cms_WV
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37 rows where "inspection_date" is on date 2019-01-25
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1131 | 1131 | HOLBROOK HEALTHCARE CENTER | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2019-01-25 | 580 | E | 0 | 1 | K04V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, the facility failed to promptly notify the physician/Nurse Practitioner of the resident's change of condition. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #81 and #34. Facility census: 84. Findings included: a) Resident #81 Review of Resident #81's medical record found this [AGE] year old male was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. Review of Resident #81's progress notes found: 1. On 10/02/18 at 4:06 pm, the Family Nurse Practitioner (FNP) was notified by Employee #71, Licensed Practical Nurse (LPN) that resident had been scratching at bottom and had removed the ointment applied to the pressure areas. The FNP instructed to place a proximal dressing for the evening and she would evaluate in the morning. No evidence the FNP evaluated the resident's pressure ulcers on 10/03/18. 2. On 10/12/18 at 5:55 pm, the resident readmitted to the facility after receiving treatment for [REDACTED]. readmitted to the facility with an indwelling urinary catheter in place due to [MEDICAL CONDITION] and would need to follow up with a urologist. Noted catheter was draining tea colored urine. No indication the NP and/or physician was notified. 3. On 10/14/18 at 5:13 pm, .the resident's catheter was noted to be draining amber colored urine. No indication the NP and/or physician was notified. 4. On 10/14/18 at 10:04 pm , resident's catheter with bright red bloody urine with minimal output; less than 100 mililiter (MM). No indication the NP and/or physician was notified. 5. On 12/25/18 at 12:40 pm, Nursing Assistant (NA) reported to the nurse that the resident had an area on his left buttock. A stage II pressure ulcer noted on left buttock measuring 2.3 centimeter (CM) in length and 1.9 cm in width and less than 0.1 cm in depth. No indication the NP and/or physician was notified. Interview with the Director of Nursing (DON) on 0… | 2020-09-01 |
| 1132 | 1132 | HOLBROOK HEALTHCARE CENTER | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2019-01-25 | 641 | D | 0 | 1 | K04V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect a resident's conditions. This was true for three (3) of twenty (20) residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident # 81's MDS was not coded correctly for contractures. Resident #83's MDS was not coded accurately for significant weight loss. Resident #72s MDS was not coded accurately in area of weight gain. Resident identifiers: #81, 83 and #72. Facility Census: 84. Findings include: a) Resident #81 Review of Resident #81's medical record found he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. MDS reviewed and found two (2) assessments (admission MDS with assessment reference date (ARD) of 10/08/18 and significant change MDS with ARD of 11/01/118) were inaccurately coded in area of contractures. On 01/23/19 at 10:10 AM, the Director of Nursing (DON) confirmed the MDS's dated 10/08/18 and 11/01/18 were inaccurate in contractures. She confirmed Resident #81 had a contracture of left knee and was present on admission. b) Resident #83 Review of Resident #83's medical record on 01/22/19, found the resident had experienced a significant decline in her health. A progress note written by the Dietary Supervisor (DS) on 09/25/18 at 10:0 am read, .Significant change related to weight loss and stage II pressure ulcer . this was noted during the look back period of 09/11/18 through 09/17/18 . MDS with ARD of 09/17/18 was reviewed and was coded no for weight loss. During an interview on 01/22/19 at 4:05 pm, the DON confirmed the MDS with ARD of 09/17/18 was inaccurately coded. She confirmed Resident #81 had a significant weight loss. c) Resident #72 Review of Resident #72's medical records revealed the MDS with ARD of 01/04/19, Section K, Swallowing/Nutritional Status, demonstrated a weight gain of five (5) percent or more in the last month or gain of ten (10) percent or more in th… | 2020-09-01 |
| 1133 | 1133 | HOLBROOK HEALTHCARE CENTER | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2019-01-25 | 656 | D | 0 | 1 | K04V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to develop a comprehensive care plan for three (3) of twenty (20) sampled residents. Residents #81 and #34's care plans' did not address the medication (Xarelto) an anticoagulant. Resident #14's care plan did not address the resident's visual needs. Resident identifiers: #81, #34 and #14. Facility Census: 84. Findings included: a) Resident #81 Review of Resident #81's medical record found he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of the comprehensive care plan did not address the use of the anticoagulant (Xarelto). Interview with the Director of Nursing (DON) on 01/23/19 at 10:10 am, confirmed the comprehensive care plan did not address the use of anticoagulant (Xarelto). She confirmed the care plan should address the use and precautions of Xarelto. b) Resident #34 Review of Resident #34's medical records on 01/23/19 at 9:40 am, found the resident had an order for [REDACTED]. The cardiologist report dated 12/20/18, found under Impression and Plan read: [DIAGNOSES REDACTED]; new onset unknown duration. She was in hospital for nose bleed and [MEDICAL CONDITION] felt from Ace Inhibitors. They held [MEDICATION NAME] for two (2) days and then put her back on [MEDICATION NAME]. I spoke with her concerning the risk and benefits of Xarelto. She decided she would try it. New order to stop [MEDICATION NAME] and start Xarelto 15 mg one tablet by mouth daily. I instructed to call me (cardiologist) if any bleeding . Review of the comprehensive care plan did not address the use of the anticoagulant (Xarelto). Interview with Director of Nursing (DON) on 01/24/19 at 11:10 am confirmed the comprehensive care plan did not address the use of anticoagulant (Xarelto). She confirmed the care plan should address the use and precautions of Xarelto. c) Resident #14 An interview with the resident at 11:42 AM on 01/21/19, revealed he had visual pro… | 2020-09-01 |
| 1134 | 1134 | HOLBROOK HEALTHCARE CENTER | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2019-01-25 | 684 | E | 0 | 1 | K04V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and resident interview, the facility failed to ensure residents received needed care and services to meet each resident's physical, mental, and psychosocial needs. For Resident #51 neurological checks following a fall was not obtained as directed by the physician's orders [REDACTED]. Resident identifiers: #51 and #14. Facility Census: 84. Findings include: a) Resident #51 Review of Resident #51's medical record revealed the resident had experienced an unwitnessed fall on 12/28/18 at 10:47 PM. The Progress Note stated, This nurse was doing med pass heard someone yell Help went to check resident was laying in flood (floor) beside her bed, moves all extremities with out pain no rotation noted in hips legs equal in length, denies pain vital sign obtained and recorded. Notified POA at 9:45 p, Doctor and RN on call. (The Progress Note was typed as written). The Event Report documented an initial neurological assessment was performed after the resident's fall. The neurological assessment reported level of consciousness, pupil size and reaction to light, speech, and movement of the facial muscles and the extremities. There was no documentation of follow-up neurological assessments to evaluate Resident #51 for injury from her fall. Additionally, review of Resident #51's medical records revealed the resident had experienced the following unwitnessed falls, after which follow-up neurological assessments were obtained. - 12/31/18 at 5:30 AM. The Event Report documented an initial neurological assessment was performed after the fall. The Progress Notes and the Treatments Administration History documented follow-up neurological assessments were performed every shift for 72 hours after the fall. The first follow-up neurological assessment after the fall was performed on 12/31/18 at 12:48 PM, or more than seven (7) hours after the fall. - 01/03/19 at 12:30 AM. The Event Report documented an initial neurological assessm… | 2020-09-01 |
