said her mother has not had her glasses for over 2 months, but I told her I thought they were found because I just put a pair of glasses on her last week. I remember because I had to fix her bangs … | 2020-09-01 |
| 3436 | 3436 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 323 | E | 1 | 0 | 25Q611 | > Based on observation and staff interview, the facility failed to ensure the residents' environment remained as free of accident hazards as is possible. Electric baseboard heaters in the main hallways had sharp corner edges where they were mangled and bent. The main hallways on the North and South sides were utilized as main thoroughfares by residents. This finding had the potential to affect more than an isolated number of residents. Facility census: 115. Findings include: a) Observations during the initial tour of the facility on 06/21/17 at 4:30 p.m., found the electric baseboard heaters in the main hallways were mangled and bent with sharp corner edges. There were three (3) baseboard heaters on the 200 hall, two (2) on the 100 hallway, three (3) on the 300 hallway, and two (2) on the 400 hallway. When observed on 06/21/17 at 5:00 p.m. accompanied by the Maintenance Director, he stated, Those baseboard heaters are not used. I just need to remove them and repair the baseboards. Yes, the baseboard heaters look bad in the hallways and with those sharp edges could certainly be an accident hazard because someone could scratch or cut themselves on those corners. | 2020-09-01 |
| 3965 | 3965 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 161 | E | 0 | 1 | 25Q611 | Based upon review of facility documents and staff interview, the facility failed to have an approved surety bond to ensure the security of the residents' personal funds. This failed practice had the potential to affect one-hundred-six (106) residents having personal funds deposited in the care of the facility, and so had the potential to affect more than a limited number of residents. Facility census: 115. Findings include: a) The review of the facility's surety bond began on 06/28/17 at 9:30 a.m. A copy of the surety bond had been requested upon entrance. The facility provided a certificate listing the names of persons appointed as attorneys-in-fact to act to provide surety up to an amount of $2,000,000.00. There was no mention of the facility or its relationship to all or any portion of the amount specified. Clarification was requested from the Administrator on 06/28/17 at 10:00 a.m. She provided a second document entitled continuation certificate which stated a bond was in force in the amount of $76,000.00 for the facility's resident funds account for the period from 07/01/17 to 07/01/18. An approval of the bond, or a continuation approval of the facility's bond, by the West Virginia Attorney General was requested from the Administrator. She said the facility did not have such a document. She offered to contact the Office of Health Facility Licensure and Certification, the agency which facilitates the process of obtaining the required approval documentation of West Virginia nursing facilities from the Attorney General's office to find out the status of the facility's surety bond. She reported there was no approved surety bond in effect as required by statute due to the fact the bond was not submitted by the parent corporation in accordance with the provisions of the law. | 2020-04-01 |
| 3966 | 3966 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 223 | D | 0 | 1 | 25Q611 | Based on observation, staff interview, family interview, and policy review, the facility failed to ensure residents were free from verbal abuse. Resident #44, a mentally challenged individual with documented communication deficits demonstrated increased agitation and fearful facial expressions after a nurse aide yelled at him in the hall. Resident identifier: #44. Facility census: 115. Findings include: a) Resident #44 A random observation on 06/27/17 at 9:38 a.m., found Nurse Aide (NA) #61 in the hall across from the nurses' station, loudly say, Don't punch me! as she backed away from Resident #44. Resident #44, who sat in his wheelchair, exhibited tight facial muscles, clenched fists, and held his right arm across his at chest as though to strike out. Licensed Practical Nurse (LPN) #142 was standing near the nurses' desk during this incident. When interviewed on 06/27/17 at 9:40 a.m., he agreed NA #61 raised her voice at Resident #44. When asked if he would consider this verbal abuse he stated, I will talk to her. LPN #142 reported this incident to the Risk Manager after this interview. During an interview on 06/27/17 at 9:45 a.m., NA #61 stated, I am a loud talker, and denied raising her voice or yelling at Resident #44. Review of the resident's medical record on 06/27/17 at 2:10 p.m., revealed Resident #44 was alert, mentally challenged individual with a severe intellectual disability since birth, and had unclear speech with limited verbalization skills. He resided in an assisted living home for several years, but after a hospitalization , he was not eligible to return to his previous home because of his need for total care. The resident's care plan, dated 05/03/17, identified behaviors as a problem and included verbal outbursts and Potential/shows aggression towards staff and other residents. The care plan for mood, depression, and anxiety included the interventions of, Speak softly, clearly & stand/sit directly in front when communicating (Don't want misinterpretation). In an interview on 06/29/17 at 10:28 … | 2020-04-01 |
