cms_WV
Data source: Big Local News · About: big-local-datasette
41 rows where "inspection_date" is on date 2019-03-20
This data as json, copyable, CSV (advanced)
Suggested facets: facility_name, facility_id, address, city, zip, scope_severity, eventid, filedate (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1781 | 1781 | COLUMBIA ST. FRANCIS HOSPITAL | 515110 | 333 LAIDLEY STREET | CHARLESTON | WV | 25322 | 2019-03-20 | 684 | D | 0 | 1 | MRLP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (1) of five (5) residents reviewed for the care area of unnecessary medications. The physician was not notified when Resident #159's medication was held. Additionally, blood glucose monitoring was performed for Resident #159 without a physician's orders [REDACTED]. Resident identifier: #159. Facility census: 12. Findings included: a) Resident #159 1. Physician notification of held medication Review of Resident #159's medication administration record (MAR) revealed the resident's blood pressure medications, [MEDICATION NAME] and [MEDICATION NAME], were not given on 03/15/19 at 8:53 AM. The reason documented in the MAR for not giving the medication was hold for parameters. Resident #159's [MEDICATION NAME] and [MEDICATION NAME], were also not given on 03/16/19 at 9:09 AM. The reason documented in the MAR for not giving the medication was low bp (blood pressure). Resident #159's [MEDICATION NAME], was also not given on 03/19/19 at 7:59 AM. The reason documented in the MAR for not giving the medication was hold for parameters. A note written by the nurse on 03/19/19 at 8:00 AM stated, [MEDICATION NAME] 20 mg po (oral) held this am per orders (physician's name) d/t (due to) BP 100/64. The medical records contained no indication the physician was notified when Resident #159's blood pressure medications were held on 03/15/19 and 03/16/19. During an interview on 03/19/19 at 1:57 PM, the Registered Nurse (RN) Clinical Coordinator stated Resident #159 did not have physician's orders [REDACTED]. The RN Clinical Coordinator stated there was no evidence in the medical records that Resident #159's physician was notified when the nurse held her blood pressure medication on 03/15/19 and 03/16/19. No furt… | 2020-09-01 |
| 1782 | 1782 | COLUMBIA ST. FRANCIS HOSPITAL | 515110 | 333 LAIDLEY STREET | CHARLESTON | WV | 25322 | 2019-03-20 | 732 | C | 0 | 1 | MRLP11 | Based on review of staffing documentation and by staff interview, the facility failed to ensure the complete staffing numbers for each shift is posted daily. There were days noted where the staff available for only one shift was recorded on the form and the other two shifts were blank. This was for three days out of months of (MONTH) and March. This practice has the potential to affect more than a limited number of residents and family who are to have access to this informaiton. Findings included: a) 03/19/19 at 1:20 p.m. discussion with the director of nursing (DON) verified the staff postings had not been completely filled out for the evening and night shifts This was found during a review of the staff posting sheets on file for (MONTH) and so far for the month of March. The documentation was incomplete for (MONTH) 14 and 17. Also for (MONTH) 9, 2019. This informaiton is to be posted for all the public to have access to the information. | 2020-09-01 |
| 1783 | 1783 | COLUMBIA ST. FRANCIS HOSPITAL | 515110 | 333 LAIDLEY STREET | CHARLESTON | WV | 25322 | 2019-03-20 | 812 | E | 0 | 1 | MRLP11 | Based on observations and staff interview, the facility failed to ensure foods and equipment were maintained in a sanitary condition. Foods were stored undated it indicate when it was opened and some equipment was in need of cleaning. This has the potential to affect more than a limited number of residents who consume food served from this central location. Facility census: 12. Findings included: a) Observations During the tour of the dietary department on 03/18/19 at 10:00 a.m. with the assistance of the dietary manager, the following issues were noted: --Can of vegetable beef soup had dents around the rim of the can but located on the shelf to still be in use. --A container of cooked spaghetti and a container of butter was in the refrigerator, and was undated to indicated the date opened or placed in refrigerator. --A bag of shredded cheese was unlabeled and undated in the walk in refrigerator. --Serving utensils were found in a storage drawer all jumbled together with the serving portions touching the handles of others. This could lead to the possibility of cross contamination. --Drip pan under the range top was found to be heavily soiled with food debris and in need of cleaning. The dietary manager was present and verified the above issues. | 2020-09-01 |
| 2168 | 2168 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 580 | E | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the attending physician and/or the responsible party when residents suffered a weight loss. This was true for four (4) of six (6) residents reviewed for nutrition. Resident identifiers: #44, #33, #17 and #24. Facility census: 56. Findings included: a) Resident #44 A review of Resident #44's medical record at 8:16 a.m. on 03/19/19 found the following weights recorded since admission on 02/09/19: --02/09/2019 - 132.0 pounds (Lbs.) --02/20/19- 123.8 Lbs. --02/27/19 - 122.4 Lbs. --03/01/19 at 8:46 am - 121.2 Lbs. and re-weight at 1:06 pm on 03/01/19- 122.2 Lbs. --03/08/19 - 119.0 Lbs. --03/13/19 - 114.4 Lbs. Using the following formula (% of body weight loss = (usual weight - actual weight) / (usual weight) x 100) Resident #44's weight loss for the last 30 days was calculated and found Resident #44 lost 17.6 Lbs. or 13.3 % of his body weight from 02/09/19 to 03/13/19. This is considered a severe weight loss for 30 days. Review of the Centers for Medicare and Medicaid (CMS) State Operations Manual (SOM) Appendix PP interpretive guidelines for F692 found the following regarding weight loss parameters for evaluating significance of unplanned and undesired weight loss are: --1 month - 5% = a significant weight loss while greater than 5% = a severe weight loss --3 months - 7.5% = a significant weight loss while greater than 7.5% = a severe weight loss --6 months - 10% = a significant weight loss while greater than 10% = a severe weight loss The following formula determines percentage of weight loss: --% of body weight loss = (usual weight - actual weight) / (usual weight) x 100. Nutritional assessment reviewed was completed on 02/19/19 by the registered dietician (RD). Recommendation: 1) Multivitamin (MVI) with minerals daily, 2) 30 milliliters (ml) liquid protein daily, 3) house snacks three times daily (TID), and 4) mighty shake once daily with lunch meal and RD available as n… | 2020-09-01 |
| 2169 | 2169 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 622 | D | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to convey necessary information to ensure a safe and effective transition of care, to the receiving provider when the resident was transferred to the hospital. The facility failed to provide information regarding the reason for the transfer/discharge, medical information including, recent vital signs, any special instructions and/or precautions for ongoing care. This was true for one (1) of one (1) resident reviewed for the care area of death. Resident identifier: #55. Facility census: 56. Findings included: a) Resident #55 Review of the resident's electronic medical record began at 8:37 AM on 03/19/19. A nursing progress note dated 01/21/19 at 1:01 AM, noted: --Nonrebreather applied at 10 lmp (liters per minute) with some slight change in Spo2 (peripheral capillary oxygen saturation, an estimate of the amount of oxygen in the blood.) After 15-20 mins (minutes) Spo2 at 86. EMT (emergency medical technicians) arrived. Resident is going to (Name of Hospital). Family called again, no answer voice message left. (Name of Physician) called message left by this nurse. At 8:54 AM on 03/19/19, the medical records clerk, Employee #7, confirmed she was unable to find a complete transfer packet sent with the resident when transferred to the hospital on [DATE]. [NAME] #7, provided a copy of the facility's transfer form which contained no information. The form required competition of the following information: --Residents name, --Birth date, --admitted , --Transfer date, --Receiving provider discharge, --Reason for the transfer, --allergies [REDACTED].>--Contact information: Physician / Provider, --Representative information, --Advance directive information, and --Special instructions for ongoing care. E #7 provided a copy of a transfer check list noting the facility provided a copy of the resident's advance directives, physician's orders [REDACTED]. At 10:09 AM on 03/19/19, [NAME] #7 said she… | 2020-09-01 |
