cms_WV
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34 rows where "inspection_date" is on date 2018-07-12
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Suggested facets: facility_name, facility_id, address, city, zip, deficiency_tag, scope_severity, complaint, eventid, filedate (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1591 | 1591 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 550 | D | 0 | 1 | 5JPY11 | Based on observation, policy and procedure review and staff interviews, the facility failed to ensure residents were treated with dignity and respect. Resident #47 did not receive her meal at the same time as her tablemate. Resident #108 lower body was exposed during personal care. These observations were random opportunities for discovery. Resident identifiers: #47 and #108. Facility census: 61. Findings included: a) Resident #47 Observation of the noon meal at 12:27 AM on 07/09/18, found Residents #47 and #46 seated at a table together. Resident #46 received her tray. Staff then served Residents #158, #11, #49, and #43, who were seated together at another table. Resident #6, who sat alone at a table in the back of the dining room, received a tray. Staff served residents seated at two (2) separate tables before returning to serve Resident #47. At 12:32 PM on 07/09/18, the activities director, Employee #15 said Resident #47's tray came out on the cart going to the hallways because, You never know where she is going to be. At 9:43 AM on 07/12/18, the Director of Nursing was advised of the above dining room observation. The DoN said she was aware of the issue. b) Resident #108 A random observation of Hall 100 on 07/11/18 at 7:50 AM, found Nurse Aide (NA) #45 and NA #46 repositioning Resident #108. The door to the resident's room was open and Resident #108 was uncovered and exposed from the waist down to anyone passing by in the hallway. During an interview on 07/11/18 at 7:55 AM, NA#45 and NA#46 said the door should have been closed. NA #46 further stated he/she, Usually shuts the door, but didn't think of it. A review of the facility's policy and procedure OPS213, Treatment: Considerate and Respectful, Section 1.8, Privacy found it instructed, Maintain patient privacy of body including Patient sufficiently covered. An interview with the Administrator on 07/11/18 at 8:35 AM, confirmed facility staff should adhere to the policy to avoid exposing a resident during care. | 2020-09-01 |
| 1592 | 1592 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 584 | D | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family interview, and staff interview, the facility failed to provide a safe, clean, comfortable and homelike environment. Residents room with strong foul odor of urine reaching the hallway and heavy brown stains of urine on floor and an electrical outlet box lying on the floor in urine. This was a random opportunity for discovery. Identified Resident #37. Facility census 61. Findings included: a) Upon entry to the facility on [DATE] at 11:08 AM, a strong foul odor of urine was noticed before reaching the doorway of the room that was the source. The room, belonging to Resident #37, had a brown stain on the floor between the bed and window and under the air conditioner. The air conditioner, that was not on, was plugged into a metal electrical box that was on the floor in what appeared to be urine. During an interview on 07/09/17 at 3:58 PM, the residents brother said his brother received good care at the facility, but the only problem he had was the room smelled so bad. He stated he had spoken to the administrator countless times in the past about the room being dirty and smelling. He also was concerned about the facility turning off his brother's air conditioner so that he could not control the temperature of his own room. He said he was told that because his brother urinated in the air conditioner unit, they turned it off. He stated that did not address the problem with the odor along with the stains on the floor. He said his brother now has a fungal infection on his body folds from not having air conditioning on the very hot days. During an interview on 07/10/18 at 9:59 AM, Housekeeping Supervisor (HS) #4 said she and her boss decided to strip and wax the floor. She also said that her boss said it would not last, because of him urinating on the floor. She was asked how long does urine have to be on the floor before it causes those heavy large brown stains and the strong odor? Her response was, Housekeeping is only here… | 2020-09-01 |
| 1593 | 1593 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 585 | E | 0 | 1 | 5JPY11 | Based on Resident Council interviews, observation, and staff interview, the facility failed to ensure residents had access to information on how to file a grievance or complaint. This had the potential to affect more than an isolated number of residents. Facility Census: 61. Findings included: a) On 07/10/18 at 1:57 PM, prior to beginning an interview with ten (10) residents that attended the Council Meeting, Resident #24, the wife of the Resident Council President, stated, Before we get started we would like to have the Activities Director (AD) and Administrator (NHA) in our meeting. When the Administrator and Activities Director came in the room, Resident #24 said, See I told you that I would get you in this meeting like you wanted. After a lengthy discussion on how they (all the residents at the meeting) loved everything and loved all the staff, it was learned that none of the residents knew where the grievance or complaint information was or how to file one. The activities director and administrator stated the forms were not placed out for the residents to use as they wished at that time but would find a place to have them readily available. They both agreed that it was the right of the residents to have these forms and information available. | 2020-09-01 |
| 1594 | 1594 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 607 | L | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel file review, staff interview, and review of the facility's policy for screening of employees, the facility failed to verify two (2) of four (4) direct care staff hired by a staffing agency and used by the facility were thoroughly screened for a history of abuse, neglect, exploitation, and/or any applicable criminal activity that would identify the individual as unfit to work in a long-term care facility. The facility failed to ensure two (2) of three (3) individuals were screened through the West Virginia Clearance for Access and Employment Screening (WV CARES) system, a program initiated by the Centers for Medicare and Medicaid Services (CMS) National Background Check Initiative. Employee identifiers: #64 and #7. After consultation with the State Agency, a determination of immediate jeopardy was made based on the facility's failure to thoroughly screen the backgrounds of two (2) of three (3) Licensed Practical Nurses (LPNs). In addition, two (2) of three (3) LPNs did not have proof of West Virginia Licensure and were currently working at the facility. This practice had the potential to affect all residents residing in the facility. Notice of the immediate jeopardy (IJ) was given to the Administrator on [DATE] at 6:19 PM. An acceptable plan of correction (P[NAME]) was received from the Administrator on [DATE] at 6:35 PM. After verification of the implementation of the plan of correction (P[NAME]), the immediate jeopardy (IJ) was abated on [DATE] at 6:35 PM. After removal of the immediate jeopardy, a deficient practice remained at a scope and severity of [NAME] for this requirement for failure to ensure Nurse Aide #83 maintained a current registration. Facility census: 61 The findings included: a) LPN #64 A review of personnel files, on [DATE] at 3:00 PM, revealed the facility had employed agency staff, LPN #64 on [DATE]. When the employee files were brought to the surveyor for review, the file for Employee LPN #64 was not i… | 2020-09-01 |
