cms_WV
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35 rows where "inspection_date" is on date 2018-12-07
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 284 | 284 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 550 | D | 0 | 1 | SPY211 | Based on observation and staff interview, the facility failed to preserve one (1) resident's dignity during a mealtime. Private medical information was discussed with this resident in the presence of other residents dining at the same table. This was found during a random opportunity for observation. Resident identifier: #252. Facility census: 52. Findings included: On 12/03/18 at 12:07 PM, facility Urologist #179 was observed speaking to Resident #252 about confidential medical information while she was eating lunch. Two (2) other residents were dining at the table with Resident #252. Urologist #179 asked Resident #252 about potentially placing a catheter because she can't pee. At 12:12 PM, Urologist #179 was interviewed about the observations. He said that most of the residents in the facility know each other and that a lot of them have catheters. He added, What (Resident #252) said to me didn't make sense anyway. He said the alternative would have been to interrupt Resident #252's lunch and take her to her room to have the conversation in private instead. He said he thought talking to her in front of others while she was eating lunch was a preferable method to communicate the information. He then said, You're right, and added that maybe it should have been a private conversation. On 12/06/18 at 8:39 AM the facility's Director of Nursing (DoN) was informed of the issue. No further information was provided prior to the end of the survey. | 2020-09-01 |
| 285 | 285 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 565 | E | 0 | 1 | SPY211 | Based on resident interview, policy and procedure review and staff interview, the facility failed to ensure resident grievances/concerns were reconciled in a timely manner for two (2) of 18 residents reviewed during the Resident Council meeting. Resident identifiers: #20. Facility census: 52. Findings included: a) Resolution of Grievances/Concerns A review of the policy and procedure dated 03/01/02 Handling of Complaints/Grievances to the Extended Care Facility (ECF) found All complaints must be reported to the hospital CEO (Chief Executive Officer) or licensed nursing home administrator within 24 hours of the initial report. In the section titled Resident Council Meetings stated that any suggestions or concerns that residents may have are assigned to the appropriate person and shall be followed up in the next meeting. In addition for those residents with suggestions/concerns who wish to remain anonymous or for those residents who are unable to complete a form, the ECF Director of Nursing shall complete the form and submit it along with the meeting ' s minutes to the CEO or COO (Chief Operations Officer) with 24 hours of the meeting. In the Time Guidelines, B. The administrator or designee shall conduct (or direct) an investigation and initiate any corrective action within five (5) working days of receipt. A review of the Resident Council minutes during the survey found that grievances/concerns were reported to the Administrator and Supervisor and resolution was completed by the next monthly meeting or were marked ongoing. The minutes from the 07/09 and 08/06/18 meetings found a concern regarding Restorative nursing being pulled to the nursing units. Not until the 09/10/18 was the issues resolved. No evidence was provided by the facility that the residents received a response to this concern for two (2) months. In an interview with the Nursing Home Administrator (NHA) on 12/04/18 at 2:37 PM, when asked who was the facility Grievance Officer, the NHA stated there was no designated Grievance Officer. The NHA did no… | 2020-09-01 |
| 286 | 286 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 577 | E | 0 | 1 | SPY211 | Based on observation, staff interview and policy review, the facility failed to post survey results that were readily available, visible, and accessible to residents and visitors. This had the potential to affect more than a limited number of residents. Facility census: 52. Findings included: a) Survey Results During resident council meeting on 12/03/18 at 2:45 PM resident council president (Resident #101) stated he was unaware survey results were available for residents to review and did not know where the survey results were located. Observation on 12/03/18 at 3:20PM revealed a red sign at the lobby of the entrance that stated: This facility is certified by Medicare/Medicaid and is regularly surveyed by the WV Office of Health Facility Licensure Certification. Written survey results are available in the West Solarium. During an interview on 12/03/18 at 03:22, the Director of Nursing (DoN) #99 stated she does not know where the survey results are posted at and suggested asking the Administrator (NHA) for help finding them. At 03:24 on 12/03/18 during an interview, survey results were located by NHA and were found to be located on a wall identified by the Administer as the West Wing of building. Survey results were kept inside a binder and stored inside a single pocket wall file holder that was mounted adjacent to nursing station. The sign above stated: Federal Regulations require that inspection survey results and plan of corrections are available for public review. Please contact the ECF supervisor to see such documentation. | 2020-09-01 |
| 287 | 287 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 584 | D | 0 | 1 | SPY211 | Based on observation, and staff interview, the facility failed to ensure that two (2) of 18 sampled residents' rooms and equipment were in good repair. Resident Identifiers: Resident #16 and Resident #1. Facilty census: 51. Findings included: Observations made 12/03/18, at 12:11 PM, revealed both side rails on Resident #16's bed were scraped and rough and areas on the resident's door and walls were scraped. Observations made 12/03/18, at 3:01 PM, revealed scraped walls behind Resident #1's bed and holes in the wall outside the bathroom. An interview with the Maintenance Supervisor, on 12/06/18, at 11:55 AM, confined the areas needing repair in the rooms occupied by Resident #16 and Resident #1. The Maintenance Supervisor stated the areas would be repaired. | 2020-09-01 |
| 288 | 288 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 585 | E | 0 | 1 | SPY211 | Based on resident interviews, review of policy, staff interview, and observation, the facility failed to provide residents with information on how to file a grievance. This had the potential to affect more that a limited number of residents. Facility census: 52. Findings included: a) Grievances During Residence Council Meeting on 12/03/18 at 2:41 PM, Resident Council President #101 stated that he just learned of the grievance form 2 months ago. The remainder of Residence Council members present stated they did not know how to file a grievance or where to obtain form. Review of the facility's policy with effective date of 03/01/02 titled Handling of Complaints/Grievances to the Extended Care Facility: stated: ECF Suggestion/Concern forms shall be available in solariums and from the Social Worker. All completed ECF Suggestion/Concern Forms and accompanying documentation shall be permanently stored in the Administration file. On 12/04/18 at 2:23 PM observation of A wing Solarium revealed no grievance forms posted or available in the A solarium as stated in the grievance policy. On 12/04/18 at 2:26 PM observation revealed a B/C wing solarium revealed a faded teal colored 8x10 sign hanging above eye level on wall in B/C wing solarium that stated: ECF suggestion/concern Form/Medicare concern form/SMH Customer Complaint Form/Medicare & Medicaid Information. Below the sign was a wall mounted chart holder that contained a thin blue paper binder containing blank forms titled: Summersville Memorial Hospital ECF Suggestion/Concern Form. Positioned directly below the forms was a soiled linen cart blocking access to the forms. During an interview on 12/04/18 at 3:06 PM Administrator (NHA) #72 clarified that the grievance forms were only available in the B/C wing solarium. | 2020-09-01 |