| 2170 | 2170 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 641 | E | 0 | 1 | 0UC011 | Based on record review and staff interview, the facility failed to ensure Residents' minimum data set (MDS) was accurate and complete. This was true for two (2) of six (6) residents reviewed for the care area of nutrition and one (1) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #35, #42, and #15. Facility census: 56. a) Resident #35 Review of the resident's medical record found the following weights: --12/02/18 122.2 pounds --12/19/18 112.4 pounds --12/26/18 110.2 pounds --01/02/19 112.6 pounds --01/30/19 112.6 pounds --02/05/19 112.4 pounds --02/18/19 112 pounds --03/01/19 110.6 pounds --03/18/19 108.8 pounds Review of the resident's completed and transmitted MDS's found the following MDS's completed in the above time frame: --A five day MDS with an assessment reference date (ARD) of 12/23/18, --A 14 day MDS with an ARD of 12/29/18, --A thirty day MDS with an ARD of 01/11/19, --A quarterly MDS with an ARD of 02/11/19. None of the above MDS's coded the resident as having any weight loss. The MDS defines a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. 03/20/19 10:43 AM, Registered Nurse, (RN) #75, the author of the MDS's, confirmed the MDS's with ARD's of 12/23/18, 12/29/18, 01/11/19, and 02/11/19 were incorrectly coded. RN #75 said she would submit corrected copies of the MDS's. b) Resident #42 Review of the resident's medical record found the following recorded weights: --01/02/19 160.4 pounds --02/05/19 151.6 pounds --02/06/19 147.2 pounds --02/13/19 150 pounds --02/20/19 145 pounds A quarterly, MDS, with an ARD of 02/22/19, found the MDS coded the resident as not having any weight loss. A weight loss is defined on the MDS as: Loss of 5% or more in the last month or loss of 10% or more in the last 6 months. On 03/19/19 at 10:00 AM, RN #75 confirmed the MDS with an ARD of 02/22/19, was incorrectly coded. RN #75 confirmed the resident had more than a 5% weight loss when the MDS was completed on 02/22/19. On 03/19/19 at 1:13 PM, the direct… | 2020-09-01 |
| 2171 | 2171 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 656 | E | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and/or implement comprehensive care plans for three (3) of nineteen (14) sample Residents (#53, #17 and #35) to address actual or potential care needs. Resident identifiers: #53, #17, and #35. Facility census: 56. Findings included: a) Resident #53 Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/29/18, Resident #53's [MEDICAL CONDITION] had deteriorated. On 11/29/18, the attending physician made a hospice referral request. On 12/03/18, Resident #53 was accepted in the Hospice program for [DIAGNOSES REDACTED]. Review of Resident #53's current comprehensive care plan, last revised on 12/04/18, identified Resident #53 as being in Hospice program but did not identify/reconcile her need for Hospice/end of life care, or any related goals or interventions for these treatments. On 03/20/19 at 9:39 a.m., interview with the Director of Nursing (DON). The current comprehensive care plan was reviewed and she verified the facility's care plan had not been reconciled with the Hospice care plan to address her needs for end of life care. b) Resident #17 A review of Resident #17's medical record at 12:45 p.m. on 03/19/19 found the following care plan focus statement: (First Name of Resident #17) is at nutritional/malnutrition risk related to [DIAGNOSES REDACTED]. This goal was initiated on 04/23/15 and revised on 05/01/18. The goal associated with this focus statement read as follows, (First name of Resident #17) will maintain adequate nutritional status as evidenced by no further unplanned signficant weight loss (5% in 30 days or 10%in 6 months), no sign or symptoms malnutrition through review date. This was initiated: 04/23/15 with a revision date of 10/10/17 with a target date 04/04/19. The interventions associated with this focus and goal statement included: Administer Supplements as ordered. This was initiated on 01/06/16 an revised on 03… | 2020-09-01 |
| 2172 | 2172 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 684 | D | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to monitor and provide ongoing clinical assessment during the final days of one (1) of one (1) resident reviewed for the care area of death. Resident identifier: #54. Facility census: 56. Findings included: a) Resident #54 Resident #54 was system selected for review of the care area of death. Review of the nursing notes found no indication the resident expired at the facility. The last nursing note written, prior to the Resident's death, was dated [DATE] at 4:21 PM, Family request for resident not be on BM (bowel movement) protocol. Further record review found a death certificate noting the resident died of natural causes on [DATE] at 2:30 PM. At 11:00 AM on [DATE], the director of nursing (DON) reviewed the Resident's medical record and confirmed there was no evidence the resident was assessed and provided comfort care as indicated on the Resident's POST (physician's orders [REDACTED]. The DON presented documentation the Resident's family was offered Hospice services on [DATE]. Hospice services were declined. The DON said the resident's family was at her bedside when she died . She said the family did not want vital signs to be obtained; however, the DON could not find evidence to substantiate her comments. The DON provided a nursing note, dated [DATE] at 3:28 AM, Patient repositioned in bed from her back to left side, patient responded with raising her eyebrows slightly upon position change. Patient has changing respiratory patterns at this time, Cheyney (typed as spelled) stokes, facial muscles remain relaxed as well as body posture. Patients upper and lower extremities warm to touch, no mottling noted at this time. Pupils approximately 2 MM and non reactive to light, however positive bite reflex intact when providing oral care. Education continues with family per EOL (end of life) care and dying process, active listening provided as well. Family voiced understanding and appea… | 2020-09-01 |
| 2173 | 2173 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 686 | E | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and record review, the facility failed to follow the professional standards of practice, regarding identifying, staging and monitoring of pressure ulcers. This was true for two (2) of two (2) reviewed for pressure ulcers. Resident identifiers: #10 and #44. Facility census 56. Findings included: a) Resident #10 During an observation on 03/19/19 at 11:29 AM, Licensed Practical Nurse (LPN) #55 was providing wound care to the right hip and right lateral proximal foot. It was pointed out to the nurse that there was a pressure ulcer above the one the was documented, that was not mentioned in the pressure ulcer assessment sheet. During a review of the Wound-Weekly Observation Tool revealed the following: --Effective Date:03/12/19 --Date acquired: 08/29/17 --Original Pressure Ulcer Stage: Suspected Deep Tissue Injury (SDTI) --Current: Stage at the highest level, Do Not stage down as the wound heals. --Staged at II During a review of the Wound-Weekly Observation Tool revealed the following: --Effective Date:09/26/18 --Date acquired: 08/29/17 --Original Pressure Ulcer Stage: Suspected Deep Tissue Injury (SDTI) --Current: Stage at the highest level, Do Not stage down as the wound heals. --Staged at IV It is unclear what the highest level this wound was staged do to the staff staging down. In accordance with the, National Pressure Ulcer Advisory Panel (NPUAP). States that the pressure ulcer is staged at its highest level but is never staged down until healed completely. In other words, it can increase the level of staging only. The NPUAP does recognize that federal regulations require long term care facilities to reverse stage at the present time; however, long term care facilities are encouraged to also document in the medical record appropriate healing using either descriptive characteristics of the wound (i.e., depth, width, presence of granulation tissue) or using a validated pressure ulcer healing tool. If a p… | 2020-09-01 |
