cms_WV
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36 rows where "inspection_date" is on date 2018-09-27
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 181 | 181 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2018-09-27 | 550 | D | 0 | 1 | DL7D11 | Based on random observation, staff interviews and policy review, the facility failed to promote care for residents in a manner that maintained or enhanced dignity. The staff entered a resident's room without knocking, identifying themselves, or obtaining permission. This practice had the potential to affect a minimal number of residents. Resident identifiers: #24 and #31. Facility census 52. Findings included: a) Resident #24 and #31 During an observation of a resident room, on 09/24/18 at 11:30 AM, revealed Nurse Aide (NA) #40 walked into the room without knocking, identifying themselves, and asking for permission to enter Resident #24 and #31's room. NA #40 walked over to Resident #24's bed and stated, It is time to go to the bathroom. NA #40, turned around and left the room. A few minutes later NA#40 returned to room with NA #17 without knocking, identifying themselves, and asking for permission to enter Resident #24 and #31's room. The NA's walked over to Resident #24's bed. NA #17 went around to the far side of the bed. NA #40 was on the opposite side of the bed closest to the Resident in the A - bed and the door. NA#40 reached up and pulled down Resident #24's bed covers exposing the resident in an adult brief to her roommate with the door to the resident's room wide open for anyone to view inside. In an interview on 09/24/18 at 11:32 AM, NA #40 and #17, revealed the NA's forgot to knock on the residents door, identifying themselves and ask for permission prior to enter the room. The NA's also agreed they should have closed the entrance door to the room and pulled the curtain between the residents prior to pulling down Resident #24's bed covers. An interview on 09/24/18 at 12:00 PM, with the Assistant Administrator #13, she was informed of the observation above and she stated, I will address this matter. A review of the facility policy, on 09/27/18 at 2:00 PM, titled Promoting/Maintaining Resident Dignity with a revision date of 08/30/18, stated, Maintain Privacy. Staff shall knock on doors and properly ann… | 2020-09-01 |
| 182 | 182 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2018-09-27 | 583 | D | 0 | 1 | DL7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observation, staff interview and policy review, the facility failed to provide privacy for a resident during personal care. Staff failed to pull the curtain while performing personal care and close the door to the resident room. This practice had the potential to affect a minimal number of residents. Resident identifier: #24. Facility census 52. Findings included: a) Resident #24 During an observation of room [ROOM NUMBER], on 09/24/18 at 11:30 AM revealed Nurse Aide (NA) #40, walked into the room without knocking, identifying themselves, and asking for permission to enter Resident #24 and #31's room. NA #40 walked over to Resident #24's bed, in which she resides in the b bed, and stated, It is time to go to the bathroom. NA #40, turned around and left the room. A few minutes later NA#40 returned to room with NA #17 without knocking, identifying themselves, and asking for permission to enter Resident #24 and #31's room. The NA's walked over to Resident #24's bed. NA #17 went around to the far side of the bed. NA #40 was on the opposite side of the bed closes to the Resident in the A - bed and the door. NA#40 reached up and pulled down Resident #24's bed covers exposing the resident in an adult brief to her roommate with the door to the resident's room wide open for anyone to view inside. In an interview on 09/24/18 at 11:32 AM, NA #40 and #17, revealed the NA's forgot to knock on the residents door, identifying themselves and ask for permission prior to enter the room. The NA's also agreed they should have closed the entrance door to the room and pulled the curtain between the residents prior to pulling down Resident #24's bed covers. An interview on 09/24/18 at 12:00 PM, with the Assistant Administrator #13, she was informed of the observation above and she stated, I will address this matter. A review of the facility policy, on 09/27/18 at 2:10 PM, titled Resident Right to Privacy During Care with a revision date of 08/30/18,… | 2020-09-01 |
| 183 | 183 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2018-09-27 | 761 | D | 0 | 1 | DL7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure all multi-dose vials of insulin were dated when initially opened for used and needle-punctured. According to manufacturer's guidelines, [MEDICATION NAME]left in a multi-dose vial beyond twenty-eight (28) days of opening must be discarded. By not dating the multi-dose vial when initially opened, nursing staff had no way of knowing when to discard the vial. This practice had the potential to negatively impact the safety and/or potency of the insulin. This was evident for one (1) of ten (10) opened and used multi-dose vials of insulin observed. Resident identifier: #26. Facility census: 52. Findings include: a) Resident #26 Opened and used (needle punctured) multi-dose vials of insulin were observed on 09/27/18 at 10:53 AM. An opened and needle punctured vial of [MEDICATION NAME]for this resident contained no date to indicate when it had initially been opened for use. The label on the vial indicated pharmacy filled that prescription on 09/13/18. Licensed nurse employee #25 (E#25) was present at this time. She said staff should have dated this vial when initially opened to ensure that staff disposed of the vial twenty-eight (28) days after it was first opened for use. She said the [MEDICATION NAME]is used as sliding scale coverage for this resident's blood glucose checks per the glucometer. On 09/27/18 at 11:10 AM the director of nursing (DON) provided a copy of their policy titled Labeling of Medications and Biologicals with revision date of 08/30/18. Page two (2) and item number eight (8) of this policy stated All opened or accessed vials should be discarded within twenty-eight (28) days unless the manufacturer specified a different (shorter or longer) date for that opened vial. An interview was conducted with the administrator and assistant administrator on 09/27/18 at 1:15 PM. No further information was provided prior to exit. | 2020-09-01 |
| 184 | 184 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2018-09-27 | 842 | D | 0 | 1 | DL7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , medical record review, and staff interview, the facility failed to ensure accurate medical transcription and documentation of a physician's orders [REDACTED]. A nurse wrote a physician's orders [REDACTED]. This order was transcribed onto the medication administration record at 2% strength. Nurses documented twelve (12) times they administered a 2% strength dose. However, pharmacy provided this prescription at 0.5% strength. Per a nursing drug handbook information, this ophthalmic ointment is only available at 0.5% strength. This was evident for one (1) of four (4) residents observed during medication pass out of thirty-four (34) medication administration observations. Resident identifier: #50. Facility census: 52. Findings included: a) Resident #50 During a medication administration observation on 09/26/18 at 9:10 AM, licensed nurse employee #26 (E#26) administered [MEDICATION NAME] 0.5% ophthalmic ointment to this resident's right eye. Observation of the electronic medical record found directive to administer [MEDICATION NAME] 2% ointment to the right eye. Review of the hard copy medical record revealed a hand-written physician's verbal order which was written by a nurse on 09/18/18 at 3:00 PM. This order directed to instill [MEDICATION NAME] ointment 2% topically to the right eye twice daily for seven (7) days related to irritation, redness, swelling. Review of the facility's Nursing (YEAR) drug handbook which was located at the nurses' station, found that [MEDICATION NAME] ophthalmic ointment is only available at the 0.5% strength. An interview was conducted with the assistant administrator on 09/26/18 at 9:15 AM regarding this scenario. She said this was a transcription error. The medication administration record (MAR) was reviewed on 09/26/18. The MAR contained a typed order to administer [MEDICATION NAME] ointment 2% to the right eye topically twice daily for seven (7) days. Nursing staff initialed on the electron… | 2020-09-01 |