| 289 | 289 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 600 | D | 0 | 1 | SPY211 | Based on observation, and staff interview the facility failed to ensure the residents were free from abuse, including but not limited to verbal and physical abuse. Resident identifier: #28. Facility census: 52. Findings included: a) Resident # 28 During an observation on 12/03/18 at 11:35 AM, Residents were in dining room trays had just arrived. Physical Therapist Assistant (PTA) #180 was seen by Surveyor take the doll in a blanket from Resident #28 without asking or explaining what she was doing. She then pulled Resident # 28 forward by placing her hand on the back of the resident's head. The resident yelled for her to let go of her head. That is when PTA #180 put her face very close to the face of the resident and said, you are not being very lady like in a loud and harsh tone. She then very roughly placed this resident in a wheelchair. Licensed Practical Nurse (LPN) # 96 was trying to tell the resident what they were doing but was not allowed the time to do so by PTA #180. LPN# 96 realized this resident was not in her wheelchair and PTA # 180 appeared to be frustrated by huffing and throwing up her arms. The correct wheel chair was collected by LPN# 96. Again Resident #28 was not told what they were going to do. PTA #180 got behind the resident placing both hands on her upper back and pushed her forward she directed LPN #96 to place the gait belt behind her. This action of pushing her forward appeared to scare the resident as evidenced by her facial expression and she yelled loudly, stop you are hurting me. PTA #180 did not stop her actions towards Resident #28. It looked as though PTA #180 was pushing her out of her wheelchair. PTA #180 roughly pulled the resident into her wheelchair. When she was removing the belt now in front of the resident she once again put her face inches from the resident's face and repeated, You are not very lady like in a loud tone of voice. On 12/05/18 at 3:20 PM, DoN revealed LPN#96 told her on that day that PTA #180 was rude to the resident right in front of the surveyor and not t… | 2020-09-01 |
| 290 | 290 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 655 | D | 0 | 1 | SPY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to fully develop a baseline care plan to address pertinent care needs upon admission. This affected one (1) of 18 residents reviewed for care plans. Resident identifier: #252. Facility census: 52. Findings included: a) Baseline Care Plan Resident #252 was admitted to the facility on [DATE]. On 12/04/18 at 09:20 AM, review of Resident #252's base line care plan (titled Admission Care Plan) revealed only to have resident name written at top, no admitted , no resident identifiers, and no initiation dates for goals or plan of care and no progress dates. On 12/05/18 at 8:40 AM review of the facility's policy titled Care Planning Process with review and revise date of 11/08/18, stated an initial care plan addressing the specific needs of the resident will be developed by the IDT team within 48 hours after admission. During an interview on 12/05/18 at 8:48 Director of Nursing (DoN) #99 agreed care plan was incomplete with no date or time of implementation, no date of admission. DoN #99 also stated that the missing information on the care plan made the care plan unacceptable to use. | 2020-09-01 |
| 291 | 291 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 684 | F | 0 | 1 | SPY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy and procedure review, the facility failed to administer medications within acceptable time frames for 7 of 8 sampled residents. Resident Identifiers : Residents #16, # 8, #22, #35, #25, #2, and #18. Findings included: a) Resident #16 1. A review of the Medication Administration Policy, effective date 02/20/18, page 7, verified per standard protocol, medications can be administered one (1) hour before or one (1) hour after scheduled time. 2. An interview with Resident #16, on 12/03/18, at 12:11 PM, revealed the resident suffered from painful arthritis but did not always receive pain medication in a timely fashion because staff are usually late with the medication. 3. Review of the medical record showed Resident #16 to have a physician's orders [REDACTED]. A review of the Medication Administration Record, [REDACTED]. The medication was administered late 23 times in (MONTH) (YEAR) and was late with administration four times during the month of (MONTH) (YEAR). Examples of the late administration were as follows: --[MEDICATION NAME] was given late on 11/14/18 through 11/18/18, 11/20/18, 11/22/18, 11/23/18, 11/27/18, 11/27/18, 11/29/18,11/30/18, 12/01/18, 12/2/18, and 12/03/18. Further review of the MAR indicated [REDACTED]. The medication was given late on 11/13/18, 11/16/18, 11/22/18 and 11/28/18. A review of (MONTH) MARs showed the dose of [MEDICATION NAME] was late 7 of the 10 documented administered doses. Doses were administered late on 09/02/18, 09/05/18, 09/11/18, 09/14/18, 09/17/18, 09/20/18, and 09/23/18. The 20:00 dose was administered as late as 22:16 on 9/23/18 and 22:17 on 09/05/18. 4. An interview with the Director of Nursing on 12/05/18, at 10:19 AM, revealed medications are to be given within the hour of the time ordered. She further stated I understand these pain meds are being given late and the resident is experiencing pain. b) Resident #8 1. A review of the medical record for R… | 2020-09-01 |
| 292 | 292 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 697 | D | 0 | 1 | SPY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and resident interview, the facility failed to provide pain management in accordance with physician's orders for one of 18 sampled residents who experienced pain. Resident identifier: #16. Facility census: 52. Findings included: a) Resident #16 1. A review of the Medication Administration Policy, effective date 02/20/18, page 7, verified per standard protocol, medications can be administered one (1) hour before or one (1) hour after scheduled time. 2. An interview with Resident #16, on 12/03/18, at 12:11 PM, revealed the resident suffered from painful arthritis but did not always receive pain medication in a timely fashion, stating staff are usually late with the medication. 3. Review of the medical record showed Resident #16 to have a physician's orders for a [MEDICATION NAME] every 12 hours, [MEDICATION NAME] 25 mcg/hr once a day every third day. 4. A review of the Medication Administration Record, [REDACTED]. The medication was administered late 23 times in (MONTH) (YEAR) and was late with administration four times during the month of (MONTH) (YEAR). Examples of the late administration were as follows: --[MEDICATION NAME] was given late on 11/14/18 through 11/18/18, 11/20/18, 11/22/18, 11/23/18, 11/27/18, 11/27/18, 11/29/18,11/30/18, 12/01/18, 12/2/18, and 12/03/18. 5. Further review of the MAR indicated [REDACTED]. The medication was given late on 11/13/18, 11/16/18, 11/22/18 and 11/28/18. 6. A review of (MONTH) MARs showed the dose of [MEDICATION NAME] was late 7 of the 10 documented administered doses. Doses were administered late on 09/02/18, 09/05/18, 09/11/18, 09/14/18, 09/17/18, 09/20/18, and 09/23/18. The 20:00 dose was administered as late as 22:16 on 9/23/18 and 22:17 on 09/05/18. 7. An interview with the Director of Nursing, on 12/05/18, at 10:19 AM, revealed medications are to be given within the hour of the time ordered. She further stated I understand these pain meds are being given lat… | 2020-09-01 |