| 2174 | 2174 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 692 | E | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, policy review and review of Centers for Medicare and Medicaid Services (CMS) State Operations Manual (SOM), the facility failed to four (4) out of six (6) residents reviewed for the care area of nutrition during the Long Term Care Survey, maintained acceptable parameters of nutritional status. Resident identifiers: #17, #24, #44, and #33. Facility census: 56. Findings included: a) Resident #17 A review of Resident #17's medical record at 8:38 a.m. on 03/19/19 found the following weights recorded within the last six (6) months: --03/01/19 - 149.0 pounds (lbs) --02/05/19 - 146.2 Lbs --01/02/19 - 156.4 Lbs --12/02/18 - 153.6 Lbs --11/03/18 - 154.8 Lbs --10/04/2018 - 153.4 Lbs Using the following formula (% of body weight loss = (usual weight - actual weight) / (usual weight) x 100) Resident #17's weight loss from 01/02/19 to 02/05/19 a 30 day time period was calculated and found Resident #17 lost 6.52 % of her body weight from 01/02/19 to 02/05/19. This is considered a severe weight loss for 30 days. Review of the Centers for Medicare and Medicaid (CMS) State Operations Manual (SOM) Appendix PP interpretive guidelines for F692 found the following regarding weight loss parameters for evaluating significance of unplanned and undesired weight loss are: --1 month - 5% = a significant weight loss while greater than 5% = a severe weight loss --3 months - 7.5% = a significant weight loss while greater than 7.5% = a severe weight loss --6 months - 10% = a significant weight loss while greater than 10% = a severe weight loss The following formula determines percentage of weight loss: --% of body weight loss = (usual weight - actual weight) / (usual weight) x 100. A review of Resident #17's meal percentages from 01/20/19 until current found several occasions where the facility failed to document the amount of the meal Resident #17 ate. The facility failed to document her meal percentages on the follo… | 2020-09-01 |
| 2175 | 2175 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 710 | E | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the attending physician supervises the resident's medical care. The facility failed to notify the physician of weight loss for four (4) of six (6) reviewed for nutrition. Resident identifiers: #44, #33, #24 and #17. Facility census: 56. Findings included: a) Resident #44 A review of Resident #44's medical record at 8:16 a.m. on 03/19/19 found the following weights recorded since admission on 02/09/19: --02/09/2019 - 132.0 pounds (lbs) --02/20/19- 123.8 lbs --02/27/19 - 122.4 lbs --03/01/19 at 8:46 am - 121.2 lbs and re-weight at 1:06 pm on 03/01/19- 122.2 lbs --03/08/19 - 119.0 lbs --03/13/19 - 114.4 lbs Using the following formula (% of body weight loss = (usual weight - actual weight) / (usual weight) x 100) Resident #44's weight loss for the last 30 days was calculated and found Resident #44 lost 17.6 Lbs. or 13.3 % of his body weight from 02/09/19 to 03/13/19. This is considered a severe weight loss for 30 days. Review of the Centers for Medicare and Medicaid (CMS) State Operations Manual (SOM) Appendix PP interpretive guidelines for F692 found the following regarding weight loss parameters for evaluating significance of unplanned and undesired weight loss are: --1 month - 5% = a significant weight loss while greater than 5% = a severe weight loss --3 months - 7.5% = a significant weight loss while greater than 7.5% = a severe weight loss --6 months - 10% = a significant weight loss while greater than 10% = a severe weight loss The following formula determines percentage of weight loss: --% of body weight loss = (usual weight - actual weight) / (usual weight) x 100. Nutritional assessment reviewed was completed on 02/19/19 by the registered dietician (RD). Recommendation: 1) Multivitamin (MVI) with minerals daily, 2) 30 milliliters (ml) liquid protein daily, 3) house snacks three times daily (TID), and 4) mighty shake once daily with lunch meal and RD availa… | 2020-09-01 |
| 2176 | 2176 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 726 | E | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, observations, and personnel file reviews the facility failed to ensure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. The facility did not ensure Employee #44 and #66 were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. For Resident #44 and #10 the nursing staff failed to provide care meeting the professional standards of practice when identifying, assessing and treating their pressure ulcers. For Resident #54 the facility failed to monitor and provide ongoing clinical assessment during the final days of her life. These practices have the potential to effect more than and isolated number of residents. Resident identifiers: #44, #10, and #54. Employee identifiers: #44 and #66. Facility census: 56. Findings included: a) Employee # 44 On [DATE] at 4:00 p.m. the competency check list for Employee #44 was requested. At 8:12 a.m. on [DATE] Registered Nurse (RN) #79 indicated that Employee #44, who had a hire date of [DATE], did not have a competency check list. b) Employee # 66 On [DATE] at 4:00 p.m. the competency check list for Employee #66 was requested. At 8:12 a.m. on [DATE] Registered Nurse (RN) #79 indicated that Employee #66, who had a hire date of [DATE], did not have a competency check list. c) F686 1. Resident #10 During an observation on [DATE] at 11:29 AM, Licensed Practical Nurse (LPN) #55 was providing wound care to the right hip and right lateral proximal foot. It was pointed out to the nurse that there was a pressure ulcer above the one the was documented, that was not mentioned in the pressure ulcer assessment sheet. During a review of the Wound-Weekly Observation Too… | 2020-09-01 |
| 2177 | 2177 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 730 | E | 0 | 1 | 0UC011 | Based on record review and staff interview, the facility failed to ensure Employee #42 had a performance evaluation completed at least every 12 months. This failed practice had the potential to effect more than an isolated number of residents. Employee identifier: #42. Facility census: 56. Findings included: a) Employee #42 On 03/19/19 at 4:00 p.m. the employee performance appraisal for the previous year for employee #42 was requested. At 8:12 a.m. on 03/20/19 Registered Nurse (RN) #79 indicated that Employee #42, who had a hire date of 06/24/15, did not have an employee performance evaluation completed within the last 12 months. | 2020-09-01 |