| 185 | 185 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2018-09-27 | 865 | E | 0 | 1 | DL7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility's quality assurance and performance improvement program (QAPI) / quality assessment and assurance (QAA) committee failed to identify and implement corrective action for quality deficiencies for which they should have been aware of to improve the lives of the residents. The facility failed to ensure that 10 out of 13 residents either received the appropriate pneumococcal immunization, or did not receive the pneumococcal immunization due to medical contraindication or refusal. These practices had the potential to affect more than a limited number of residents at the facility. Resident Identifiers: #26, #35, #42, #201, #24, #5, #101, #15, #4, #16, #17, #2, #30. Facility census: 52. Findings included: a) Staff interview at 11:13 on 09/26/18 with Licensed Practical Nurse (LPN) #70 revealed the facility did not routinely offer or administer the 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13). The PVC13 is not readily available within the facility. LPN #70 also stated they only administer the PVC13 vaccine if it is specifically ordered by the physician, and the vaccine is not a standing order upon admission. b) Review of facility policy for Pneumococcal Vaccine state under Policy Explanation and Compliance Guidelines each resident will be offered a pneumococcal immunization unless it is medially contraindicated, or the resident has already been immunized, and prior to immunization the resident or resident's representative will have the opportunity to refuse. The policy also state the type of pneumococcal vaccine, 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13) or 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME] 23) offered will depend upon the recipient's age and suitability to pneumonia, in accordance with current Centers for Disease Control (CDC) guidelines and recommendations. Explanation of the facility's complian… | 2020-09-01 |
| 186 | 186 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2018-09-27 | 880 | E | 0 | 1 | DL7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview the facility failed to maintain an effective infection control program designed to provide a safe and sanitary environment to help prevent the development of and transmission of communicable disease to the extent possible. A nursing assistant provided care to Resident #101 who was in contact precautions, without donning a gown or gloves. Licensed nurses cleaned the facility's two (2) resident shared glucometers improperly using 70% ethyl alcohol. One facility staff member was observed utilizing an improper hand-washing technique. The facility also failed to handle, store, and/or process linens in a satisfactory manner to prevent infection. These practices had the potential to affect more than a limited number of residents. Resident identifier: #101. Facility census: 52. Findings included: a) Resident #101 Observation on 09/24/18 at lunch time found nursing assistant employee #32 (E#32) entered the room of Resident #101 to deliver his lunch tray. A sign on the door conveyed that he was in contact precautions. An isolation cart sat outside his door in the hallway. E#32 did not don an isolation gown or gloves. She touched his bed linens with her bare hands. She touched his overbed tray with her bare hands. She picked up the bed control with her bare heads and raised the head of his bed. She helped him become positioned comfortably, and removed the brown plastic lid which covered the hot foods on his plate. At 12:19 PM E#32 walked down the hallway to the dining room where she passed this brown plastic plate cover through the kitchen window, where she placed it on top of other plate covers. She then used hand sanitizer and left the dining room. Review of the medical record on 09/25/18 found a physicians order dated 09/21/18 for contact isolation due to [MEDICAL CONDITION] resistant [DIAGNOSES REDACTED] aureus (MRSA) of the right foot wound. An interview was conducted with infection control r… | 2020-09-01 |
| 187 | 187 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2018-09-27 | 883 | E | 0 | 1 | DL7D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, policy review and documentation review, the facility failed to ensure 10 out of 13 sample residents were given opportunity to receive, refuse, or to have contraindication determined for the appropriate pneumococcal vaccination to be administered. Resident identifiers: #26, #35, #42, #201, #24, #5, #101, #15, #4, #16, #17, #2, #30. Facility census: 52. Findings included: a) Staff interview at 11:13 on 09/26/18 with Licensed Practical Nurse (LPN) #70 revealed the facility did not routinely offer or administer the 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13). The PVC13 is not readily available within the facility. LPN #70 also stated they only administer the PVC13 vaccine if it is specifically ordered by the physician, and the vaccine is not a standing order upon admission. b) Review of facility policy for Pneumococcal Vaccine state under Policy Explanation and Compliance Guidelines each resident will be offered a pneumococcal immunization unless it is medially contraindicated, or the resident has already been immunized, and prior to immunization the resident or resident's representative will have the opportunity to refuse. The policy also state the type of pneumococcal vaccine, 13-valent pneumococcal conjugate vaccine (PVC13, Prevnar 13) or 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME] 23) offered will depend upon the recipient's age and suitability to pneumonia, in accordance with current Centers for Disease Control (CDC) guidelines and recommendations. Explanation of the facility's compliance guidelines indicate the residents medical record must include documentation that indicates the resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. c) Centers for Disease Control (CDC) guideline for Pneumococcal Vaccine Timing for adults [AGE] years or older state for those who have not received any pneumococcal vaccines, or t… | 2020-09-01 |
| 3481 | 3481 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 559 | D | 0 | 1 | DXEI11 | Based on resident interview, staff interview and record review, the facility failed to explain to Resident #385 the reason for her room change. This was during a random opportunity for discovery. Resident identifier: #385. Facility census: 89. Findings included: a) Resident #385 On 09/24/18 at 1:30 PM, Resident #385 and her son were interviewed. They stated Resident #385 was moved to a new room and not notified of the reason for the room change. A progress note written in Resident #385's medical record on 09/13/18 at 1:21 PM stated, (Resident #385) was moved from 201 to 217 B. The details regarding this room change can be found on the form, Room Change Notification. The form Room Change Notification - V 3 was reviewed. The form was completed by Social Services Supervisor #92 on 09/13/18. Under item four, Reason for Room/Bed Change, the reason was noted as Moving to a semi private room. No further explanation was documented. Under item five of the form, Social Services Supervisor #92 documented the resident was notified of the room change 09/13/18 01:00. Item six c. of the form was checked for A copy of this notice is being provided to the resident's representative. On 09/25/18 at 10:21 AM, Social Services Supervisor #92 was interviewed regarding the actual room change, the room change form, and resident notification of the room change. She stated that Resident #385's new roommmate (Resident #386) was about to come to blows with her previous roommate (Resident #53), so Resident #53 was swapped with Resident #385. Resident #53 was getting in (Resident #386)'s stuff and Social Services Supervisor #92 was afraid for (Resident #53)'s safety. She also stated Resident #385 was agreeable to move. She said she did not want to put information about Resident #53 and Resident #386 into Resident #385's Room Change Notification form or into Resident #385's progress notes. On 09/26/18 at 4:03 PM, Resident #385 reiterated she was not asked if she wanted to move or notified of the reason for the move. | 2020-09-01 |