| 293 | 293 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 804 | D | 0 | 1 | SPY211 | Based on observation, staff interview, resident interview, and record review, the facility failed to provide food and drink that was safe and at an appetizing temperature. Residents reported being served cold food that was not palatable. This had the potential to affect more than a limited number of residents. Resident identifier: #16. Facility census: 52. Findings included: a) Resident #16 During an interview on 12/03/18 at 2:12 PM Resident #16 stated the food was still being served cold, that she liked her soup hot and it was never warm enough for her eat. Resident council minutes dated 10/01/18 revealed Resident #16 voiced a concern of cold food when delivered with corrective action as trays would be passed in a more timely manner and facility do a test tray. Resident council minutes dated 11/05/18 also revealed that Resident #16 complained the food was not hot when served. b) Test Tray On 12/05/18 at 11:39 AM observation for test tray started when staff started passing trays in B/C wing solarium. At 11:46 AM trays split between carts for meal tray hall pass. At 11:51 AM just prior to being served, notified staff that the last tray left on meal cart will be tested . Test tray temperatures obtained by Dietary Manager (DM) #170 at 11:55 AM consisting of: --Ground spaghetti with meat temperature 125 degrees Fahrenheit (F). --Spinach 1/2 cup temperature of 118 degrees (F). --Ground citrus cup temperature 48 degrees (F) --Chocolate milk temperature 51 degrees (F) --Grape juice temperature 51 degrees (F) --Gelatein (nutritional supplement) temperature 48 degrees (F) --Garden Salad temperature 60 degrees (F) c) Dietary Manager Interview During an interview on 12/05/18 at 2:30 PM Dietary Manger (DM) #170 stated she was aware that some of the residents have complained about cold food, and they have tried staggering out the meal times and tray line processing to allow meal trays to be delivered more timely while hot. | 2020-09-01 |
| 294 | 294 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 812 | E | 0 | 1 | SPY211 | Based on observation, staff interview, and policy review, the facility failed to ensure that resident food was stored appropriately in unit refrigerators and that a unit microwave was kept clean. This had the potential to affect more than a limited number of residents. Facility census: 52. Findings included: On 12/03/18 at 11:24 AM, a tour of the facility's main kitchen, waste disposal areas, and unit kitchens began with Certified Dietary Manager (CDM) #170. At 11:46 AM, the microwave in the A wing unit kitchen was found to be dirty. Multiple droplets of a pink substance were present on the bottom of the inside of the microwave. CDM #170 acknowledged that the microwave was dirty. At 11:50 AM, a pie with one (1) piece missing was found in the B wing refrigerator. It was marked with a date of 11/28/18. A sticker on the refrigerator stated that resident food should be discarded after three (3) days. CDM #170 confirmed that the pie should have been removed after three (3) days. Also at 11:50 AM, a plastic reusable container with food in it was found in a plastic shopping bag in the B wing refrigerator. The container was not labeled with any dates or identifying information. CDM #170 said she was concerned about this and removed it from the refrigerator, along with the pie. She said she would discard both items. At 2:51 PM, the facility's policy for food brought into the facility for residents was obtained and reviewed. The policy, titled Patient Food from Non-Hospital Sources was most recently reviewed on 05/19/18 by CDM #170. The policy stated, Any food brought in from the outside shall be labeled with patient's name, date and room number, and held in a unit refrigerator specifically designated for patient food, for 24- hours only. A document titled Safe Food Handling Tips was provided with the policy and stated, All cooked or prepared foods stored in pantry or refrigeration will be checked daily by the diet clerk from Nutrition Services, and will be tossed if not properly labeled. On 12/06/18 at 8:39 AM the facilit… | 2020-09-01 |
| 295 | 295 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 880 | D | 0 | 1 | SPY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The nurse failed to use a protective barrier when she placed the two inhalers on the resident's side table and failed to provide isolation precautions by not posting signs alerting the public of an infection control risk for residents in isolation. These were random Resident opportunities for discovery. Identified Residents #14 and #16. Facility census was 52. Findings included: a) Resident #14 On 12/04/18 at 7:45 AM, Licensed Practical Nurse (LPN) #78 failed to place a barrier on Resident's #14 bedside table before laying to inhalers on the table. LPN#78 said she realized what she did as soon as she did it and that is why she wiped the inhalers off with an alcohol pad. On12/04/18 at 12:38 PM, Director of Nursing (DoN) was informed of observation and said that LPN#78 had already told her about it. b.) Resident #16 Observations during the tour, on 12/03/18, at 12:00 PM, , revealed no precautionary measures alerting staff and visitors to obtain more information about care provided to Resident #16 before entering the room. b.) A review of the medical record for Resident #16, showed the resident was being isolated in Contact Isolation for an infection as of 11/25/18, c.) An interview with LPN #137, on 12/03/18, at 01:51, revealed Resident #16 was being isolated for [MEDICAL CONDITION] but verified there was no sign on the door to alert staff and visitors that extra precautions would be required when entering the room. LPN #137, further stated, a sign that stated STOP should have been on the resident's door. d.) An interview with the infection control nurse, on 12/03/18, at 2:10 PM, verified the isolation policy required a sign on the door but stated it must have… | 2020-09-01 |
| 296 | 296 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 947 | E | 0 | 1 | SPY211 | Based on inservice record review and staff interviews, the facility failed to ensure Nurse Aides (NA's) received the required twelve (12) hours of annual inservice training. This practice was true for three (3) of employee inservice records reviewed. Employee identifiers: #145, #65, #155. Facility census: 52. Findings include: On 12/05/18 02:36 PM a review of inservice records found three (3) of five (5) inservice records for NA's #145 (hire date 05/02/16), #65 (08/04/08), #155 (hire dated (05/10/17) had no evidence of the required 12 hours of inservices. An interview with Registered Nurse (RN #173), stated that the previous nursing educator had retired and produced a copy of the nursing schedule with a hand written Infection Control, Handwashing and PPE's (personal protected equipment) at the top of the schedule. Red check marks were beside staff names who attended the inservice. RN #173 was unable to confirm the length of time of the inservices. RN #173 stated that she would try to contact the retired inservice educator to obtain the length of the inservices. An additional interview on 12/06/18 at 8:12 AM, RN #155 confirmed there was no evidence of the number of hours of inservice education provide for the facility NA's. | 2020-09-01 |
| 2231 | 2231 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2018-12-07 | 684 | D | 1 | 0 | DXEJ11 | > Based on record review and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for the care area of falls, received treatment and care in accordance with professional standards of practice. After a fall in which the resident hit her head, the facility failed to complete neurological assessments to ensure the resident did not have any untoward pathology. Resident identifier: #32. Facility census: 59. Findings included: a) Resident #32 Review of the facility's fall documentation report found the following: At 8:30 PM on 11/27/18, Pt (Patient) was walking don A-Hall when she tripped and fell . Pt hit her head on the wall and fell to the floor. Pt hand was hurting during incident. Minimal blood noted. Neuro (neurological) checks initiated. Unable to give statement. The physician and family were notified. The physician ordered an x-ray of the right hand. Review of the neurological assessment flow sheet found neurological assessments were to start at 8:45 PM on 11/27/18. Review of the facility's procedural guidelines for Neurological assessments found the following: Neurological assessments must be performed: 15 minutes for one hour 60 minutes for four hours Two (2) hours for 18 hours. Every shift until at least 48 hours have elapsed and resident is stable. Neurological assessments include (at a minimum) pulse, respirations, and blood pressure measurements; assessment of pupil size and reactivity; and equality of hand grip strength. Completing the Glasgow Coma Scale immediately; then once each shift following a head injury, helps keep findings objective. Further review of the facility's neurological assessment flow sheet found the first neurological assessment was completed not completed until 11:45 PM on 11/27/18. The facility did not complete a neurological assessment of the resident until three (3) hours and fifteen (15) minutes after her fall when the facility knew the resident hit her head. The neurological checks should have occurred every fifteen minutes for the first hour: (… | 2020-09-01 |