| 2178 | 2178 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 744 | D | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure a resident with dementia, received non-pharmacological, person-centered, approaches to care. The resident's antipsychotic medication was not reduced in a timely manner. In addition, the Resident's antipyschotic medication was increased in the absence of behaviors. Resident identifier: #14. Facility census: 56. Findings included: a) Resident #14 Medical record review found the resident had been receiving the antipsychotic medication, [MEDICATION NAME] since (YEAR). Review of the Medication Administration Record [REDACTED]. On 06/12/18, the pharmacist advised the physician the resident's antipsychotic medication was due for evaluation. The resident was receiving [MEDICATION NAME] 25 mg. two times a day and [MEDICATION NAME] 50 mg. at bedtime. The physician signed the recommendation form and agreed to a gradual dose reduction (GDR) on 06/28/18. Review of the MAR found the order to reduce [MEDICATION NAME] was not written until 08/23/18. [MEDICATION NAME] was reduced from to 25 mg. two (2) times a day, to [MEDICATION NAME] 25 mg. daily. The resident continued receiving [MEDICATION NAME] 50 mg. at bedtime. On 10/02/18, the physician increased the [MEDICATION NAME] from 25 mg. daily to 25 mg's two (2) times a day. [MEDICATION NAME] remained at 50 mg's at bedtime. On 03/20/19 at 12:59 PM, the director of nursing (DON) said she was unable to find any documented behaviors or reasons for the increase of [MEDICATION NAME] on 10/02/18. In addition, the DON verified the GDR of [MEDICATION NAME], approved by the physician on 06/28/19 should have been initiated within 30 days. The DON confirmed she was unable to find any evidence of documented behaviors since at least (MONTH) (YEAR). The DON said staff document by exception if the resident exhibits any behaviors. The DON was asked, what are the targeted behaviors you hope to improve with the use of [MEDICATION NAME]. The… | 2020-09-01 |
| 2179 | 2179 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 756 | D | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a pharmacist recommendation, approved by the physician, was carried out by facility staff in a timely manner. For Resident #14 a timely gradual dose reduction of an antipsychotic medication was not timely. For Residents #15 and #33, the facility failed to obtain laboratory values as ordered. This was true for three (3) of fourteen (14) records reviewed. Resident identifiers: #14, #15, and #33. Facility census: 65. Findings included: a) Resident #14 On 06/12/18, the pharmacist advised the physician the resident's antipsychotic medication was due for evaluation. The resident was receiving [MEDICATION NAME] 25 mg. two times a day and [MEDICATION NAME] 50 mg. at bedtime. The physician signed the recommendation form and agreed to a gradual dose reduction (GDR) on 06/28/18. Review of the MAR found the order to reduce [MEDICATION NAME] was not written until 08/23/18. [MEDICATION NAME] was reduced from to 25 mg. two (2) times a day, to [MEDICATION NAME] 25 mg. daily. The resident continued receiving [MEDICATION NAME] 50 mg. at bedtime. On 03/20/19 at 12:59 PM, the director of nursing (DON), verified the GDR of [MEDICATION NAME], approved by the physician on 06/28/19 should have been initiated within 30 days. b) Resident #15 A review of Resident #15's medical record at 9:37 a.m. on 03/19/19 found a Physician Recommendation Form completed by the Consultant Pharmacist completed on 10/23/18. This recommendation read as follows: (First and Last Name of Resident #15 ) is taking [MEDICATION NAME] BID (Twice a day) 800- 2000 Please consider the followng: 1. Give [MEDICATION NAME] with Meals to help reduce adverse effects and is more effective. 2. Please obtain an annual B-12 level as [MEDICATION NAME] depletes Vitamin B-12. The physcian accepted this recommendation 11/15/18. Further reveiw of the medical record found no B- 12 level results. An interview with Registered Nurse (RN) #76 a… | 2020-09-01 |
| 2180 | 2180 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 758 | D | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of five (5) residents reviewed for unnecessary medications received a timely gradual dose reduction. In addition, the Resident's antipsychotic medication was increased in the absence of behaviors and in the absence of non-pharmacological interventions. Resident identifier: #14. Facility census: 56. Findings included: a) Resident #14 Medical record review found the resident had been receiving the antipsychotic medication, [MEDICATION NAME] since (YEAR). Review of the Medication Administration Record [REDACTED]. On 06/12/18, the pharmacist advised the physician the resident's antipsychotic medication was due for evaluation. The resident was receiving [MEDICATION NAME] 25 mg. two times a day and [MEDICATION NAME] 50 mg. at bedtime. The physician signed the recommendation form and agreed to a gradual dose reduction (GDR) on 06/28/18. Review of the MAR found the order to reduce [MEDICATION NAME] was not written until 08/23/18. [MEDICATION NAME] was reduced from to 25 mg. two (2) times a day, to [MEDICATION NAME] 25 mg. daily. The resident continued receiving [MEDICATION NAME] 50 mg. at bedtime. On 10/02/18, the physician increased the [MEDICATION NAME] from 25 mg. daily to 25 mg's two times a day. [MEDICATION NAME] remained at 50 mg's at bedtime. On 03/20/19 at 12:59 PM, the director of nursing (DON) said she was unable to find any documentation of any behaviors or reasons for the increase of [MEDICATION NAME] on 10/02/18. In addition, the DON verified the GDR of [MEDICATION NAME], approved by the physician on 06/28/19 should have been initiated within 30 days. The DON confirmed she was unable to find any evidence of behaviors since at least August, (YEAR). The DON was asked, what are the targeted behaviors you hope to improve with the use of [MEDICATION NAME]. The DON said that was why she was trying to do dose reductions and eventually discontinue the [MEDICATION N… | 2020-09-01 |
| 2181 | 2181 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 770 | D | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide and/or obtain laboratory services to meet the needs of its residents. This had the potential to affect a limited number of residents requiring laboratory services. Resident identifiers: #33 and #15. Facility census: 56. Findings include: a) Resident #33 Review of Resident #33's medical records found a consultant pharmacist recommendation dated 05/15/18. This recommendation read: This resident is currently receiving a statin medication for the treatment of [REDACTED]. The last (AST/ALT) was done 02/23/17. Please evaluate and consider ordering this lab if you feel it necessary. On 06/07/18, the attending physician agreed and approved this order. No labs for the liver function tests and lipid panel could be found in the medical records. Interview on 03/20/19 at 1:10 pm with the DON, she confirmed these above labs had not been obtained. b) Resident #15 A review of Resident #15's medical record at 9:37 a.m. on 03/19/19 found a Physician Recommendation Form completed by the Consultant Pharmacist completed on 10/23/18. This recommendation read as follows: (First and Last Name of Resident #15 ) is taking [MEDICATION NAME] BID (Twice a day) 800- 2000 Please consider the followng: 1. Give [MEDICATION NAME] with Meals to help reduce adverse effects and is more effective. 2. Please obtain an annual B-12 level as [MEDICATION NAME] depletes Vitamin B-12. The physcian accepted this recommendation 11/15/18. A Further reveiw of the medical record found no B- 12 level results. An interview with Registered Nurse (RN) #76 at 1:19 p.m. on 03/19/19 confirmed the facility did not obtain the B-12 level as directed by the pharmacy recommendation which was accepted by the physcian on 11/15/18. | 2020-09-01 |
| 2182 | 2182 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 773 | D | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to obtain Resident #11's labs only when ordered by a physician. The facility obtained a Basic Metabolic Panel (BMP) laboratory test on 12/17/19 when there was no physician's order to obtain the BMP. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #11. Facility Facility census: 56. Findings included: a) Resident #11 A review of Resident #11's medical record at 8:33 a.m. on 03/20/19 found lab results for a BMP that was obtained on 12/17/18. Further review of the record found no physician order for [REDACTED]. An interview with the Director of Nursing (DON) at 1:03 p.m. on 03/20/19 confirmed there was no physician order for [REDACTED]. | 2020-09-01 |