| 1135 | 1135 | HOLBROOK HEALTHCARE CENTER | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2019-01-25 | 685 | D | 0 | 1 | K04V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and record review, the facility failed to ensure one (1) of two (2) residents reviewed for the care area of communication-sensory, vision / hearing, was assisted in gaining access to vision services. Resident identifier: #14. Facility census: 84. Findings include: a) Resident #14 An interview with the resident at 11:42 AM on 01/21/19, revealed he had visual problems. The resident said, I do need glasses but I can't afford them. I don't have any glasses, reading or prescription. The resident was working a puzzle in his room. He said some glasses would help him see his puzzle better. The resident prefers to stay in his own room and work puzzles daily. Review of the most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 10/30/18, coded the resident as having visual impairment without corrective lenses. The MDS also coded the resident as having a score of 15 on his brief interview for mental status (BIMS). A score of 15 indicates the resident is cognitively intact. The resident's admission MDS with an ARD of 07/30/18, coded the resident as having impaired vision without corrective lenses. Review of the current care plan, revised on 11/07/18, found the problem: Vision problems related to requires large print to read. The goal associated with the problem is: The resident will have no visual decline thru next review. Approaches included: Do not rearrange personal belongings without asking/notifying resident first, Orient to surroundings until familiar and able to find own way, Ensure adequate lighting during tasks, Escort to activity of choice. Further review of the care area assessment (CAA) for visual impairment, completed with the admission MDS with an ARD of 07/30/18, found the following summary documentation: Visual function triggered because resident needs large print to read, refer to admission nursing assessment. Problem, at risk for further visual decline, Residen… | 2020-09-01 |
| 1136 | 1136 | HOLBROOK HEALTHCARE CENTER | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2019-01-25 | 689 | E | 0 | 1 | K04V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to ensure the resident's environment, over which the facility has control, was as free from accident hazards as possible. Observation found Resident #25 had several medications left, unattended in his room. In addition, documentation in the medical record of Resident #4 found staff had also left medication in this Residents room. This was a random opportunity for discovery. Resident identifiers: #25 and #4. Facility census: 84. Findings include: a) Resident #25 On 01/21/19 at 12:17 PM, a medicine cup with numerous medications was observed on the residents over the bed table. The resident was in bed and asleep. The resident does not have a roommate. The door to the resident's room was closed. At 12:18 on 01/21/19, the resident's Licensed Practical Nurse (LPN) #128 was asked to come to the residents room. LPN #128 observed the cup of medicine and said, I did that, I shouldn't have left them there, I thought he was going to take them. LPN #128 asked the resident if he would take his medications, the resident agreed. LPN #128 was asked to identify the medications left in the resident's room. The following list of medications was identified and provided by LPN #128: Iron 325 milligrams (mg's) [MEDICATION NAME], 300 mg's, -a scheduled II controlled pain medication. [MEDICATION NAME], 300 mg's Vitamin C,-250 mg's [MEDICATION NAME], 10 mg's, Aspirin, 81 mg's [MEDICATION NAME], 12.5 mg's [MEDICATION NAME], 75 mg's [MEDICATION NAME], 5 mg's [MEDICATION NAME], 100 mg's According to the Medication Administration Record [REDACTED]. As medications can be given 1 hour before or 1 hour after the scheduled time, the medication would have been in the resident's room for a least 4 hours. According to the physician's orders [REDACTED]. 01/22/19 12:53 PM, the Director of Nursing (DON) said LPN #128, already told me about it The DON said she was in the process of providing disciplinary ac… | 2020-09-01 |
| 1137 | 1137 | HOLBROOK HEALTHCARE CENTER | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2019-01-25 | 711 | D | 0 | 1 | K04V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the physician reviewed the Resident's total program of care, including medications prescribed for the treatment of [REDACTED]. This was true for one (1) of three (3) residents reviewed for the care area of catheter care and urinary tract infections. Resident identifier: #23. Facility census: 84. Findings include: a) Resident #23 Record review found the facility's Family Nurse Practitioner (FNP) prescribed the antibiotic [MEDICATION NAME] 875-125 milligrams, twice a day, for a [DIAGNOSES REDACTED]. Further review of the medical record found a progress note from the facility physician, dated 02/28/18: .The patient does have a history of severe UIT's that have led [MEDICAL CONDITION] and required hospitalization , so she will be started on an antibiotic as soon as culture results indicate what would be the appropriate antibiotic . On 01/23/19 at 04:04 PM, the FNP confirmed she started the resident on the antibiotic on 02/27/18, without having the culture and sensitivity report available. The FNP said the resident frequently has UTI's and has been known to become septic quickly. According to the FNP, the resident was complaining of pain in her abdomen when the antibiotic was started. The FNP did not know why the physician wrote the progress note on 02/28/18. The FNP said she notified the physician an antibiotic was being started on 02/27/18. Further review of the medical record found the laboratory report of the urinalysis had never been scanned into the resident's medical record. The FNP obtained a copy of the urinalysis on 01/23/19, which confirmed the urinalysis was obtained on 02/27/18. The facility was notified of the results of the urinalysis with a culture a sensitivity report on 03/01/18. The urine culture report validated the resident did have a UTI and the infection was susceptible to treatment with the antibiotic, [MEDICATION NAME]. On 01/24/19 12:03 PM, the admi… | 2020-09-01 |
| 1138 | 1138 | HOLBROOK HEALTHCARE CENTER | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2019-01-25 | 727 | F | 0 | 1 | K04V11 | Based on review of staff postings, licensed nurse schedules, payroll records and daily assignment records, the facility failed to ensure the services of a Registered Nurse (RN) for at least eight (8) consecutive hours a day, seven (7) days a week. This had the potential to affect all residents residing in the facility. Facility census: 84. Findings include: a) RN coverage Review on 01/23/19 at 2:10 PM of the facility's daily posting, actual working schedule and payroll records for months of (MONTH) and (MONTH) (YEAR) and (MONTH) 1st through (MONTH) 23rd, 2019 found no RN coverage on the following dates: --November (YEAR): 11/2/18, 11/08/18, 11/09/18, 11/14/18, 11/21/18 and 11/28/18. (6 days out of 30 days) --December (YEAR): 12/03/18, 12/05/18, 12/07/18, 12/08/18, 12/12/18, 12/20/18, 12/29/18, 12/30/18 and 12/31/18. (9 days out of 31 days) --January 1st through 23rd 2019: 01/02/19, 01/03/19, 01/04/19, 01/07/19, 01/08/19, 01/09/19, 01/10/19, 01/11/19, 01/14/19, 01/15/19, 01/16/19, 01/17/19, 01/18/19, 01/21/19, 01/22/19 and 01/23/19. (16 days out of 23 days) During an interview on 01/2/19 at 9:15 am., the Nursing Home Administrator (NHA) stated, thought the facility had RN coverage for eight (8) hours, seven (7) days a week. After review of the records it was found on the above mentioned dates the Staff Education Nurse was to be the RN on duty but was listed as the Staff Educator in the above-mentioned dates. No further information provided. | 2020-09-01 |
| 1139 | 1139 | HOLBROOK HEALTHCARE CENTER | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2019-01-25 | 755 | F | 0 | 1 | K04V11 | Based on record review and staff interview, the facility failed to maintain complete and accurate drug records to ensure an account of all controlled medications (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence). In addition, the pharmacist failed to identify and report the incomplete controlled substance shift count forms during his medication room reviews and inspection. This practice has the potential to affect all residents residing in the facility. Facility census: 84. Findings include: a) At 12:31 PM on 01/22/19, a review of the 100-200 hall medication room and carts with Licensed Practical Nurse (LPN) #77 revealed incomplete controlled substance medication count sheets for both the 100 and 200 halls. LPN #77 reported the off going and the on coming nurse count the controlled medications together and then sign the Controlled Substances Shift Count form. The 100 hall form dated (MONTH) 2019 lacked signatures for the on-coming night nurse on 01/06 and 01/20. The 200 hall form dated (MONTH) 2019 lacked signatures for the off-going night nurse on 01/07 and signatures for the on-going night nurse on 01/06, 01/08 and 01/20. The Controlled Substance Shift Count form states at the top: Federal Drug Standards require accountability for all controlled substances. The count must be verified at the time there is a change of responsibility for the drugs from one nurse to another. Two (2) licensed nurses, oncoming and off going, will count the controlled drugs together and signed to verify the accuracy of the count. Any discrepancy, without exception, must immediately be reported to the Director of Nursing or Designee . The controlled substance shift count forms for (MONTH) (YEAR), lacked signatures on the following dates: 100 hall --off-going night nurse 11/01, 11/08, 11/14 --on-coming evening nurse 11/17, 11/29 --on-coming night nurse 11/05, 11/07, 11/13, 11/14, 11/25 200 hal… | 2020-09-01 |