| 3482 | 3482 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 561 | D | 0 | 1 | DXEI11 | Based on resident interview and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for the care area of choices, had the opportunity to exercise autonomy regarding those things that are important in her life. Resident #76 was not offered a choice in choosing her shower schedule. Resident identifier: #76. Facility census: 89. Findings included: a) Resident #76 On 09/24/18 at 11:21 a.m., the resident said she only gets 2 showers per week but she would prefer more showers. She did not believe it was possible to have any more showers because the facility just offers 2 showers per week. At 10:23 a.m., on 09/25/18, the resident's nursing assistant (NA) #32, said the resident gets showered on Tuesday and Friday. Review of the look back report report for activities of daily living (ADL) care found the resident received showers every Tuesday and Thursday from 08/25/18 to 09/25/18 as directed. The resident did not refuse any of her showers according to the documentation. On 09/25/18 at 10:26 AM, the resident was interviewed with the director of nursing present. The resident asked the DON, What are my options? The DON told the resident she could shower every day of the week if she wanted. The resident chose to have a shower on Monday, Wednesday, Friday and Saturday. The DON said residents are asked upon admission what shower schedule they prefer. The DON said she had nothing in written form to verify her statement. | 2020-09-01 |
| 3483 | 3483 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 580 | E | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and staff interview, the facility failed to notify Resident #24 when there were changes made in her plan of care. On multiple occasions Resident #24's family was notified of medication changes and diagnostic testing results with no evidence that Resident #24 was also notified of the changes or the results. This was a random opportunity for discovery. Resident identifier: #24. Facility census: 89. Findings included: a) Resident #24 An interview with Resident #24 at 3:35 p.m. on 09/26/18 found her medication for her heartburn was discontinued without her knowledge. She stated, They took me off that medicine for heart burn without talking to me first and I have had heartburn ever since. I need that medicine back as soon as they can give it back to me. Resident was referring to her pantoprazole which was decreased on 09/06/18 and eventually discontinued two weeks later. A review of Resident #24's medical record at 4:00 p.m. on 09/26/18 found a physician's determination of capacity dated 04/19/18 which indicated the resident has capacity to make health care decisions. Further review of the record found the following notes: Note dated 07/10/18 at 9:02 p.m. read as follows, Two view right ankle. Right ankle fracture. NP (Nurse Practitioner) notified gave orders for NWB (non weight bearing) right foot and schedule ortho consult. (Name of Husband), her husband was notified of the fracture and the ortho consult. He stated that he had no preference for orthopedic physicians. I informed him that I would ask Diane and we would schedule the appointment and call back with place, date, and time. Note dated 07/30/18 at 12:21 p.m. read as follows, (Name of Nurse Practitioner) new orders: obtain stool for[DIAGNOSES REDACTED] clear liquid diet X3 days [MEDICATION NAME] 4 mg po (by mouth) q6 (every 6 hours) prn (as needed) d/t (due to) nausea X 7 days. (Name of Husband) (husband) notified and in agreement. Note dated 08/23/… | 2020-09-01 |
| 3484 | 3484 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 582 | D | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure two (2) of three (3) residents reviewed for the care area of beneficiary protection notifications, received the required notification when Medicare Part A services ended. Resident identifiers: #35 and #79. Facility census: 89. Findings included: a) Entrance conference information The entrance conference worksheet for beneficiary notice-Residents discharged within the last six months was provided to the facility upon entrance to the facility on [DATE] at 10:45 a.m. The form instructs the facility to please complete and return this worksheet to the survey team within 24 hours. Please provide a list of residents who were discharged from Medicare covered Part A stay with benefit days remaining in the past 6 months. Please indicate if the resident was discharged home or remained in the facility. (Exclude beneficiaries who received Medicare Part B benefits only, were covered under Medicare Advantage insurance, expired, or were transferred to an acute care facility or another SNF (skilled nursing facility) during the sample date range.) b) Resident #35 Review of the residents discharged from Medicare, Part A services within the last six months, with benefit days remaining, was provided by the facility on [DATE]. According to the beneficiary notice form, Resident #35 was discharged from Medicare services on [DATE] and continued to remain in the facility with benefit days remaining. On [DATE], the facility provided, the Centers for Medicare and Medicaid Services, (CMS) form # , to the resident/responsible party. b) Resident #79 Review of the residents discharged from Medicare, Part A services within the last six months with benefit days remaining was provided by the facility on [DATE]. According to the beneficiary notice form, Resident #79 was discharged from Medicare services on [DATE] and continued to remain in the facility with benefit days remaining. On [DATE], the facility … | 2020-09-01 |
| 3485 | 3485 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 583 | D | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview and during a random opportunity for discovery, the facility failed to ensure two residents' health information was protected. The facility also failed to ensure a resident's privacy was maintained in the spa room. Resident identifiers: #74, #81, and #6. Findings included: a) Resident #74 During a random observation on 09/25/18 at 3:30 PM, [MEDICATION NAME] packaging was found in the trash can on the side of a med cart with Resident #74's name printed on the packaging, visible to passersby. Licensed Practical Nurse (LPN) #17 was notified. LPN #17 then shredded the packaging. b) Resident #81 On 09/25/18 at 10:59 AM, [MEDICATION NAME] and KlorCon packaging with Resident #81's name visible on the label were found in the trash can on the side of a med cart, visible to passersby. LPN #88 and LPN #17 were notified and they shredded the packaging. c) Resident #6 On 09/25/18 at 3:55 PM a nurse aide (NA) opened the door to the spa room to reveal Resident #6, who was lying unclothed on the shower bed. The curtain was not drawn. LPN #17 was notified and she said the curtain should have been drawn. LPN #17 then went into the spa room to ensure the curtain was drawn. | 2020-09-01 |
| 3486 | 3486 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 585 | D | 0 | 1 | DXEI11 | Based on review of grievance/concern forms, policy review, record review and staff interview, the facility failed to reflect in their investigation the steps taken to resolve a grievance. This occurred during a random opporunity for discovery. Resident identifier: #385. Facility census: 89. Findings included: a) Resident #385 On 09/24/18 at 1:30 PM, Resident #385 and her son were interviewed. They stated Resident #385 was moved to a new room and not notified of the reason for this room change. After the room change, Resident #385 had problems with her roommate (Resident #386) yelling out and being disruptive. Resident #385 then filed a grievance (concern form) with the social services department, but this did not resolve the issue. Resident #385 then began sleeping on the couch in the common area on her unit to escape the noise in her room. Resident #385's son stated he asked the facility multiple times to move his mother over the previous week, but they repeatedly told him the facility was full and they could not accommodate the request. On 09/25/18 at 10:21 AM, Social Services Supervisor #92 was interviewed. She said Resident #385 would likely be going home with her son within forty-eight hours. She stated interventions with Resident #385's roommate were completed per nursing and said nurses have called the roommate's daughters in to sit with her as an intervention. When asked about the reason that Resident #385 could not move to a quieter room, Social Services Supervisor #92 said the facility didn't have a room to put her in right now. We're full. She said, We tried to figure out somebody who might be compatible with her. We did talk about it. I did offer her earplugs and she didn't want that. When asked how it was decided there were no compatible residents for Resident #386, Social Services Supervisor #92 stated, We just talked about it amongst ourselves. She said staff did not approach any residents about moving in with Resident #386. She also said that a hospice resident was a possibility, but staff did not… | 2020-09-01 |