| 3967 | 3967 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 241 | D | 0 | 1 | 25Q611 | Based on observation and staff interview, the facility failed to assist and promote care for each resident in a manner that maintained or enhanced dignity and respect by ensuring a Resident #115 was seated in a manner to allow her to eat in a dignified manner. This practice had the potential to affect an isolated number of residents. Resident identifer: #115. Facility census: 115. Findings include: a) Resident #115 A dining observation on 06/27/17 at 12:12 p.m. noted Resident #115 sat at a table with three (3) other residents. When asked about the height of the table and if it was suitable for meal service, Resident #115 stated, I have a problem with the table, I can't reach it. I am too far back. Additional observations on Thursday 06/22/17 and Monday 06/26/17 during lunch, noted th resident sitting in the same position. She stated, I am too far back from the table, it is hard to get something to drink even though they have not brought my food yet. Resident #115 was seated in a high back wheelchair with front facing leg rests preventing her from being close up to the table due to the table having a metal middle pole with four legs extending for balance and stability. Resident #115 asked if the surveyor could find someone to fix the situation. She stated, They just park me here and never ask if I can reach anything. The Referral Manager/Social Worker (RM/SW) who was near by, was asked if if she was able to assist Resident #115 to be closer to the table to enable her to reach her drinks. The RM/SW asked the Social Worker (SW #127) for assistance to move the table. RM/SW asked Scheduler (Employee #131) to assist when she was called away for a telephone call. Employee #131 asked, Why are you moving the table when all you need to do is swing her leg rests to the side and she (Resident #115) will then be up to the table? Employee #131 proceeded to swing Resident #115's wheelchair leg rests to either side and she was able to reach her drinks without difficulty. SW #127 was asked why Resident #115 had not been positione… | 2020-04-01 |
| 3968 | 3968 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 244 | E | 0 | 1 | 25Q611 | Based upon review of resident council meeting minutes, review of complaints and grievances, and staff interview, the facility failed to consider the views of a resident or family group and act promptly upon the grievances voiced by the Resident Council concerning issues of resident care and life in the facility. The facility was not able to demonstrate its responses and rationale for such responses. This had the potential to affect more than a limited number of residents residing in the facility. Facility census: 115. Findings include: a) Review of the Resident Council Meeting Minutes for the previous six (6) months on 06/21/17 at 4:00 p.m. found the record of the meetings began with a form called Resident Council Quality of Life Assessment - Group Interview. For some of the months, the form had two (2) pages, and for others, there were three (3). Not all the issues had responses noted. For those that did, some negative responses were found as follows: -- For the 06/05/17 meeting, for the question, Does the group have input into the rules of the facility? the response was No, because they always give you reason for the rules. The question Does the facility listen to your suggestions? was answered Sometimes. The question Are there places you can go when you want to be with other residents? was answered Not really, need more places. -- For the 05/05/17 meeting, for the question Does the group have input into the rules of the facility? the response was No. The question Does the facility listen to your suggestions? was answered Sometimes. The question Are there places you can go when you want to be with other residents? was answered No. The question Are the temperatures of your foods ok? was answered Sometimes. The question How did staff react? (to a voiced grievance/concern) was answered They listened, but it depends on who it is. -- For the (MONTH) (YEAR) meeting (no specific date was on the minutes), for the question Does the group have input into the rules of the facility? the response was No. The question Are me… | 2020-04-01 |