| 2183 | 2183 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 804 | E | 0 | 1 | 0UC011 | Based on observation and staff interview, the facility failed to maintain proper food temperature that is palatable, attractive, and at a safe. This was a random opportunity for discovery. Facility census: 56. Findings included: During an observation of breakfast on 03/20/19 at 8:38 AM, the trays were on the floor already at this time. The staff started passing out trays at 8:45 AM. A resident told the Nurse Aide (NA) #65 that her food was cold, and she took it to reheat it. The last tray was being delivered at 8:52 AM. NA#65 was asked to ask for a replacement tray for that resident and get the kitchen staff to take the temperature of the food on that tray. On 03/20/19 at 9:03 AM, Kitchen Cook #14 arrived to verify the temperature of the food. The pancake was 70 degrees and the link sausage were also 70 degrees. He agrees that the temperature was too low. On 03/20/19 at 10:23 AM, Kitchen Manager #2 was informed of the temperature of the food and that there were complaints about the food being too cold. She had no comment. | 2020-09-01 |
| 2184 | 2184 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 842 | D | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure one (1) of fourteen (14) residents reviewed had an accurate medical record. Resident #35 had an indwelling Foley catheter with physician's orders [REDACTED]. Resident identifier: #35. Facility census: 56. Findings included: a) Resident #35 Observation of the resident on 03/18/19 at 1:53 PM, found she had a indwelling Foley catheter. On 10/10/18, an order was written by the physician to straight cath (catheterize) the resident x 1 every shift, as needed for [MEDICAL CONDITION]. Record review found a physician's orders [REDACTED]. Both of the above orders were transcribed to the (MONTH) 2019, Treatment Administration Record (TAR). On 03/20/19 at 8:56 AM, the Director of Nursing confirmed the order to straight cath should be removed from the resident's orders as the resident has an indwelling Foley catheter in place. | 2020-09-01 |
| 2185 | 2185 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 849 | E | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure Resident #53 receiving Hospice services care was collaborate with Hospice to provide care for this resident receiving end of life care. This deficient practice affected one (1) of one (1) resident reviewed for Hospice. Resident identifier: #53. Facility census: 56. Findings included: a) Resident #53 Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/29/18, Resident #53's [MEDICAL CONDITION] had deteriorated. On 11/29/18, the attending physician made a hospice referral request. On 12/03/18, Resident #53 was accepted in the Hospice program for [DIAGNOSES REDACTED]. Review of Resident #53's current comprehensive care plan, last revised on 12/04/18, identified Resident #53 as being in Hospice program but did not identify/reconcile her need for Hospice/end of life care, or any related goals or interventions for these treatments. On 03/20/19 at 9:39 a.m., interview with the Director of Nursing (DON). The current comprehensive care plan was reviewed and she verified the facility's care plan had not been reconciled with the Hospice care plan to address her needs for end of life care. | 2020-09-01 |
| 2186 | 2186 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 880 | F | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and observation, 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 was discovered during observation of wound care, observation of kitchen staff, observation of the laundry rooms, and while reviewing the antibiotic stewardship program. Facility census: 56. Findings included: a) Resident #10 During an observation and staff interview on 03/19/19 at 11:29 AM, Licensed Practical Nurse (LPN)#55 removed a spray bottle of wound cleanser from the wound treatment cart, she placed it on the over the bed table. With gloved hands she removed the bandage and the wet soiled [MEDICATION NAME] from Resident #10's right hip, then used the spray bottle of wound cleanser with the same pair of gloves on, she continued the use the spray bottle over and over. After she completed the wound care, she carried the bottle of wound cleanser to the sink with her soiled removed glove. She washed her hands then picked up the bottle of wound cleanser and dropped it into the in the drawer of the treatment cart with other clean unused wound care supplies to be used on any resident. LPN # 55 was asked if she uses that wound cleanser on any other residents? She said no. She was asked if the supplies that was in the drawer with that spray bottle was only to be use for this resident and she said no. She was asked if she thought it was an infection control breech if this bottle of spray wound cleanser in with other wound care supplies to be used on other residents and she said well I guess I should have put it in a plastic bag with her name on it. b) Dining observation During an observation of kitchen staff on 03/18/19 at 11:38 AM, Dishwasher #5 did not have a hair net covering his beard. He was asked about not have the hair net on and he sa… | 2020-09-01 |
| 2187 | 2187 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 881 | F | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review the facility failed to establish an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This was true for any and all residents that was treated with an antibiotic. Facility census: 56. Findings included: During an interview on 03/20/19 at 12:50 PM, Infection Control Nurse (ICN) # 77 was asked for the line listing and if she used the Mcgeers or the Lobes for checking to ensure the resident receiving an antibiotic met the criteria. She stated at this time she knew they were not doing it right (the Antibiotic Stewardship criteria) to receive antibiotics. She said, that the nurses are not doing it right and the doctor does what he wants to. She stated that they (the facility) were aware that they were not doing the Antibiotic Stewardship correctly and are working on fixing the problem. She said that the new forms were given to the nurses to start using this week. She said, that she had not explained the new process to the Physician. During an interview on 03/20/19 at 1:30 PM, ICN#77 agreed that without being able to provide evidence of any monitoring of resident being treated for [REDACTED]. | 2020-09-01 |
| 2188 | 2188 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2019-03-20 | 883 | E | 0 | 1 | 0UC011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide accurate education before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization, so that the resident or resident representative can make an informed decision. This was true for five (5) of five (5) Residents that were reviewed of pneumococcal immunizations. Identified Resident #37, #43, #42, #35 and #10. Facility census 56. Findings included: During an interview on 03/20/19 at 7:37 AM, Registered Nurse #77(the infection control nurse), she was asked about the five residents that are being reviewed for pneumococcal immunizations and why there was no education sheets provided for the pneumococcal immunization. She said that she cannot find anything because that was before she was doing infection control. During a brief interview on 03/20/19 at 9 AM, RN#77 an education sheet for the pneumococcal immunization that was dated 2001, it did not contain any education from the Center of Disease Control (CDC) recommendations for the Pneumococcal Conjugate (PCV13) or Pneumococcal [MEDICATION NAME] (PPSV23). RN #77 was asked if she knew that this was the not an updated version for the pneumococcal. She did not answer. During an interview on 03/20/19 at 9:30 AM, Admissions #16 was asked for the information she provides to new admitted residents. She had a print out with the PPSV23, but she was unaware of the PCV13. She was asked if she asked for information about what type of pneumococcal immunizations they received prior to admission. She said that she just asks them if they had received one within the last five (5) years. Review of records revealed that in the last year all but two (2) residents were marked as declining the pneumococcal immunization. All the Residents that were admitted were not given current/relative information on the recommendation of recei… | 2020-09-01 |