| 2232 | 2232 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2018-12-07 | 758 | E | 1 | 0 | DXEJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to consistently ensure non-pharmacological interventions were implement before administering a [MEDICAL CONDITION] medication, as needed (PRN). This was true for one (1) of three (3) residents reviewed for pharmacy services/unnecessary medication. Resident identifier: #11. Facility census: 59 Findings included: a) Resident #11 Medical record review found a [AGE] year old female admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED].>[MEDICAL CONDITION], unspecified Dementia without behavioral disturbances, and Anxiety. On 08/23/18, the physician prescribed the antianxiety medication, [MEDICATION NAME] 0.5 milligrams mg's to be given every six (6) hours as needed (PRN) for Anxiety. At 9:00 AM on 12/04/18, the resident's medication administration records (MAR'S) for October, (MONTH) and December, (YEAR), were reviewed with the director of nursing (DON). The DON confirmed [MEDICATION NAME] 0.5 mg's was administered on the following dates: 10/07/18, 10/21/18, 10/22/18, 10/31/18, 11/21/18, 11/25/18, 11/29/18, 12/01/18, and 12/03/18. The DON confirmed licensed nursing staff failed to document the non-pharmacological interventions administered on eight of the nine occasions when the [MEDICATION NAME] was administered. for the months of October, (MONTH) and December. The DON provided evidence nursing staff only documented attempts to re-direct before administering [MEDICATION NAME] on 12/03/18 at 6:01 PM. | 2020-09-01 |
| 2618 | 2618 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 550 | D | 1 | 1 | F19R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview, the facility failed to ensure one (Resident #90) of four sampled residents was treated in a dignified manner. This was evidenced by being dressed in clothing that was torn and had holes. The facility census was 96. Findings include: On 12/03/18 at 12:22 PM, Resident #90 was observed sitting in his wheelchair near the Station 4 nurses' station. He was wearing a long sleeve T-shirt with multiple holes/tears around the neck and across the shoulder seams. At 12:25 PM on 12/03/18, Licensed practical Nurse (LPN) #9 was asked to observe the T-shirt worn by Resident #90. She stated residents were not to be dressed in clothing with holes and tears. She stated, It (the T-shirt) should have been thrown away a long time ago. On 12/04/18 at 1:02 PM, the clinical record of Resident #90 was reviewed. It documented the resident had [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment, dated 11/14/18, documented the resident had severe cognitive impairment and required extensive assistance with dressing. The care plan, most recently reviewed/revised 11/28/18, documented the resident had a problem related to his activities of daily living performance deficit. Interventions for the problem included Resident #90 required cueing, encouragement, and physical assistance to dress and staff were to assist him to choose simple comfortable clothing that maximized his ability to dress himself. | 2020-09-01 |
| 2619 | 2619 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 583 | D | 1 | 1 | F19R11 | > Based on observation, policy review and interview, the facility failed to ensure two (Residents #82 and #85) of two residents were provided privacy during medication administration. The facility census was 96. Findings include: 1. On 12/05/18 at 8:11 AM, Licensed Practical Nurse (LPN) #3 was observed as she administered insulin to Resident #85. LPN #3 prepared the insulin dosage and entered the resident's room. Upon the LPN entering the room, Resident #85 lifted his shirt so LPN #3 could administer the insulin into his abdomen. The LPN did not close the hallway door. Resident #85's entire abdomen was exposed to anyone who walked by in the hallway. At 8:31 AM on 12/05/18, the observation was reviewed with LPN #3. She stated she should have closed the door to administer the resident's insulin. 2. On 12/05/18 at 9:28 AM, LPN #73 was observed as she administered medications via a feeding tube to Resident #82. She had not closed the door to the hallway, nor did she pull the privacy curtain. The resident was exposed to anyone who walked by the resident's door in the hallway. At 9:41 AM on 12/05/18, the observation was reviewed with LPN #73. She stated she had not ensured privacy for the resident by failing to close the door and/or pull the privacy curtain. The facility's Medication via Enteral Tube documented: .Procedure .Provide for privacy . | 2020-09-01 |
| 2620 | 2620 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 600 | D | 1 | 1 | F19R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure residents were free from neglect as Resident #59 did not receive necessary care and services when she sat on a bedpan for over three hours without resulting physical or psychosocial outcome. Additionally, the facility failed to prevent resident to resident physical abuse between Resident #52 and #78. This affected three of three residents reviewed for neglect and abuse. The facility census was 96. Findings include: 1. The clinical record of Resident #59 was reviewed on 12/04/18 at 02:30 PM. The physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 11/06/18, documented the resident was cognitively intact and required extensive assistance with bed mobility, transfer and toilet use. The assessment documented Resident #59 had functional limitation in range of motion of her upper and lower extremities bilaterally. The assessment documented Resident #59 was frequently incontinent of bladder and bowel. On 12/03/18 at 10:56 AM, during an interview in Resident #59's room, she stated, on 11/29/18, she had used her call light at 2:00 AM and asked Certified Nurse Aide (CNA) #27 to place her on the bedpan. She stated she fell asleep and woke up a 04:00 AM and was still on the bedpan. She stated she used her call light, and no one came. Resident #59 stated she started crying and was hurting. Resident #59 stated she called the facility's phone number at 5:40 AM and Licensed Practical Nurse (LPN) #69 answered the phone. She stated LPN #69 was working on another floor and came down to her floor and told CNA #27 to take her off the bedpan. Resident #59 stated Assistant Director of Nursing (ADON) #110 talked to her later the morning of 11/29/18 and told her the incident would be reported to the Director of Nursing (DON). The resident stated the administrator, nor the DON, had talked to her about the incident as of this interview date/time. On 12/03/18 at 2:11 P… | 2020-09-01 |