| 1595 | 1595 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 641 | D | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments for two (2) of twenty (20) residents reviewed during the annual Long Term Care Survey Process (LTCSP). Eight (8) of Resident #14's MDS assessments did not accurately reflect the resident's contractures that were present on admission. Additionally, Resident #56's admission MDS with an ARD of 06/29/18 was not completed in the area of cognitive status. Resident identifiers: #14 and #56. Facility census: 61. Findings included: a) Resident #14 Review of Resident #14's medical records found the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Further review found a physical therapy evaluation, dated 02/27/17, identified Resident #14 had contractures of the bilateral hips, knees, and ankles. Review of the eight (8) MDSs completed since the resident's admission on 02/25/18, found the MDSs did not accurately reflect the resident's multiple contractures which were present at the time of admission. An interview on 07/11/18 at 3:30 p.m. with the Director of Nursing (DoN) and the Nursing Home Administrator (NHA) confirmed the eight (8) MDSs completed for Resident #14 since admission were inaccurate in the area of contractures. b) Resident #56 Review of the resident's admission minimum data set (MDS), with an assessment reference date (ARD) of 06/29/18, found the cognitive section of the MDS was not completed. Further record review found the resident had capacity to make medical decisions. At 10:57 AM on 07/10/18, the Social Services Director (SSD) said the cognitive questions on the admission MDS should have been completed for the resident. The SSD said, I was on vacation that week so I guess no one did that section. On 07/12/18, when advised of the incomplete MDS, the NHA stated she was aware of the situation. | 2020-09-01 |
| 1596 | 1596 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 655 | D | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop and implement baseline care plans within forty-eight (48) hours of admission for three (3) of twenty (20) new admissions whose care plans were reviewed. Resident #208's baseline care plan failed to include the resident's immediate care and needs for end stage [MEDICAL CONDITION], which required [MEDICAL TREATMENT] treatments three (3) days a week. Resident #108's baseline care plan failed to address the resident's immediate activity, toileting, and pain needs. Resident #52's baseline care plan failed to include this resident's immediate needs for isolation precautions. Resident Identifiers: #208, #108, and #52. Facility census: 61. Findings included: a) Resident #208 Medical record review on 07/10/18 at 10:07 AM found the resident's baseline care plan addressing her immediate needs was not completed within forty-eight (48) hours of her original admission on 06/27/18, nor was there evidence of an updated care plan after readmission on 06/30/18. It was not completed until 07/09/18. During an interview on 07/10/18 11:43 AM, the Director of Nursing (DON) verified the baseline [MEDICAL TREATMENT] care plan for Resident #208 was not completed within forty-eight (48) hours of her admission on 06/27/18 and re-admission date of [DATE]. b) Resident #108 1. A review of the resident's medical record on 07/10/18, revealed the 07/06/18 admission assessment identified the resident was continent of bowel. The assessment further identified the resident used the bathroom or bedpan for toileting. The resident was also assessed as being continent of urine with urgency and toileting method of commode or bedpan. On 07/10/18 at 11:20 AM, Nurse Aide (NA) #43 stated Resident #108 knew when she needed to go to the bathroom and would ask for a bedpan. The initial care plan, dated 07/07/18, noted Resident #108 was incontinent with an intervention to provide incontinence care. The care pla… | 2020-09-01 |
| 1597 | 1597 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 657 | D | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and record review, the facility failed to ensure Resident #43 was offered/given the opportunity to attend and/or participate in her care planning process. This was true for one (1) of twenty (20) residents whose care plans were reviewed. Resident identifier: #43. Facility census: 61. Findings included: a) Resident #43 At 12:14 PM on 07/09/18, Resident #43 said she did not think she had been invited to attend any care plans. She said she would attend the meeting if invited. Record review found the resident was admitted to the facility on [DATE]. Review of the most recent quarterly, minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/14/18, found the resident's score on the Brief Interview for Mental Status (BIMS) was 14, indicating she was cognitively intact. Further review of the notes in the resident's electronic medical record found care plan meetings were held on 06/12/18 and 03/20/18. The notes indicated the resident's responsible party was invited to the care plan on 06/12/18, but did not attend. On 03/20/18, the care plan note indicated the resident's responsible party attended the meeting via telephone. At 8:59 AM on 07/11/18, the Social Service Director (SSD) said that she was unable to find any evidence to substantiate the resident was invited to her care plan meetings. She said the resident had a court appointed medical guardian. The SSD said she was aware the resident's BIMS score was 14 indicating the resident was cognitively intact. The SSD was unable to provide evidence the resident was unable to participate in her care planning process. At 9:49 AM on 07/12/18, the administrator said she was aware the resident was not invited to participate and or attend her care plan meetings. | 2020-09-01 |
| 1598 | 1598 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 684 | E | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, responsible party interview, observation, record review, policy review, and staff interview, the facility failed to identify and provide needed care and services that were resident centered in accordance with resident preferences, goals for care and professional standards of practice to meet each resident's physical, mental, and psychosocial needs for five (5) of twenty (20) residents reviewed. The facility failed to follow up with Resident #4's attending physician when the resident's cardiologist recommended medication changes. The facility failed to coordinate services of a Hospice agency for Resident #31. Resident #56 did not receive medications ordered by the facility physician. Resident #46 failed to have completed neurological checks after falls on three separate occasions. The facility failed to follow physician's orders [REDACTED].#260. Resident identifiers: #4, #56, #31, #46, and #260. Facility census: 61. Findings include: a) Resident #4 Record review found the resident was admitted to the facility from her home on 03/29/18. Review of medical information from a hospital, dated 02/26/18, and supplied to the facility upon admission found the resident's admitting [DIAGNOSES REDACTED].>- Chronic ischemic [MEDICAL CONDITION], - [MEDICAL CONDITION], - Hypertension, - [MEDICAL CONDITION] infarction, - [MEDICAL CONDITION]. Past surgeries included: - Cardiac pacemaker placement, - coronary artery angioplasty, and - coronary artery bypass graft. On 05/23/18, the resident kept a previously scheduled visit to a local cardiologist. The cardiologist provided a written consult of the visit and ordered: Stop [MEDICATION NAME] 30 milligrams (mg) twice daily and start [MEDICATION NAME] CD 120 mg daily. Start [MEDICATION NAME] 20 mg once daily. Weigh self-daily. First thing in the morning following restroom use. Record weights daily. Low sodium diet. 2,000 mg/day guideline. ([MEDICATION NAME] is a drug that is used for tre… | 2020-09-01 |