| 2760 | 2760 | WEBSTER NURSING AND REHABILITATION CENTER | 515165 | 411 ERBACON ROAD | COWEN | WV | 26206 | 2019-03-20 | 580 | D | 0 | 1 | T7D211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the physician when a resident experienced a change in condition. A resident was newly assessed with [REDACTED]. The physician was not notified timely of the change in condition. This was evident for one (1) of fifteen (15) sampled residents. Resident identifier: #13. Facility census: 59. Findings include: a) Resident #13 Review of the medical record on 03/19/19 found this resident was assessed with [REDACTED]. Review of section S of the most recent minimum data sets (MDS's) found the following assessments of joint contractures: * The quarterly MDS with assessment reference date (ARD) 07/02/19 assessed this resident as having no contractures. * The quarterly MDS with ARD 10/01/19 assessed this resident as having no contractures. * The quarterly MDS with ARD 12/26/19 assessed this resident as having a contracture of the right hand, contracture of the right elbow, and contracture of the right ankle. Review of the medical record found it was silent for notifying the physician of the development of the these contractures, or for requesting new or different treatment modalities. An interview was conducted with occupational therapy assistant #70 (OTA #70) on 03/19/19 at 12:40 PM. After first reviewing therapy notes, she said this resident had no occupational therapy (OT) or physical therapy (PT) in (YEAR). She said PT evaluated her on 03/04/19 because she was wanting to use her feet to propel. She said PT is now working with her on that issue, as well as working with her on bed mobility. Upon inquiry as to whether the therapy department received a referral following the 12/26/18 MDS assessment related to her contractures, she replied in the negative. She said the physician ordered a therapy evaluation on 03/04/19. She added that OT would most likely begin working with her when PT finishes services. Review of the medical record found physician's orders [REDACTED]. * PT … | 2020-09-01 |
| 2994 | 2994 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2019-03-20 | 550 | D | 0 | 1 | MPGI11 | Based on observation and staff interview, the facility failed to treat Resident #23 with dignity and respect. Facility had incorrect spelling of Resident #23's name on door name plate. This was true for one (1) of 61 residents. Resident identifier: #23. Facility census: 61. Findings included: a) Resident #23 During the initial tour on 03/18/19 at 10:30 AM , it was observed a name plate on Resident #23's door. The last name on the name plate was not correct spelling of Resident #23's last name. Interviewed Nurse Aide (NA) #44 on 03/19/19 at 8:37 AM. NA #44 confirmed the last name on name plate was not correct and someone must have misspelled last name when making the name plate. Interviewed the Administrator #16 on 03/19/19 at 8:50 AM. Administrator #16 stated that when Resident #23 got a new roommate a new name plate was made and name was misspelled. | 2020-09-01 |
| 2995 | 2995 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2019-03-20 | 558 | D | 0 | 1 | MPGI11 | Based on observation, staff interview, resident interview, record review and policy and procedure review, the facility failed to ensure call lights were within reach and/or accessible for 3 of 61 residents reviewed. Resident identifiers: R#49, R#110, R#23. Facility census: 61. Findings included: a) R#49 An observation on 03/18/19, at 11:33 AM, revealed R#49 was requesting assistance, by calling out for help, because she was unable to locate the call light. Interview with Nurse Aide (NA) #36, on 03/18/19, verified the call light was out of the reach of R#49. b) R#110 An observation, on 03/19/19, at 01:05 PM, noted R#110, unable to locate/reach the call light for assistance. An interview, on 03/19/19, at 1:05 PM with RN#58, verified R#110's call light was near the side rail on the left side of the resident and the resident was unable to reach it. Review of the baseline care plan, on 03/19/19, revealed a problem for R#110 being dependent for activity of daily living care with an intervention for R#110 to have the call light on the right side of the bed due to weakness on left side. A review of the policy and procedure NSG101 Call lights, revised 10/01/12, noted patients will have a call light or alternative communication device within their reach at all times when unattended. c) Resident #23 During an interview with Resident #23, on 03/18/19 10:35 AM, it was observed that the call light was out of reach and not accessible to Resident #23. The call light was attached to the intercom on the wall not assessable to Resident #23 who was laying in bed. On 03/18/19 at 10:38 AM, interviewed Activity Assistant (AA) #50 regarding position of call light. AA #50 stated housekeeping must have been in and moved it up when room was cleaned. AA #50 moved call light to Resident #50's lap and confirmed call light was supposed to be assessable. | 2020-09-01 |
| 2996 | 2996 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2019-03-20 | 623 | D | 0 | 1 | MPGI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide a Notice of Transfer to the State Long Term Care Ombudsman (SLTCO). This was discovered for one (1) of two (2) residents reviewed for hospitalization s during the Investigation phase of the survey process. Resident #5 was discharged [DATE] and 03/08/19 to an acute care hospital with with no notification of transfers sent to the SLTCO. Resident identifier: #5. Facility census: 61. Findings included: a) Resident #5 A medical record review on 03/20/19 revealed the Minimum Data Sets (MDS) for 12/16/18 and 03/08/19 had Resident #5 (R5) discharged to an acute care hospital on these dates. Further review of the medical record indicated the SLTCO had not received notifications of transfer for hospitalization s for R5 on 12/16/18 and 03/08/19. During an interview with E33 Social Service Director (SSD) on 03/20/19 at 9:45 AM verified she had not sent the notification of transfers for hospital discharges on 12/16/18 and 03/08/to the OMB for the discharge/transfer on 12/16/18 and 03/08/19 for R5. | 2020-09-01 |
| 2997 | 2997 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2019-03-20 | 625 | D | 0 | 1 | MPGI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide the resident/resident representative with the written Bed Hold Policy upon discharge to the hospital. This was true for one (1) of two (2) residents reviewed for hospital discharges during the Investigation phase of the survey process. Resident identifier: #5. Facility census: 61. Findings included: a) Resident #5 A medical record review on 03/20/19 revealed the Minimum Data Sets (MDS) completed on 12/16/18 for a discharge to an acute care hospital for Resident #5 (R5). Further review of the medical record indicated the resident/resident representative had not received the written Bed Hold Policy for the discharge on 12/16/18. In an interview with E27 the Business Office Manager on 03/20/19 at 9:46 AM verified she had not provided the resident/resident representative with the written Bed Hold Policy for the discharge to hospital on [DATE] for R5. | 2020-09-01 |
| 2998 | 2998 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2019-03-20 | 636 | D | 0 | 1 | MPGI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete an accurate comprehensive Minimum Data Set (MDS) for Resident #50. This was true for one (1) of twenty-one (21) resident's MDSs reviewed during the Investigation phase of the survey process. The MDS for Resident #50 did not include the [DIAGNOSES REDACTED]. Resident identifier: #50 Facility census: 61. Findings included: a) Resident #50 A review on 03/20/19 of the quarterly MDS with the annual review date (ARD) of 03/06/19 for Resident #50 (R50), revealed Section I: Medical [DIAGNOSES REDACTED]. In an interview on 03/19/19 at 4:25 PM with E34, Clinical Resource Coordinator (CRC ) verified she had not included the [DIAGNOSES REDACTED]. | 2020-09-01 |