| 2621 | 2621 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 607 | D | 0 | 1 | F19R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Abuse & Neglect policy and procedure had been implemented to report and investigate an allegation of neglect/abuse and failed to protect residents from the possibility of further abuse/neglect pending outcome of a thorough investigation. This affected one (Resident #59) of three sampled residents whose clinical records were reviewed for abuse/neglect. Findings include: 1. The clinical record of resident #59 was reviewed on 12/04/18 at 02:30 PM. The physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 11/06/18, documented the resident was cognitively intact and required extensive assistance with bed mobility, transfer and toilet use. The MDS documented she had functional limitation in range of motion of her upper and lower extremities bilaterally (both sides). The MDS documented Resident #59 was frequently incontinent of bladder and bowel. On 12/03/18 at 10:56 AM, during an interview in Resident #59's room, Resident #59 stated on 11/29/18 she had used her call light at 2:00 AM and asked Certified Nurse Aide (CNA) #27 to be put on the bedpan. She stated she fell asleep and woke up at 04:00 AM and was still on the bedpan. She stated she used her call bell but no one came. The resident stated she started crying and was hurting. Resident #59 stated she called the facility's phone number at 5:40 AM and Licensed Practical Nurse (LPN) #69 answered the phone. She stated LPN #69 was working on another floor and came down to her floor and told CNA #27 to get her off the bedpan. Resident #59 stated Assistant Director of Nursing (ADON) #110 talked to her later in the morning and stated she would report the incident to the Director of Nursing (DON. The resident stated the Administrator, nor the DON had talked to her about the incident as of this interview date/time. On 12/03/18 at 2:11 PM, during an interview with the Administrator, the DON, Regional Di… | 2020-09-01 |
| 2622 | 2622 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 609 | D | 0 | 1 | F19R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of neglect/abuse to the state agency within 24 hours. The facility staff failed to immediately report an allegation of neglect/abuse to the Administrator. This affected one (Resident #59) of three sampled residents whose clinical records were reviewed for abuse/neglect. The facility census was 96. Findings include: The clinical record of Resident #59 was reviewed on 12/04/18 at 2:30 PM. The physician's orders [REDACTED]. On 12/03/18 at 10:56 AM, during an interview in Resident #59's room, Resident #59 stated on 11/29/18 she had used her call light at 02:00 AM and asked Certified Nurse Aide (CNA) #27 to be put on the bedpan. She stated she fell asleep and woke up at 04:00 AM and was still on the bedpan. She stated she used her call light but no one came. The resident stated she started crying and was hurting. Resident #59 stated she called the facility's phone number at 05:40 AM and Licensed Practical Nurse (LPN) #69 answered the phone. She stated LPN #69 was working on another floor and came down to her floor and told CNA #27 to get her off the bedpan. Resident #59 stated Assistant Director of Nursing (ADON) #110 talked to her later in the morning and stated she would report the incident to the Director of Nursing (DON). The resident stated the Administrator, nor the DON had talked to her about the incident as of this interview date/time. On 12/03/18 at 2:11 PM, during an interview with the Administrator, the DON, Regional Director of Operations #1 and Regional Director of Operations #2, the Administrator was asked if she was aware of the allegation of neglect involving Resident #59 and CNA #27. She stated she knew nothing of the incident. The Administrator stated it was the facility's policy that the administrator be informed immediately of an allegation of abuse/neglect. The DON stated she had not heard of the incident nor had she seen any report of the incide… | 2020-09-01 |
| 2623 | 2623 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 610 | D | 0 | 1 | F19R11 | Based on interview and record review, the facility failed to: a. Promptly initiate a thorough investigation of an allegation of abuse/neglect for one (Resident #59) of three sampled residents whose clinical records were reviewed for abuse/neglect. Resident #59 had informed a staff member of an allegation of neglect the morning of 11/29/18. No investigation was initiated until the afternoon of 12/03/18. b. Prevent potential further abuse/neglect by allowing the alleged perpetrator of abuse/neglect to provide care/services for residents for two 8-hour shifts following the facility's knowledge of an allegation of abuse/neglect. This affected one (Resident #59) of three sampled residents whose clinical records were reviewed for abuse/neglect. The facility census was 96. Findings include: On 12/03/18 at 10:56 AM, during an interview in Resident #59's room, Resident #59 stated on 11/29/18 she had used her call light at 2:00 AM and asked Certified Nurse Aide (CNA) #27 to be put on the bedpan. She stated she fell asleep and woke up at 4:00 AM and was still on the bedpan. She stated she used her call light but no one came. The resident stated she started crying and was hurting. Resident #59 stated she called the facility's phone number at 05:40 AM and Licensed Practical Nurse (LPN) #69 answered the phone. She stated LPN #69 was working on another floor and came down to her floor and told CNA #27 to get her off the bedpan. Resident #59 stated Assistant Director of Nursing (ADON) #110 talked to her later in the morning and stated ADON #110 would report the incident to the Director of Nursing (DON). The resident stated neither the Administrator or the DON had talked to her about the incident as of this interview date/time. On 12/03/18 at 2:11 PM, during an interview with the Administrator, the DON, Regional Director of Operations #1 and Regional Director of Operations #2, the Administrator was asked if she was aware of the above allegation of neglect involving Resident #59 and CNA #27. She stated she knew nothing of the inci… | 2020-09-01 |
| 2624 | 2624 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 655 | D | 0 | 1 | F19R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a baseline care plan within 48 hours of admission to ensure effective care, person-centered care was provided. This affected two (Residents #94 and #143) of ten sampled residents who were admitted after 11/28/17. The facility census was 96. Findings include: 1. On 12/04/18 at 03:36 PM, the clinical record of Resident #143 was reviewed. The electronic clinical record documented the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 09/07/18, documented the resident had moderate cognitive impairment; required supervision with eating; required limited assistance with transfer; and required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. The MDS documented the resident did not ambulate; had no functional limitation in range of motion; and used a wheelchair for mobility. The MDS documented Resident #143 was occasionally incontinent of bladder and frequently incontinent of bowel; received antidepressant, anticoagulant, antibiotic and diuretic medication on seven of seven days prior to the assessment date; received oxygen, suctioning, [MEDICAL CONDITION] care, IV medications; and expected to be discharged to the community. The clinical record contained no 48-hour baseline care plan. On 12/07/18 at 1:53 PM, the Director of Nursing stated no 48-hour baseline care plan had been developed for Resident #143. 2. On 12/04/18 at 12:22 PM, the clinical record of Resident #94 was reviewed. The clinical record documented the resident had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 10/03/18, documented the resident had moderate cognitive impairment; required supervision to limited assistance with most activities of daily living; was occasionally incontinent of bladder and frequently incontinent of bowel… | 2020-09-01 |