| 1140 | 1140 | HOLBROOK HEALTHCARE CENTER | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2019-01-25 | 756 | E | 0 | 1 | K04V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review and staff interview, the pharmacist failed to identify a drug irregularity related to an incomplete medication order without adequate indication for use and adequate monitoring. In addition, the facility failed to develop and maintain policies and procedures for the monthly Medication Regimen Review (MRR) that include, but are not limited to, time frames for the different steps in the monthly medication review process. This practice has the potential to affect all. Resident identifier: #10. Facility census: 84. Findings include: a) Resident #10 Review of Resident (R) #10's medical record on 01/22/19, revealed the following order with a start date of 10/02/2018: [MEDICATION NAME] ([MEDICATION NAME]) tablet; 20 mg (milligrams); amt (amount): 20 mg; oral Special Instructions: dx (diagnosis): [MEDICAL CONDITION] Once a Day - PRN (as needed); PRN 1 The electronic Medication Administration Record [REDACTED]. Pharmacy reviews from 10/04/18 to 01/23/19 note the following identified irregularities: 11/26/18 - [MEDICATION NAME] 250 mg three times a day due for semi annual evaluation of continued use of this [MEDICAL CONDITION] medication. 12/30/18 - [MEDICATION NAME] 20 mg every morning due for semi-annual evaluation for continued use. **The monthly pharmacist reviews lack any information related to the incomplete [MEDICATION NAME] order. The Health Information Management Director #13, confirmed there were no other pharmacy recommendations for R#10, for the time period of 10/04/18 through 01/23/19, during an interview on 01/23/19. On 01/23/19 at 2:30 PM, the Director of Nursing (DON) confirmed R#10's [MEDICATION NAME] order was incomplete, lacking an adequate indication for use and adequate monitoring. In addition, the DON acknowledged the pharmacist should have identified this incomplete order during his monthly medication review. b) The facility policy titled Monthly Regimen Review with a revision date of… | 2020-09-01 |
| 1141 | 1141 | HOLBROOK HEALTHCARE CENTER | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2019-01-25 | 757 | D | 0 | 1 | K04V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure each resident's drug regimen is free from unnecessary medications. [MEDICATION NAME] a diuretic, was ordered on an as needed basis for Resident (R) #10's [MEDICAL CONDITION] without adequate indication for use and adequate monitoring. In addition, the medication was not discontinued after not being administered for 30 days. This was found for one of five residents reviewed for unnecessary medications. Resident identifier #10. Facility census: 84. Findings include: a) Review of Resident (R) #10's medical record on 01/22/19, revealed the following order with a start date of 10/02/2018: [MEDICATION NAME] ([MEDICATION NAME]) tablet; 20 mg (milligrams); amt (amount): 20 mg; oral Special Instructions: dx (diagnosis): [MEDICAL CONDITION] Once a Day - PRN (as needed); PRN 1 The electronic Medication Administration Record [REDACTED]. Pharmacy reviews from 10/04/18 to 01/23/19 note the following identified irregularities/recommendations: 11/26/18 - [MEDICATION NAME] 250 mg three times a day due for semi annual evaluation of continued use of this [MEDICAL CONDITION] medication. 12/30/18 - [MEDICATION NAME] 20 mg every morning due for semi-annual evaluation for continued use. **The monthly pharmacist reviews lack any information related to the incomplete [MEDICATION NAME] order and/or recommendations to discontinuing the prn [MEDICATION NAME] that had not been administered since 11/19/2018. The Health Information Management Director #13, confirmed there were no other pharmacy recommendations for R#10, for the time period of 10/04/18 through 01/23/19, during an interview on 01/23/19. On 01/23/19 at 2:30 PM, the Director of Nursing (DON) confirmed R#10's [MEDICATION NAME] order was incomplete, lacking an adequate indication for use and adequate monitoring. In addition, the DON acknowledged the pharmacist should have identified this incomplete order during his monthly medicati… | 2020-09-01 |
| 1142 | 1142 | HOLBROOK HEALTHCARE CENTER | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2019-01-25 | 775 | D | 0 | 1 | K04V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure laboratory reports were filed and/or scanned in the resident's clinical record. This was true for one (1) of three (3) records reviewed for the care area of urinary catheter or urinary tract infection. Resident identifier: #23. Facility census: 84. Findings include: a) Resident #23 Record review found the facility's Family Nurse Practitioner (FNP) prescribed the antibiotic [MEDICATION NAME] 875-125 milligrams, twice a day, for a [DIAGNOSES REDACTED]. On 01/23/19 at 04:04 PM, the FNP said she started the resident on the antibiotic on 02/27/18, because she suspected the resident had a urinary tract infection. She also ordered a urinalysis with culture and sensitivity on 02/27/18. The FNP reviewed the facility's electronic medical record and confirmed the results of the laboratory values from the 02/27/18 urinalysis report with culture and sensitivity was never scanned into the resident's medical record. The FNP obtained a copy of the laboratory report on 01/23/19 at 4:15 PM. The report verified the urinalysis was obtained on 02/27/18. The facility was made aware of the results of the laboratory report on 03/01/18. On 01/24/19 at 12:03 PM, the above information was provided to the administrator. At the close of the survey on 01/24/19 at 2:00 PM no further information was provided by the facility. | 2020-09-01 |
| 1143 | 1143 | HOLBROOK HEALTHCARE CENTER | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2019-01-25 | 777 | D | 0 | 1 | K04V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain a radiology test (x-ray of left hip) for Resident #81, as ordered by the physician. This was a random opportunity for discovery. Resident identifier: #81. Facility census: 84. Findings include: a) Resident #81 Review of Resident #81's medical record found he was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. On 10/16/18 at 3:00 PM, consult with the orthopedic surgeon recommendations read: Please get left hip x-ray in four (4) weeks. Fax report to us (Orthopedic Surgeon's fax number). No follow up is needed unless fracture is unstable. The results of a left hip x-ray were unavailable in the chart. Interview with the Director of Nursing (DON) on 01/23/19 at 10:10 am, confirmed the x-ray of left hip was not obtained as directed by the physician's orders [REDACTED].> | 2020-09-01 |
| 1144 | 1144 | HOLBROOK HEALTHCARE CENTER | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2019-01-25 | 842 | E | 0 | 1 | K04V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to keep residents' medical information confidential and/or maintain complete and accurate medical records. Individual medication packets were disposed in the general trash without attempts to remove or hide the residents' identifiable information. Enteral feeding tube orders lacked caloric counts, the desired fluid volume in a 24 hour period and the amount of flush to be used with each medication administration. Resident identifiers: #63, #79, #47, #76 and #332. Facility census: 84. Findings include: a) Resident #63 and #79 During observations of medication administration on 01/23/19, Licensed Practical Nurse (LPN) #115 discarded medication packs containing Resident (R) #63 and R#79's name, the medication name and dose and the administration date into the trash bag attached to the medication cart. No attempts were made to remove or cover the identifiable information and/or to destroy the medication packets. During an interview on 01/23/19 at 8:45 AM, LPN #115, reported the trash bag with the medication packets is tied up and disposed of with the regular trash in the dumpster. At 9:445 AM, on 01/23/19, the DON reported the individualized medication packets contain the residents' name, the name and description of the medication and the administration date. The DON acknowledged the facility practice of disposing of residents' medication packets without destroying or hiding the identifiable information is a breech of resident confidentiality as defined in the Health Insurance Portability and Accountability Act (HIPAA). b) Resident #47 Review of the medical record on 01/23/19, revealed Resident #47 is in a persistent vegetative state and receives enteral feedings 24 hours a day via a gastric tube (tube inserted into stomach for feeding). The dietary note dated 01/21/19, states Resident (R) #47 receives [MEDICATION NAME] 1.2 39 milliliters (ml)/hour (hr) via Kangaroo Pump… | 2020-09-01 |