| 2999 | 2999 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2019-03-20 | 655 | D | 0 | 1 | MPGI11 | Based on observation, resident interview, staff interview and record review, the facility failed to implement a baseline care plan for 1 of 5 residents reviewed with baseline care plans. Resident identifier: #110. Facility census: #61. Findings included: a.) Resident #110 An observation, on 03/19/19, at 01:05 PM, noted Resident #110 (R110), unable to locate/reach the call light for assistance. An interview, on 03/19/19, at 1:05 PM with RN#58, verified R110's call light was near the side rail on the left side of the resident and the resident was unable to reach it. Review of the baseline care plan, on 03/19/19, revealed a problem for R110 dependent for activity of daily living care with an intervention for R110 to have the call light on the right side of the bed due to weakness on left side. | 2020-09-01 |
| 3000 | 3000 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2019-03-20 | 656 | D | 0 | 1 | MPGI11 | Based on resident interview, medical record review and staff interview, the facility failed to develop a person-centered comprehensive care plan indicating Resident # 7's hearing impairment and the use of a hearing aid. This was true for one (1) of 21 residents. Resident identifier: #7. Facility census: 61. Findings included: a) Resident #7 Interviewed Resident #7 on 03/18/19 at 12:52 PM. Resident #7 stated the facility lost hearing aid for the third time and it had now been missing for about 6 months. Interviewed Social Worker (SW) #33 on 03/19/19 at 3:41 PM. SW #33 stated the facility had replaced Resident # 7's hearing aid multiple times. SW provided a completed missing report of the missing left hearing aid dated 02/16/19. Report revealed the facility could not find the hearing aid and facility would replace. Hearing aid was approved for purchase on 3/19/19. SW provided an invoice dated for 3/3/18 in the amount of $450.00 where facility had replaced left hearing aid in the past. Reviewed medical record, on 03/19/19 at 4:40 PM, the care plan revealed no hearing loss impairment or hearing aid addressed on plan. Interviewed Director of Nursing (DoN) on 03/20/19 at 8:07 AM. DoN looked over the care plan and confirmed hearing impairment and hearing aid are not currently addressed on the care plan. DoN confirmed hearing impairment should be addressed on care plan. | 2020-09-01 |
| 3001 | 3001 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2019-03-20 | 657 | D | 0 | 1 | MPGI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family interview and staff interview, the facility failed to the invite residents and/or the residents' representatives to the care plan meetings. In addition, the Interdisciplinary Team (IDT) failed to update the discharge planning section of a care plan for a resident with dementia. This was found for two (2) of 21 residents reviewed during the annual survey. Resident identifiers: #55 and #14. Facility census: 61. Findings included: a) Resident #55 (R55) 1. Invitation to care plan meeting During an interview on 03/18/19 11:14 AM, R55's wife/Medical Power of Attorney (MPOA) reported her husband has lived at the facility for almost a year and requires total care. When asked if she participated or attended his care plan meetings, she stated I don't know what that is. I have never been invited to a meeting about his care. Review of the medical record on 03/19/19, revealed no information R55 and or his MPOA were ever invited to a care plan conference with the IDT. After review of her records/files, Social Worker (SW) #33, confirmed R55 and his wife/MPOA were never invited to a care plan meeting since admission on 04/20/18. 2. Care plan update Review of R55's medical record on 03/19/19, revealed he was admitted in (MONTH) (YEAR), with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment with an assessment reference date of 03/08/19, notes R55 has a Brief Interview of Mental Status (BIMS) of 1 (indicating severe impairment), and requires total to extensive assistance with all activities of daily living except eating. The care plan with a review date of 03/13/19, lists the following focus initiated 05/02/18 and revised 05/15/18 (typed as written): (Name) has potential for discharge, or is expected to be discharged , related to: Resident's desire to discharge to community and his admission is for a skilled short-term stay. The goal is: (Name) will have an ongoing discharge plan that provides for a safe and ef… | 2020-09-01 |
| 3002 | 3002 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2019-03-20 | 684 | D | 0 | 1 | MPGI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and staff interview, the facility failed to obtain a physician's order before administering oxygen to Resident #10. This is true for one (1) of three (3) residents. Resident identifier: #10. Facility census: 61. Findings included: a) Resident #10 Interviewed Resident #10 on 03/18/19 at 1:16 PM. It was observed that Resident #10 was receiving oxygen through nasal cannula at 3 liters per minute. Medical record reviewed on 03/19/19 at 12:16 PM revealed no current physician order for [REDACTED].>Interviewed Registered Nurse (RN) #20 on 03/19/19 at 12:48 PM regarding oxygen used on Resident #10 and current physician orders. RN #20 confirmed there was no order for oxygen and confirmed that physician orders should have been received prior to oxygen administration to Resident #10. Reviewed the facility oxygen policy on 03/19/19 at 1:04 PM. Evidence revealed the first step to the oxygen policy was to verify order Interviewed Director of Nursing (DoN) on 03/20/19 at 8:07 AM. DoN reviewed the care plan and confirmed oxygen was not addressed on the care plan. DoN stated that oxygen was never ordered so oxygen would not be on the care plan without an order. | 2020-09-01 |
| 3003 | 3003 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2019-03-20 | 695 | D | 0 | 1 | MPGI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and staff interview the facility failed to provide respiratory care and services that was in accordance with professional standards. The facility did not obtain an order for [REDACTED]. Resident identifier: #10. Facility census: 61. Findings included: a) Resident #10 Interviewed Resident #10 on 03/18/19 at 1:16 PM. It was observed that Resident #10 was receiving oxygen through nasal cannula at 3 liters per minute. Medical record reviewed on 03/19/19 at 12:16 PM revealed no current respiratory order for oxygen. Evidence revealed no respiratory order that addressed oxygen delivery method, flow rates or when to administer or discontinue oxygen. Interviewed Registered Nurse (RN) #20 on 03/19/19 at 12:48 PM regarding oxygen used on Resident #10 and respiratory order. RN #20 confirmed there was no respiratory order for oxygen and confirmed that an order should have been received prior to oxygen administration to Resident #10. Reviewed the facility oxygen policy on 03/19/19 at 1:04 PM. Evidence revealed the first step to the oxygen policy was to verify order Interviewed Director of Nursing (DoN) on 03/20/19 at 8:07 AM. DoN reviewed the care plan and confirmed oxygen was not addressed on the care plan. DoN stated that oxygen was never ordered so oxygen would not be on the care plan without an order. | 2020-09-01 |