| 1599 | 1599 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 689 | K | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the reported allegations of elopement to the nursing home program, and review of facility policy, the facility failed to provide an environment free from accident hazards over which the facility had control. Secure care equipment failed to function properly which had the potential to allow a resident, utilizing the secure care equipment, to leave the facility without staff knowledge. Once the door was opened by a visitor, a resident, or anyone not wearing a secure care alarm, any resident with a secure care alarm could exit the building without activating the alarm. Resident #34 was observed attempting to leave the facility when another resident exited the building. No alarm sounded although the resident had secure care devices on her ankle and wheelchair. Testing of the system found it failed to activate an alarm when a resident wearing a secure care device went through the door when opened by a visitor or other person not wearing a device. Further investigation found an incident when a former resident, Resident #58, had exited the facility while the door was held open by another resident. The report regarding that incident noted, Equipment will be tested , . The transmitter was tested and was working properly according to the immediate action taken. However, the investigation did not indicate if the testing was done when the door was opened or closed. After consultation with the State office a determination of immediate jeopardy was made based on the facility's failure to ensure the secure alarm system was working properly to prevent residents with secure care systems from exiting the facility without staff knowledge. The facility was previously aware of the elopement of Resident #58 on 05/24/18. This incident should have alerted the facility the secure care system was not operating properly. The facility NHA was notified of the immediate jeopardy on 07/11/18 at 12:05 PM The facility provided… | 2020-09-01 |
| 1600 | 1600 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 690 | D | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, staff interview, and record review, the facility failed to ensure one (1) of two (2) residents who was continent of bowel and bladder on admission, received care and services to maintain continence. Resident identifier: #108. Facility census: 61. The findings included: a) Resident #108 During a random observation on 07/09/18 at 1:00 PM, Resident #108 complained she was not assisted to the bathroom and she was wet. With assistance of staff, it was verified that the resident had a brief on and it was soiled. In an interview on 07/09/18 at 1:07 PM, Nurse Aide (NA) #43 stated the resident knew when she needed to go to the bathroom and would ask for the bedpan. A review of the resident's medical record on 07/10/18, revealed an admission assessment dated [DATE], noting Resident #108 was continent of bowel on admission. The assessment further stated the resident used the bathroom or bedpan for toileting. The assessment also identified the resident was continent of urine with urgency and used the commode or bedpan. On 07/10/18, at 11:15 AM, accompanied by Center Nurse Executive #74, NAs responsible for the care of Resident #108 were interviewed. When NA #85 was question about the toileting practices and care for Resident #108, the NA responded, I do not know the answer. During an interview on 07/10/18 at 11:21 AM, NA #25 said she, had her a couple of days ago and she had a brief on and was not taken to the toilet. At 11:20 AM on 07/10/18, NA #43 stated Resident #108 knew when she needed to go to the bathroom and would ask for a bedpan. The initial care plan, dated 07/07/18, identified Resident #108 as incontinent with an intervention to provide incontinence care. The care plan did not reflect the admission assessment that identified the resident as continent of bladder and bowel function, nor were modalities to maintain or improve Resident #108's bowel and bladder function identified. | 2020-09-01 |
| 1601 | 1601 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 697 | H | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to ensure Resident #14 received pain management consistent with his needs and physician's orders [REDACTED]. Resident #14 said he had to beg for pain medication and expressed anger at the staff. Due to a transcription error, Resident #14's pain medication ([MEDICATION NAME]) was given on an as needed (PRN) basis, although the physician's orders [REDACTED]. The failure to ensure the resident received adequate pain management was determined to be actual harm, both physical and psychosocial. Resident identifier: #14. Facility census: 61. Findings included: a) Resident #14 During an interview with Resident #14 on 07/09/18 at 11:30 a.m., he stated, I am hurting all over. A staff nurse was immediately notified of the resident's complaint of pain. On 07/10/18 at 10:45 a.m., when asked about his pain he said, I don't know why I can't get my pain medication. I had it four (4) times daily and then it was increased to six (6) times a day when I was having pain in my suprapubic area. I am supposed to get it four (4) times a day now and I can only get it if I beg for it. The resident expressed anger at the staff and referred to them in a derogatory manner. On 07/10/18 at 11:40 a.m., review of Resident #14's physician's orders [REDACTED]. This was to be given around the clock. Prior to (MONTH) 14, (YEAR), the resident had received [MEDICATION NAME] six (6) times a day as he stated during the interview. Review of the resident's medication administration records (MAR) found from 06/14/18 until the end of June, the resident received [MEDICATION NAME] 4 times a day, around the clock. He received it at 12 midnight, 6:00 AM, 12:00 noon, and 6:00 PM until July, when the medication was entered into the computer as a PRN medication in error. Review of Resident #14's Medication Administration for (MONTH) (YEAR), found beginning on 07/01/18, the pain medication [MEDICATION NA… | 2020-09-01 |
| 1602 | 1602 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 698 | E | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of the facility's policy for care and treatment for [REDACTED].#208 received ongoing assessment of her condition before and after [MEDICAL TREATMENT] to monitor for complications. The facility also failed to ensure there was ongoing communication and collaboration with the [MEDICAL TREATMENT] facility. Furthermore, the facility failed to implement its own policy which was consistent with standards of practice. This was true for one (1) of one (1) resident reviewed for [MEDICAL TREATMENT]. Resident identifier: #208. Facility census: 61. Findings included: a) Resident #208 Review of medical records found Resident #208 was originally admitted to the facility on [DATE] and then was readmitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Further review found the resident had a arteriovenous (A-V) fistula in her upper left arm and an external [MEDICAL TREATMENT] catheter in the right [MEDICATION NAME] area (collar bone area). There was no evidence facility staff were monitoring either site. Review of the facility's policy for care and services needed for residents receiving [MEDICAL TREATMENT] included, but not limited to: - the methods of communication between the nursing home and the [MEDICAL TREATMENT] facility including how it would occur, with whom, and where the communication and responses would be documented, - the development and implementation of a coordinated comprehensive care plan(s) that identified nursing home and [MEDICAL TREATMENT] responsibilities, and - provided direction for nursing home staff; and - the development and implementation of interventions, based upon current standards of practice including, but not limited to documentation and monitoring of complications, pre-and post-[MEDICAL TREATMENT] weights, access sites, nutrition and hydration, lab tests, vital signs including blood pressure and medications, the provision of medications… | 2020-09-01 |