| 3487 | 3487 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 641 | E | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, facility failed to accurately complete the Minimum Data Set (MDS) to reflect each resident's status. This was true for five (5) of twenty-five (25) sampled residents. Resident #52's section, Preferences for Customary Routine and Activities was blank for the resident and/or responsible party interview. Resident #87's was inaccurate for prognosis. For Residents #73 and #47 was inaccurate in area of dental status. Additionally, Resident #386s was inaccurate in area of behavioral and emotional status. Resident identifiers: #52, #87, #73, #47 and #386. Facility census: 89. Findings included: a) Resident #52 A review of Resident #52's medical records, found an admission MDS with an ARD of [DATE]. Review of the MDS found Section F Preferences for Customary Routine and Activities was not completed; it was indicated with a 0, which is No this indicates the resident is rarely/never understood and family/significant other not available for the interview. Further review found an Activity Assessment which was completed on [DATE]. This assessment was noted to be completed via telephone with the daughter. Interview with Director of Nursing on [DATE] at 2:10 pm, found no reason documented to indicate why the Activity Director (AD) did not complete Section F of the MDS. She acknowledged the AD had completed the activity assessment via the telephone with the daughter. b) Resident #87 A review of Resident #87's medical record, on [DATE] at 1:00 PM, found an admission MDS with an (ARD) of [DATE]. Review of section J1400- Prognosis was coded 0, this indicates the resident does not have a condition or chronic disease that may result in a life expectancy of less than 6 months. (Requires physician documentation. Review of the discharge summary from acute care facility dated [DATE] (this was also her date of admission to the facility. This discharge summary read, She is otherwise very weak, in fact too weak to go to… | 2020-09-01 |
| 3488 | 3488 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 656 | E | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview and family interview, the facility failed to develop and or implement a comprehensive person-centered care plan for four (4) of twenty-five (25) residents reviewed. The care plan for activities of daily living (ADL) related to meal assistance was not implemented for Resident #78. A care plan was not developed for Resident #74 to include non-pharmacological interventions for use of an antipsychotic medication. Resident #52's care plan was not implemented for activities. A care plan was not developed for Hospice services for Resident #55. Resident identifiers: #78, #74, #52, and #55. Facility census: 89. Findings included: a) Resident #78 Observation of the first meal served, after entrance to the facility, was the noon meal on [DATE] at 12:30 PM. The resident was in bed when the noon meal was served. Staff delivered the resident's tray, set up the tray, on the over the bed table, and left the room. The resident was sleeping in bed, laying on her right side in a fetal position. The resident did not get out of bed for the meal. Approximately ten minutes after serving the tray, staff returned to pick up the tray. Documentation on the meal intake noted the resident refused the tray. Review of the medical record found the resident's diet orders: NDD level 1, pureed texture, regular consistency, Kennedy cup with straws for all meals. A level 1 national dysphagia diet (NDD) includes only pureed foods. Pureed foods should have the same texture as pudding. They should be smooth and free of lumps. Review of the resident's care plan found the following problem: Resident has a ADL (activities of daily living) self care Performance deficit related to impaired mobility, weakness, impaired memory. The goal associated with the problem: Patient is expected to have variations in her ADL's due to Alzheimer's. She will have no complications related to current level of function in bed mobility, transfers,… | 2020-09-01 |
| 3489 | 3489 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 657 | D | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, family interview, and resident interview, the facility failed to ensure review and revision of the comprehensive care plan for two (2) of twenty-five (25) residents reviewed during the Long-term Care Survey process. Additionally, the facility failed to ensure participation of the resident in the comprehensive care plan process for one (1) of two (2) residents reviewed in the are of Care Planning. Resident identifiers: #285, #74, #24. Facility census: 89. a) Resident #285 Resident #285 had a suprapubic catheter. On 09/25/18 at 11:13 AM, Certified Nursing Assistant #13 was observed during performance of suprapubic catheter care to Resident #285. The suprapubic catheter tubing was noted not to be secured to the resident's leg. Securing the catheter tubing is the standard of care to prevent the catheter from being accidently dislodged due to extensive tension on the catheter. Resident #285's comprehensive care plan contained the intervention to secure catheter. On 09/25/18 at 11:55 AM, Quality Standards Coordinator #108 was informed Resident #285's suprapubic catheter tubing was not secured to his leg as instructed in his comprehensive care plan. When this surveyor and Quality Standards Coordinator #108 went into Resident #285's room at this time, the resident's daughter stated she and the resident preferred not to have the suprapubic catheter tubing not secured to his leg. Quality Standards Coordinator #108 stated she would revise Resident #285's comprehensive care plan to reflect the resident's preferance to not have his suprapubic catheter tubing secured to his leg. b) Resident #74 On 09/24/18 at 1:18 PM, the resident was observed with her noon meal tray. She was in bed with the meal on the over the bed table. The resident asked the surveyor to feed her because, I need help because of my hands. Observation found both of the residents hands were severely contracted. The resident was eating h… | 2020-09-01 |
| 3490 | 3490 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 677 | D | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview and staff interview, the facility failed to ensure two (2) of three (3) dependent residents received assistance with activities of daily living (ADL's) Resident #78 did not receive assistance with meals when needed. Resident #20 did not receive assistance with personal grooming as desired. Resident identifiers; #78 and #20. Facility census: 89. Findings include: a) Resident #78 Observation of the first meal served, after entrance to the facility, was the noon meal on 09/24/18 at 12:30 PM. The resident was in bed when the noon meal was served. Staff delivered the resident's tray, set up the tray, on the over the bed table, and left the room. The resident was sleeping, laying on her right side in a fetal position. The resident did not get out of bed for the meal. Approximately ten minutes after serving the tray, staff returned to pick up the tray. Documentation on the meal intake noted the resident refused the tray. Review of the medical record found the resident's diet orders: NDD level 1, pureed texture, regular consistency, Kennedy cup with straws for all meals. A level 1 national dysphagia diet (NDD) includes only pureed foods. Pureed foods should have the same texture as pudding. They should be smooth and free of lumps. At approximately 12:30 PM on 09/25/18, the resident received the noon meal tray. She was seated in a personal recliner beside her bed. The nursing assistant (NA) set up her tray by opening the silverware and removing the lids from bowls. The resident's milk was poured in her Kennedy cup and she had a straw. The NA left the resident's room. At 1:06 p.m. on 09/25/18, the resident was observed with a bite of a pureed sandwich pocketed in her mouth. It appeared the resident had only taken 1 bite of the pureed sandwich. Her spoon was still sticking straight up in the bowl of pureed broccoli cheese soup, which she had not attempted to feed herself. She was slumped to the rig… | 2020-09-01 |