| 3969 | 3969 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 252 | E | 0 | 1 | 25Q611 | Based on observation and staff interview, the facility failed to provide a homelike environment for residents who were served their meals in the dining room where floor tiles and cove molding were in disrepair and for a resident who had a feces covered washcloth laying on the floor in her room. This had the potential to affect more than an isolated number of residents. Resident identifier: #1. Facility census: 115. Findings include: a) Dining room Observations of dining for the lunch meal on 06/22/17 at 11:57 a.m., found cracked and missing floor tiles around the back wall of the dining room and cove molding that was not attached to the wall. Residents were seated at tables located around this area. At 12:21 p.m. on 06/22/17, when shown the area, the Director of Nursing (DON) stated, Oh my, I will have them fix it. The shower room on the other side of this wall has just been repaired and remodeled and maybe that caused it. On 06/26/17 at 10:30 a.m. the Maintenance Director reported, I have replaced those tiles in the dining room, so it looks better. b) Resident #1 On 06/27/17 at 9:10 a.m., a visit to Resident #1's room found Nurse Aide #64 in the room cleaning an area of the floor between the resident's bed and the bathroom door. She said she had been called to the room by the resident's responsible party because there was feces on the washcloth and the floor. She said she was not the one who had left it there, but she was cleaning it up. The responsible party entered the room and said she had found the mess on the floor when she arrived for her visit and since there was no one around, she had gone in search of someone to clean it up. | 2020-04-01 |
| 3970 | 3970 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 253 | F | 0 | 1 | 25Q611 | Based on observation and staff interview the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, clean and comfortable homelike interior. Bathroom sink cabinets were chipped and broken and the interiors were stained and discolored. Faucets were dripping and sink drains were rusted or broken. Insulation was hanging below the front sink edge and caulking was cracked or missing around the sinks and toilets. Cove molding was loose and damaged in the bathrooms and vinyl bathroom floors were cracked. Bathroom mirror facings were chipped along the bottom edge. The central bathrooms on the 200 and 300 halls were cluttered with resident equipment and supplies. Wall heaters on the North and South ends of the building were rusted and floor base heaters on the 100, 200, and 300 halls were in disrepair with mangled sharp edges, loose parts, and large dust particles inside. These findings had the potential to affect all residents in the facility. Facility census: 115. Findings include: a) Observation of the facility during Stage 1 and Stage 2 of the Quality Indicator Survey revealed the following rooms had environmental concerns and cosmetic imperfections. 1. Room 103 The sink faucet was constantly dripping, the cove molding on the side of the commode was easily pushed in and there was dirt and grime accumulation in the corner of the bathroom door. 2. Room 104 The caulking was stained and discolored around the commode and the cove molding was not secured to the wall on the right side of the toilet. 3. Room 105 The sink cabinet was chipped and in disrepair and the floor was stained and discolored around the toilet base. 4. Room 202 The left side of the board on the bottom of the sink cabinet was dislodged and resting on the floor. The right cabinet face panel was loose and slid easily to the side. The plaster was off the exterior wall corner next to the sink exposing the metal support which was leaning out. 5. Room 205 The bathroom mirror facing was missing along the edge.… | 2020-04-01 |
| 3971 | 3971 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 278 | D | 0 | 1 | 25Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the individual assessing and certifying the accuracy of Section B of Resident #52's quarterly Minimum Data Set (MDS), failed to ensure the assessment was accurate regarding a resident's vision. This was found for one (1) of twenty-eight (28) Stage 2 sample residents whose MDS was reviewed during the Quality Indicator Survey (QIS). Resident identifier: #52. Facility census: 115. Findings include: a) Resident #52 On 06/28/17 at 10:31 a.m., a medical record review revealed Resident #52 was originally admitted to the facility on [DATE] with her most recent re-admission on 12/04/17. Her [DIAGNOSES REDACTED]. Review of the MDS with an assessment reference date (ARD) of 09/09/16 found the resident's vision coded as impaired. Review of the quarterly MDS with an ARD of 12/09/16 found her vision coded as impaired. Review of the quarterly MDS with an ARD of 03/01/17 found her vision coded as adequate. Review of the quarterly MDS with an ARD of 05/29/17 found her vision coded as adequate. After reviewing the quarterly MDSs with ARD of 09/09/16 to 05/29/17 on 06/29/17 at 1:04 p.m., MDS Nurse #117 stated, I coded those two (2) MDSs wrong (quarterly MDS with ARD of 03/01/17 and 05/29/17) for her (Resident #52) vision. It should be coded as impaired and guess I will be sending in corrections for that. | 2020-04-01 |
| 3972 | 3972 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 279 | D | 0 | 1 | 25Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a care plan that addressed the use of an an antiplatelet medication ([MEDICATION NAME]). This was found for one (1) of twenty-eight (28) Stage 2 sample residents whose care plans were reviewed during the Quality Indicator Survey (QIS). Resident identifier: #42. Facility census: 115. Findings include: a) Resident #42 On 06/28/17 at 4:33 p.m., medical record review revealed Resident #42 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. Her medications included [MEDICATION NAME] 75 mg po (by mouth) daily. The care plan was silent for interventions and possible side effects related to the antiplatelet medication [MEDICATION NAME]. Serious side effects of the medication [MEDICATION NAME] include, bruising, nosebleeds, bloody or tarry stools, coughing up blood, unusual bleeding in the mouth, vagina or rectum, purple or pinpoint spots under the skin, and vomiting that looks like coffee grounds. After review of the care plan for Resident #42 on 06/28/17 at 5:09 p.m., Registered Nurse (RN)/Unit Manager #109 verified there were interventions and side effects related to the use of an anti-platelet medication. He stated, It (care plan) should have something there regarding bleeding and bruising precautions and what to watch for.) | 2020-04-01 |