| 1603 | 1603 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 730 | D | 0 | 1 | 5JPY11 | Based on staff interview and employee record review, the facility failed to ensure performance evaluations were completed at least once every 12 months and failed to provide employees with regular in-service education based on the outcome of these reviews. One (1) of four (4) employees reviewed did not receive in-services as required and three (3) of four (4) employees did not have an annual performance appraisal as required. Employees identifiers: #83, #45, #16. Facility census: 61. Findings included: a) Nurse Aide (NA) #83 NA #83's personnel file identified a hire date of 04/06/2016, with the last performance evaluation dated 04/25/17. An interview with the Corporate Registered Nurse (RN) #87 on 07/11/18 at 03:34 PM, verified there was not a more recent performance evaluation than 04/25/17. b) NA #45 The NA #45's personnel file revealed a hire date of 10/10/16. There was no record of a performance evaluation for this employee, only a skills check off sheet dated 02/09/18. There was no in-service record to review. An interview with Corporate RN #87 on 07/11/18 at 3:34 PM verified that there was no performance evaluation or in-service record for this employee. c) NA #16 Review of the personnel file for NA #16 on 07/11/18, revealed a hire date of 04/20/16. The last performance evaluation was completed 04/19/17. An interview with the Corporate RN #87 on 07/11/18 at 4:02 PM verified there was no current performance evaluation for this employee. | 2020-09-01 |
| 1604 | 1604 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 761 | D | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and manufacturer's guideline review, the facility failed to ensure all multi-use insulin vials were dated when opened to ensure the medication's safety and potency. The 200 Hall medication cart, which was one (1) of two (2) medication carts observed, contained an undated open vial of [MEDICATION NAME]. This was true for one (1) of five (5) vials of insulin in the medication cart and had the potential to directly affect one (1) resident, Resident #45. Facility census: 61. Findings included: a) Resident #45 An inspection of the medication cart on the 200 Hall on 07/12/18 at 9:19 AM, found a multi-dose vial of [MEDICATION NAME] (insulin used to control blood sugar) with no date to indicate when the vial was opened. Licensed Practical Nurse (LPN) #75 was witness to this finding. The medication belonged to Resident #45. When discussed with Corporate Nurse #87 on 07/12/18 at 9:40 AM, she stated she would take care of the matter. The manufacturer's instructions included: In-use [MEDICATION NAME](R) vials 1. Vials must be kept in the refrigerator or at room temperature below 86 F (30 C) for up to 42 days. 2. Keep vials away from direct heat or light. 3. Throw away an opened vial after 42 days of use, even if there is insulin left in the vial . | 2020-09-01 |
| 1605 | 1605 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 812 | E | 0 | 1 | 5JPY11 | Based on observation and staff interview, the facility failed to ensure food was stored in a manner to prevent food borne illnesses. Outdated food items were present in the walk-in refrigerator in the kitchen. This practice had the potential to affect more than an isolated number of residents. Facility census: 61. Findings include: a) Initial tour of the kitchen Upon entrance to the facility at 11:00 a.m. on 07/09/18, observation of the kitchen with the Dietary Manager (DM) found a dessert identified by the DM as being made with whipped cream cheese and cookies, dated 06/26/18. The DM said the 06/26/18 date was when the item was made. The DM said the dessert should have been discarded within seven (7) days - 07/03/18. A second observation found a container of sour cream with a manufacturer's stamped date of discard - 07/07/18. The DM said she would throw away the dessert and the sour cream. At 11:20 a.m. on 07/12/18, the Administrator said she was aware of the findings and provided no further comment or information. | 2020-09-01 |
| 1606 | 1606 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 835 | F | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observation, record review, policy review, 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, mental, and psychosocial well-being of each resident. The facility received an immediate jeopardy when the system did not alarm to alert staff wandering residents wearing devices were leaving the facility. On 05/24/18, another resident (now discharged ) with a secure care alarm, was found outside the facility without facility knowledge. On 07/11/18, Resident #34, who had two secure care alarm devices was able to exit the front door of the facility without the alarm sounding. The failure of the facility to take corrective actions after the 05/24/18 occurrence, resulted in continuation of the failure of the secure care alarm to work effectively. This practice had the potential to affect five (5) of five (5) residents with a secure care alarms. Resident identifiers: #2, #38, #34, #37, and #45. Facility census: 61. Findings included: a) Resident #34 On the morning of 07/10/18, at approximately 10:30 AM, observations found Resident #34 attempting to leave the facility when another resident, without an alarm system, was exiting the building. No alarm sounded at that time. At the time of the incident, the surveyor was unaware Resident #34 was wearing a secure alarm system. The surveyor was alerted to the incident when the male resident was cursing Resident #34, telling her to get back into the building. Licensed Practical Nurse, #52 intervened and assisted Resident #34 back inside the building. Review of the resident's medical record at 8:30 on 07/11/18, found a ninety-eight (98) year old female resident admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's current care plan found a focus/problem of, Resident is at risk for elopement related to Cognitive Loss/ Dementia, dated 09/08/16… | 2020-09-01 |
| 1607 | 1607 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 842 | D | 0 | 1 | 5JPY12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure Resident #300's medical record was complete and accurate. This was true for one (1) of fourteen (14) medical records reviewed during the Revisit survey to the Long-Term Care Survey completed on 07/13/18. Resident Identifier: #300. Facility Census: 56. Findings included a) Resident #300 1. [MEDICAL CONDITION] A review of Resident # 300's medical record found nursing assessments dated 09/11/18 and 09/18/18 which indicated Resident #300 did not have an ostomy. A review of Resident #300's physician's orders [REDACTED]. An interview with the Director of Nursing (DON) and Corporate Resource Nurse (CRN), concluding at 9:40 a.m. on 09/19/18, confirmed the assessments dated 09/11/18 and 09/18/18 did not accurately reflect that Resident #300 had a [MEDICAL CONDITION] on admission to the facility. 2. Urinary Continence Status A review of Resident # 300's medical record found a nursing assessment dated [DATE] which indicated Resident #300 was always continent of her urine. A review of Resident #300's activities of daily living (ADL) flow sheets since admission to the facility on [DATE] through current, found the resident was always incontinent of her urine. An interview with Resident #300 at 9:00 a.m. on 09/19/18 found that she was incontinent of urine. She stated, I wet myself, I don't know when I have to go. I think my shut off valve is broke. An interview with the DON and CRN concluding at 9:40 a.m. on 09/19/18 confirmed the assessment dated [DATE] was inaccurate related to Resident #300's incontinence status. | 2020-09-01 |