| 2625 | 2625 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 656 | E | 0 | 1 | F19R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and observations, the facility failed to develop, revise and/or implement a person-centered care plan. This affected five out of 26 sampled residents reviewed for care plans. (Residents #30, #41, #52, #24, #85) Specifically, the facility failed to: 1) update a care plan after a fall with injury; develop a care plan for the use of oxygen to maintain a resident's oxygen saturation levels at 93% or higher (Resident #30); 2) develop a care plan for a resident with a rash (Resident #41); 3) develop a care plan for resident to resident altercation (Resident #52);, 4) follow care plan for keeping call bell within reach (Resident #24); and 5) monitor for side effects of a psychoactive medication (Resident #85). The facility census was 96. Findings include: 1. Review of the clinical record for Resident #30 on 12/04/18 at 10:03 AM revealed an admission history dated 08/06/15 with a re-admission on 09/21/18. The admission history documented Resident #30 was admitted to the facility with [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) assessment, dated 09/28/18, documented Resident #30 needed extensive assistance of two people for bed mobility and transfers. The MDS documented Resident #30 was not walking. Resident #30 required extensive assistance of one to two people for toileting and personal hygiene. There was a physician's orders [REDACTED].#30 to receive oxygen via nasal cannula to maintain oxygen saturations at or above 93% as needed for oxygen saturations. Resident #30 had a care plan (CP), dated 11/06/18, that documented, Resident #30 has had an actual fall; poor balance, unsteady gait. The goal for the CP was, Resident #30 will resume usual activities without further incident through the review date. The target date was 12/06/18. The interventions included, continue interventions for at risk plan and for no apparent acute injury, determine and address causative factor of the fall. Bot… | 2020-09-01 |
| 2626 | 2626 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 657 | D | 0 | 1 | F19R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team. Specifically, the facility failed to update the care plan to reflect the resident did not have the siderails referred to in the care plan. This affected one (Resident #24) of 26 residents reviewed for care plans. The facility census was 96. Findings include: Review of the face sheet for Resident #24 revealed [DIAGNOSES REDACTED]. The resident was admitted on [DATE]. Review of the annual Minimum Data Set (MDS) assessment, dated 09/25/18, revealed the resident did not have a Brief Interview for Mental Status (BIMS) completed. According to section V, the resident's previous BIMS score was three out of 15 which indicated severe cognitive impairment. Section P for physical restraints: bed rails- not used. Resident #24 was observed on 12/04/18 at 10:28 AM. She was observed lying in bed on her right side. Her bed was low, and the fall mat was next to the bed. There were no side rails observed. Resident #24 was observed again on 12/05/18 at 9:28 AM. She was lying in bed with no side rails visible. Review of the care plan, revised on 06/21/17, revealed the resident has had an actual fall with injury, unsteady gait, poor balance, poor communication/comprehension. Interventions included 1/2 bedrails to promote independence with activities of daily living (ADL's). Certified Nurse Aide (CNA) #132 was interviewed on 12/05/18 at 9:38 AM. When asked about fall prevention measures, she stated that side rails were not used for this resident. She said it was a restraint. When asked who oversaw creating/changing the care plan, she said she wasn't sure. When asked if she looked at the care plan, she said No. The Director of Nurses (DON) was interviewed on 12/05/18 at 3:50 PM. She stated she would check this resident's last assessment on side rails. She said the assessment mentioned the resi… | 2020-09-01 |
| 2627 | 2627 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 677 | D | 0 | 1 | F19R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain grooming. Specifically, the facility failed to ensure Resident #11 was shaved and Residents #11 and #75 received nail care. This affected two (Residents #11 and #75) of four residents investigated for ADLs. The facility census was 96. Findings include: 1. Review of the face sheet for Resident #11 revealed [DIAGNOSES REDACTED]. The resident was admitted on [DATE] with readmission on 08/08/18. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/08/18, revealed the resident did not have a Brief Interview for Mental Status (BIMS) completed. The resident's functional status for personal hygiene was extensive assistance. Resident #11 was interviewed on 12/03/18 at 9:23 AM. When asked about her facial hair, she said I want it taken off. Resident #11 was observed eating breakfast in her room on 12/04/18 at 7:47 AM. She had facial hair with the appearance of a short beard. She had long nails with nail polish coming off. Resident #11 was interviewed again on 12/05/18 at 8:01 AM. When asked if the staff usually shaved her face and she said Yes. She said the last time they shaved her facial hair was the week before. When asked if she wanted the facial hair, she said No. When asked if she wanted her nails long, she said No. She said she wanted them as short as you can get it. She stated her facial hair was like a man's beard. Certified Nurse Aide (CNA) #132 was interviewed on 12/05/18 at 8:50 AM. She stated when the resident's nails got long, they asked them if they wanted a trim. There was no place to document that. They would look at the resident's nails when they gave the resident's their baths. With this resident, she said the resident did not like them cut. She let her daughter cut them. When the CNA was notified of the resident's requ… | 2020-09-01 |
| 2628 | 2628 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 684 | J | 1 | 1 | F19R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review and staff interview, the facility failed to obtain prompt emergency medical services, resulting in Immediate Jeopardy, for one (Resident #143) of 21 sampled residents whose clinical records were reviewed for quality of care. One additional resident (Resident #41) was placed at no actual harm but potential for more than minimal harm that is not Immediate Jeopardy when the facility failed to provide care and treatment for [REDACTED]. On [DATE] at 1:36 PM, the Administrator and Regional Director of Clinical Operations #135 were notified Immediate Jeopardy began on [DATE] at 3:40 AM, when Resident #143 became short of breath, requested the inner cannula of her [MEDICAL CONDITION] be re-inserted and be suctioned. Attempts to re-insert the inner cannula were unsuccessful, Resident #143's shortness of breath worsened, and her oxygen saturation went down to 52% (normal range is 95%-100%). Blood oxygen saturation levels below 80% can compromise organ function. The Licensed Practical Nurse (LPN) #73 in charge did not call 911 for 29 minutes. Subsequently, Resident #143 went into respiratory arrest and required cardiopulmonary resuscitation as emergency medical services arrived nine minutes after 911 was called. The Immediate Jeopardy was removed on [DATE] at 4:43 PM, when the facility reduced the potential for imminent danger as no other residents had a [MEDICAL CONDITION]. Additionally, the facility conducted an audit for all residents for a change in condition and notification of the physician. The facility provided in-service for nurse regarding notification of change in condition, notification of physician and sending residents out 911. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until all staff attended inservice training and completed competencies on [MEDICAL CON… | 2020-09-01 |
| 2629 | 2629 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 686 | G | 1 | 1 | F19R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interviews, the facility failed to ensure residents receive pressure ulcer care, consistent with professional standards of practice. Specifically, the facility failed to follow their protocol after the identification of a newly developed pressure ulcer. This resulted in no treatment being done and the worsening of the pressure ulcer. This affected two (Residents #24 and #142) of four residents investigated for pressure ulcers. This resulted in actual harm for resident #24.The facility census was 96. See F692 for additional information regarding Resident #24 and severe weight loss. Findings include: 1. Review of the face sheet for Resident #24 revealed [DIAGNOSES REDACTED]. The resident was admitted on [DATE]. Review of the annual Minimum Data Set (MDS) assessment, dated 09/25/18, revealed the resident did not have a Brief Interview for Mental Status (BIMS) completed. According to section V, the resident's previous BIMS score was three out of 15 which indicated severe cognitive impairment. The resident's functional status for bed mobility was extensive assistance. The resident was assessed as high risk for pressure ulcers. The MDS assessment documented Resident #24 had no unhealed pressure ulcers at the time of the assessment. The resident was observed on 12/04/18 at 10:28 AM. She was lying in bed on her right side. The resident was observed on 12/04/18 at 2:35 PM. She was lying on her back in her bed, sleeping. Review of the progress notes on 12/03/18 at 2:06 PM revealed: 11/27/18 at 22:11: New area on sacrum area observed, is red and opened approximately the size of a half dollar, [MEDICATION NAME] was applied, turned and repositioned every two hours for comfort and care. Will continue to monitor and inform oncoming nurse of new concerns. Observation of the resident's skin with the Wound Care Nurse (WCN-RN) #72 on 12/05/18 at 10:19 AM revealed the resident had a sacral ulcer with approximate me… | 2020-09-01 |