| 3004 | 3004 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2019-03-20 | 730 | F | 0 | 1 | MPGI11 | Based on review of facility personnel files, staff interview and policy and procedure review, the facility failed to ensure annual performance evaluations were completed for 5 of 5 nurse aides reviewed. Staff identifiers: NA #19, NA#30, NA#48, NA#60 and NA#44. Facility census: 61. Findings included: a) Review of personnel files A review of the personnel file information for NA#19, noted an annual performance evaluation due (MONTH) (YEAR), but there was no performance evaluation to review. A review of the personnel file information for NA#30, noted an annual performance evaluation due (MONTH) (YEAR), but there was no performance evaluation to review. A review of the personnel file information for NA#48, noted an annual performance evaluation due (MONTH) (YEAR), but there was no performance evaluation to review. A review of the personnel file information for NA#60, noted an annual performance evaluation due (MONTH) (YEAR), but there was no performance evaluation to review. A review of the personnel file information for NA#44, noted an annual performance evaluation due (MONTH) (YEAR), but there was no performance evaluation to review. b) Interview An interview, on 03/19/19, at 1:54 PM and 2:05 PM, with the Administrator, revealed performance evaluations for NA#,19, NA#30, NA#48, NA#60, and NA#44, had not been completed annually as required. c) Review of policy and procedure A review of the policy and procedure, revision date,11/28/16, HR616 Performance Appraisal Program: Employee noted , Managers will meet with their regular full-time, and regular casual employees at least annually to conduct a performance appraisal. | 2020-09-01 |
| 3005 | 3005 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2019-03-20 | 744 | D | 0 | 1 | MPGI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the interdisciplinary team (IDT) failed to develop and implement a person-centered care plan with individualized interventions for a resident with dementia. This was found for One (1) of four (4) residents reviewed for dementia. Resident identifier: #55. Facility census: 61. Findings included: a) Resident (R) #55 Review of medical record on 03/19/19, revealed R #55 was admitted to the facility in (MONTH) (YEAR), with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment with an assessment reference date of 03/08/19, notes R #55 has a Brief Interview of Mental Status (BIMS) of 1 (indicating severe impairment). Section [NAME] notes an overall presence of behaviors putting R #55 at risk for injury and interfering with his care. The assessment note dated 03/18/19 states (Typed as written): Assessment Note: Since the last evaluation behavior symptoms have increased. Aggressive behaviors; hitting and choking staff while attempting ADL care . Reason for medication initiation/increase: non-pharmacological intervention(s) being ineffective .Redirection hard at times . The current care plan with a revision date of 03/13/19, identifies a focus of physical behaviors related to cognitive loss/dementia. Interventions include (Typed as written): Monitor for conditions that could contribute to aggressive behaviors. Attempt non-pharmacological interventions to alleviate pain .Notify physician of uncontrolled behaviors that are not helped with interventions. and Provide all effective interventions (e.g., non-pharmacological, pharmacological) for behaviors. Document behaviors and interventions. Notify physician of all alternatives used. **The care plan lacks individualized, non-pharmacological approaches/interventions related to R #55's symptomology, including meaningful activities related to his customary routines, interests, preferences and choices to enhance his well-being. During an interview on 03… | 2020-09-01 |
| 3006 | 3006 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2019-03-20 | 761 | E | 0 | 1 | MPGI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide separately locked, permanently affixed compartments for the storage of a controlled medication that falls under the US Drug Enforcement Agency (DEA) Schedules II-V, has a potential for abuse and may lead to physical or psychological dependence. A multi dose bottle of liquid [MEDICATION NAME] (also known as [MEDICATION NAME] and used for anxiety) a Schedule IV drug was found unsecured in the medication room refrigerator. This was found in one (1) of one (1) medication rooms and has the potential to affect more than a limited number of residents residing in the facility. Facility census: 61. Findings included: a) An observation of the medication room refrigerator on 03/20/19 at 2:00 PM, with Licensed Practical Nurse (LPN) #37 revealed a 30 milliliter (ml) bottle of liquid [MEDICATION NAME] two (2) milligrams (mg)/ml in the bottom drawer, unlocked and unsecured. LPN #37 reported the refrigerator was just purchased to store this medication for Resident #47 and confirmed the [MEDICATION NAME] was not stored in a permanently affixed compartment inside the refrigerator. During an interview at 2:02 PM on 03/20/19, the DON reported the pharmacist checks the controlled medications with her monthly and never identified this concern. At 2:25 PM, the DON reported the pharmacist is providing a locked box for the refrigerator. | 2020-09-01 |
| 3007 | 3007 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2019-03-20 | 812 | E | 0 | 1 | MPGI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to store food in a safe and sanitary manner. During the initial kitchen and food storage tour, items were found to be expired and were not pulled for non-use. A lid did not provide appropriate seal on a container of cheese according to professional standards. This had the potential to affect more than limited number of residents. Facility Census: 61. Findings included: a) Kitchen During the kitchen and food storage tour with the District Manager (DM) #91 on [DATE] at 10:10 AM items were found to be expired. A plastic container of white shredded cheese with an expiration date of [DATE] was discovered on shelf and had not been discarded by expiration date. Two (2) pre-filled bottles of Ranch dressing with an expiration date of [DATE] was discovered on shelf and had not been discarded by expiration date. DM #91 confirmed the items were expired during the tour. Additionally, a container of orange square cheese had a lid that would not seal properly and continued to pop off container when DM #91 attempted to close the container. DM #91 confirmed that container of cheese was not properly sealed and stated the lid was probably distorted due to the high heat of the dish washer. | 2020-09-01 |
| 3008 | 3008 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2019-03-20 | 842 | D | 0 | 1 | MPGI11 | Based on medical record review and staff interview, the facility failed to accurately represent a true oxygen administration experience of Resident #10. Resident #10's medical record, regarding oxygen administration, revealed Resident #10 recieved oxygen five (5) times when no oxygen was recieved. This was true for one (1) of 21 residents. Resident identifier: #10. Facility census: 61. Findings included: a) Resident #10 Reviewed medical record on 03/19/19 at 12:16 PM. Oxygen levels were reviewed and revealed Resident #10 received oxygen through a nasal cannula on 01/03/19, 01/14/19, 01/28/19, 01/30/19, 01/31/19 Interviewed Director of Nursing (DoN) on 03/20/19 at 8:07 AM. DoN reviewed the oxygen levels documented in Resident #10 medical record. DoN confirmed that no orders were present for oxygen and Resident #10 did not receive oxygen in (MONTH) 2019. DoN stated any oxygen level stating Resident #10 received oxygen with a nasal cannula was incorrect and documented in the medical record wrong by the nurse. | 2020-09-01 |
| 3009 | 3009 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2019-03-20 | 921 | D | 0 | 1 | MPGI11 | Based on observation, resident and staff interview, the facility failed to ensure the resident's environment was functional and in good repair for 2 of 19 sampled residents. Resident identifiers: #49 and #110. Facility census: 61. Findings included: a.) Observation of Resident #49's (R49) room, noted the bathroom faucet to be running in a steady stream, unable to be turned off. b.) Observation of R110's room, on 03/18/19, at 12:01 PM and 03/19/19, at 11:47 AM, noted the left side window pane was cloudy. An interview with R49, on 03/18/19, at 12:01 PM revealed difficulty for the resident to see out the window. c.) An interview, on 03/19/19, at 1:47 AM, with the Maintenance Supervisor, verified the faucet in R49's room could not be turned off and had to be replaced. Additionally, it was verified at this time, R110'S window would have to be replaced because of the seal being broken causing the window to fog up. | 2020-09-01 |
Advanced export
JSON shape: default, array, newline-delimited
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 );