| 3491 | 3491 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 679 | D | 0 | 1 | DXEI11 | Based on medical record review, family/responsible party interview and staff interview, the facility failed to ensure for each resident an ongoing resident centered activities program that incorporates the resident's interests, hobbies and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being and independence. Resident #52' s priest from the Catholic church attempted to visit on two (2) separate occasions and was unable to meet with the resident. Resident identifier: #52. Facility census: 89. Findings include: a) Resident #52 Observation on 09/24/18 and 09/25/18 Resident #52 was in bed all day. Interview 09/24/18 01:20 PM with Resident #52's daughter found the daughter states she comes in every day at lunch and dinner to feed her mother. Review of the progress notes found on two (2) occasions on 08/31/18 at 1:13 pm. Progress note written by Employee #8, activity director, Catholic priest attempted to conduct a clergy and communion on this date, however, resident was involved in another activity. and on 09/07/18 at 11:41 am Catholic priest attempted to conduct a clergy and communion on this date, however, resident was in bed, sleeping per preference. Interview with the activity director on 09/25/18 at 12:40 pm when asked about the priest not being able to visit with the resident she said, on 08/31/18 the other activity was a shower. (Review of Resident #52's Activities of Daily Living documentation indicated the resident received a shower at 2:46 pm) Additionally, on 09/07/18 the resident was asleep no evidence the staff attempted to awaken the resident. Interview with family (two (2) daughters and son-in-law) on 09/25/18 at 12:10 pm, they all expressed the resident always attended Mass when she was able and although she cannot participate in communion due to her physical condition she would want to visit and pray with priest. At 1:41 p.m. on 09/27/18, these observations and interviews with staff were discussed with the Administrator and t… | 2020-09-01 |
| 3492 | 3492 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 684 | E | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, family interview, policy review and record review, the facility failed to ensure received quality care. This was true for 3 of 25 residents reviewed in the quality care area. Resident #55 the facility failed to collaborate with hospice for the development, implementation and revision of the coordinated plan of care and/or communicate and collaborate with hospice. This was true for one resident of one in the care area of hospice. For Resident #74 the facility failed to identify skin issues. For resident #68 the facility failed to complete neuro checks after an unwitnessed fall. Resident identifiers: # 55, #74 and #68. Facility census 89. Finding included: a) Resident #55 During an observation and interview on [DATE] at 12:40 PM, Nurse Aide (NA) #13 said that, she has not seen hospice, and does not know when hospice is to come to the facility, she said she provides a bed bath daily for Resident # 55. She is at bedside currently feeding Resident # 55. During an interview on [DATE] at 12:46 PM, Clinical Care Supervisor #73 was asked about communications and correlations with hospice. She said that the hospice registered nurse may have been to the facility, but she is not sure when. She said that, she has not seen an aide come to provide care for Resident #55. Hospice started on [DATE]. She said that she is not sure when the Hospice nurse and aide are supposed to come. She was asked if she could find any notes from the Hospice nurse. She could only find two (2) notes dated [DATE] and [DATE], both in regard to a giving the resident Intravenous (IV) fluids. She also called the DON and asked her when Hospice was scheduled to come and provide care and where can she find their notes. She the Hospice nurse and/or aide is supposed to complete a note and give it to the Charge nurse, then it will be scanned into the Resident's Chart. During an interview on [DATE] at 1:28 PM, DON was asked if she can find any notes fro… | 2020-09-01 |
| 3493 | 3493 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 686 | E | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure ulcers from developing. The facility failed to complete an accurate and complete pressure ulcer assessment for one (1) of three (3) residents reviewed for the care area of pressure ulcers. Resident identifier: #50. Facility census: 89. Findings included: a) Resident #50 Resident #50 was readmitted to the facility on [DATE] after a brief stay in the hospital. Prior to being discharged from the facility to the hospital, Resident #50 had a stage two (2) pressure ulcer on her left inner thigh. Review of the resident's medical records revealed no pressure ulcer assessment when the resident returned to the facility on [DATE]. On 09/27/18 at 08:30 AM, the Director of Nursing (DoN) provided a Skilled Service Note dated 09/22/18 which documented the presence of a stage two (2) pressure ulcer on Resident #50's left inner thigh. The DoN stated Resident #50's pressure ulcer was not documented prior to this document. The DoN stated Resident #50's pressure ulcer had not been measured. She stated a Wound Assessment Form should have been completed upon Resident #50's readmission to the faci.lity, but it had not been done. | 2020-09-01 |
| 3494 | 3494 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 689 | D | 0 | 1 | DXEI11 | Based on observation and staff interview, the facility failed to ensure the environment was free of accident hazards for one out of one resident reviewed for the care area of accidents. The hazard was a medicated powder left at the bedside. Resident identifier: #385. Facility census: 89. Findings included: a) Resident #385 During observation on 09/25/18 at 3:30 PM, a bottle of Medline Remedy Phytoplex antifungal powder was found on the Resident #385's bedside table. Package information indicated the product was harmful if swallowed. Licensed Practical Nurse (LPN) #17 was notified and removed the antifungal powder from Resident #385's room and placed it in the med cart. LPN #17 agreed the powder should not have been left at the resident's bedside. During resident council meeting on 09/26/18 at 2:00 PM, residents complained about a wandering resident who was entering other residents' rooms and pilfering their things. | 2020-09-01 |
| 3495 | 3495 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 690 | E | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of two (2) residents reviewed for the care area of urinary catheter. Resident #68 was admitted with an indwelling catheter with no [DIAGNOSES REDACTED]. Resident identifier: #68. Facility census: 89. Findings included: a) Resident #68 The resident was admitted to the facility on [DATE] from an acute care facility. Review of the discharge summary found, a Foley catheter was placed during diuresis. This may be removed and straight catheterization performed after return to the nursing home (NH). Further review found a Physician visit assessment note dated 07/29/18 read, [MEDICAL CONDITION] is chief complaint. She was diuresis in the hospital. a Foley was placed for diuresis and remains (retention?). Plan of care: .will see if the Foley can be discontinued. Physician orders [REDACTED]. Nurses notes were silent to the bladder training completed on 08/16/18. On the morning of 09/26/18, the Director of Nursing (DON) was asked to provide this surveyor with a policy/protocol for bladder training with a Foley catheter. She said the facility did not have a policy addressing bladder training with a Foley catheter. Unable to explain the process for the bladder retraining with a catheter and was given an in-service dated (MONTH) (YEAR). This in-service did not have the contents of the in-service just listed Discontinuing catheters- bladder retraining every 2 hours. | 2020-09-01 |