| 1145 | 1145 | HOLBROOK HEALTHCARE CENTER | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2019-01-25 | 867 | E | 0 | 1 | K04V11 | Based on record review, observation, and staff interview, the facility failed to ensure the quality assessment and assurance committee implemented a plan of correction for a quality deficiency for which they know about or should have know about. The facility failed to identify resident's incomplete narcotic count sheets. This was a random opportunity for discovery. Facility census: 84. Findings include: a) At 12:31 PM on 01/22/19, a review of the 100-200 hall medication room and carts with Licensed Practical Nurse (LPN) #77 revealed incomplete controlled substance medication count sheets for both the 100 and 200 halls. LPN #77 reported the off going and the on coming nurse count the controlled medications together and then sign the Controlled Substances Shift Count form. The 100 hall form dated (MONTH) 2019 lacked signatures for the on-coming night nurse on 01/06 and 01/20. The 200 hall form dated (MONTH) 2019 lacked signatures for the off-going night nurse on 01/07 and signatures for the on-going night nurse on 01/06, 01/08 and 01/20. The Controlled Substance Shift Count form states at the top: Federal Drug Standards require accountability for all controlled substances. The count must be verified at the time there is a change of responsibility for the drugs from one nurse to another. Two (2) licensed nurses, oncoming and off going, will count the controlled drugs together and signed to verify the accuracy of the count. Any discrepancy, without exception, must immediately be reported to the Director of Nursing or Designee . The controlled substance shift count forms for (MONTH) (YEAR), lacked signatures on the following dates: 100 hall --off-going night nurse 11/01, 11/08, 11/14 --on-coming evening nurse 11/17, 11/29 --on-coming night nurse 11/05, 11/07, 11/13, 11/14, 11/25 200 hall --off-going night nurse 11/01, 11/08, 11/14, 11/19, 11/30 --on-coming evening nurse 11/03 --off-going evening nurse 11/12 --on-coming night shift nurse 11/07, 11/13, 11/30 300 hall --off-going night nurse 11/05, 11/23, 11/29, 11/30 --… | 2020-09-01 |
| 1146 | 1146 | HOLBROOK HEALTHCARE CENTER | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2019-01-25 | 880 | E | 0 | 1 | K04V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain an effective infection control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. Medication contaminated during preparation were administered to the resident. This practice has the potential to affect more than an isolated number. Resident identifier: #79. Facility census: 84. Findings include: a) Resident #79 During an observation of medication administration on 01/23/19 at 8:21 AM, Licensed Practical Nurse (LPN) #115, dropped a [MEDICATION NAME] 150 milligram (mg) capsule onto the top of the medication cart. LPN #115 picked the capsule up with her bare hand, placed the capsule in the medication cup with other pills and administered the medications to Resident (R) #79. This observation was reviewed with the Director of Nursing (DON), during an interview on 01/23/19 at 9:45 AM. The DON confirmed this was an infection control concern. LPN #115, should have discarded the contaminated [MEDICATION NAME] capsule and replaced it. | 2020-09-01 |
| 1401 | 1401 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 550 | E | 0 | 1 | LL0G11 | Based on observation, record review, staff interview, and resident interview the facility failed to provide a dignified experience for five (5) out six (6) residents. Issues were found with dignity during dining, failing to knock on doors before entering, and not providing a resident with privacy while toileting. Resident identfieirs: #28, #49, #50, #171, and #33. Facility census: 65 Findings included: a) Resident #28 During an interview, on 01/21/19 at 1:00 PM, Resident #28 was trying to talk and the aides kept coming in the room without knocking. This happened twice, both times Nurse Aide students (NA) #60 and #28 were involved. Resident #28 said, see that happens all the time they do not knock. b) Resident #49 During an interview, on 01/22/19 at 11:25 AM, Resident #49 said, they do not always knock on the door. While still interviewing the resident in the room doing NA#60 came in the room without knocking. c) Resident #50 During an observation, on 01/21/19 at 11:28 AM, of the main dining area there were 19 residents, six (6) were being fed by student NAs. Resident #50 was trying to drink from empty cup for ten (10) minutes, while three (3) staff members (NA #3, NA #22, and NA #41) were sitting in chairs on other side of room. This surveyor asked the NAs if they could assist the residents. During an interview, on 01/21/19 at 12:10 PM, the administrator was asked about staff not helping during lunch. No further information was provided. d) Resident #171 On 01/22/19 at 11:24 AM Nursing Assistant (NA) #38 entered Resident #171's room to assist the resident to the bathroom. NA #38 did not close the entry door or pull the residents privacy curtain. Wearing a hospital gown the resident was assisted to the bathroom, with the back of the gown open causing the brief to be exposed. The resident was not wearing any additional clothing. At 11: 34 AM NA #41 entered the room and closed the entrance door and pulled the privacy curtain to assist the resident to bed. During an interview, on 01/22/19 at 11:35 AM, NA #41 agreed p… | 2020-09-01 |
| 1402 | 1402 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 558 | D | 0 | 1 | LL0G11 | Based on observation and staff interview, the facility failed to ensure call light devices were within reach for two (2) of twenty (20) sampled residents. Resident identifiers: #42, #22. Facility census: 65. Findings included: a) Resident #42 Observation on, 01/22/19 at 9:06 AM, found Resident #42 lying in his bed. The call bell was not in reach or even in the bed. Instead, the cord hung from the wall between the two (2) beds in the room. An interview was conducted with Licensed Practical Nurse (LPN) #43 at this time. She said she did not think the resident could use the call bell. She said he yelled out loud when he wanted something. She attached the call light/cord to his bed, and draped it over his right knee. The resident was observed fiddling with the call light for a couple of minutes, looking at it and touching it. When asked if he knew how to ring the call light for the nurse, he did not reply. He activated the call light by using his thumb to press down on the red button at the tip of the call light device several times repeatedly. On 01/22/19 at 9:09 AM, Nurse Aide (NA) #15 responded to the call light and asked the resident what he needed. He replied pizza. This NA said although she was not assigned to his room today, she has worked with him. She said he sometimes uses the call bell. She said she would go see if she could get him some pizza. Another observation, on 01/24/19 at 3:15 PM, observed him lying in bed. The call bell was not visible. Observation on 01/24/19 at 4:00 PM found him still lying in bed. The call bell was not visible. At this time, an interview was conducted LPN #11. LPN #11 agreed the call bell should be within his reach at all times. LPN #11 found the call bell and cord lying beneath his bed. She attached the cord to the resident's bed, and draped in across his lap where he could reach it. During an interview with the Director of Nursing (DON), on 01/24/19 at 5:30 PM, DON said it was her expectation that residents' call bells were always within reach. b) Resident (R) #22 Observation… | 2020-09-01 |
| 1403 | 1403 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 641 | D | 0 | 1 | LL0G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and staff interview the facility failed to ensure one (1) of twenty (20) residents, had an assessment completed that accurately reflected their status. Resident #59's assessment did not reflect the resident's status concerning range of motion (ROM). This had the potential to affect more than a limited number of residents. Resident identifiers: #59 Facility census: 65 Findings included: a) Resident #59 Observations during the provision of wound care, on 01/23/19 at 10:40 AM, revealed the resident's right leg appeared stiff. Resident#59 was unable to move her right leg without difficulty. Review of the resident's Minimum Data Set (MDS) with an assessment reference date (ARD) 12/26/18, on 01/23/19 at 11:51 AM, revealed section 'G' was marked the resident had no impairment in functional limitations in range of motion (ROM) of the upper or lower extremities. However, pertinent [DIAGNOSES REDACTED]. [MEDICAL CONDITION], according to Merriam Webster Medical Dictionary, is total or [DIAGNOSES REDACTED] of one side of the body that results from disease of or injury to the motor centers of the brain. [MEDICAL CONDITION] according to Merriam Webster Medical Dictionary, is muscular weakness or [DIAGNOSES REDACTED] restricted to one side of the body. An interview with the wound nurse Licensed Practical Nurse (LPN#64), revealed the resident can only move one leg, but not the right leg due to it being messed up from an old surgery. LPN#64 confirmed the resident has a ROM impairment to the right lower extremity. On 01/23/19 at 03:28 PM, an interview with the Director of Nurses (DON) revealed Resident #59 does have ROM impairment to the right lower extremity. The DON stated the MDS is inaccurate. During an interview with the Registered Nurse Clinical Reimbursement Coordinators (RNCRC), the nurses responsible for completing the MDS, on 01/24/19 at 03:25 PM, RNCRC#48 and RNCRC#68 confirmed the MDS was inaccurate. | 2020-09-01 |