| 2630 | 2630 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 692 | G | 0 | 1 | F19R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure a resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Specifically, the facility failed to adequately assess the effectiveness of current nutritional interventions along with ensuring the resident received needed assistance with meals. This lead to continued nutritional decline and severe weight loss. This affected one (Resident #24) of four residents investigated for nutritional status which resulted in actual harm. The facility census was 96. See F686 for additional information regarding Resident #24 developing pressure ulcers. Findings include: Review of the face sheet on 12/10/18 at 2:00 PM for Resident #24 revealed [DIAGNOSES REDACTED]. The resident was admitted on [DATE]. Review of the annual Minimum Data Set (MDS) assessment, dated 09/25/18, revealed the resident did not have a Brief Interview for Mental Status (BIMS) completed. According to section V, the resident's previous BIMS score was three out of 15 which indicated severe cognitive impairment. The resident's functional status for eating was supervision. Resident #24 was observed on 12/03/18 at 9:33 AM. She was lying in bed. Her facial feature and upper extremities had a bony prominence. -At 12:55 PM, the resident was observed in her bed with food on the table in front of her. No staff assistance was observed. She was feeding herself with her fingers. She had a plate of cake in her lap and she was eating the cake with her hands. She picked up spaghetti noodles and pieces of chicken with her fingers and tried placing in her mouth. She appeared to have difficulty feeding herself. She did not use any silverware throughout the observation. She was able to pick up a glass of juice and drink from a straw. Her… | 2020-09-01 |
| 2631 | 2631 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 726 | E | 0 | 1 | F19R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that all the licensed nurses had the clinical competencies to care for a resident with a [MEDICAL CONDITION]. This affected eight (#125, #110, #133, #105, #123, #24, #34, and #39) of 27 licensed nurses in the sample. The facility census was 96. Findings include: Review of the Facility assessment dated [DATE] on 12/07/18 revealed the facility had accepted residents who needed [MEDICAL CONDITION] care. On 12/07/18 at 2:10 PM, the record review of training hours for the licensed nurses was reviewed. The record review revealed the facility offered a 30-minute, online course that reviewed [MEDICAL CONDITION] care. Per the online class syllabus, the learning objectives for the course were to, Identify the complications associated with having a [MEDICAL CONDITION]. Identify the equipment needed for [MEDICAL CONDITION] care. Explain how to provide to those with tracheostomies including suctioning, [MEDICAL CONDITION] cleaning and changing inner cannula. There was no documentation to verify the licensed staff were competent performing [MEDICAL CONDITION] care. The following licensed nurses that did not view the 30 minute [MEDICAL CONDITION] Care training video included: Director of Nursing (DON) #125, a registered nurse (RN) Assistant Director of Nursing (ADON) #110, RN ADON #133, RN RN Supervisor #105 RN Supervisor #123 Licensed Practical Nurse (LPN) #24 LPN #34 LPN #39 On 12/07/18 at 2:17 PM the Human Resources Director (HR) #12 was interviewed. HR #12 stated that the licensed nurses are assigned online classes through the company's online training system, but she was not aware of how the classes were assigned or by who. HR #12 stated that it would have been her expectation that if the facility was going to accept a patient with a [MEDICAL CONDITION], then the licensed nurses would have gone through [MEDICAL CONDITION] care training. HR #12 was under the assumption that the nurse e… | 2020-09-01 |
| 2632 | 2632 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 730 | E | 0 | 1 | F19R11 | Based on record review and interview, the facility failed to ensure that all Certified Nurse Aides (CNAs) had a performance review completed every 12 months; and therefore, failed to provide appropriate outcome based in-service trainings. This affected five (CNAs #1, #27, #54, #61, and #116) of five sampled CNA employment files reviewed out of a total of 41 CNAs. The facility census was 96. Findings include: On 12/06/18 at 1:15 PM, Human Resources Director (HR) #12 was interviewed. HR #12 stated since the parent company took over the building in (YEAR), she was unable to locate evidence that any of the CNAs had their annual performance reviews. HR #12 stated that she was unable to locate a performance review for any of the CNAs that were eligible for an annual performance review. HR #12 stated that she had advised their direct supervisor when they were due, but she had not received any completed performance reviews. Through the online training system, the CNAs were required to take online training classes, but the classes were not assigned based on the outcome of the annual performance review. On 12/06/18 at 12:07 PM, Director of Nursing (DON) #125 was interviewed. DON #125 stated that she also looked for records of performance reviews and trainings. She was unable to locate any documentation of performance reviews for CNA #1, #27, #54, #61, or #116. | 2020-09-01 |
| 2633 | 2633 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 758 | D | 0 | 1 | F19R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure two (Residents #85 and #30) of five sampled residents reviewed for unnecessary medications was monitored for side effects of antidepressant ([MEDICATION NAME]) and had clinical indications for usage of a mood stabilizer ([MEDICATION NAME]). The facility census was 96. Findings include: 1. On 12/05/18 in the afternoon, the clinical record of Resident #85 was reviewed. The physician's orders [REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 11/20/18, documented the resident had moderate cognitive impairment; had no mood symptoms including depression or hopelessness, and no behavioral symptoms. The assessment documented the resident had received antidepressant medication on seven of seven days prior to the assessment date. The care plan, dated 12/05/18, documented the resident's problems included his use of antidepressant medication related to his depression. An intervention was to monitor/document side effects of the medication. The physician's orders [REDACTED]. The original order was dated 11/13/18. The medication administration records (MAR) and treatment administration records (TAR), dated 11/2018 and 12/2018, were reviewed. There was no documentation the resident had been monitored for side effects of [MEDICATION NAME]. On 12/06/18 at 10:26 AM, during an interview with the Director of Nursing (DON) in her office, the DON reviewed the clinical record of Resident #85 and stated he had not been monitored for side effects of [MEDICATION NAME] since it was first administered on 11/14/18. She stated the care plan had not been followed to monitor/document side effects of [MEDICATION NAME]. 2. Review of the clinical record for Resident #30 on 12/04/18 at 10:03 AM revealed an admission history dated 08/06/15. The admission history documented Resident #30 was admitted to the facility with [DIAGNOSES REDACTED]. The re-admission tracking MDS assessment, dated 11/16/18… | 2020-09-01 |