| 3973 | 3973 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 280 | D | 0 | 1 | 25Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to revise the care plans for two (2) of twenty-eight (28) sample residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #52's care plan was not revised to reflect the use of glasses for impaired vision and Resident #44's care plan was not revised to reflect his current behaviors. Resident identifiers: #52 and #44. Facility census: 115. Findings include: a) Resident #52 Resident #52's daughter reported during a Stage 1 family interview on 06/26/17 at 12:16, that her Mother had poor vision and wore glasses, but the facility lost them two (2) months ago. On 06/28/17 at 10:31 a.m., medical record review revealed Resident #52's quarterly minimum data set (MDS) assessments with assessment reference dates (ARD) of 09/09/16 and 12/09/16 identified the resident had impaired vision. The resident's care plan had, Has impaired vision circled indicating that was a problem. Other problems marked with an x included, [MEDICAL CONDITION] repaired and dry eyes. An x by a handwritten note (typed as written), Glasses are worn (then a word crossed out with error written above it) often-are at home. After reviewing the care plan for Resident #52 on 06/29/17 at 1:19 p.m., MDS Nurse #117 stated, The original admission date of [DATE] was when it was handwritten on there (care plan) that her glasses were at home and it was not updated when her daughter brought the glasses to the facility a few days later. Also, it should be checked on the care plan that she forgets to wear her glasses. So, the care plan was incorrect and was not revised. Additionally, the resident's care plan was not revised to reflect the loss of her glasses 2 months ago and any adaptations/interventions that might be required to help her compensate for the additional visual impairment. b) Resident #44 Review of the resident's medical record on 06/27/17 at 2:10 p.m., rev… | 2020-04-01 |
| 3974 | 3974 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 282 | D | 0 | 1 | 25Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family interview, and staff interview, the facility failed to follow the comprehensive care plan for two (2) of twenty-eight (28) Stage 2 residents reviewed during the Annual Quality Indicator Survey. The facility failed to implement Resident #80's care plan for drawing labs as ordered and Resident #52's care plan was not implemented when a vision consult was not obtained after her glasses were lost. Resident identifiers: #80 and #52. Facility census: 115. Findings include: a) Resident #80 Medical record review on 06/29/17 at 8:15 a.m. revealed Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 06/28/16, the physician ordered (typed as written), FBS (fasting blood sugar) every month. Her care plan included an intervention of, Labs (laboratory tests) as ordered Review of the resident's medical record found no laboratory results for a FBS in (MONTH) (YEAR). During an interview on 06/29/17 at 10:30 a.m., Registered Nurse (RN)/Nurse Educator #110 reported, There is no laboratory result for a FBS in (MONTH) (YEAR) because it was not done. After reviewing the care plan RN/Nurse Educator #110 agreed, The care plan was not followed, for the intervention Labs as ordered. On 06/29/17 at 11:10 a.m., the Assistant Director of Nursing (ADON) provided copies of the physician's orders [REDACTED]. After review of the care plan, she verified the services for monthly laboratory testing were not provided according to the care plan. b) Resident #52 Resident #52's daughter reported during a Stage 1 family interview on 06/26/17 at 12:16 p.m. that her Mother had poor vision and wore glasses, but the facility had lost them two (2) months ago. On 06/28/17 at 10:31 a.m., medical record review revealed Resident #52 had a history of [REDACTED]. Review of the quarterly minimum data set assessment (MDS) with an assessment reference date (ARD) of 09/09/16 found the resident's vision coded as impaired. The quart… | 2020-04-01 |