| 3496 | 3496 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 698 | D | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, resident interview and staff interview, the facility failed to ensure a [MEDICAL TREATMENT] resident received appropriate care. Resident #235 has venous access device in her right chest wall which is used for her [MEDICAL TREATMENT] access. Because of this access Resident #235 has a physician's orders [REDACTED].#235's right arm for blood pressures and lab draws. On two (2) separate occasions while at the facility labs were obtained from Resident #235's right arm. This is true for one (1) of one (1) residents reviewed for the care area of [MEDICAL TREATMENT] during the Long Term Care Survey Process. Resident identifier: #235. Facility census: 89. Findings included: a) Resident #235 An interview with Resident #235 and her daughter on 09/24/18 at 3:34 p.m. revealed that on one occasion right after admission to the facility Resident #235's right arm was used to obtain lab work. The residents daughter indicated this caused the resident to have a large hematoma to her right arm. The resident and her daughter both indicated this happened when they were obtaining a PT/INR ([MEDICATION NAME] time/international normalized ratio) one Monday morning. A review of Resident #235's medical record on 11/26/18 at 9:00 a.m. found the following lab/Diagnostic Note, Note Dated 09/10/18 at 7:44 a.m. read as follows, Order: PT/INR. Services Provided (including who collected specimen, obtained x-ray, patient tolerance etc.) : Specimen collected by (name of local lab service) lab tech from RAC(Right Antecubital) on Second Stick. First Stick in LAC (Left Antecubital). Note Dated 09/17/18 at 6:37 a.m. read as follows, Order: PT/INR. Services Provided (including who collected specimen, obtained x-ray, patient tolerance etc.) : Services provided by (Name of Local Lab) lab. Specimen obtained from Right AC (Antecubital). Tolerated well. Further review of the medical record found the following physician order [REDACTED]. An intervi… | 2020-09-01 |
| 3497 | 3497 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 757 | D | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #67's drug regimen was free from unnecessary medications. Resident #67 received an extra dose of antibiotic on two (2) separate occasions during the month of August, (YEAR). This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during the Long Term Care Survey Process. Resident identifier: #67. Facility census: 89. Findings included: a) Resident #67 A review of Resident #67's medical record at 9:11 a.m. on 09/25/18 found a physician order [REDACTED]. Further review of the record found a progress note related to this order which read as follows, Dr. (last name of attending physician) on facility, [MEDICATION NAME] 500 mg po (by mouth) daily X (for) 7 days . A review of the Medication Administration Record [REDACTED]. Additional review of the medical record found a physician order [REDACTED]. Also contained in the medical record was a hand written prescription from a local hospital dated 08/07/18 which read, [MEDICATION NAME] - [MEDICATION NAME] (Generic name for Bactrim DS) (100 mg - 800 mg) Take 1 tablet by mouth two times per day for three days. This was a hand written prescription given to the resident upon her discharge from the hospital on [DATE]. A review of Resident #67's MAR for the month of August, (YEAR) found Resident #67 received one (1) dose of bactrim on 08/07/18 at 9:00 p.m. and two doses daily beginning on 09/09/18 through 09/11/18. This was a total of seven (7) doses instead of the physician prescribed six (6) doses. An interview with the Director of Nursing (DON) at 3:00 p.m. on 09/25/18 confirmed Resident #67 received an extra dose of the [MEDICATION NAME] and bactrim. | 2020-09-01 |
| 3498 | 3498 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 759 | D | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and staff interview, the facility failed to maintain a medication administration error rate less than 5% the error rate was 5.41%. This was true for 37 opportunities with two (2) errors. Resident identifiers: #14 and #44. Facility census 89. Findings included: a) Resident #14 During an observation and interview on 09/26/18 at 8:01 AM, Licensed Practical Nurse (LPN) #9 approached Resident #14 with his AM medication while he was in the dining room eating his breakfast. LPN #9 spooned the pills into his mouth mixed with apple sauce and handed him the [MEDICATION NAME] (a stool softener) in a cup of water, she did not mix the [MEDICATION NAME] most of the medication remained in the bottom of the cup. This was brought to her attention and she said, Do you want me to give him more? She was instructed to check with her Supervisor. She agreed that most of the powdered medication was remaining in the cup. During an interview on 09/26/18 at 8:51 AM, Director of Nursing was informed about observation. She said she is new has been working at this facility since 08/28/18. b) Resident #44 During an observation on 09/26/18 at 9:43 AM, LPN #9 was holding the measuring cup in the air pouring [MEDICATION NAME]/[MEDICATION NAME] liquid into the cup. It was pointed out to her that she may need to check the measurement on a flat surface. She did place the measuring cup on the medication cart, then had to pour some of the medication back into the bottle. Resident #44 orders revealed she was to receive 5 Milliliters (ML) of [MEDICATION NAME]/[MEDICATION NAME] for a cough. The amount Resident # 44 would have received without surveyor intervention would have been 10 ML., twice the ordered amount. She agreed there was too much of this medication in the medicine cup. During an interview on 09/26/18 at 1:51 PM, Administrator to inform about finding and looking policy for disposal of medications and medication administration. Facility … | 2020-09-01 |
| 3499 | 3499 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 761 | D | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review, the facility failed to appropriately labelled medications with resident's name and open date on the bottle of multi-use eye drops. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable., the resident's name, and route of administration. The medication should also be labelled with or accompanied by appropriate instructions and precautions (such as shake well, take with meals, do not crush, special storage instructions). For medications designed for multiple administrations (e.g., inhalers, eye drops), the label should identify the specific resident for whom it was prescribed. This was true for three (3) of 12 eye drops in the medication cart. This had the potential to adversely affect two (2) Residents #44 and#37. Facility census 89. Findings included: a) Resident #44 During an observation on 09/26/18 at 9:07 AM, in the medication cart on the light house hall, three (3) of 12 eye drops. For Resident #44 there were two (2) separate eye drops, Fluorometholone (steroid) medicine to prevent inflammation and Ketotifen ([MEDICATION NAME]) eye drops did not have the residents name on the bottle or the date it was opened. The pharmacy label that was supposed to be on the bottle was placed on the lid of the box. Licensed Practical Nurse (LPN) #9 verified there was no name or date they were opened on these eye drops. b) Resident #37 The medication Latanoprost eye drops (is a [MEDICAL CONDITION] Medication to help prevent the pressure from rising inside of the eye. There was not any label on the bottle to indicate whom this medication belonged to or the date it was opened. LPN #9 verified there was no name or date it was opened on this bottle of eye drops. During an interview on 09/26/18 at 10:01 AM, DON informed about finding… | 2020-09-01 |
| 3500 | 3500 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 773 | D | 0 | 1 | DXEI11 | Based on record review and staff interview, the facility failed to ensure all labs were obtained only when ordered by a physician. Resident #235 had a PT/INR ordered for one (1) week on 09/10/18. The lab was obtained on 09/19/18 instead of the one (1) week as ordered by the physician. This was a random opportunity for discovery. Resident identifier: #235. Facility census: 89. Findings included: a) Resident #235 A review of Resident #235's medical record on 09/26/18 at 9:00 a.m. 09/27/18 found the results of PT/INR that was obtained on 09/17/18. Handwritten on the lab results was the following, Increase to 4.5 mg every day. Repeat INR in one week. This was hand written by the facility's nurse practitioner on 09/17/18. Further review of Resident #235's medical record found a PT/INR result dated 09/19/18. An interview with the Director of Nursing (DON) at 11:08 a.m. on 09/26/18 confirmed the PT/Inr was obtained on 09/19/18. She stated that she will have to look and see if there was additional physicians order changing the dated from 09/24/18 to 09/19/18. An additional interview with the DON on 09/26/18 at 4:58 p.m. confirmed the lab was obtained with out a physician order. She stated the nurse put the date in the computer wrong and they should have not obtained the lab until 09/24/18. | 2020-09-01 |