| 1404 | 1404 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 655 | D | 0 | 1 | LL0G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop and/or implement a baseline care plan. This is true for one (1) of three (3) new admission records reviewed. Resident identifier: #30. Facility census: 65. Findings included: a) Resident #30 A review of Resident #30's medical records revealed the resident was admitted to the facility on [DATE]. The initial nursing assessment was also completed on 11/30/18. The care plan located in medical records had an initiated date of 12/04/18. On 01/23/19 the director of nursing (DON) explained she could not find evidence a interim plan of care was completed within forty-eight (48) of admission. | 2020-09-01 |
| 1405 | 1405 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 656 | E | 0 | 1 | LL0G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to develop and/or implement care plans with measurable objectives and/or person-centered interventions for six (6) of twenty (20) sampled residents. This was evident for Resident #42 related to his floor/safety mat, for Resident #36 related to the need for extensive assistance with feeding, for Resident #41 related to [MEDICAL CONDITION] medications/behaviors, for Resident #30 related to diabetic management, for Resident #66 related to anxiety, and for Resident #22 related to bowel protocol. Resident identifiers: #42, #36, #41, #30, #66, #22. Facility census: 65. Findings included: a) Resident #42 Review of the care plan, on 01/22/19, found a care planned focus which addressed the resident was at risk for falls related to impaired mobility, poor safety awareness, use of [MEDICAL CONDITION] medication, history of [MEDICAL CONDITION], and inconsistency with ambulation. A intervention included having a safety mat to the floor on the right side of his bed. This intervention was initiated on 11/21/18. Observation, on 01/22/19 at 4:30 PM, found the resident lying in his bed. There was no fall mat on the floor beside either side of the bed, nor was there a fall mat anywhere in his room. An interview was conducted with Registered Nurse (RN)#6 on 01/22/19 at 4:30 PM. She checked his room and acknowledged that there was no fall mat anywhere in his room. She checked the treatment sheet and found that he was supposed to have a fall mat to the right side of his bed. She said she would obtain a fall mat for his room right away. An interview was conducted with the director of nursing (DON) on 01/24/19 at 5:30 PM. She acknowledged the care plan directed the resident to have a fall mat to the right side of his bed, and failure to have a fall mat to the right side of his bed indicated that the care plan was not implemented and/or followed in that regard. b) Resident #36 Review… | 2020-09-01 |
| 1406 | 1406 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 657 | D | 0 | 1 | LL0G11 | Based on record review and staff interview, the facility failed to revise nutrition care plans after a significant weight loss occurred. This was true for two (2) of eight (8) residents reviewed for the care area of nutrition. Resident identifiers: #59, and #33. Facility census: 65. Findings included: a) Resident #59 On 01/23/19 at 8:43 AM, a review of Resident #59's weight records was conducted. Per these records, Resident #59 weighed 108.4 pounds on 01/17/19, 118.3 pounds on 12/12/18, and 137.5 pounds on 10/17/18. Based on the most recent weight measurement of 108.4 pounds on 01/17/19, Resident #59 had lost 8.37 percent of her body weight over a period of one (1) month and 21.16 percent of her body weight over a period of three (3) months. To be considered significant weight change, one's body weight must change by more than five (5) percent in 30 days (or one month) or more than 7.5 percent in 90 days (or three months). A review of Resident #59's nutrition care plan during the survey revealed the following nutritional goal, created on 10/16/18 and updated on 01/21/19: Resident will maintain a stabilized weight with no sig(nificant) changes through next review. On 01/24/19 at 10:01 AM, an interview was conducted with Registered Dietitian (RD) #112 regarding this care plan goal. RD #112 acknowledged that the goal in the nutrition care plan was not updated to reflect Resident #59's significant weight loss. She stated that when a resident has significant weight loss, she acknowledges the loss in a nutrition note, but does not typically update the care plan weight goal. A review of Resident #59's nutrition care plan revealed the following intervention, initiated on 10/19/18: Administer ProHeal (a protein supplement) as ordered. Resident #59's orders did not direct to provide ProHeal, however. On 01/23/19 at 5:01 PM, the facility's Director of Nursing (DoN) said that the ProHeal had possibly been discontinued and if this was the case, then it should not be on the care plan. On 01/23/19 at 5:07 PM, Registered Nurse (… | 2020-09-01 |
| 1407 | 1407 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 677 | D | 0 | 1 | LL0G11 | Based on observation, resident interview, and staff interview the facility failed to ensure three (3) of four (4) residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene and nutrition. Resident identifiers: Resident #28, #41, and #6 Facility census: 65. Findings included: a) Resident #28 During an interview, on 01/21/19 at 12:34 PM, Resident #28 said some of the aides do not provide very good care when providing bed bath and peri care with a catheter. The resident stated she refused showers because she was scared they would drop her. She said that an aide on night shift with purple hair left her in the shower alone and was gone 30 minutes, she left her four (4) times in the shower because her phone was ringing, and she kept stepping out to answer it. During an observation, on 01/23/19 at 9:30 AM, Nurse Aide (NA) #2 was providing peri care, using same water that was in the basin and wash cloth that was used by the resident used to wash her upper body, the basin water was soapy. She did not fold the wash cloth into sections to use a clean part of the wash cloth with every wipe, she wiped the top of the pubis mound, then on the inside of the leg creases, one stroke downward without opening the inter vaginal folds, she then patted the same area dry. NA #2 was asked if she used the no-rinse cleanser she said, yes. She was then asked to show the bottle and said, oh I'm sorry I used the wrong one it is the regular soap. She was then asked if she should rinse the peri area now that she used a soap that required rinsed. She got a clean wash cloth and wet it in the sink. She washed the resident's back and buttock area with the soapy water in the basin, patted her dry with a dry towel, again she did not rinse the area. Resident asked for lotion and it was applied. NA#2 picked up the Residents phone and handed it the resident, pulled the curtain back while still wearing the gloves she was wearing to provide care. NA #2 then stated that she was done w… | 2020-09-01 |
| 1408 | 1408 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 684 | D | 0 | 1 | LL0G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview; the facility failed to ensure residents receive necessary treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was true one (1) of twenty (20) sample resident and one (1) confidential resident reviewed during the annual Long-Term Care Survey Process. The facility failed to follow physician orders [REDACTED]. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #22 and confidential resident. Facility census: 65. Findings included: a) Resident #22 On 01/22/19 at 09:38 AM, an interview with Resident #22 revealed the resident had issues with constipation. The resident said she is sometimes constipated as much as a week at a time without a bowel movement (BM). Review of records, on 01/24/19 at 05:09 PM, revealed the resident's care plan had the focus area: Resident exhibits or is at risk for gastrointestinal symptoms or complications related to constipation, . Interventions included: Provide bowel regimen, utilize pharmacologic agents as appropriate i.e. [MEDICATION NAME] suppository, Milk of Magnesia, Fleet Enema. Refer to standing orders. Review of the resident's Activities of daily living (ADL) sheets revealed the resident had bowel movements on: 12/01/18, 12/02/18, 12/11/18, 12/13/18, 12/17/18, 12/18/18, 12/28/18, and 12/30/18 during the month of December, a total of eight (8) days out thirty-one (31) days. The current months record revealed BMs on 01/03/19, 01/08/19, 01/14/19, 01/22/19, and 01/23/19. On 01/08/19 the resident had two (2) bowel movements. As of (MONTH) 24, 2019, the resident had bowel movements on five (5) days out of twenty-four (24) days of January. Review of orders, on 01/24/19 at 05:32 PM, revealed orders for Milk of Magnesia (MOM) Suspension 400 MG/5ML, give 30 ml (thirty milli-liters) by m… | 2020-09-01 |