| 3975 | 3975 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 315 | D | 0 | 1 | 25Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to maintain and/or restore continence to the extent possible. There was no evidence the resident was provided with any type of toileting program. This was found for one (1) of three (3) residents' reviewed for urinary incontinence during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #14. Facility census: 115. Findings include: a) Resident #14 During an interview with Resident #14 on 06/27/17 at 10:48 a.m., he stated, No they never have taken me to the bathroom since I have been here, maybe a few times in the beginning now they just change my diaper. Doesn't do any good to ask to go to the bathroom because they just tell me it takes two (2) people and they are too busy. Review of the minimum data set (MDS) for Resident #14, on 06/27/17 at 11:08 a.m., found his admission MDS with an assessment reference date (ARD) of 02/15/17 identified he was frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). The 14-day MDS with an ARD of 03/09/17 also indicated he was frequently incontinent and that he was not on a current toileting program or trial. The 30-day MDS with an ARD of 03/23/17 again identified he was frequently incontinent and that he was not on a toileting program. The Quarterly MDS with ARD of 05/15/17 assessed him as always incontinent (no episodes of continent voiding). A continuing review of the medical record revealed Resident #14 was admitted on [DATE]. His [DIAGNOSES REDACTED]. He was admitted on an antibiotic for UTI, required another dose of antibiotics on 03/02/17 for UTI and another dose of antibiotics for UTI on 03/16/17 for UTI. The resident's care plan included a problem of bladder incontinence. The plan noted he was not not a candidate for a toileting program due to im… | 2020-04-01 |
| 3976 | 3976 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 319 | D | 0 | 1 | 25Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family interview, and staff interview, the facility failed to ensure that a resident who displayed and/or was diagnosed with [REDACTED]. Resident #44 was admitted to the facility with a history of outpatient psychiatric treatment for [REDACTED]. His next scheduled psychiatric appointment was missed because the facility failed to obtain a complete medical and psychiatric history from his previous home and family. Staff's lack of knowledge of Resident #44's previous drug regimen and recent changes, and the failure to identify previously defined nonpharmacological interventions, along with mental and psychosocial adjustment difficulties related to a change in his living environment caused the resident to act out towards others in an aggressive nature. Arrangements for psychiatric services were not made until the resident's behaviors towards others continued all day with no response to listed nonpharmacological interventions and isolation. These failures had the potential to cause harm to the resident and potential to cause harm and affect other residents and staff. Resident identifier: #44. Facility census: 115. Findings include: a) Resident #44 Review of the medical record on 06/27/17 at 2:10 p.m., revealed this alert, mentally challenged individual had had a severe intellectual disability since birth and had unclear speech with limited verbalization skills. He resided in an assisted living type home for several years until he became ill and required hospitalization . He was unable to return to his previous residence because of his increased care needs for all of his activities of daily living (ADLS) and was admitted to the facility on [DATE]. Resident #44's medications were adjusted during his hospitalization because of questionable symptoms of drug toxicity to [MEDICATION NAME]. His medical discharge Medication Reconciliation Report (MRR) dated 04/26/17 noted the following medications changes: -- [MEDICATION NA… | 2020-04-01 |
| 3977 | 3977 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 334 | E | 0 | 1 | 25Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to educate each resident and/or the resident's legal representative on the benefits and potential side effects of the influenza vaccine prior to administering the vaccine during the current (YEAR)-2017 flu season. In addition, the consent forms presented on admission were not updated to reflect the CDC's current vaccine information statement. This was found for four (4) of five (5) Stage 1 sampled residents reviewed during the annual Quality Indicator Survey (QIS). Resident identifiers: #79, #124, #34, and #26. Facility census: 115. Findings include: a) Residents #79, #124, #34, and #26 Review of the medical records for these residents on 06/28/17 at 2:00 p.m., revealed all four (4) medical records lacked documentation indicating the resident and/or the resident's legal representative received education regarding the current benefits and potential side effects of the influenza vaccine prior to administration during the current flu season. Resident #124 received the [MEDICATION NAME] flu vaccine on 10/11/16 and Residents #79, #34, and #26 received the [MEDICATION NAME] vaccine on 10/12/16. Licensed Practical Nurse (LPN) #119 reviewed the medical records during an interview on 06/28/17 at 2:40 p.m. and confirmed the records lacked any information related to consents and/or education regarding the benefits and potential side effects of the influenza vaccine. LPN #119 contacted Social Worker #143, the admissions person, and reported the only resident/family education provided was on the Pneumococcal & Annual Influenza Vaccination Information & Request form which was signed on admission and contained a revision date of 02/2007. During an interview at 3:00 p.m. on 06/28/17 the Assistant Director of Nursing (ADON) provided copies of the Influenza (flu) consents for Residents #79, #124, #34, and #2… | 2020-04-01 |