| 1608 | 1608 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 868 | F | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observation, policy review, review of staff personnel files, and record review, the facility failed to identify issues with respect to which quality assessment and assurance activities are necessary. The facility received an immediate jeopardy for failure to provide an environment free from accident hazards over which the facility had control. Secure care equipment failed to function properly which has the potential to allow a resident, utilizing the secure care equipment, to leave the facility without staff knowledge. This practice had the potential to affect five (5) of five (5) residents with a secure care wandering device. Resident identifiers: #2, #38, #34, #37, and #45. The facility received a second immediate jeopardy for failure to ensure two (2) of four (4) direct care staff were screened for a history of abuse, neglect, exploitation and or any applicable criminal activity that would identify the individual as unfit to work in a long term care facility. This practice had the potential to affect all residents residing at the facility. Employee identifiers #64 and #7. In addition the facility failed to ensure the required staff members attended the quarterly meetings of the Quality Assurance (QA) Committee. This practice had the potential to affect all residents residing at the facility. Facility census: 61. Findings included: a) An immediate jeopardy existed when the facility's secure care alarm failed to alert staff when a resident wearing a secure care device was able to go through the main door. 1. Resident #34 On the morning of 07/10/18, at approximately 10:30 AM, observations found Resident #34 attempting to leave the facility when another resident, without an alarm system, was exiting the building. No alarm sounded at that time. At the time of the incident, the surveyor was unaware Resident #34 was wearing a secure alarm system. The surveyor was alerted to the incident when the male resident was cursing… | 2020-09-01 |
| 1609 | 1609 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 880 | F | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy, record review, resident interview and staff interview the facility failed to implement infection control procedures to prevent the spread of disease and infection to the extent possible. Laundry Room staff were air-drying towels used in the kitchen in the soiled utility room. Resident #56 was not placed in contact isolation for 24 hours after treatment for [REDACTED].#52 was not placed in contact isolation as ordered by her physician for [MEDICAL CONDITION] (C diff) infection. These findings had the potential to affect all residents. Resident identifiers: #56 and #52. Facility census: 61. Findings included: a) Laundry An observation on 07/10/18 at 11:00 AM, with Housekeeping Supervisor (HS) #4 found towels tied in a knot on a rack between the two (2) washing machines in the soiled laundry room. When asked what that was between the two washers, she said, Those are the towels used in the kitchen. We were told it was a fire hazard to air dry them in a dryer. So that is why they air-dry them. A soiled laundry cart was pushed against the drying rack on which the kitchen towels were drying. After questioning the cleanliness of air-drying in the soiled laundry room, she agreed that it was not a good idea to have the kitchen towels dry in the soiled side of the laundry room. In an interview on 07/12/18 at 9:00 AM, the Administrator said she had no idea housekeeping was not using the dryer. Housekeeper Supervisor #4 said that she would move the drying rack to the clean side of the laundry room. She agreed it was not following infection protocol to dry them in the soiled room. b) Resident #56 Record review on 07/09/18 at 3:00 PM, found Resident #56 was admitted with lice. She was treated for [REDACTED]. During an interview on 07/10/18 at 12:00 PM, the Director of Nursing (DON) verified Resident #56, and three (3) other roommates were also treated for [REDACTED]. During an interview on 07/10/18 at 2:38 PM, the DON reported … | 2020-09-01 |
| 1610 | 1610 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 883 | E | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based medical record review, review of the Center for Disease Control and Prevention (CDC) recommendations, and staff interview, the facility failed to ensure all eligible residents received, or were voffered, pneumococcal vaccinations. This was evident for four (4) of the five (5) residents reviewed for immunization status. Residents identifiers: #3, #31, #37, and #34. Facility census: 61. Findings included: a) Resident #3 Immunization status for this resident was reviewed with the Director of Nursing (DoN) on 07/11/18 at 9:00 AM. This resident was admitted to the facility on [DATE]. Evidence revealed this resident received Prevnar13 (PCV13) on 08/09/15 with no evidence of receiving [MEDICATION NAME] 23 (PPSV23) one year later, as recommended the CDC. b) Resident #31 This resident entered the facility on 04/01/17. Review of medical records with the DoN revealed this resident's daughter reported the resident had received a pneumonia vaccine four (4) or five (5) years ago, but was not sure which one. No other information was obtained. The facility failed to consult with the resident's physician regarding administration of pneumococcal vaccines. c) Resident #37 Review of medical records with the DoN revealed this resident was admitted to the facility 01/11/17. The facility failed to obtain information regarding resident's pneumococcal vaccinations. The only documentation about pneumococcal vaccines was a discharge note from a local hospital with the admitted handwritten on the paper. d) Resident #34 The facility failed to provide this resident with recommended pneumococcal vaccinations in accordance with CDC recommendations. The DoN reviewed the resident's medical records and found a consent form dated 08/23/16 from the resident's daughter for the vaccine to be administered. Written on the form was, Received at another facility 9/1/15. There was no indication of which pneumonia vaccine was given and no record to indicate whether any pneumococca… | 2020-09-01 |