| 3501 | 3501 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 791 | D | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation resident interview and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for dental services received routine dental care. Resident identifier: #76. Facility census: 89. Findings included: a) Resident #76 On 09/24/18 at 2:44 PM, the resident said staff don't always help her brush her teeth 2 times a day. The resident said she had her own natural teeth and she had not been out to get her teeth cleaned at a dental office since her admission. She thought she should at least see a dentist. Record review found a [AGE] year old female admitted to the facility on [DATE]. Review of the activities of daily living, brushing teeth, documentation by nursing assistants, 2 times a day found the resident frequently gets her teeth brushed. The documentation was not completed on 6 occasions for brushing teeth in the morning and at night in a 25 day documentation period. (09/01/18-09/25/18). Observation of residents oral cavity with the director of nursing (DON) found the resident had a medium amount of plaque around the area where the gum meets the teeth on 09/25/18, at 10:30 a.m. The DON verified the resident had most of her natural teeth present. The resident told the DON she would like to see a dentist for a cleaning. The DON told the resident she would have to call her sister to see if she would allow the resident to see the dentist. The DON verified she did not believe the resident had been out to see a dentist since her admission. The DON completed a written oral evaluation on 9/25/18 at 12:08 p.m. The evaluation noted, the right eye tooth had a dull yellow color which could possible be a cavity, she also had plaque build up around the gum lines. SS (social service) notified to make an appointment for cleaning. Review of the medical record on 09/27/18 found an appointment was scheduled at dental office for 10/19/18 at 3:00 PM. | 2020-09-01 |
| 3502 | 3502 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 802 | E | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to employ dietary staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Multiple concerns were found by the survey team which include undated, and expired food available for use, food being held at the wrong temperatures prior to service, staff not following recipes when making pureed food, pureed food being held at the wrong temperature resulting in it being remade and still at the wrong temperature causing a delay in meal service for residents who receive a pureed diet, food being at the wrong temperature at the time of service, and pureed food being served at the wrong consistency. For several of these items the Certified Dietary Manager asserted that he had just inserviced his staff about the concerns but they were still not carrying out the functions of the dietary department to ensure the dietary needs of each resident was met on a daily basis. These failures have the potential to effect all residents currently residing in the facility. Facility Census: 89. Findings included: a) Store and Serve Food in a safe and sanitary manner. 1. Initial Tour of the Kitchen and Facility Pantries An initial tour of the kitchen and the facility's pantries on [DATE] beginning at 10:55 a.m. and concluding at 11:50 a.m. with the Certified Dietary Manager (CDM) found the following concerns: In the walk in cooler the following was found: --A five (5) pound container of sour cream opened on [DATE] and had a use by date of [DATE]. --A five (5) pound container of ricotta cheese opened and not dated as to when it was opened. --An opened roll of hamburger was in a storage container and had an open date of [DATE] and use by date of [DATE]. The CDM stated the use by date should have been [DATE] because that would have been the 7 days from the date it was opened. -- Shredded parmesan cheese had a date of [DATE] in the use by section of the la… | 2020-09-01 |
| 3503 | 3503 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 803 | F | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to follow recipes for the preparation of pureed foods. This affected 17 of 17 residents receiving a pureed diet. Resident identifier: #68. Facility census: 89. Findings included: A kitchen observation of pureed food preparation was conducted on 09/25/18 at 12:00 PM. Dietary Services Assistant #50 began re-making pureed turkey club sandwiches (original container of pureed sandwich was in an unsafe temperature range, so it was discarded and a new batch had to be made). Dietary Services Assistant #50 added mayonnaise, sweet pickle relish, turkey, eggs, and onion, and pureed these together. She did not measure any of these ingredients. This surveyor asked her how she determined if the mixture was the right consistency. She stated that it needed to be a pudding consistency and demonstrated for this surveyor that the mixture stood up on a spoon. She stopped processing the mixture after this demonstration and began spooning it into a dish for serving. The pickle relish was not fully incorporated into the mixture (small chunks were visible throughout the finished product.) A copy of the recipe for the turkey club sandwiches was obtained from Dietary Services Supervisor #75. The pureed recipe for a turkey club sandwich required bread, mayonnaise, lettuce leaf, tomato, salt and pepper, and turkey breast. Dietary Services Assistant #50 did not follow the list of ingredients outlined in the recipe. The recipe instructions stated, Puree turkey & vegetables together; bread separately. Count/measure out number of portions needed. Place in food processor and process to a smooth consistency. Add additional liquid (broth, milk, juice, etc.) a little at a time as needed to achieve smooth consistency. Add thickener as needed and blend thoroughly. Allow to stand 60 seconds - mixture should just hold its shape. Add additional thickener or liquid as needed. Serve turkey & vegetables on pur… | 2020-09-01 |
| 3504 | 3504 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 804 | F | 0 | 1 | DXEI11 | Based on observation, staff interview, temperature measurements and resident interviews, the facility failed to ensure that food was served at a preferable temperature at the time of service. Also the facility failed to ensure that pureed food was served at the appropriate texture. This practice has the potential to affect all residents currently residing in the facility. Facility census: 89. Findings included: a) Meal Temperatures at time of service. An interview with Resident #76 at 12:44 p.m. on 09/24/18 found that the food is not always good and that sometimes the food is cold and not at the proper temperature. An interview with Resident #52's daughter at 1:20 p.m. on 09/4/18 found they always bring Resident #52's tray last even though the daughter is there to feed her. She stated that when they bring in her mother's tray that the food is always cold and crusted over where it has sat so long. A review of the Resident council meeting minutes for the previous six months found the residents complained of cold food on the following occasions: 04/19/18: Stated that the food is cold sometimes and they cook the meat and potato's too long. The facility's response to this concern was to in service dietary staff. 07/19/18: Stated warmers are not always being put under plates and the food is not staying warm. The response to this complaint was to again in service staff to use plate warmers. Observation of the noontime meal on 09/25/18 found the temperatures at the point of service for Resident #76 and Resident #52 to be to warm for the cold foods served on this day. The following temperatures were obtained with the Certified Dietary Manager: Resident #76 a regular consistency diet temperatures were obtained at 12:35 p.m. and were as follows: Turkey Club Sandwich was 62 degrees Fahrenheit (F). [NAME]to's and Lettuce were 58 degrees F. Resident #52's a pureed diet temperatures were obtained at 12:41 p.m. on 09/25/18 and were as follows: [NAME]to Juice was 54 degrees F. Interview with the CDM confirmed the above mentioned … | 2020-09-01 |