| 3978 | 3978 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 371 | F | 0 | 1 | 25Q611 | Based on observation and staff interview, the facility failed to ensure food was served under sanitary conditions. While taking food temperatures, an employee failed to wash her hands after brushing her nose with her hand. Additionally, the drain pipes of an ice machine did not have a gap between the pipes and the drain, and a refrigerator in a nutrition room was in disrepair and was not clean. This practice had the potential to affect all residents. Facility census: 115. Findings include: a) On 06/26/17 at 11:30 a.m., staff obtained food temperatures in the presence of the Dietary Manager (DM). After obtaining the food temperature on the prepared rice and writing down the food temperature, Cook #93 swiped her nose with the back of her ungloved hand then proceeded to continue to take temperatures of other foods. When this was brought to her attention, she stopped and performed hand hygiene. Immediately following this observation, Cook #93 stated, This is my usual routine to stop after each food temperature was taken and find a pen then write it down on the temperature log. Yes, I did swipe my nose and did not wash my hands after that before going back to taking temperatures. The DM agreed that Cook #93 should have washed her hands after wiping her nose during an interview on 06/26/17 at 2:35 p.m. She added, Yes I saw that the same as you did standing there. b) Ice machine An observation of the North hall nutrition room with Licensed Practical Nurse (LPN) #112 on 06/21/17 at 4:30 p.m., revealed three (3) drain pipes from the North hall ice machine running into the floor drain. Two of the drain pipes were in direct physical contact with the floor drain cap. There was no gap between the drip lines and floor drain to back-siphonage. During an interview on 06/21/17 at 4:44 p.m., Maintenance Supervisor #133 acknowledged the ends of the ice machine drains were in direct contact with the floor drain and stated he could easily repair this by cutting off the ends of the pipes. c) North hall refrigerator An observation of t… | 2020-04-01 |
| 3979 | 3979 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 425 | D | 0 | 1 | 25Q612 | . Based on observation, staff interview, and review of manufacturer's recommendations, the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. Two (2) insulin pens and one (1) insulin vial were open for greater than the time allowed per manufacturer's recommendations. Use of medication from a multi-dose vial or pen which was open for a time period greater than that recommended by the manufacturer, had the potential to negatively impact the safety and/or potency of the medication. This practice was evident for both of the facility's medication storage room refrigerators, and affected a limited number of residents. Resident identifiers: #54, #99, #115. Facility census: 112. Findings include: a) North hall medication storage room refrigerator. On 09/25/17 at 10:30 a.m., the North hall medication storage room was observed, in the presence of Registered Nurse (RN) #1. 1. The medication storage room refrigerator contained a Humalog insulin pen which belonged to Resident #54. It had been opened and partially used. The expiration date of 09/22/17 was inscribed (hand-written) on the pen. RN #1 said this vial should have been discarded on 09/22/17, and it was not. He said the date it was initially opened for use must have been twenty-eight (28) days prior . He acknowledged that the date of first opening was not inscribed on the vial. He disposed of the vial. 2. The medication storage room refrigerator contained a multi-dose vial of Lantus insulin which belonged to Resident #99. It had been opened and partially used. The expiration date of 09/23/17 was inscribed (hand-written) on the vial. Registered Nurse (RN) #1 it should have been discarded on 09/23/17, and it was not. He said it is their policy to discard multi-dose vials twenty-eight days after initially opened. He said he would dispose of this vial. b) South hall medication storage room refrigerator On 09/25/17 at 11:00 a.m. the South hall medication storage room was observed, in the presence of Licensed Practica… | 2020-04-01 |
| 3980 | 3980 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 431 | E | 0 | 1 | 25Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, controlled medication sheet review, policy review, and staff interview, the facility failed to store medications, alcoholic beverages and biological's in accordance with professional guidelines. A liter (33.8 ounces) bottle of Lord Calvert 80% Canadian Whiskey sitting on the counter in the North unit medication room not labeled and no procedure to mark the remaining amount of liquid after administering a dose, one (1) of two (2) medication room refrigerators contained expired medication and opened medication which was not labeled and/or dated, two (2) of four (4) medication carts contained opened unlabeled and/or undated multi-dose medications. In addition the facility failed to ensure controlled substance records contained information to show complete reconciliation by on-coming and off-going nurses. This was found for two (2) of four (4) narcotic