| 1611 | 1611 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 908 | D | 0 | 1 | 5JPY11 | Based on a random opportunity for discovery, observation and staff interview, found the facility failed to maintain all mechanical electrical in safe and operational condition. The air conditioner in Resident #37's room was turned off at the breaker box, which rendered it unusable. Additionally, the metal electric outlet box in which the air conditioner was plugged into, was lying on the floor. This was random opportunity for discovery. Resident identifier: #37. Facility census 61. Findings included: a) Resident #37 During an interview on 07/09/17 at 3:58 PM, the residents brother said that his brother received good care at the facility, but the only problem he had was that his room smelled so bad. He said in the past he had spoken to the administrator about the room being dirty and smelling countless times. He also was concerned about the facility turning off the air conditioner in the room so his brother could not control the temperature of his own room. He said was told that because his brother urinated in the air conditioner unit, they turned it off. He stated that did not address the problem with the odor. He said his brother now has a fungal infection on his body folds from not having air conditioning on the very hot days. During an interview on 07/10/18 at 8:36 AM, Nurse Aide (NA) #82 said the air conditioner/heater unit was working, but when she tried to turn it on, it would not come on. It was also noted at that time, that the air conditioner was plugged into an electrical box lying on the floor in brown stains that remained on the floor. During an interview on 07/10/18 at 8:37 AM, the Administrator said she was also unaware that his air conditioner was not working or that the outlet box the unit was plugged into was not mounted on the wall, but was lying on the floor. During an interview on 07/10/18 at 8:53 AM, Maintenance Supervisor (MS) # 18 said he was aware that this Resident's air conditioner unit was not working and had been off for one month or more. He stated he was afraid the resident would get… | 2020-09-01 |
| 1772 | 1772 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2018-07-12 | 655 | F | 0 | 1 | 3KXQ11 | Based upon record review, staff interview and resident interview, the facility failed to provide the resident or their representative with a written summary of the baseline care plan within 48 hours of admission. This was found for residents #80, #11, #32, #35, #15, #20, #37, and #3, and had the potential to affect all residents in the facility. Census: 30. Findings included: a) Resident #11 Resident #11 was admitted in the month of (MONTH) (YEAR). She is acting as her own responsible party. During an interview on 7/10/18 at 10:00 AM, Resident #11 was asked if the facility had met with her within forty-eight hours of her admission to discuss her care needs and plan the care and services to be provided during her stay, and the desired goals of those services. She said they had not. b) Resident #15 Resident #15 was admitted to the facility in the month of (MONTH) (YEAR). She is acting as her own responsible party. Resident #15 was interviewed on 7/10/18 at 9:19 AM. She was asked if her care needs and the facility's plan to meet them were discussed within 48 hours of her admission, and if she was provided with a written summary of the discussion. She said could not recall discussing or receiving any written copy of a plan regarding her care needs, the care and services to be provided during her stay, or the desired goals of those services. c) Resident #32 Resident #32 was interviewed on 7/10/18 at 9:36 AM. She said she could not recall discussing or receiving any written copy of a plan regarding her care needs, the care and services to be provided during her stay, or the desired goals of those services. d) Resident #35 Resident #35 was interviewed on 7/10/18 at 10:15 AM, and he also said he could not recall discussing or receiving any written copy of a plan regarding his care needs, the care and services to be provided during his stay, or the desired goals of those services. e) Staff Interview The Director of Nursing, Registered Nurse #39, was interviewed on 7/10/18 at 3:30 PM. She said the facility does not furnish… | 2020-09-01 |
| 1773 | 1773 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2018-07-12 | 657 | D | 0 | 1 | 3KXQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F657 S/S=D Based upon record review, staff interview, and resident interview, the facility failed to develop and implement person-centered comprehensive care plans that were sufficiently individualized to ensure all staff were equipped to provide effective care to each resident based upon their specific needs and circumstances. This was found for the two (2) residents who had been in the facility long enough to have a comprehensive care plan completed. Resident Identifiers: #11 and #15. Facility census: 30. Findings include: a) Resident #11 is [AGE] years of age. She was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She is acting as her own responsible party. Resident #11 was interviewed on 7/10/18 at 10:00 AM. She said that she was admitted to the acute care hospital initially due to severe pain in her neck and the back of her head. She said the pain caused her to clench her teeth so hard she fractured one of her teeth. She said while she was in the hospital, her bowel obstruction happened and she had to have emergency surgery. She expressed her concerns were that her fractured tooth be attended to, that she had a new [MEDICAL CONDITION] and was apprehensive about being able to care for it herself, and her extensive surgical wound that required sponges to be inserted into her abdomen. She said she was concerned that she would not be able to get enough physical exercise to prevent decline because of the extent of her abdominal surgery. She said she was afraid to eat because the other day her [MEDICAL CONDITION] bag filled up and burst all over her. Resident #11 was one of two residents with a stay of sufficient duration to have a comprehensive care plan completed. Review of the comprehensive care plan found no mention of her tooth, her [MEDICAL CONDITION], or the specific issues regarding her extensive surgical wound. A copy of the comprehensive care plan including signatures was requested and provided by the Director of Nursi… | 2020-09-01 |
| 1774 | 1774 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2018-07-12 | 756 | F | 0 | 1 | 3KXQ11 | Based on policy review and staff interview, the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the monthly medication regimen review process. This practice has the potential to affect all. Facility census: 30. Findings included: a) The facility policy titled 9.1 Medication Regimen Review with an effective date of 11/28/16, states the Medication Regimen Review (MRR) of each resident must be reviewed at least once a month by a licensed pharmacist. Section 6 of the procedure states: The pharmacist will address copies of residents' MRRs to the Director of Nursing and/or attending physician and to the Medical Director . Section 7 states: Facility should encourage Physician/Prescriber or other responsible parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR . Section 11 states: The attending physician should address the consultant pharmacist's recommendations no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. **Except for the identified urgent irregularities, the policy lacks time frames for the various steps in the process. During an interview with Employee #72, Pharmacist on 07/11/18 at 2:45 PM, reported there was no policy with time frames for pharmacy review. | 2020-09-01 |
| 3686 | 3686 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 558 | D | 0 | 1 | SQBP11 | Based on observation, resident interview, and staff interview, the facility failed to provide services with reasonable accommodation for residents. Resident #21 and #323's over the bed light cords were not long enough to be easily reached by the residents. This practice affected two (2) of nineteen (19) residents observed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #21 and #323. Facility census: 72. Findings included: a) Resident #21 An observation of the Resident, on 07/10/18 at 10:30 AM, revealed the Resident's over the bed light cord was approximately four inches long. An interview with the Resident, on 07/10/18 at 10:35 AM, revealed the Resident could not reach the over the bed light cord while in bed. The Resident stated the light was hard to turn on and off with the short cord. The resident stated she had reported the light cord to multiple staff members. b) Resident #323 An observation of the Resident's room, on 07/10/18 at 1:45 PM, revealed the Resident's over the bed light cord was approximately four inches long. An interview with Licensed Practical Nurse (LPN) #140, on 07/10/18 at 1:55 PM, revealed the over the bed light cords were too short. The LPN stated he would ensure the light cords were reported to the supervisor so they could be fixed immediately. | 2020-09-01 |