| 1409 | 1409 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 686 | D | 0 | 1 | LL0G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide necessary care and services consistent with professional standards of practice to promote the prevention of pressure ulcer/injury development. The facility failed to ensure a resident's skin integrity was maintained during wound care. This was true one (1) of two (2) sample resident reviewed during the annual Long-Term Care Survey Process for pressure ulcer wound care. This practice had the potential to affect more than a limited number of residents. Resident Identifier: #31. Facility census: 65 Findings included: a) Resident #31 Review of records, on 01/22/19 at 10:29 AM, revealed Resident #31 has a history of reoccurring pressure ulcers in the same area of the lower back. Currently Resident #31 had a healing in house acquired stage III pressure ulcer located over the spinal boney prominence of the lower back. Review of the resident's significant change minimum data set (MDS) with an assessment reference date (ARD) 12/07/18, on 01/24/19 at 10:56 AM, revealed the resident's Brief Interview for Mental Status (BIMS) with a score of six (6) indicating the resident has a severe cognitive impairment. The resident needed total assistance with activities of daily living, except she needed supervision with eating and extensive assistance with toileting. The resident had range of motion (ROM) impairment in her lower extremities on one side. Resident was always incontinent of both bowel and bladder. Some pertinent [DIAGNOSES REDACTED]. The resident weighs ninety-two (92) pounds. Review of orders, on 01/23/19 at 08:44 AM, revealed a current order to, Apply non-adhesive Opti foam then times two large (X2 Lg) Allevyn dressings to middle and upper spine. Cleanse lower spine with wound cleanser apply [MEDICATION NAME] Ag cover with non-adhesive Opti foam then large Allevyn dressing. Wound(s): Monitor site(s) Daily for status of surrounding tissue and wound pain. Observation of pressure… | 2020-09-01 |
| 1410 | 1410 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 689 | D | 0 | 1 | LL0G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview the facility failed to ensure the environment was as free from accident hazards as possible over which the facility had control. This was evident for one (1) of five (5) residents reviewed for falls/accident hazards, and one (1) random observation for discovery. Resident identifiers: #42 and #46. Facility census: 65. Findings include: a) Resident #42 The medical record was reviewed on 01/22/19. Pertinent [DIAGNOSES REDACTED]. The most recent minimum data set (MDS) with assessment reference date (ARD) of 12/17/18, assessed that his brief interview for mental status (BIMS) score was nine (9). This indicates severe cognitive impairment. The MDS also assessed that he is totally dependent on staff for bed mobility and transfers. Medications received in the look-back period included anticoagulant use daily. The MDS assessed that he experienced one (1) fall without injury since the former assessment in (MONTH) (YEAR). Review of the facility's log sheets for falls revealed that he experienced a fall on 11/20/18 at 5:35 PM in his room with no injury. Current physician's orders [REDACTED]. twice daily. Anticoagulant therapy may increase the likelihood of significant bleeding with an accident or injury. Current physician's orders [REDACTED]. Review of the resident's care plan found a focus on page twenty-seven (27) which identified this resident was at risk for falls related to impaired mobility, poor safety awareness, use of [MEDICAL CONDITION] medications, history of [MEDICAL CONDITION], and inconsistency with ambulation. One (1) of the care planned interventions stated Safety mat to floor on right side of bed. 1. Observation on 01/22/19 at 9:06 AM found Resident #42 lying in his bed. The call bell was not in reach or even in the bed. Instead, the cord hung from the wall between the two (2) beds in the room. An interview was conducted with licensed practical nurse employee #43 (LPN #43) … | 2020-09-01 |
| 1411 | 1411 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 690 | D | 0 | 1 | LL0G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, and policy review the facility failed to ensure two (2) of three (3) residents with urinary catheters received appropriate catheter care to prevent urinary tract infections. Resident identifiers: #28 and #59. Facility census: 65 Findings included: a) Resident #28 During an observation, on 01/23/19 at 9:30 AM, Nurse Aide (NA) #2, used the same basin of soapy water and wash cloth that the resident used to wash her upper body. She did not fold the wash cloth in section, so she could use a clean section of the wash cloth for each wipe. She wiped the top of the pubis mound, then on the inside of the leg creases, the one stroke downward without opening the inter vaginal folds, she only wiped the part of the indwelling Foley catheter tubing that was outside of the vagina, she then patted the area dry. NA#2 was asked if she used the no-rinse cleanser she said yes. She was then asked to show the bottle and said, oh I'm sorry I used the wrong one it is the regular soap. she was asked if she should rinse the area now that she used a soap that was to be rinsed. An interview on 01/23/19 at 9:49 AM, DoN informed about the observation of catheter care. b) Resident #59 On 01/23/19 at 10:40 AM after observing Licensed Practical Nurse (LPN#64) providing Resident #59's pressure ulcer wound care, it was noted that R#59's Foley catheter bag's drainage tubing was not secured to the resident's leg. After LPN #64 completed wound care, Nurse Aide (NA) #49 repositioned Resident #59, covered the resident with a sheet and blanket, and started lowering the resident's bed. This surveyor asked LPN#64 and NA#49 if they were finished providing care to Resident#59. NA#49 said, Yes, we're done. This surveyor asked NA#49 to look at the Foley catheter drainage tubing to see if tubing was secured to the resident's leg. NA#49 pulled back the sheet and blanket and confirmed the Foley catheter drainage tubing was not secured a… | 2020-09-01 |
| 1412 | 1412 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 692 | D | 0 | 1 | LL0G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain the nutritional status of a resident by failing to communicate nutritional recommendations for a protein supplement. This deficient practice was found for one (1) of eight (8) residents reviewed for the care area of nutrition. Facility census: 65. Resident identifier: #59. Findings included: a) Resident #59 During the survey, nutritional recommendations for Resident #59 were reviewed. On 01/15/19, Registered Dietitian (RD) #112 recommended a protein supplement to be given to Resident #59 twice daily. However, Resident #59's orders did not reflect a protein supplement. A review of Resident #59's laboratory results during the survey revealed multiple instances of low [MEDICATION NAME] levels over two (2) months. Blood collected on 12/04/18 revealed an [MEDICATION NAME] level of 1.8 grams per deciliter (gm/dL) and blood collected on 01/10/19 revealed an [MEDICATION NAME] level of 1.9 gm/dL. Per the lab reports, the reference (normal) range for [MEDICATION NAME] was 3.8-4.8 gm/dL. According to the National Institutes of Health (NIH), [MEDICATION NAME] (low [MEDICATION NAME] level in the blood) is the result of the combined effects of inflammation and inadequate protein and caloric intake in patients with chronic disease. On 01/24/19 at 9:04 AM, the facility's Director of Nursing (DoN) said during an interview that she was unsure why the RD's recommendation for a protein supplement was not implemented and that she would check on it. On 01/24/19 at 9:53 AM, Registered Nurse (RN) #23 provided a form titled Genesis Healthcare Food & Nutrition Services Nutritional Care Recommendations from 01/15/19. RN #23 explained that the protein supplement was not ordered because RD #112 had failed to place the recommendation on this communication form. The form contained nutritional recommendations for six (6) residents, but Resident #59 was not one of them. Therefore, since the recommend… | 2020-09-01 |