| 2634 | 2634 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 801 | F | 0 | 1 | F19R11 | Based on record review and interviews, the facility failed to employ a qualified Certified Dietary Manager (CDM). This had the potential to affect all 96 residents currently residing in the facility. See F812 for additional information. Findings include: The Dietary Manager (DM) was interviewed on 12/03/18 at 8:50 AM. She stated she was not a certified dietary manager (CDM). She had been in this position for about six to seven months. She was previously a cook. She was currently in the CDM course. The Registered Dietitian (RD) was in the building about three days a week. RD #137 was interviewed on 12/03/18 at 3:20 PM. She stated she did not have a role in the kitchen. She was in the building two days a week. She kept in contact with the DM for resident preferences. DM #18 was interviewed on 12/05/18 at 1:34 PM. She said the District Manager for Dietary (DMD) #136 was in and out of the building. There was no set schedule or time. She stated she was in the CDM course and was about to go into the fourth module out of seven. She stated was told as long as she was in the program, she was okay. She was given a deadline of six months to finish the training. The Administrator was interviewed on 12/05/18 at 1:36 PM. She stated she was aware the DM was enrolled in the program. She was not aware the time frame had passed for the regulatory requirements. They contracted out for dietary services. The personnel file for DM #18 was reviewed on 12/06/18 at 9:59 AM and confirmed the DM was not a certified dietary manager. | 2020-09-01 |
| 2635 | 2635 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 812 | F | 0 | 1 | F19R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ased on observations, policy review and interviews, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure cleanliness in the kitchen; expired foods were disposed; adequate hairnet use; ensure ready-to eat foods were not touched with bare hands; ensure personal hygiene in dietary; and ensure proper temperatures for meal service. This affected one of one kitchen and one of three dining rooms. The facility census was 96. See F801 for additonal information. Findings include: [NAME] Cleanliness The kitchen was observed on [DATE] at 8:50 AM with the following: -The wall behind the three-pan sink was observed as dirty. -The green cutting board and the brown cutting boards were hanging and touching the outside of a tea container. -The wall behind the stove was observed as dirty. -The wall behind the handwashing sink was observed as dirty. The kitchen was observed on [DATE] at 10:19 AM. A drawer labeled green scoops contained a dirty ladle stored alongside the clean utensils. The ladle had large white pieces of food attached the scoop surface. Outside of the drawer was observed as dirty with a small hair along the outside of the lower drawer handle. -The wall behind the hand washing sink was observed as dirty. -The wall around the glove station was observed as dirty. -There was a spider web observed around the handwashing sink. Dietary Manager (DM) #18 was interviewed on [DATE] at 9:09 AM. She stated she was working on getting the cleaning schedule back in place. She stated the staff should be monitoring that every day. Review of the Cleaning and Sanitizing policy received on [DATE] at 9:09 AM, undated, revealed the purpose: To educate all new hires and current employees on the importance of and proper method for cleaning and sanitizing to ensure safety for all staff and residents .Cleaning is the physical removal of soil and food matter from … | 2020-09-01 |
| 2636 | 2636 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 867 | H | 0 | 1 | F19R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility's quality assessment and assurance (QAA) committee failed to have a system in place to identify quality of care problems and to develop/implement measures to correct the problems and maintain ongoing compliance with the Code of Federal Regulations. This resulted in a pattern of harm in quality of care areas. The facility census was 96. Findings include: On 12/07/18 at approximately 4:40 PM, the Director of Nursing (DON), who was the contact person for the QAA committee, was interviewed in the conference room. She stated issues which require the QAA committee's attention are discussed in the facility's morning meeting. She stated the QAA committee compared the facility's percentage of quality of care issues to the state and federal percentage to determine when a deviation for performance or a negative trend was occurring. The DON stated staff know to tell their charge nurse/supervisor about quality concerns which need the QAA committee's attention. She stated the charge nurse/supervisor reports the concern to the assistant director of nursing who takes it to the QAA committee. The DON stated the QAA committee decided which issues to work on by using Care Watch. She stated the QAA committee knew that corrective action had been implemented for concerns because it was discussed during QAA meetings and weekly risk meetings. She stated the QAA committee knew when improvement of problems was occurring through review and discussion during the QAA meetings. The DON stated the QAA committee continued to monitor an issue which had been corrected all the time because it can change at any time. She stated the QAA committee's decision to monitor an issue which had been corrected was decided by looking at interventions that had been initiated and using the state, federal and facility statistics and quality of care areas of concerns. She stated a resident with an identified quality of care concern would be … | 2020-09-01 |
| 2637 | 2637 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 880 | D | 0 | 1 | F19R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy/procedure review, the facility failed to ensure staff used appropriate infection control practices to prevent cross-contamination. This affected two (#24 and #44) of two residents whose pressure ulcer treatments were observed and one (#82) of one resident for whom medication administration via feeding tube was observed. The facility census was 96. Findings include: 1. On 12/05/18 at 10:19 AM, Registered Nurse (RN) #72 was observed as she performed a pressure ulcer treatment to Resident #24. RN #72 entered the room of Resident #24 and, without establishing a clean surface, set wound care supplies directly onto the overbed table. The overbed table was soiled with dried spills and debris. Resident #24 had a wound on her right lower buttock and another wound to the sacral area. RN #72 removed the soiled dressings from both wounds and proceeded to clean the buttock wound and then the sacral wound. RN #72 did not change gloves/wash hands or use hand gel between cleaning the two wounds. At the time of the observation, RN #72 stated the buttock wound was not a pressure ulcer but a shearing because the wound blanched when pressure was applied. She proceeded to use her gloved index finger to apply pressure to the buttock wound to demonstrate blanching of the wound and then used the same gloved finger to apply pressure to the sacral wound to demonstrate it did not blanch. She did not change gloves/wash hands or use hand gel between touching the wounds with the same gloved finger. At 10:38 AM, the above observations were reviewed with RN #72. She stated she had not changed gloves/washed hands between cleaning the two wounds and acknowledged she had used the same gloved finger to apply pressure to test for blanching for both wounds. She stated it would have been possible to transfer bacteria from one wound to the other. 2. On 12/05/18 at 10:55 AM, RN #72 was observed as she provided a pressure ulcer treatment for… | 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 );