| 3687 | 3687 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 583 | D | 0 | 1 | SQBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to protect the personal privacy of a resident including personal and health information. An unlocked computer monitor was left unattended on top of a medication cart revealing personal and medical information for a resident. This was a random observation. Resident identifier: #69. Facility census: 72. Findings included: a) Observation A random observation, on 07/10/18 from 9:30 AM to 9:35 AM, revealed Licensed Practical Nurse (LPN) #140 left the computer monitor open on top of the medication cart for Resident #69. The computer monitor was left unattended in the hallway while the LPN went into a resident's room. The computer contained the following information: -Resident name -Date of birth -Physician -Medications -allergies [REDACTED]. b) Interviews An interview with LPN #140, on 07/11/18 at 9:35 AM, revealed he should not have left any patient information viewable on top of the medication cart while unattended. The LPN stated he usually covers the computer monitor while being away from the medication cart. An interview with the First Floor C Hall Unit Manager, on 07/11/18 at 9:40 AM, revealed the LPN should have covered the computer monitor before leaving it unattended. | 2020-09-01 |
| 3688 | 3688 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 584 | E | 0 | 1 | SQBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide maintenance services for six (6) of sixty (60) rooms observed during the Long Term Care Survey Process (LTCSP). The issues identified included resident's rooms and bathrooms with scratched walls, missing paint, damaged cabinets, dirty light fixtures, cracked floor tiles, a dirty vent, broken window screens, and rusted ceiling tiles . Room identifiers: #100, #103, #112, #215, #300, and #301. Facility census: 72. Findings included: a) Observations The following observations were made on 07/09/18, 07/10/18 and 07/11/18 during the LTCSP: -room [ROOM NUMBER]-The bathroom wall was scraped with missing paint The bathroom light was dirty. -room [ROOM NUMBER]-The bathroom wall had missing paint with scratches. The floor tiles by the bed were cracked. The clothing cabinet was missing chunks in several places. -room [ROOM NUMBER]-The bathroom light was dirty. The bathroom vent was filled with dust. The bathroom floor tiles were stained. The bathroom walls were missing paint. The ceiling tiles in the room were rusted. -room [ROOM NUMBER]-The wall behind the bed was missing paint. -room [ROOM NUMBER]-The window in the bathroom had a broken screen. -room [ROOM NUMBER]-The window in the room had a broken screen. b) Interview An interview with the Administrator, on 07/11/18 at 3:15 PM, revealed the nursing managers do daily room rounds looking for maintenance issues. The Administrator stated any issues found are put on a work order for the maintenance department. The Administrator stated the Maintenance Director does weekly rounds on the rooms as well as addresses maintenance requests from the staff. The Administrator stated since the building is so old it is impossible to keep up with all the maintenance issues. | 2020-09-01 |
| 3689 | 3689 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 600 | D | 1 | 1 | SQBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of allegations reported to the State and the facility's investigation findings, resident interview, staff interview and medical record review, the facility failed to protect a resident's right to be free from abuse. The facility failed to recognize and address abuse. This was true for one (1) of one (1) resident reviewed for abuse during the Long-Term Care Survey Process (LTCSP) and investigation of complaint # . This practice had the potential to affect more than a limited number of residents. Resident identifier: #4. Facility Census: 72. Findings included: An interview with Resident #4, on 07/09/18 at 3:23 PM, revealed the resident said the staff did talk mean to her sometimes. When asked if she told anyone, she said she had reported things to the administrator and nurses, but nothing is ever done. Resident #4 stated, Sometimes staff will say that I lied about it. When the resident was asked how this made her feel she replied, It hurts my feelings, sometimes I go to my room and cry. When asked which staff was mean to her she said, Not everyone, a few of the aides but would not give this surveyor any names. During the interview the resident spoke slowly in a low raspy voice, taking time to form her words. At times the resident had difficulty forming her words. Resident #4 communicated with this surveyor mostly by writing notes on a legal pad paper with a pencil, that she had in bed beside her, in answer to the surveyor's questions. The resident also made yes or no gestures by nodding her head. Review of the resident's last quarterly minimum data set (MDS) with an assessment reference date (ARD) 03/28/18, on 07/10/18 at 03:00 PM, revealed the resident has adequate hearing and vision, unclear speech, and sometimes makes herself understood and has ability to understand others. Brief Interview for Mental Status (BIMs) score is fifteen (15) indicating resident is cognitively intact. Pertinent [DIAGNOSES REDACTED]. On 07/11/18 at… | 2020-09-01 |
| 3690 | 3690 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 641 | D | 0 | 1 | SQBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) for one (1) of nineteen (19) residents reviewed during the long-term care survey. Resident identifier: #35. Facility census: 72. Findings included: a) Resident #35 Resident #35 had an order for [REDACTED]. Rivaroxaban (Xarelto) is an anticoagulant medication. Resident #35's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 05/08/18, Section N, Medications, stated no anticoagulant medication had been received by the resident during the last seven (7) days. An interview was conducted on 07/10/18 with Registered Nurse (RN) #13, who performed MDS Assessments. RN #13 stated that Resident #35's MDS with ARD 05/08/18, Section N, Medications, was incorrect and should have stated the resident received seven (7) days of anticoagulant medication. | 2020-09-01 |
| 3691 | 3691 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 656 | D | 0 | 1 | SQBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop comprehensive care plans for two (2) of nineteen (19) residents reviewed during the long-term care survey. The facility failed to develop comprehensive care plans for Resident #47 in the area of anxiety and for Resident #4 in the area of communication. Resident identifiers: #47, #4. Facility census: 72. Findings included: a) Resident #47 Review of the medical record revealed Resident #47 had a history of [REDACTED]. Review of Resident #47's comprehensive care plan revealed the problem, Impaired decision making due to: [MEDICAL CONDITION] disorder, anxiety, and dementia. The goal was, Will make daily choices in care. The comprehensive care plan revealed no problem specifically related to anxiety and no goals related to anxiety. On 07/11/18 at 3:57 PM, Registered Nurse (RN) #13 was interviewed about a care plan focus of anxiety on Resident #47's comprehensive care plan. RN #13 stated the problem area Impaired decision making in Resident #47's care plan contained interventions applicable to anxiety. However, she agreed additional interventions such as medication administration would be implemented for anxiety and were not included in the care plan. RN #13 also agreed Resident #47's care plan did not contain a measurable goal specifically related to anxiety. b) Resident #4 An interview with Resident #4, on 07/09/18 at 03:23 PM, revealed the resident said her vocal cords were damaged from having a stroke. Resident #4 spoke slowly in a low raspy voice, taking time to form her words. At times the resident had difficulty forming her words and became frustrated. Resident #4 answered the surveyor's questions and communicated with this surveyor, mostly by writing notes with a pencil on legal pad paper. The pencil and legal pad paper was lying on the bed beside her at the time of the interview. The resident also gestured by nodding her head yes or no. Review of the residen… | 2020-09-01 |