books reviewed. This practice has the potential to affect more than an isolated number of residents. Resident identifiers: #28. Facility census: 115. Findings include: a) North unit medication room 1. Observation of the North unit medication room accompanied by Licensed Practical Nurse (LPN) #104 on [DATE] at 2:50 p.m. revealed a liter (33.8 ounces) bottle of Lord Calvert 80% Canadian Whiskey sitting on the counter not labeled with a resident name. Above hanging on the cabinet door was a progress note with resident #28's name, times and dates of administration of 30 ml (milliliters) by mouth. Upon inquiry if this should be stored in a different area and how to determine how much liquor/liquid if left in the bottle, LPN #104 stated, It always just sits on the counter since _________ (first name of Resident #28) was admitted back in (MONTH) (2017). His wife just brings in a new bottle when he needs it. LPN #104 verified that the bottle was not labeled with a resident name or dated when opened. LPN #104 further stated, No there is now way to know if the correct amount is left in … | 2020-04-01 |
| 3981 | 3981 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 441 | F | 0 | 1 | 25Q611 | Based on observation, confidential staff interviews, a family member's comment, and staff interviews, the facility failed to maintain an Infection Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. A random observation found staff did not clean a mechanical lift removed from the soiled utility room (where it was stored) before or after use to transfer a resident. An uncovered toilet plunger sat on the floor beside the toilet in a common resident bathroom. In addition, a washcloth with feces lay on the floor in a resident's room. These findings had the potential to affect more than a limited number of residents. Resident identifiers: #71 and #1. Facility census: 115. Findings include: a) Resident #71 Observations on 06/29/17 at 9:09 a.m. noted Employee #R removed a mechanical lift (Hoyer lift) from the soiled utility room on the North unit - 400 hall without sanitizing the equipment. She proceeded down the hallway to Resident #71's room and with the assistance of Employee #O, utilized the mechanical lift to transfer Resident #71 from his bed to his wheelchair. The mechanical lift was taken back to the soiled utility room without sanitizing the equipment. Immediately following this observation during a confidential interview with Employee #R, she verified the mechanical lift was not properly sanitized before or after the transfer of Resident #71. Employee #R stated, The lifts are always kept in soiled utility room and they (mechanical lift) are never cleaned by any staff before or after used to transfer residents. I didn't know we were supposed to clean them and even if we wanted to there is nothing to clean them with. (First name of Housekeeping Supervisor) never leaves us anything to clean them with. Employee #O, present during the previous confidential interview verified the lift was not cleaned after removing from soiled utility room or before the transfer of Resident #71. She stated, No we have never cleaned anythin… | 2020-04-01 |
| 3982 | 3982 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 490 | F | 0 | 1 | 25Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, resident interview, family interview, staff interview, policy review, and record review, the facility was not 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 survey found the facility did not have an approved surety bond to safeguard residents' personal funds entrusted to the facility, failed to address and respond promptly to complaints and grievances voiced by residents, family members, and the resident council, failed to provide appropriate care and treatment for [REDACTED]. The systemic nature of some of the deficient practices identified substandard quality of care and required an extended survey. Facility census: 115. Findings include: a) The review of the facility's surety bond on 06/28/17 at 9:30 a.m. The facility provided a certificate listing the names of persons appointed as attorneys-in-fact to act to provide surety, but there was no mention of the facility or it relationship to all or any portion of the amount specified. Upon request, the Administrator provided a second document entitled continuation certificate which stated that a bond was in force in the amount of $76,000.00 for the facility's resident funds account for the period from 07/01/17 to 07/01/18. An approval of the bond, or a continuation approval of the facility's bond by the West Virginia Attorney General was requested. The administrator said the facility did not have such a document. She offered to contact the Office of Health Facility Licensure and certification, the agency which facilitates the process of obtaining the required approval documentation of West Virginia Nursing Facilities from the Attorney general's office to find out the status of the facility's surety bond. She reported there was no approved surety bond in effect as required by statute due to the fact the bond was not s… | 2020-04-01 |