| 1413 | 1413 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 725 | D | 0 | 1 | LL0G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to deploy sufficient staff to ensure the timely feeding assistance of a resident who required extensive assistance of one (1) person. This was evident for one (1) of eight (8) residents reviewed for nutrition. Resident identifier: #36. Facility census: 65. Findings include: a) Resident #36 Review of the medical record, on 01/23/19, found current physician's orders [REDACTED]. Pertinent [DIAGNOSES REDACTED]. Her most recent brief interview for mental status (BIMS) score was three (3), which indicated severe cognitive impairment. Review of the resident's care plan revealed an intervention on page three (3) which directed to provide the resident with extensive assistance of one (1) for eating. Further review of the medical record found evidence that the physician had been actively involved with trying to combat her weight loss. Recent physician's orders [REDACTED]. 1. 11/16/18 - house supplement twice daily 2. 12/03/18 - [MEDICATION NAME] five (5) milligrams (mg) daily (a medication used to improve appetite) 3. 12/03/19 - [MEDICATION NAME] five (5) mg. before meals (used to treat heartburn and ulcers in people with [MEDICAL CONDITION] reflux disease). 4. 12/04/18 - [MEDICATION NAME] forty (40) mg. daily (a medication used to improve appetite) 5. 01/01/19 - Speech/language therapy five (5) times per week for dysphasia/speech 6. 01/16/19 - Increase house supplement to three (3) times daily. Meal observations were conducted as follows: 1. Observation on 01/23/19 for breakfast found a nursing assistant fed her. She ate about 75% of her meal, and drank almost a cup of milk. 2. Observation on 01/23/19 at 12:30 PM found her lying in bed asleep. A central supply nursing assistant employee #49 was in the hallway helping to serve trays. She said they were going to serve her tray to her soon, and they had plans to assist her with her meal. At 12:40 PM on 01/23/19 a student nursing assistant sat i… | 2020-09-01 |
| 1414 | 1414 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 726 | D | 0 | 1 | LL0G11 | Based on observation, resident interview, and staff interview the facility failed to ensure personal hygiene needs were met in accordance with professional standards of care. This was true for one (1) of four (4) reviewed in the care of Activities of Daily Living. Resident identifier: Resident # 28. Facility census 65. Findings included: a) Resident #28 During an interview on 01/21/19 at 12:34 PM Resident #28 said some of the aides do not provide very good care when providing bed bath and peri care with a catheter. She states she refuses showers because she is scared they while drop her. She said that an aide on night shift with purple hair left her in the shower alone and was gone 30 minutes, she left her four (4) times in the shower because her phone was ringing, and she kept stepping out to answer it. During an observation, on 01/23/19 at 9:30 AM, Nurse Aide (NA) #2 was providing peri care, using same water that was in the basin and wash cloth that was used by the resident used to wash her upper body, the basin water was soapy. She did not fold the wash cloth into sections to use a clean part of the wash cloth with every wipe, she wiped the top of the pubis mound, then on the inside of the leg creases, one stroke downward without opening the inter vaginal folds, she then patted the same area dry. NA #2 was asked if she used the no-rinse cleanser she said yes. She was then asked to show me the bottle and said oh I'm sorry I used the wrong one it is the regular soap, she was sked if she should rinse the peri area now that she used a soap that is required to be rinsed. She got a clean wash cloth and wet it in the sink. She washed the resident's back and buttock area with the soapy water in the basin, patted her dry with a dry towel, again she did not rinse the area. Resident asked for lotion and it was applied. NA#2 picked up the Residents phone and handed it the resident, pulled the curtain back while still wearing the gloves she was wearing to provide care. NA #2 then stated that she was done with her bed bath.… | 2020-09-01 |
| 1415 | 1415 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 744 | D | 0 | 1 | LL0G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident diagnosed with [REDACTED]. The facility failed to identify, document, and communicate specific targeted behaviors and expressions of distress, as well as desired outcomes, for a resident with a [DIAGNOSES REDACTED]. This was evident for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #41. Facility census: 65. Findings include: a) Resident #41 The medical record was reviewed on 01/24/19. The most recently completed minimum data set (MDS) with assessment reference date (ARD) 12/17/18, assessed that his level of inattention fluctuates, and disorganized thinking comes and goes and changes in severity. Per this MDS, he was assessed with [REDACTED]. Section [NAME] assessed that he had no behaviors in the seven (7) day look-back period. Medications received daily in the seven (7) day look-back period included antipsychotic medication daily and antidepressant medication daily. [DIAGNOSES REDACTED]. Review of the care plan revealed a focus that he used [MEDICAL CONDITION] medications. However, the focus did not identify targeted behaviors and/or expressions of distress the facility and resident/family desired to treat. Medical record review found [MEDICAL CONDITION] medications prescribed for him in (MONTH) included [MEDICATION NAME] (a medication used in the treatment of [REDACTED]. twice daily. [MEDICAL CONDITION] medications he took in (MONTH) included [MEDICATION NAME] (an antidepressant medication) twenty (20) mg. daily, [MEDICATION NAME] (an anti-depressant medication) fifty (50) mg. daily, and [MEDICATION NAME] (an antipsychotic medication) two (2) mg. daily. Review of the care plan found it contained no measurable goals related to the need for [MEDICAL CONDITION] medications, or what behaviors or symptoms of distress the facility and/or resident/family wished to accomplish by using [MEDICAL CONDITION] medication… | 2020-09-01 |
| 1416 | 1416 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 761 | E | 0 | 1 | LL0G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and manufacturer guideline review, the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. A multi-dose vial of Purified Protein Derivative (PPD), a medication injected beneath the skin to aid in the detection of exposure to [MEDICAL CONDITION], was not dated when initially opened. This had the potential to negatively impact the safety and/or potency of the medication, and had the potential to affect any resident who might receive an injection of medication/serum from this vial. One (1) of three (3) medication storage room refrigerators contained a vial of PPD serum which was not dated when initially opened for use. The facility also failed to date a multi-dose vial of insulin which belonged to Resident #62 after the vial was initially opened and needle-punctured for use. This was found for one (1) of four (4) multi-dose insulin vials on the B-hall medication cart. This had the potential to negatively impact the safety and/or potency of the medication for Resident #62. Resident identifier: #62. Facility census: 65. Findings include: a) PPD serum The facility's only medication room was observed, on 01/24/19 at 2:40 PM, while accompanied by Licensed Practical Nurse #64 (LPN #64). One (1) of the rooms three (3) medication storage refrigerators contained a vial of Purified Protein Derivative (PPD) serum which had been opened for use and needle-punctured. The vial held enough serum for ten (10) tests when full, and was approximately half-full at this time. There was no date on the vial of PPD or the box which held it to indicate when it had first been opened for use. LPN #64 said she would see that this vial of PPD was disposed. Review of manufacturer's guidelines revealed that PPD vials should be inspected visually for both particulate matter and discoloration prior to administration and discarded if either is seen. Vials in use for more than thirty (30… | 2020-09-01 |
| 1417 | 1417 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 801 | F | 0 | 1 | LL0G11 | Based on observation, staff interview, and personnel file review, the facility failed to ensure that they had a qualified person to serve as the director of food and nutrition services. This deficient practice had the potential to affect all residents in the facility. Facility census: 65. Findings included: During an interview, on 01/22/19 at 8:14 AM, Food Service Supervisor (FSS) #97, hired on 04/02/17, stated that he was not a Certified Dietary Manager (CDM). He said that he had just recently enrolled in a CDM course, but had not started it yet. On 01/22/19 at 8:18 AM, FSS #97 was asked how often a Registered Dietitian (RD) visits the facility. FSS #97 replied that RD #112 visited the facility twice weekly. During an interview, on 01/23/19 at 9:36 AM, the facility's Administrator was informed of what FSS #97 had said regarding the CDM course and RD #112 coming to the building only twice per week. The Administrator added that FSS #97 had been enrolled in a CDM course in (MONTH) (YEAR) and that RD #112 and District Manager (DM) #110 made regular visits to the facility. He added that DM #110 was taking the CDM course along with FSS #97, meaning that DM #110 was also not a CDM. The Administrator added that he did not know how to find out how many hours per week RD #112 and DM #110 visited the facility, but that he would contact RD #112 and DM #110's supervisors. During the survey, the Administrator provided a copy of an email from FSS #97 and DM #110's supervisor, stating that DM #110 would be in the facility between three (3) and five (5) days during the week of the survey. The supervisor further stated that DM #110 had been in the facility two (2) days the week before the survey, and one (1) day the week prior to that. The supervisor added that he was unable to provide information about how many hours or days RD #112 worked in the facility in any given week. On 01/24/19 at 8:31 AM, the Administrator said he was unable to get coverage information for the DM who came to the facility before DM #110 started coming, a… | 2020-09-01 |