| 3505 | 3505 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 805 | F | 0 | 1 | DXEI11 | Based on observation and staff interview, the facility failed to assure pureed food was prepared in the appropriate form to meet residents' needs. This affected seventeen out of seventeen residents receiving a pureed diet. Resident identifier: #68. Facility census: 89. Findings included: a) Dining observation During dining observation on 09/24/18 at 12:29 PM, pureed foods were observed running together on resident #68's plate. The individual food items on the plate did not hold their shape. Throughout the lunch period, multiple pureed items were observed running together on multiple other plates. The pureed foods served on this date were not of the proper consistency. b) Food preparation observation A kitchen observation of pureed food preparation was conducted on 09/25/18 at 12:00 PM. Dietary Services Assistant #50 began re-making pureed turkey club sandwiches (original container of pureed sandwich was in an unsafe temperature range, so it was discarded and a new batch had to be made). Dietary Services Assistant #50 added mayonnaise, sweet pickle relish, turkey, eggs, and onion, and pureed these together. She did not measure any of these ingredients. This surveyor asked her how she determined if the mixture was the right consistency. She stated that it needed to be a pudding consistency and demonstrated for this surveyor that the mixture stood up on a spoon. She stopped processing the mixture after this demonstration and began spooning it into a dish for serving. The pickle relish was not fully incorporated into the mixture (small chunks were visible throughout the finished product.) A copy of the recipe for the turkey club sandwiches was obtained from Dietary Services Supervisor #75. The pureed recipe for a turkey club sandwich required bread, mayonnaise, lettuce leaf, tomato, salt and pepper, and turkey breast. Dietary Services Assistant did not follow the list of ingredients outlined in the recipe. The recipe instructions stated, Puree turkey & vegetables together; bread separately. Count/measure out number o… | 2020-09-01 |
| 3506 | 3506 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 812 | F | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, measurement of food temperatures prior to service, review of the Centers for Medicare and Medicaid Services (CMS) appendix PP State Operations Manual (SOM) and staff interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. There was multiple items in the walk in cooler, freezer, and dry storage area that was not out of date, not dated when opened, and/or beyond the manufactures best by date. There were items in the facility's pantry refrigerators which were beyond the manufactures best by date. Also, all the microwaves in the pantries were dirty and in need of cleaning. Also, the food held on the steam table for service was above and/or below the minimum required temperature prior to service. These practices have the potential to effect all residents currently residing at the facility. Facility census: 89. Findings included: a) Initial Tour of the Kitchen and Facility Pantries An initial tour of the kitchen and the facility's pantries on [DATE] beginning at 10:55 a.m. and concluding at 11:50 a.m. with the Certified Dietary Manager (CDM) found the following concerns: In the walk in cooler the following was found: -- 5 pound container of sour cream opened on [DATE] and had a use by date of [DATE]. -- 5 pound container of ricotta cheese opened and not dated as to when it was opened. -- An opened roll of hamburger was in a storage container and had an open date of [DATE] and use by date of [DATE]. The CDM stated the use by date should have been [DATE] because that would have been the 7 days from the date it was opened. -- Shredded parmesan cheese had a date of [DATE] in the use by section of the label. The CDM indicated that had to be the open date and the use by date should have been [DATE]. In the freezer the following items were found to be opened and were not dated as to when they were opened: --Garlic Bread --Beef [NAME]es --Steak Fries --Potat… | 2020-09-01 |
| 3507 | 3507 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 842 | D | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure a complete and accurate medical record for one resident. Resident identifier: #24. Facility census: 89. Findings included: a) Resident #24 During an interview of Resident #24 on [DATE] at 03:52 PM, she stated she was very upset because her husband had died approximately two weeks prior. Upon review of her electronic medical record, it was discovered that her deceased husband was listed as her number one emergency contact and power of attorney (POA). On [DATE] at 03:41 PM, Social Services Supervisor #92 was interviewed regarding Resident #24's deceased husband being listed as her emergency contact/PO[NAME] Social Services Supervisor #92 agreed this was a problem and immediately removed the inaccurate information from the electronic medical record. | 2020-09-01 |
| 3508 | 3508 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 849 | E | 0 | 1 | DXEI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, family interview, policy review and record review, the facility failed to ensure received quality care. This was true for Resident #55 the facility failed to collaborate with hospice for the development, implementation and revision of the coordinated plan of care and/or communicate and collaborate with hospice. This was true for one resident of one in the care area of hospice. Resident identifier: # 55. Facility census 89. Finding included: a) Resident #55 During an observation and interview on [DATE] at 12:40 PM, Nurse Aide (NA) #13 said that, she has not seen hospice, and does not know when hospice is to come to the facility, she said she provides a bed bath daily for Resident # 55. She is at bedside currently feeding Resident # 55. During an interview on [DATE] at 12:46 PM, Clinical Care Supervisor #73 was asked about communications and correlations with hospice. She said that the hospice registered nurse may have been to the facility, but she is not sure when. She said that, she has not seen an aide come to provide care for Resident #55. Hospice started on [DATE]. She said that she is not sure when the Hospice nurse and aide are supposed to come. She was asked if she could find any notes from the Hospice nurse. She could only find two (2) notes dated [DATE] and [DATE], both in regard to a giving the resident Intravenous (IV) fluids. She also called the DON and asked her when Hospice was scheduled to come and provide care and where can she find their notes. She the Hospice nurse and/or aide is supposed to complete a note and give it to the Charge nurse, then it will be scanned into the Resident's Chart. During an interview on [DATE] at 1:28 PM, DON was asked if she can find any notes from the hospice nurse about when a Nurse Aide, Social Worked, Clergy, and Nurse has been here. She said that, the only note she can find is that the Registered Nurse was in the facility on Thursday [DATE]. During an inte… | 2020-09-01 |
| 3509 | 3509 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2018-09-27 | 880 | F | 0 | 1 | DXEI11 | Based on observation and staff interview the facility failed to ensure, prevent and maintain an infection prevent program to prevent spread of and communicable disease and infections, related to air flow from the soiled laundry room into the clean laundry room . This has the potential to effect more then a limited number of residents. A breech of infection control while providing catheter care and administratoring medication. Resident identifiers: #68 and #64. Facility census 89. Findings included: a) Laundry Room During an observation and interview on 09/26/18 at 2:57 PM, Environment Assistant (EA) #55 was present for the tour. The door from soiled laundry room to the clean laundry had air blowing from soiled to the clean room at the bottom of the door. This was wittnessed by EA#55 and Environment Supervisor #91. Using a dryer sheet standing on the clean side of the door, the dryer sheet was being blowed out from the soiled side of the room. This indicated airflow from the soiled laundry room was blowing into the clean side. ES #91 stated she would have it fixed right away. On 09/27/18 at 8:22 AM, Environment Supervisor #91 came in room to inform surveyor that the problem with the door was fixed last night by placing a door sweep on the doors. b) Resident #68 During an observation of catheter care on 09/27/18 at 9:30 AM, for Resident # 50 Nursing Aide (NA) #27, while preforming catheter care she breeched an infection control by touching her face, glasses and the privacy curtain with her soiled gloves. When asked why she would do that she replied,because my hair was in my eyes and my glasses were sliding down. She was asked if she should have used her arm or removed the soiled gloves then and before touching the privacy curtain. During an interview on 09/27/18 at 9:40 AM, informed Administrator of these finding and he stated he will have the curtain replaced. c) Facility task - medication administration On 09/26/18 at 9:53 AM Licensed Practical Nurse (LPN) #88 was observed for the facility task of medication admi… | 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 );