| 3692 | 3692 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 657 | D | 0 | 1 | SQBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to revise a care plan in the care area of activities of daily living (ADL). This was true for one (1) of one (1) resident reviewed for ADLs during the Long-Term Care Survey Process (LTCSP). This practice had the potential to affect more than a limited number of residents. Resident identifier: #4. Facility Census: 72. Findings included: On 07/09/18 at 03:26 PM observation of resident revealed Resident#4 had greasy hair, body odor, and was wearing a dirty t-shirt stained with what appeared to be dried food. The resident said she did not get the help she needs to clean herself up. Review on, 07/10/18 at 03:00 PM, of a quarterly minimum data set (MDS) with an assessment reference date (ARD) 03/28/18 revealed the resident has unclear speech and sometimes makes herself understood. The resident has ability to understand others and her Brief Interview for Mental Status (BIMs) score is fifteen (15) indicating resident is cognitively intact. Resident #4 needs supervision with dressing and bathing and limited assistance with personal hygiene. The resident is frequently incontinent of bladder and always with bowel. Pertinent [DIAGNOSES REDACTED]. On 07/11/18 at 10:00 AM, review of records revealed resident was admitted to the facility on [DATE]. Review of care plan revealed a problem area, Resident has selfcare deficit; requires assist with ADLs. Resident has behaviors of asking staff to perform ADL tasks for her that she is capable of doing. Interventions initiated in (YEAR) and (YEAR) included; Encourage resident to exercise and walk as much as possible daily; TED hose .applied in morning remove at bedtime; Encourage good personal hygiene; Shower with Shampoo 2x weekly and prn; personal hygiene non shower days; denture care; nail care; shave axilla and legs prn; hair care daily; right side bed cane assist with mobility; encourage resident to be as independent as possib… | 2020-09-01 |
| 3693 | 3693 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 684 | E | 0 | 1 | SQBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents ' choices for one (1) of nineteen (19) residents reviewed during the long-term care survey. The facility failed to follow the physician's orders [REDACTED].#47. Resident identifier: #47. Facility census: 72. Findings included: a) Resident #47 Resident #47 had a [DIAGNOSES REDACTED]. She was prescribed pain medication, [MEDICATION NAME] 5 milligrams (mg)/[MEDICATION NAME] 235 mg, three times a day. She also had an order for [REDACTED]. Review of Resident #47's medical records for the week of 07/04/18 through 07/10/18 revealed Pain Management Logs completed on the following dates at the following times: - 07/04/18 at 12:04 AM - 07/05/18 at 2:01 AM - 07/06/18 at 2:04 AM - 07/06/18 at 4:52 PM - 07/07/18 at 3:11 AM - 07/07/18 at 5:04 PM - 07/08/18 at 2:27 AM - 07/08/18 at 7:00 PM - 07/09/18 at 2:50 AM - 07/10/18 at 1:51 AM On 07/11/18 at 5:29 PM, an interview was conducted with the Director of Nursing (DoN) and with Registered Nurse (RN) #150. The DoN and RN #150 agreed pain management logs were not completed every shift for Resident #47. They stated pain assessments may have been documented elsewhere. Untimed shift reports were provided by the DoN and revealed the following information regarding Resident #47's pain: - 07/05/18: Denies any pain - 07/07/18: No complaints of pain - 07/09/18: No complaints of pain - 07/10/18: No complaints of pain However, medical records documenting pain assessments performed every shift as ordered by the physician were not provided. No further documentation was provided through the end of the survey. | 2020-09-01 |
| 3694 | 3694 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 689 | E | 0 | 1 | SQBP11 | Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. A medication cart was unlocked and accessible to anyone. This practice had the potential to affect more than a limited number of residents. Facility census: 72. Findings included: a) Observation A random observation of the First Floor C Hall, on 07/10/18 at 9:30 AM, revealed a medication cart was unlocked while in the hallway. The cart was unlocked, unattended, and out of sight of any staff from 9:30 AM until 9:35 AM. The cart contained all the medications for the C Hall residents. b) Interview An interview with Licensed Practical Nurse (LPN) #140, on 07/10/18 at 9:30 AM, revealed the medication cart should always be locked when not in sight of the nurse. | 2020-09-01 |
| 3695 | 3695 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2018-07-12 | 880 | E | 0 | 1 | SQBP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and State Operations Manual review, the facility failed to ensure an effective infection control program to the extent possible over which it had control. During medication pass observation, a nurse laid a medication box directly onto a resident's bedside table with no barrier to protect it from potentially picking up organisms which could be brought back to the medication cart. During observation of a fingerstick blood glucose test to check the blood sugar level of two (2) residents, the nurse laid the commonly shared blood glucose machine directly onto objects in the residents' rooms with no barrier to protect it from potentially picking up organisms. Also, the nurse cleaned the glucose machine with 70% alcohol between patient uses, although 70% [MEDICATION NAME] (alcohol) solutions are not effective against [MEDICAL CONDITION] bloodborne pathogens according to the Federal Drug Administration (FDA) . The facility's policy directed staff to follow manufacturer's guidelines to clean the commonly shared blood glucose machines. The manufacturer's guidelines were vague on how to clean the blood glucose machines between multiple patient uses. These practices had the potential to affect more than a limited number of residents. Resident identifiers: #57, #25, #15. Facility census: 72. Findings included: a) Resident #57 During observation of a medication administration on 07/10/18 at 8:39 a.m., registered nurse Employee #60 (E#60) removed a box from the medication cart which contained a [MEDICATION NAME] hand-held inhaler. She then removed the inhaler from its box, and laid the now empty box directly onto the resident's bedside table. After the resident used the inhaler, E#60 then placed the inhaler back into its box. After E#60 washed her hands, she then picked up the boxed inhaler from the resident's bedside table and carried it back to the medication cart where she placed the container on top … | 2020-09-01 |
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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 );