| 1418 | 1418 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 804 | E | 0 | 1 | LL0G11 | Based on resident interview, staff interview, and observation of test trays, the facility failed to ensure that food and beverages were served to residents at a safe and appetizing temperature. This deficient practice had the potential to affect more than an isolated number of residents. Facility census: 65. Resident identifiers: #33, #28, #46. Findings included: a) The kitchen On 01/23/19 at 12:42 PM, the final lunch tray to be served was pulled just prior to service from the A hall tray cart and staff were informed that the owner of the tray would require a new one from the kitchen. The tray was taken to the kitchen by surveyors, where Food Service Supervisor (FSS) #97 tested the temperature of each food item on the tray with his own thermometer at 12:43 PM. The tater tots on the tray were 82.8 degrees Fahrenheit, the Philly steak sandwich was 105 degrees Fahrenheit, and the soup was 135.8 degrees Fahrenheit. District Manager (DM) #110 stated that the correct point of service temperature was 125 degrees Fahrenheit, meaning that the tater tots and Philly steak sandwich were too cold. West Virginia State nursing home regulations dictate that food not be served below 120 degrees Fahrenheit. Both the tater tots and the Philly steak sandwich were not in compliance with West Virginia State nursing home regulations regarding serving temperatures. b) Resident #33 On 01/22/19 at 9:02 AM, Resident #33 complained that her food was cold. On 01/23/19 at 12:17 PM, a cart containing Resident #33's lunch tray was delivered to the A hall of the facility. The cart sat in the hallway for a period of time before staff began serving trays. Resident #33's tray happened to be the first tray to be served from the cart. When staff pulled it out of the cart to serve, they were informed that this tray would be needed as a test tray and that Resident #33 would require a new lunch tray. Shortly after the request for the new lunch tray was made, on 01/23/19 at 12:27 PM, Food Service Supervisor (FSS) #97 came to the A hall with his own therm… | 2020-09-01 |
| 1419 | 1419 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 812 | E | 0 | 1 | LL0G11 | Based on observation, record review, policy review, and staff interview, the facility failed to maintain a sanitary environment in the kitchen and failed to practice safe food handling standards. This deficient practice had the potential to affect more than an isolated number of residents. Facility census: 65. Findings included: a) Kitchen On 01/21/19 at 11:28 AM, an initial tour of the kitchen began with Food Service Supervisor (FSS) #97. At 11:30 AM, an open bag of sausage in the freezer was found to have no date written on it to indicate when it had been opened. FSS #97 took out a marker and began to date the bag at the time of the finding. FSS #97 was asked how he knew when the bag had been opened. He said since sausage was served for breakfast that morning, the bag must have been opened on 01/21/19. Review of the facility menu for breakfast on 01/21/19 revealed the following breakfast options: orange juice, cinnamon oatmeal, banana, egg and cheese biscuit, scrambled egg, fried egg, and white, wheat, rye, or raisin bread. Sausage was not listed as a breakfast option for that day. At 11:32 AM, the reach-in refrigerator was noted to have rusty shelves, creating a potential food contamination hazard. FSS #97 acknowledged that there was rust and said he wipes the shelves down regularly to keep them clean and that sometimes staff paint over the rust. At 11:33 AM, FSS #97 turned on the garbage disposal in the dish room to remove some food waste. The garbage disposal began spraying water and food waste particles outward and downward underneath the counter, creating a potential contamination hazard for the clean dishes and utensils stored in the room. The water and food particles pooled on the floor of the dish room because there was not a drain close enough to the garbage disposal area to remove the liquid. FSS #97 stated that the garbage disposal just does this sometimes, but he would have someone look at it. At 11:34 AM, multiple dish racks were observed on the floor of the dish room in the pool of food and liquid… | 2020-09-01 |
| 1420 | 1420 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 867 | F | 0 | 1 | LL0G11 | Based on the issues identified during the annual Long-Term Care Survey Process, the facility failed to ensure their Quality Assessment and Assurance (QA&A) program identified quality deficiencies of which they should have been aware. The deficient practices below had the potential to affect a widespread number of residents. Resident census: 65. Issues were found in the following areas: Resident rights The facility failed to: ensure staff provide privacy during care; ensure staff knock on resident's doors and wait for permission before entering. Resident Records Facility failed tomonitor and ensure no missing records were in the pilot skin program (IPOD) system. Food and Nutrtion Services Facility failed to identify multiple sanitation issues in the kitchen; failed in the kitchen to ensure thirty-five (35) hour per week coverage by a certified dietary manager or registered dietitian. Quality of Life Facility failed to ensure adequate supervision of residents while being fed. Infection Control Facility failed to maintain an effective infection control program to the extent possible in the laundry. These practices had the potential to affect more than an isolated number of residents. Findings included: Resident Rights Resident #28 During an interview, on 01/21/19 at 1:00 PM, Resident #28 was trying to talk and the aides kept coming in the room without knocking. This happened twice, both times Nurse Aide students (NA) #60 and #28 were involved. Resident #28 said, see that happens all the time they do not knock. Resident #49 During an interview, on 01/22/19 at 11:25 AM, Resident #49 said, they do not always knock on the door. While still interviewing the resident in the room doing NA#60 came in the room without knocking. Resident #50 During an observation, on 01/21/19 at 11:28 AM, of the main dining area there were 19 residents, six (6) were being fed by student NAs. Resident #50 was trying to drink from empty cup for ten (10) minutes, while three (3) staff members (NA #3, NA #22, and NA #41) were sitting in chairs on… | 2020-09-01 |
| 1421 | 1421 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2019-01-25 | 880 | F | 0 | 1 | LL0G11 | Based on observation, policy review, staff interviews, 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. This is related the laundry services. This has the potential to effect all residents. Facility census: 65. Findings included: a) Infection Control On 01/23/19 at 7:53 AM, a tour of the laundry room revealed, the door between the soiled room and the clean room was blocked open with a laundry basket, Health Care Service Employee (HCSE) #84 stated she was listening for the washer to stop. There were mop heads and kitchen towels together s in a clear bag in the hand washing sink. There was a sign above the sink that read Hand Washing Only. HCSE#84 was asked if she always puts them in that sink and she said yes. She was asked where she washes her hands before entering the clean side of the laundry room and after she handles the soiled laundry. She stated, that she does not wash her hand there she goes next door to wash her hands. On 01/23/19 at 7:58 AM, Maintenance Supervisor (MS) #75 was informed of employee having door propped open and air flow around the door blowing from the soiled laundry room to the clean laundry room, he said he would put a door sweep on the door, the exhaust fan in the soiled laundry room was turned off causing the air flow to blow from soiled to clean, MS #75 stated the staff keep turning it off, and he does not know why they keep doing that but he will turn it back on. | 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 );