| 3983 | 3983 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 502 | D | 0 | 1 | 25Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain laboratory services as ordered by the physician. A fasting blood sugar (FBS) was no obtained as ordered for Resident #80. This affected one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #80. Facility census: 115. Findings include: a) Resident #80 Medical record review on 06/29/17 at 8:15 a.m. revealed Resident #80's [DIAGNOSES REDACTED]. Her current medications include, Humalog insulin 8 units subcutaneous (subq) injection three times a day (TID) with meals for DMII and [MEDICATION NAME] 44 units subq at bedtime for DMII. A physician's orders [REDACTED]. The laboratory results for the FBS in (MONTH) (YEAR) were not found in the resident's medical record. During an interview with Registered Nurse (RN)/Nurse Educator #110 on 06/29/17 at 10:30 a.m., she said, There is no laboratory result for a FBS in (MONTH) (YEAR) because it was not done. On 06/29/17 at 11:10 a.m., the Assistant Director of Nursing (ADON) provided copies of the physician's orders [REDACTED]. She stated, The physician's orders [REDACTED]. So, no, the FBS was not monitored as ordered and I admit we did not know this until you asked for April's results. | 2020-04-01 |
| 3984 | 3984 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 514 | E | 0 | 1 | 25Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain complete, accurately documented clinical records for each resident. Laboratory test results were absent in the chart for review for one (1) of five (5) Stage 2 sample residents reviewed for unnecessary medications. Inventory of Personal Effects forms were blank and/or incomplete for four (4) of four (4) Stage 2 sample residents whose charts were reviewed during the QIS survey. In addition there were no education sheets for the yearly flu vaccinations and immunization consents for five (5) of five (5) sample residents reviewed for immunizations during the QIS survey. These findings had, the potential to affect more than an isolated number of residents. Resident identifiers: #80, #81, #14, #1, #52, #42, #123, #79, #26, and #34. Facility census: 115. Findings include: a) Resident #80 Medical record review on 06/29/17 at 8:15 a.m. found a physician's orders [REDACTED]. The HGBA1C results for 12/29/16 were not found in the resident's medical record. Registered Nurse (RN)/Nurse Educator #110 provided copies of the HGBA1C results for 12/29/16 on 06/29/17 at 10:30 a.m. She stated, I had to get them off of the computer because they were not in the chart where they are supposed to be located. Yes, they should have been in the chart because we do not have electronic records other than than the minimum data set (MDS). I agree it is an incomplete medical record because only the nurses have access to the chart and may not know to look there for the results. b) Inventory of Personal Effects forms On 06/28/17 at 10:31 a.m., during a medical record review for Resident #52 (who had missing glasses while in the facility) found her Inventory of Personal Effects form lacked signature of employee, signature of relative or resident and dates. Continued medical record reviews on 06/28/17 at 10:40 a.m. of Inventory of Personal Effects forms discovered the following: -- Resident #1's form lack… | 2020-04-01 |
| 3985 | 3985 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 520 | F | 0 | 1 | 25Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, resident interviews, confidential staff interviews, and confidential resident interviews, and review of Quality Assurance and Assessment (QA&A) Committee sign-in sheets, the facility failed to identify and/or correct quality deficiencies of which they were aware, or should have been aware. These deficient practices included failure to ensure prompt efforts to resolve concern/grievances in a timely manner, failure to maintain residents' dignity with proper positions during dining, failure to maintain a clean comfortable homelike environment in the dining room and ensuring used wash cloths with feces are not left in a resident room, failure to provide housekeeping and maintenance services to maintain a sanitary orderly and comfortable interior by repairing and/or replacing cosmetic imperfections in hallways and resident rooms, to maintain hallways that are free of accident hazards by repairing or replacing electric baseboard heaters in main hallways, failure to provide yearly education prior to the administration of the influenza vaccine, to maintain an effective infection control program and to maintain complete and accurate medical records. These practices have the potential to affect all residents residing in the facility. Facility census: 115. Citation Text for Tag 0520, Regulation FF10 [NAME], [NAME] [NAME], [NAME] [NAME] Based on observation, staff interviews, resident interviews, confidential staff interviews, and confidential resident interviews, and review of Quality Assurance and Assessment (QA&A) Committee sign-in sheets, the facility failed to identify and/or correct quality deficiencies of which they were aware, or should have been aware. These deficient practices included failure to ensure prompt efforts to resolve concern/grievances in a timely manner, failure to maintain residents' dignity with proper positions during dining, failure to maintain a clean comfortable homelike environment in … | 2020-04-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );