cms_WV
Data source: Big Local News · About: big-local-datasette
42 rows where "inspection_date" is on date 2019-07-02
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Suggested facets: facility_name, facility_id, address, city, zip, scope_severity, complaint, standard, 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 841 | 841 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 550 | E | 0 | 1 | LUON11 | Based on observation and staff interview, the facility failed to provide a dignified dining experience for Resident #103, Resident #79, Resident #41, Resident #11, Resident #21, Resident #64, and Resident #211 during the noon time meal in the Maple Dining Room on 06/24/19. Also for Resident #94 the facility failed to provide dignity during wound care. These were both random opportunities for discovery during the Long Term Care Survey at the facility. Resident identifiers: #103, #79, #41, #11, #21, #64, #211, and #94. Facility census: 117. Findings included: a) Maple Dining Room Observations of the noontime meal in the Maple Dining Room began on 06/2419 at 12:45 a.m When the observations began Resident #1, Resident #15, Resident #12 and Resident #42 had their meal and had eaten a large portion of their food. Theses four (4) residents were sitting at three (3) separate tables. Resident #79, Resident #41, Resident #11 were sitting at a another table and did not have their meal when this observation began. They were not served their meal until 1:05 p.m. which was 20 minutes after this observation began. Resident #21 and Resident #64 were also sitting at another table in the Maple Dining room and did not have their meal when this observation began. They were note served their meal until 1:10 p.m. which was 25 minutes after this observation began. Resident #80 and Resident #107 was also sitting at a separate table and did not have their meal when this observation began. They were not served their meal until 1:15 p.m. which was 30 minutes after this observation began. At 12:55 p.m. Resident #103 entered the dining room and sat at the table with Resident #12 who had almost consumed his entire meal by this time. Resident #103 was not served her meal until 1:17 p.m. which was 22 minutes after she entered the dining room. An interview with Nurse Aide #36 at 1:21 p.m. on 06/24/19 confirmed that all residents seated in the dining room are usually served their meal at the same time. She stated, all the trays did not come out t… | 2020-09-01 |
| 842 | 842 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 561 | D | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review policy review and staff interview, the facility failed to ensure the resident had the right to make choices about aspects of their life which were important to them. For Resident #106 and Resident #94 the facility failed to allow the resident to make choices about their bathing schedule. For Resident #49 the facility failed to allow her to make choices about her bathing schedule and her religious preferences. This was true for 3 of 5 residents reviewed for the care area of self-determination. Resident identifiers: #49, #106, #94. Facility census: 117. Findings included: a) Resident #49 1. Bathing Schedule: During an interview on 06/24/19 Resident stated, I would like to get more showers, since I have moved over here (Maple Unit) I hardly get any. I am supposed to get at least two (2) a week. Resident was noted to have transferred from Dogwood Unit room [ROOM NUMBER]A to Maple unit room [ROOM NUMBER]B on 05/13/19. Review of Activities of Daily Living (ADL) sheets for Resident #49 revealed Resident received showers for only 4 out of 8 opportunities in May, and 4 out 9 opportunities in June. Record review indicated the shower schedule for when Resident was residing in room [ROOM NUMBER]A in the Dogwood unit was Monday and Thursday. The shower schedule for the Maple Unit while Resident was residing in room [ROOM NUMBER]B was Wednesday and Saturday. After Resident was transferred from room [ROOM NUMBER]A to room [ROOM NUMBER]B on 05/13/19, the Resident went for days in a row from 05/15/19 - 5/18/19 without any type of bathing, and only received two (2) showers (on 06/14/19, and on 06/25/19) thereafter through the end of June. Review of Resident's care plan revealed an active focus point that stated, (Resident's first name) stated that it is important that she has the opportunity engage in daily routines that are meaningful relative to their preferences, with a goal of, Resident will plan and choose to eng… | 2020-09-01 |
| 843 | 843 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 580 | D | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to promptly notify the physician and family and/or responsible party promptly of resident's change of condition (fall). This was a random opportunity for discovery. Resident identifiers: #78. Facility census: 117. Findings included: a) Resident #78 Review of Resident #78's medical records found the resident was admitted on [DATE] to the facility. Additionally, the resident had experienced two (2) falls on 06/22/19 at 1:30 a.m. and 1:00 p.m. Review of the incident reports found: (typed as written) Incident #1- 06/22/19 at 1:30 am- Resident found lying on left side of floor. Assessed for injury and pain, ST (skin tear) to back of bilateral hands, ST to posterior LLE (left lower extremities) and left elbow. Immediate actions taken to protect resident: assessed for injury, pain, assisted to bed and treatments to skin tears. Root cause/conclusion: poor safety awareness. Doctor and family notified on 06/22/19 at 1:00 pm of this incident. Incident #2- 06/22/19 at 1:00 pm- Resident on floor in front of chair laying on stomach. Resident denies pain or discomfort currently. BS (blood sugar) 94 currently. Immediate actions taken to protect resident: assessed for injury skin tears to left forehead, left hand, and right forearm dressings.Root cause/conclusion: resident attempted to get out of chair without assistance and fell on to the floor. Doctor and family notified on 06/22/19 at 1:00 pm of this incident. Review of the transfer report dated 06/22/19 at 2:35 pm, found the resident was transferred to a hospital for evaluation and treatment due to fall (06/22/19 at 1:30 am and 1:00 pm). Resident #78 was readmitted to the facility on [DATE]. Review of the History and Physical (H&P) and Discharge Summary found the following: (typed as written) This [AGE] year-old male who is a resident of a nursing home who presents to the hospital with passing out and falling spells. Patient states that last … | 2020-09-01 |
| 844 | 844 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 584 | E | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure housekeeping services to maintain a sanitary, orderly and comfortable interior. The facility failed to clean fecal matter from the shower room floor on the 200 hall, the floor at the nurse's station on the 300 hall and the privacy curtain in room [ROOM NUMBER]. In addition, one resident had an oxygen concentrator that was overdue for maintenance. This practice affected more than a limited number of residents. Resident identifiers: #47. Facility census 117. Findings included: a) Shower room on the 200 hall During an observation of the shower room on the 200 hall, it was noted that there was dried fecal matter on the shower room floor, it appeared that it had been stepped in and smeared across the floor. On 06/30/19 at 9:50 PM, Licensed Practical Nurse (LPN) #71 verified there were feces on the shower room floor. She was asked when the shower room was last used. She stated, that no one was showered from the 200 hall on this day. She was asked if housekeeping was here today. She stated, that the housekeepers left at 2:00PM. On 07/01/19 at 8:32 AM, Account Manager (AM) #109, stated that she was the manager over housekeeping. She was asked it there was anyone scheduled to work on 06/30/19, and she stated that a Light Housekeeper (a person who cleans the rooms of the residents and sanitizes the shower room). She was asked if the housekeeper would have been expected to clean the fecal matter on the shower room floor. She replied that the NA's should have taken care of that when they had the resident in the shower room. On 07/01/19 at 3:10 PM, Director of Nursing was made aware of the fecal matter found in the shower room. b) 300 Hallway Floor On 07/01/19 at 1:23 PM, observation was made of a dark brown smashed gooey substance that appeared to be fecal matter in the floor in front of the nurse's station on 300 hall. The brown fecal-like matter had been stepped in and spread down … | 2020-09-01 |
| 845 | 845 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 600 | F | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, policy review and staff interview, the facility failed to ensure that all residents were free from abuse and/or neglect. Resident #111 experienced a fall from her bed during a bed bath. Resident #91, #78, #162, #211, #161, #163, #53, #92, #93, #95, #38, #1, #68, #101, #51, #70, #94, #49, #106, #26, #56, #97, #58, #59, #69, #27, #86, #46, #99, #25, #90, #76, #89, #8 and #16 did not receive showers according to resident's preference and/or shower schedule . Resident #162, #53, and #92 did not receive medications in a timely manner. Resident #23 was struck by another resident with no investigation to determine if it was abuse or not. Resident #161 bowel regimen (constipation) was not monitored or addressed. Resident #38 did not receive restorative program as prescribed. This practice has the potential to affect all resident's residing in the facility. This deficient practice was true for thirty-even (37) of forty-one (41) sampled residents. Resident identifiers: #111, #91, #78, #162, #211, #163, #53, #92, #93, #95, #161, #38, #1, #68, #101, #51, #70, #94, #49, #106, #26, #56, #97, #58, #59, #69, #27, #86, #46, #99, #25, #90, #76, #89, #8, #16, and #23. Facility census: 117. Findings included: a) Resident #111 Review of Resident #111's medical records found this resident was admitted to the facility on [DATE] at 6:39 pm, from an acute care facility with [DIAGNOSES REDACTED]. Noted to have impairment of right upper extremity and weakness in the right arm and both legs. Review of the interim care plan dated 02/03/19 found no directions for assistance required to provide Activities of Daily Living (ADL)s which includes bed mobility, transfers, eating, toileting, dressing, grooming, and bathing. Resident #111's experienced a fall on 02/03/19 at 3:30 pm. Resident's progress note states, Resident was being changed by nurse aide at 3:30 pm. Resident was rolling to the right hand side of the bed when the reside… | 2020-09-01 |
| 846 | 846 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 607 | F | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, staff interview, resident interview, and family interview, the facility failed to develop and/or implement policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. This practice has the potential to effect all residents currently residing in the facility. For Residents #1, #68, #101, #51, #70, #94, #26, #56, #97, #58, #59, #69, #27, #86, #46, #99, #25, #90, #76, #89, #8, #16, #161, #38, #49, #106, #91, #78, #162, #211, #163, #53, #92, #93, and #95 the facility failed to identify a pattern of missed showers which led to continued neglect of residents. For Resident #96 the facility failed to report an injury of unknown origin as directed by their policy. For Resident #29 the facility did not thoroughly investigate an allegation of abuse. For Resident #23 the facility failed to investigate a resident to resident altercation to ensure abuse had not occurred. For Resident #111 the facility failed to ensure and accident which resulted in the Resident falling from bed was investigated to rule out abuse and/or neglect. Resident identifiers: #1, #68, #101, #51, #70, #94, #26, #56, #97, #58, #59, #69, #27, #86, #46, #99, #25, #90, #76, #89, #8, #16, #161, #38, #49, #106, #91, #78, #162, #211, #163, #53, #92, #93, #95, #96, #29, #23 and #111. Facility census: 117. Findings included: a) Abuse Policy Concerning Reporting Allegations: A review of the facility's Abuse Prohibition policy with an effective date on 06/01/1996 and a review date of 06/13/18 and a revision date of 07/01/18 found the following in regards to the reporting of abuse and/or neglect: 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect the CED (center executive director) or designee will perform the following. 6.1 Enter allegation in the Risk Management System (RMS). 6.2 Report allegations involving abuse (physical, ver… | 2020-09-01 |
| 847 | 847 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 609 | F | 0 | 1 | LUON11 | Based on record review, staff interview, family interview, policy review and resident interview, the facility failed to ensure all allegations of abuse and/or neglect was reported to appropriate state agencies. Resident #15, #19, #12, #213, #212, #214, #77, #30, #57, #29 all made allegations of abuse and/or neglect against nurse aides and these were reported to the Nursing Home Program and not the Nurse Aide Program. This was true for 10 of 35 reportable incidents reviewed. For Resident #96 the facility failed to report an injury of unknown origin to appropriate state agencies. This was a random opportunity of discovery. Resident identifiers: #15, #19, #12, #213, #212, #214, #57, #77, #30, #29 and #96. Facility census: 117. Findings included: a) Resident #96 During a family interview with Resident #96's family member on 06/25/19 it was revealed a few weeks previous Resident #96 had a large bruise to her chin and jaw. An interview with Nurse Aide #65 at 3:58 p.m. on 06/26/19 confirmed Resident #96 had a bruise on her on chin she stated, I think it came from the bar where they turned her. When asked if the resident was able to move her self in the bed Nurse Aide #65 stated, She can wiggle her upper body some but is not able to really turn herself in the bed. A review of Resident #96's medical record at 9:00 a.m. on 06/27/19 found two (2) Minimum Data Sets (MDS) with Assessment Reference Dates of 04/05/19 and 06/09/19 which indicated Resident #96 was totally dependent on staff with a two person physical assist for bed mobility. Total dependence is defined on the MDS as full staff performance every time during the entire 7- day period. An interview with the Nursing Home Administrator (NHA), the Director of Nursing (DON) and the Registered Nurse Clinical Quality Specialist (RNCQS) #131 at 10:20 a.m. on 06/27/19 revealed the NHA and DON were aware of the bruise. The NHA indicated she thought the nurse may have mentioned it to her she was not sure exactly how she became aware of it. The NHA indicated the Interdisciplina… | 2020-09-01 |
| 848 | 848 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 610 | D | 0 | 1 | LUON11 | Based on resident interview, record review, staff interview and policy review, the facility failed to thoroughly investigated, report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This had the potential to affect a limited number of people. Resident identifier: #29. Facility census 117. Findings included: a) Resident 29 During an interview on 06/25/19 at 10:20 AM, Resident #29 (who is nonverbal writes with a pen and tablet) stated, that her neck hurts. She wrote that a Nurse Aide (NA) #41, jerked me out my chair to the bed NA #41 was working on night shift. She wrote that it happened on Monday or Tuesday of last week at about 10:00 PM. She reported this to the Social Worker (SW), she gave a description of the NA #41 and pointed her out to SW. She wrote, that the women the women are still here the next night. She also wrote, that the same NA push her into the door hard and hurt her sore feet and happened at 7:00PM. On 06/26/19 a review of the reportable that was provided revealed; Reportable done on 06/20/19, date of incident was on 06/17/19, this report was completed by Social Worker (SW) #49. -There was no evidence that NA #41 was reported to, Nurse Aide registry -There report had the NA named as unknown, even though he named the NA in his statement. -He did not have any witness statements attached to the report. On a typed sheet of paper read as follows: June 20, 2019 Five-day follow-up report Alleged Perpetrator: Unknown Alleged victim: Named Resident #29 Resident #29 reported that someone caring for her had been mean to her. When asked specifically about this she reported that a tall black woman with blonde hair on top of her head jerked her while providing care. She indicated she was in her wheelchair when this occurred, and it caused her foot to b… | 2020-09-01 |
| 849 | 849 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 622 | D | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide documentation to the receiving hospital to ensure a safe transfer for Resident #98. This was true for one of eight residents reviewed for the care area of hospitalization . Resident identifier: #98. Facility census: 117. Findings included: a) Resident #98 On 06/26/19 at 2:35 PM, a closed record review of Resident #98's medical chart revealed the Resident had been transferred to the hospital on [DATE]. The facility failed to ensure the necessary Resident information was documented and included in the transfer of the Resident to the receiving hospital. At 2:40 PM on 06/26/19, the Director of Nursing (DON) confirmed, by interview, the hospital discharge forms for the Resident on the transfer date of 06/18/19, .were not given. | 2020-09-01 |
| 850 | 850 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 623 | E | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, facility failed to notify the resident and the resident's representative(s) of the transfer and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. This was true for eight (8) of eight (8) residents sampled for the care area of hospitalization . Resident identifiers: #111, #78, #93, #98, #80, #6, #101 and #38. Facility census: 117. Findings included: a) Resident #111 Review of Resident #111's medical records found this resident was admitted to the facility on [DATE] at 6:39 pm, from an acute care facility with [DIAGNOSES REDACTED]. Noted to have impairment of right upper extremity and weakness in the right arm and both legs. Resident #111's experienced a fall on 02/03/19 at 3:30 pm. Resident's progress note states, Resident was being changed by nurse aide at 3:30 pm. Resident was rolling to the right hand side of the bed when the resident rolled herself from the bed to the floor, the bed was raised to waist height as the aide was performing care on the resident. Post fall the resident c/o (complained of) severe left knee and left rib pain. This nurse contacted the on-call physician who gave orders to have resident sent out to the emergency room to be evaluated for potential fractures. Nurse aide who was performing care will complete a statement regarding the incident. Bruise noted on left knee and left cheek. Review of the Notice of Transfer or discharge found the form was incomplete except Resident's name and date. No indication this was provided to the resident and/or patient's representative. Bedhold Notice of Policy and Authorization was blank of signature. Interview with the Director of Nursing (DON) on 07/01/19 at 1:10 pm. Resident #111's medical records were reviewed by the DON. She confirmed the notice of transfer and bed hold was both incomplete.… | 2020-09-01 |
| 851 | 851 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 625 | E | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that all residents received a Bed-hold notice upon transfer and/or discharge from the facility. This was true for five (5) of eight (8) residents reviewed for the care area of hospitalization . Resident identifiers: #80, #6, #111, #78, and #38. Facility census 117. Findings included: a) Resident #80 Review of records found Resident #80 was sent out to a local hospital on [DATE] and returned on 03/04/19. For a change in mental status. On 07/01/19 at 1:03 PM, Director of Nursing (DoN) was asked for a bed hold for this resident. She stated, that the bed hold was incomplete and not done. She also stated, that the ombudsman was not notified. b) Resident #6 Review of medical records revealed that, Resident #6 was sent out of the facility due [MEDICAL CONDITION], on 3/15/19 returned on 03/19/19. On 07/01/19 at 1:03 PM, Director of Nursing (DoN) stated that they did not complete a bed hold. She also stated, that the ombudsman was not notified. c) Resident #38 Record review on 06/26/19 at 3:37 PM, found the resident was discharged to the hospital on [DATE] for a severely extended abdomen. The resident returned to the facility on [DATE]. On 06/27/19 at 8:47 AM, the director of nursing (DON), provided a copy of a bed hold notice with Resident #38's name written on the bed hold. The form noted the resident had 12 days of bed hold. The DON confirmed the bed hold notice was not dated to indicate when it was sent with the resident. In addition, there was no indication the bed hold policy was discussed with the resident or the responsible party within 24 hours of transfer to the hospital. d) Resident #111 Review of Resident #111's medical records found this resident was admitted to the facility on [DATE] at 6:39 pm, from an acute care facility with [DIAGNOSES REDACTED]. Noted to have impairment of right upper extremity and weakness in the right arm and both legs. Resident #111's experi… | 2020-09-01 |
| 852 | 852 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 636 | D | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the care area assessment (CAA) worksheet of the minimum data set (MDS) was completed with current evidence-based information regarding the care area of activities for one (1) of three (3) residents who triggered activities. Resident identifier: #161. Facility census: 117. Findings included: a) Resident #161 Record review at 9:11 AM on 06/27/19, found the resident was admitted to the facility on [DATE]. The resident was discharged from the facility on 05/13/19. Review of the Resident's admission MDS with a reference assessment date of 04/17/19 found the resident triggered the care area of activities. The facility answered-yes, to the question on the CAA worksheet, Will activities-Functional status be address in the care plan? The CAA further indicated if care planning for this problem one of the overall objectives needs to be checked: improvement, slow or minimize decline, avoid complications, maintain current level of functioning, minimize risks, and symptom relief or palliative measure. None of these choices were checked. The CAA required documentation for: Description impact of this problem/need on the resident and your rationale for care plan decision. This was also incomplete. On 06/27/19 at 10:05 AM, the Registered Nurse (RN), (minimum data set coordination), RNMDSC #95 confirmed the CAA worksheet was incomplete. | 2020-09-01 |
| 853 | 853 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 641 | E | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, facility failed to ensure the Minimum Data Sets (MDS)s accurately reflected the resident's status. This was true for five (5) of forty-one (41) resident's MDSs reviewed during the Long-Term Survey Process (LTCSP). Resident #113's MDS was inaccurate in the area of prognosis/death in the facility. Residents #91 and #92's MDS was inaccurate in area of nutritional/weight loss status. Residents #103 and #3's MDS was inaccurate in area of medication. Resident's identifiers: #113, #91, #92, #103 and #3. Facility census: 117. Findings included: a) Resident #113 Resident #113 was admitted to the facility on [DATE] from an acute care facility. Resident's [DIAGNOSES REDACTED]. Review of the attending physicians' progress note dated, 03/01/19 at 2:41 pm, states, . Prognosis is terminal, with a predicted survival of less than three (3) months . Review of the admission MDS with an assessment reference date (ARD) of 03/07/19. Review of section J 1400 Prognosis was marked to indicate the resident did not have a condition or chronic disease that may result in a life expectancy of less than six (6) months. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 06/27/19 at 11:00 am, confirmed the resident had was terminal and the MDSs with ARD of 03/07/19 inaccurately coded. They both agreed the MDS should have been coded, Life expectancy of less than six (6) months. b) Resident #91 Medical record review for Resident #91, found the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Admission nursing assessment reviewed, no weight and/or height was obtained. Review of the admission MDS with ARD of 06/07/2019 under section K lists the weight as 128. Nutritional care plan for Resident #91 was initiated on 06/07/19 as follows: -- Focus: Resident is a potential nutritional concern related to (r/t) fair po (by mouth) intakes, [DIAGNOSES REDACTED]. -- Goal: No significant wei… | 2020-09-01 |
| 854 | 854 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 655 | D | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop and implement a baseline care plan for Resident #111's to include the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours of a resident's admission and include the minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders [REDACTED]. Resident identifier: #111. Facility census: 117. Findings included: a) Resident #111 Review of Resident #111's medical records found this resident was admitted to the facility on [DATE] at 6:39 pm, from an acute care facility with [DIAGNOSES REDACTED]. Noted to have impairment of right upper extremity and weakness in the right arm and both legs. Review of the interim care plan dated 02/03/19 found no directions for assistance required to provide Activities of Daily Living (ADL)s which includes bed mobility, transfers, eating, toileting, dressing, grooming, and bathing. Resident #111's experienced a fall on 02/03/19 at 3:30 pm. Resident's progress note states, Resident was being changed by nurse aide at 3:30 pm. Resident was rolling to the right hand side of the bed when the resident rolled herself from the bed to the floor, the bed was raised to waist height as the aide was performing care on the resident. Post fall the resident c/o (complained of) severe left knee and left rib pain. This nurse contacted the on-call physician who gave orders to have resident sent out to the emergency room to be evaluated for potential fractures. Nurse aide who was performing care will complete a statement regarding the incident. Bruise noted on left knee and left cheek. Review of policy for Falls Management reads: Perform neurological assessment for all unwitnessed falls and witnessed falls with head injury This survey requested t… | 2020-09-01 |
| 855 | 855 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 656 | E | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to develop and/or implement each residents care plan. For Resident #161 the facility failed to develop a complete care plan for activities. In addition the facility failed to implement the care plan for a resident with significant weigh loss. For Resident #49 the facility failed to implement the care plan for accident prevention. For Resident #28 the facility failed to develop a care plan detaining how the resident would communicate needs with staff. For Resident #51 the facility did not implement the care plan for nutrition. This was true for four (4) of forty-one (41) residents who's care plans were reviewed. Resident identifiers: #161, #49, #28, and #51. Facility census: 117. a) Resident #161-activities (part 1) Review of the resident's care plan for activities found the following focus/problem: While in the facility, resident states that it is important that she has the opportunity to engage in daily routines that are meaningful relative to their (typed as written) preferences. The goal associated with the problem: Resident will plan and choose to engage in preferred activities. Interventions included: It is important for me to choose my bedtime and I prefer to go to bed whenever I want, I enjoy watching TV, I benefit from being informed of facility happenings. At 8:36 AM on 07/01/19, the activity director (AD # 45 said the resident frequently attended church and music events while at the facility-this was her preferred activities. The care plan was reviewed with AD #45. AD#45 said those activities were not listed on the care plan as activities the resident preferred to attend. Resident #161-nutrition (part 2) Record review at 9:00 AM on 06/26/19 found the Resident was admitted to the facility from the hospital on [DATE]. The resident was discharged from the facility on 05/13/19. Review of the residents care plan found the following problem: Resident is a nutr… | 2020-09-01 |
| 856 | 856 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 657 | E | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and record review, the facility failed to ensure all residents were invited to participate in their interdisciplinary care plan meetings. Additionally, Resident #23 and Resident #28's care plans were not revised. These deficient practices were found for seven (7) of 41 sampled residents. Resident identifiers: #24, #104, #23, #80, #6, #49, #28. Facility census: 117. Findings included: a) Resident #24 On 06/25/19 at 12:13 PM, Resident #24 expressed that she wanted to go to her care plan meetings, but that she was not invited to participate. On 06/26/19 at 8:43 AM, the facility's Administrator was asked to provide Resident #24's care plan meeting notes and invitations to care plan meetings for the past year. Upon receipt of the requested information at 9:38 AM, it was noted that Resident #24's care plan meetings during the past year had been held on the following dates: 06/14/18, 08/02/18, and 10/25/18. Additionally, the only invitations to the care plan meetings provided by the facility for review were directed toward Resident #24's responsible party. Each invitation encouraged the responsible party to attend the meeting to discuss resident progress and current care needs of their loved one. Upon further review during the survey, the care plan meeting note for 06/14/18 stated, resident was invited; did not attend. The care plan meeting note for 08/02/18 stated, resident was invited; did not attend. The care plan meeting note for 10/25/18 stated, resident was invited; she did not wish to attend. On 06/26/19 at 10:53 AM, care plan meeting invitations to Resident #24 (not her responsible party) were requested from the facility's Administrator, Director of Nursing (DoN), and Clinical Quality Specialist (CQS) #118. They stated that they would contact the facility's social workers, who were both on vacation during the survey, to see if they could provide additional information about the process for inviti… | 2020-09-01 |
| 857 | 857 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 660 | D | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure Resident #102's comprehensive care plan included discharge planning. This was true for one (1) of four (4) residents reviewed for the care area of discharge. Resident identifier: #102. Facility census: 117. Findings included: a) Resident #102 Review of Resident #102's medical records revealed she was admitted to the facility on [DATE] and transferred to another long-term care facility on 06/19/19. Resident #102's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 06/12/19, Section Q, Participation in Assessment and Goal Setting, stated the resident expected to be discharged to another facility. Review of Resident #102's Comprehensive Care Plan revealed a care plan focus had not been developed regarding the resident's desire to be transferred to another long-term care facility. During an interview on 06/26/19 at 12:48 PM, the Director of Nursing agreed a care plan focus had not been developed regarding Resident #102's discharge plans. No further information was provided through the completion of the survey. | 2020-09-01 |
| 858 | 858 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 677 | E | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, policy review and staff interview, the facility failed to ensure all dependent care residents received the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #91, #78, #162, #211, #161, #163, #53, #92, #93, #95, #38, #1, #68, #101, #51, #70, #94, #49, #106, #26, #56, #97, #58, #59, #69, #27, #86, #46, #99, #25, #90, #76, #89, #8 and #16 did not receive showers according to resident's preference and/or shower schedule . This practice has the potential to affect all resident's residing in the facility. This deficient practice was true for thirty-even (37) of forty-one (41) sampled residents. Resident identifiers: #111, #91, #78, #162, #211, #163, #53, #92, #93, #95, #161, #38, #1, #68, #101, #51, #70, #94, #49, #106, #26, #56, #97, #58, #59, #69, #27, #86, #46, #99, #25, #90, #76, #89, #8, #16, and #23. Facility census: 117. Findings included: a) Resident #91 Review of Resident #91's medical records found she was admitted to the facility on [DATE]. Her shower schedule for room [ROOM NUMBER]-A was for every Wednesday and Saturday. Review of the (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received two (2) of the nine (9) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive showers on the scheduled dates in (MONTH) 2019 and no documentation existed to indicate the resident had refused. No further information provided. b) Resident #78 Review of Resident #78's medical records found the resident was admitted to the facility on [DATE]. Shower schedule for room [ROOM NUMBER]-B was for every Tuesday and Friday. Review of the (MONTH) and (MONTH) 2019 ADL (Activities of Daily Living) record found the resident only received one (1) of the eight (8) opportunities as directed by the shower schedule. On 07/02/19 at 9:00 AM, Director of Nursing… | 2020-09-01 |
| 859 | 859 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 679 | D | 0 | 1 | LUON11 | Based on resident interview, record review, staff interview and policy review, the facility failed to implement an ongoing resident centered activity program that incorporated Resident #49's preferences of church services. This was true for 1 of 3 residents reviewed for activities. Resident identifier: #49. Facility census: 117. a) Resident #49 During initial screening process on 06/24/19 at 10:56 AM Resident stated she would like to have church every Sunday instead of just once or twice a month. Review of Activities Calendar for the month of (MONTH) 2019 revealed the facility only provided the Resident with one (1) out of (5) opportunities to attend church worship service on Sunday. On 07/01/19 at 8:40 AM during an interview the Activities Director (AD) verified the (MONTH) Activity calendar to only include one (1) opportunity for the Resident to attend church services on Sunday (06/02/19) for the month of June. AD stated activities such as Father's Day celebration, bird watching, and bowling replaced the opportunity for church services on the other Sundays of the month. Review of the Facility's policy REC200 titled Resident/Patient's Choice stated Residents/Patients have the right to participate in leisure and recreation of their choosing. Review of the Facility's policy REC201 titled Spiritual Support stated spiritual and religious activities will be available to residents and their families on a routine basis, including worship services. Review of Resident's care plan revealed an activity focus point that stated, (Resident's first name) stated that it is important that she has the opportunity engage in daily routines that are meaningful relative to their preferences, with a goal the Resident will plan and choose to engage in preferred activities daily, and an intervention that stated:, Encourage and facilitate residents/patients activity preferences daily chronical, bingo, church service, special events, music. During an interview on 07/2/19 at 9:00 AM, social services specialist #96 stated, We (the facility)… | 2020-09-01 |
| 860 | 860 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 684 | E | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interviews the facility failed to provide the necessary care and services to ensure each resident is able attain or maintain this highest practicable physical mental and psychosocial well-being. This was true for nine (9) of forty (40) sampled residents. Resident #78 did not receive an anticoagulant ([MEDICATION NAME]) on two (2) separate occasions. Residents #162, #53, and #92 did not receive medication as ordered in a timely manner. Resident #211's activities of daily living (ADL) was not documented for several days after admission. Resident #111 was not assessed for ADLs to prevent a hospitalization and after a head injury the facility failed to do neurological assessments. For Resident #161, the facility failed to monitor bowel movements. For Resident #31, failed to provide wound care as ordered. For Resident #49, the facility failed to do neurological checks accurately. Resident identifiers: #78, #162, #53, #92, #211, #111, #161, #31 and #48. Facility census: 117. Findings included: a) Resident #78 Review of Resident #78's medical records found the resident was admitted to the facility on [DATE]. Medications included [MEDICATION NAME] (anticoagulant) for treatment of [REDACTED]. On 05/31/19 the PT/INR results were received, and new orders obtained to increase [MEDICATION NAME] to 5.5 milligrams (mg). Review of the Medication Administration Record [REDACTED]. On 06/19/19 the PT/INR results were received, and new orders obtained to restart [MEDICATION NAME] 4 mg. Review of the Medication Administration Record [REDACTED]. On 06/26/19 at 9:00 AM, Director of Nursing (DON) agreed that the resident did not receive his [MEDICATION NAME] on 05/31/19 and 06/19/19 as ordered. No further information provided. b) Resident #162 Interview with Resident #53 and #92 on 06/24/19 at 11:45 am. During this interview they stated, I don't get my medication due at 9:00 pm until late some nights especially 0… | 2020-09-01 |
| 861 | 861 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 687 | D | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure resident #89 received proper treatment to maintain good foot health. This was a random opportunity of discovery. Resident Identifier: #89. Facility Census: 117. Findings include: a) Resident #89 Observations of Resident #89's feet with the Director of Nursing (DON) on 07/01/19 at 10:20 a.m. found the residents toe nails to be long, thick, and brown. The DON stated she needs to see the podiatrist. Later in the morning on 07/01/19 the DON provided the Podiatrist's list and stated the resident was scheduled to see him on 07/10/19. An interview with Social Worker #96 at 11:39 a.m. on 07/01/19 found the Podiatrist comes to the facility every three months. She indicated the Podiatrist was last at the facility on 04/17/19 to 04/18/19 and Resident #89 was not seen on that date. An additional interview with DON at 12:37 p.m. on 07/01/19 confirmed Resident #89 was admitted to the facility on [DATE] and should have been added to the list to see the podiatrist when he as at the facility on 04/17/19 and 04/18/19. She stated that he toe nails are too thick and the nurses would not be able to trim them. | 2020-09-01 |
| 862 | 862 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 688 | E | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure residents received restorative therapy to improve, maintain, or prevent a decline in range of motion. This was true for four (4) of forty (40) residents reviewed. Resident identifier: #38. Facility census: 117. Findings include: a) Resident #38 Record review on 06/27/19 at 10:00 AM, revealed an order for [REDACTED]. At 10:22 AM on 06/27/19, the Registered Nurse (RN)#50, who oversees the restorative program, and the restorative aide RA#19, reviewed the restorative nursing record and confirmed there was no evidence to verify the resident received any restorative therapy. RN#50 said RA#19 said they were frequently pulled from the restorative program to work the floor because enough nursing assistants did not show up for work. RA#19 said she was unable to provide restorative nursing services because she was working as a nursing assistant. RN#50 said at times she has to work on the floor as a nurse. On 06/27/19 at 11:44 AM, the administrator said, when restorative is pulled to work the floor the nursing assistants are supposed to provide restorative therapy. The administrator was asked if she was aware there was no documentation of the restorative nursing record. She replied, no. When asked if the facility reviews restorative nursing services during the monthly Quality Assurance and Assessment (QAA) meetings, the administrator said, yes, a report is reviewed. The administrator said RN #50 had not reported any problems with providing restorative therapy. b) Resident #53 Interview with Resident #53 on 06/24/19 at 1:30 pm found the resident voiced, There is not enough staff for me to get my restorative exercises. Medical record review for Resident #53 found a physician order [REDACTED]. (pound) weights in all planes, 3 x a week for 6 weeks and resident to ambulate 100 feet times 2 with rolling walker and contact guard assistance (CGA), 3 x weekly for 6 week… | 2020-09-01 |
| 863 | 863 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 689 | E | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews, and observation, the facility failed to ensure each resident's environment remain as free of accident hazards as is possible; and ensure each resident receives adequate supervision and assistance devices to prevent accidents. This was true for three (3) of eight (8) reviewed for falls and one (1) random opportunity for discovery. Resident identifiers: #111, #162, #53, #92, #49. Facility census: 117. Findings included: a) Resident #111 Review of Resident #111's medical records found this resident was admitted to the facility on [DATE] at 6:39 pm, from an acute care facility with [DIAGNOSES REDACTED]. Noted to have impairment of right upper extremity and weakness in the right arm and both legs. Review of the interim care plan dated 02/03/19 found no directions for assistance required to provide Activities of Daily Living (ADL)s which includes bed mobility, transfers, eating, toileting, dressing, grooming, and bathing. Resident #111's experienced a fall on 02/03/19 at 3:30 pm. Resident's progress note states, Resident was being changed by nurse aide at 3:30 pm. Resident was rolling to the right hand side of the bed when the resident rolled herself from the bed to the floor, the bed was raised to waist height as the aide was performing care on the resident. Post fall the resident c/o (complained of) severe left knee and left rib pain. This nurse contacted the on-call physician who gave orders to have resident sent out to the emergency room to be evaluated for potential fractures. Nurse aide who was performing care will complete a statement regarding the incident. Bruise noted on left knee and left cheek. Review of policy for Falls Management reads: Perform neurological assessment for all unwitnessed falls and witnessed falls with head injury This survey requested the statement from the nurse aide providing care for Resident #111 on 02/03/19 at 3:30 pm and neurological checks. No information w… | 2020-09-01 |
| 864 | 864 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 690 | D | 0 | 1 | LUON11 | Based on observation and staff interview, the facility failed to ensure appropriate treatment and services for an indwelling suprapubic catheter. Failed to use of an anchor secure device (used to prevent tissue injury and/or accidental removal, excessive urethral tension, or obstruction of urine outflow. This was true for one (1) of one (1) reviewed for catheter care. Identified Resident # 6. Facility census 117. Findings included: a) Resident #6 On 07/01/19 at 9:14 AM, Registered Nurse (RN) #28 providing suprapubic catheter care. There was some dried blood on the old dressing that was removed and at the insertion site there was large amount of bright red bleeding. There was not a secure anchor device on Resident #6. It was pointed out to RN #28 and she agreed there should have been on this resident. On 07/01/19 at 9:35 AM, RN #28 placed a secure anchor device to the upper right leg. On 07/01/19 at 12:00 PM Director of Nursing was informed of findings. | 2020-09-01 |
| 865 | 865 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 692 | E | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that all residents maintained acceptable parameters of nutrition. This was true for four (4) of ten (10) residents reviewed for the care area of nutrition. Resident identifiers: #91, #92, #51 and #161, Facility Census: 117. Findings include: a) Resident #91 Medical record review for Resident #91, found the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Admission nursing assessment reviewed, no weight and/or height was obtained. Review of the admission MDS with ARD of 06/07/2019 under section K lists the weight as 128. Nutritional care plan for Resident #91 was initiated on 06/07/19 as follows: -- Focus: Resident is a potential nutritional concern related to (r/t) fair po (by mouth) intakes, [DIAGNOSES REDACTED]. -- Goal: No significant weight changes through next review. (MONTH) experience some weight fluctuations based on diuretic ([MEDICATION NAME]) treatment in place. --Interventions: Proheal (protein supplement) as ordered. Honor food preferences within meal plan. Weigh as ordered/needed and alert dietician and physician to any significant loss or gain. Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain and abnormal labs) and report to food and nutrition/physician as indicated. Monitor intake at all meals, offer alternate choices as needed, alert dietician physician to any decline in intake. Provide diet as ordered Offer snacks. --On 06/08/19, a nutritional assessment for Resident #91, completed by the Registered Dietician (RD) with no weight and/or height recorded. Under nutritional history reads: .No height/weight available at time of assessment Review of Resident #91's weight and vitals summary found resident's height and weight was obtained on 06/11/19 at 6:35 pm. Weight 127.8 and Height 59 inches. Facility's weight and height policy reviewed and found: Patients are weighed upon … | 2020-09-01 |
| 866 | 866 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 725 | E | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure they had sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. Findings include: a) Anonymous Resident Interviews -- You lay in a wet brief for long periods of time and it takes hours to answer lights. -- Staff stay on cell phones and don't work. The way staff treat me make me want to lie down and have it all be over. -- On a Sunday, I hit the call button and couldn't get an answer. Finally, staff answered call light and said they would be back. Never came back. That crew doesn't like me. Since that night, I have had problems. I am very pissed .they just don't want to do their damn job. Can't get a charge nurse to talk to me. come talk to him. -- I think they are short staffed it takes two or more hours to get changed on all shifts. -- Not enough staff on weekends to serve the dining room, so we must eat in our rooms. -- It takes the staff a long-time night to answer call lights. -- I cannot get help to go back to bed from chair and my neck hurts and burns. It takes two hours or more to answer call lights. -- Nights here are a disaster after 10 pm, one aide only. Weekends are the worst, even on dayshift its ridiculous. -- Takes forever to get a pain pill. -- Staffing on weekends is bad. -- It takes 2 hours for someone to respond to call light. Sometimes they don't come at all. -- The nurse aides need help I always must wait to get help. I must eat last and food is because I need assistance. Food is not good; it is nasty. The resident stated that at night there is only one nurse and one aide for 60 residents, and I must wait 45 minutes to an hour to get help. -- All staff is over worked. The st… | 2020-09-01 |
| 867 | 867 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 756 | D | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure the pharmacist recognized and notified the physician that Resident #31 was receiving two (2) medications from the same drug class. In addition, the physician failed to provide a timely clinical rational for declining a gradual dose reduction for Resident #103. This was true of two (2) of five (5) residents reviewed receiving medications. Resident identifiers: #31 and 103. Facility census: 117. Findings included: a) Resident #31 On 07/02/19 at 11:05 AM, Review of Resident #31's Medication Administration Record [REDACTED]. Diabetic [MEDICAL CONDITION] is a type of nerve damage that can occur if you have diabetes. It most often damages nerves in the legs and feet. The MAR indicated [REDACTED]. Both of these medications were also listed in the Resident's Progress Notes. The facility's Registered Pharmacist (RPh) failed to recognize the medication duplication upon her monthly review of the Drug Regimen Review (DRR) or MAR. On 07/02/19 at 11:30 AM, Review of the Consultation Report, developed by the Facility's RPh on 05/03/19, revealed the RPh's only recommendation to the Physician was to Please discontinue Glimepiride, which is a diabetes medication. During an interview on 07/02/19 at 11:35 AM, the Director of Nursing (DON) confirmed the Resident had received a duplicate drug therapy from 05/03/19 through 05/22/19 of two medications in the same class. b) Resident #103 A review of Resident #103's medical record during the survey revealed that the facility's Consultant Pharmacist recommended via a Consultation Report form on 05/03/19 to attempt a gradual dose reduction (GDR) of Resident #103's ordered [MEDICATION NAME] and [MEDICATION NAME] medications. The form instructed to, Please provide CMS REQUIRED patient-specific rationale describing why a GDR attempt is likely to impair function or cause psychiatric instability in this individual, and provided lines upon which the ra… | 2020-09-01 |
| 868 | 868 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 757 | D | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility failed to ensure medication regimens were free from unnecessary drugs for two (2) of five (5) residents. Resident identifiers: #73 and 31. Facility census: 117 Findings included: a) Resident #73 During an interview on 07/01/19 at 3:23 PM, the facility's Consultant Pharmacist (RPh) stated that the records did not have Resident #73 as having an allergy to [MEDICATION NAME]. While during a review of Resident #73's Progress Notes dated 01/26/19 found it to be stated the Resident is allergic to the antibiotic [MEDICATION NAME]. This statement is written on each of the Resident's Progress notes since he was admitted on [DATE]. At the end of Progress Note dated 05/22/19 the Nurse Practitioner (FNP) wrote Start [MEDICATION NAME] 500 mg po daily for 7 days . On the Medication Administration Record [REDACTED]. b) Resident #31 On 07/02/19 at 11:05 AM, Review of Resident #31's Medication Administration Record [REDACTED]. Diabetic [MEDICAL CONDITION] is a type of nerve damage that can occur if you have diabetes. It most often damages nerves in the legs and feet. The MAR indicated [REDACTED]. Both of these medications were also listed in the facility's Progress Notes. During an interview on 07/02/19 at 11:35 AM, the Director of Nursing (DON) confirmed the Resident had received a duplicate drug therapy from 05/03/19 through 05/22/19. | 2020-09-01 |
| 869 | 869 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 758 | D | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that Resident #103 and #73's drug regimens were free from unnecessary [MEDICAL CONDITION] drugs when they failed to perform Gradual Dose Reductions (GDRs) as required. This deficient practice was found for two (2) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #103, #73. Facility census: 117. Findings included: a) Resident #103 A review of Resident #103's medical record during the survey revealed that the facility's Consultant Pharmacist recommended via a Consultation Report form on 05/03/19 to attempt a gradual dose reduction (GDR) of Resident #103's ordered [MEDICATION NAME], a [MEDICAL CONDITION] medication. The form instructed to, Please provide CMS REQUIRED patient-specific rationale describing why a GDR attempt is likely to impair function or cause psychiatric instability in this individual, and provided lines upon which the rationale was to be written. The facility's Family Nurse Practitioner (FNP) signed the recommendation on 05/06/19 and indicated on the form that she declined to perform a GDR of Resident #103's [MEDICATION NAME] medication. No information was documented on the form's provided lines to explain the clinical rationale for the declination of the GDR of [MEDICATION NAME]. The lines had been left completely blank. Information regarding the clinical rationale was requested from the facility's Director of Nursing (DoN) on 07/01/19 at 9:43 AM. At 9:49 AM, the DoN provided a progress note written by the facility's FNP on 05/15/19 (nine (9) days after the [MEDICATION NAME] GDR was declined by the FNP), directing to continue providing the [MEDICATION NAME] as ordered due to behavioral issues. However, no documentation of behavioral issues was found in the medical record or in Resident #103's Minimum Data Set (MDS) assessments and no further information regarding behavioral issues was provided prior to the… | 2020-09-01 |
| 870 | 870 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 761 | E | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and medical record review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. Four (4) of seven (7) opened insulin pens located in the 200 hallway medication cart were not labeled with the dates the pens were opened. Resident identifiers: #46, #58, #86, and #36. Facility census: 117. Findings included: a) Facility task - medication storage and labeling On 06/26/19 at 9:13 AM, during inspection of the 200 hallway medication cart, four (4) of seven (7) insulin pens were noted to not be labeled with the dates the pens were opened. Specifically, the insulin pens were as follows: - [MEDICATION NAME]pen for Resident #46 - [MEDICATION NAME]pen for Resident #58 - [MEDICATION NAME] Flextouch insulin pen for Resident #86 - [MEDICATION NAME]pen for Resident #36 Licensed Practical Nurse (LPN) #29 confirmed the afore-mentioned insulin pens were not labeled with their opening dates. On 06/26/19 at 9:32 AM, the Administrator was notified four (4) insulin pens in the 200 hallway medication cart were not labeled when opened. She stated she would have these pens removed. | 2020-09-01 |
| 871 | 871 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 791 | D | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and medical record review the facility failed to ensure the necessary dental services were secured for a resident with broken teeth. This deficient practice was found for one (1) of three (3) residents reviewed for the dental care area. Resident identifier: #62. Facility census: 117. Findings included: a) Resident #62 On 06/24/19 at 12:16 PM, Resident #62 stated that one of her bottom teeth was bleeding. Upon observation, it was noted that Resident #62 was missing several of her top row of teeth. Resident #62 stated that she could not remember the last time she had been evaluated by a dentist. Record review during the survey found that Resident #62 was admitted to the facility on [DATE]. On 06/26/19 at 12:57 PM, the only document provided by the facility regarding Resident #62's dental care was reviewed. The document, a consultation report dated 08/08/18, stated, Pt. (patient) needs deep cleaning with curettage (a surgical procedure performed by a dentist, typically under anesthesia), also severed teeth and broken off roots need to be [MEDICATION NAME] down. On 06/26/19 at 3:10 PM, the facility's Director of Nursing (DoN) was asked to provide documentation that the necessary dental work written in the above consult was completed for Resident #62. At 4:56 PM, the DoN stated that this information could not be obtained because the dental office where Resident #62 was a patient was closed. No further information was provided prior to the end of the survey. | 2020-09-01 |
| 872 | 872 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 802 | E | 0 | 1 | LUON11 | Based on anonymous resident interviews, staff interview, observation, policy review, review of state regulations, and review of the facility's meal schedule the facility failed to ensure it had sufficient dietary staff available to serve meals to residents at a safe and palatable temperature and in a timely manner. This deficient practice was found during a random opportunity for discovery and had the potential to affect more than an isolated number of residents. Facility census: 117. Findings included: a) Anonymous Resident Interview During the survey, a resident stated that the facility food looked like vomit and was cold. b) Anonymous Resident Interview During the survey, a resident stated that the facility food was always cold. c) Anonymous Resident Interview During the survey, a resident stated that the facility coffee and food were not hot. d) Anonymous Resident Interview During the survey, a resident stated that their food was not hot upon receipt. e) Anonymous Resident Interview During the survey, a resident stated that the facility food was terrible. f) Anonymous Resident Interview During the survey, a resident tearfully stated that the facility food was nasty. The resident added that they would like to be knocked out before the food comes out because they were forced to watch everyone around them, including their roommate, eat their food before they were given the opportunity to eat their own food. This resident stated that they wanted their food to be hot and they wanted to receive it at the same time as the other residents. e) Anonymous Resident Interview During the survey, a resident described the facility food as sorry. This resident stated that the food was always cold and that the eggs were ice cold. f) Anonymous Resident Interview During the survey, a resident described the facility food as terrible, saying it was cold and inedible. g) Anonymous Resident Interview During the survey, a resident stated that the food was sometimes cold. They added that the food tasted bad and was sometimes inedible … | 2020-09-01 |
| 873 | 873 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 804 | E | 0 | 1 | LUON11 | Based on anonymous resident interviews, staff interview, observation, policy review, and state regulation review, the facility failed to serve food to residents at a safe and palatable temperature. This deficient practice was found during a random opportunity for discovery and had the potential to affect more than an isolated number of residents. Facility census: 117. Findings included: a) Anonymous Resident Interview During the survey, a resident stated that the facility food looked like vomit and was cold. b) Anonymous Resident Interview During the survey, a resident stated that the facility food was always cold. c) Anonymous Resident Interview During the survey, a resident stated that the facility coffee and food were not hot. d) Anonymous Resident Interview During the survey, a resident stated that their food was not hot upon receipt. e) Anonymous Resident Interview During the survey, a resident stated that the facility food was terrible. f) Anonymous Resident Interview During the survey, a resident tearfully stated that the facility food was nasty. The resident added that they would like to be knocked out before the food comes out because they were forced to watch everyone around them, including their roommate, eat their food before they were given the opportunity to eat their own food. This resident stated that they wanted their food to be hot and they wanted to receive it at the same time as the other residents. e) Anonymous Resident Interview During the survey, a resident described the facility food as sorry. This resident stated that the food was always cold and that the eggs were ice cold. f) Anonymous Resident Interview During the survey, a resident described the facility food as terrible, saying it was cold and inedible. g) Anonymous Resident Interview During the survey, a resident stated that the food was sometimes cold. They added that the food tasted bad and was sometimes inedible because it was either too hard or just nasty. h) Test Tray On 06/27/19 at 8:14 AM, a cart full of breakfast trays was d… | 2020-09-01 |
| 874 | 874 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 809 | E | 0 | 1 | LUON11 | Based on resident interview, staff interview, observation, and record review the facility failed to serve meals and snacks at a time consistent with regular meal times in the community. This deficient practice was found during a random opportunity for discovery and had the potential to affect more than an isolated number of residents. Resident identifiers: #107, #11, #20, #18, #55, #4, #56. Facility census: 117. Findings included: a) Meal Delivery During the survey, anonymous resident interviews revealed that meal delivery times were inconsistent and unreliable. A review of the facility's Meal Delivery Times schedule during the survey revealed that breakfast was to be delivered daily at 7:20 AM, lunch was to be delivered daily at 12:15 PM, and dinner was to be delivered daily at 5:15 PM. A disclaimer at the bottom of the schedule stated that meal times were approximate and may vary by a few minutes. An observation of the lunch time meal service on 06/26/19 began at 12:12 PM and concluded at 1:33 PM. At 12:12 PM there was not yet food in the main dining room, though there were numerous residents sitting at tables awaiting lunch. At 12:25 PM a drink cart was brought into the main dining room from the kitchen, but no food had been brought out yet. By 12:32 PM multiple residents had left the main dining room without receiving food. At 12:38 PM the first tray came out in the main dining room. At 1:06 PM the 400-hall's trays arrived on a cart along with a drink cart. At 1:28 PM it was observed that a medication pass had begun on the 300-hall, meaning that some residents would receive lunch and medications very close together if the trays arrived soon. At 1:33 PM Dietary Manager (DM) #121 arrived on the 300-hall with a meal cart. When asked why the cart was not delivered at 12:15 PM as scheduled, he stated that only the main dining room had to be served at 12:15 PM. He stated that there was another meal delivery schedule with different times for each unit that had not been shared with surveyors. A copy of the second mea… | 2020-09-01 |
| 875 | 875 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 812 | E | 0 | 1 | LUON11 | Based on observation, staff interview, and policy review, the facility failed to handle food and maintain equipment in a safe and sanitary manner. Equipment in the main kitchen was filthy, nourishment rooms had incomplete refrigerator temperature logs, outdated food was found in the kitchen, food was handled inappropriately by staff in the main dining room, and ice for residents was pre-poured and left uncovered on the 400-hall. These deficient practices were found during random opportunities for discovery and had the potential to affect more than an isolated number of residents. Resident identifier: #105. Facility census: 117. Findings included: a) Kitchen and Nourishment Rooms On 06/24/19 at 10:36 AM an initial tour of the facility's main kitchen began with Dietary Manager (DM) #121. The tour included both the facility's main kitchen and its two (2) resident nourishment rooms. The tour concluded at 11:11 AM. At 10:42 AM an open bottle of poultry seasoning in the dry storage area was found to have a written use by date of 06/03/19. At the time of the finding, DM #121 stated that he did not feel the seasoning had been used, even though it was open. When asked why it had a use by date written on it if it had never been used, DM #121 stated, I have no idea. I'll get rid of it. At 10:45 AM the inside of the kitchen's microwave was found to be splattered with congealed food. At 10:46 AM the juice machine was found to be splattered with juice above the nozzles and the nozzles were found to be covered in dried juice. The coffee machine was also found to have dried coffee running down the front as well as dried coffee on the nozzles. In response to these findings, DM #121 began cleaning kitchen equipment. At 10:48 AM eight (8) food carts used for meal service to residents were found in the kitchen. The carts were found to be dirty with food residue both inside and out as well as garbage inside some of them. This finding was shared with both DM #121 and Regional DM #129. They acknowledged that the carts were filthy and s… | 2020-09-01 |
| 876 | 876 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 842 | E | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** , Based on record review, resident interview and staff interview the facility failed to ensure that each residents record was complete and accurate. Resident #56's record was inaccurate in regards to location his blood pressure was obtained. For resident #78 the facility failed to document in the record about the residents fall. And for Resident #211 the facility did not complete Activities of Daily Living Documentation for multiple days after their admission to the facility. This was true for three (3) for 41 sampled residents. Resident Identifiers: #56, #78, and #211. Facility Census: 117. Findings Include: a) Resident #56 A review of Residents #56 medical record beginning at 3:11 p.m. on 07/01/19 found Resident #56 has an AV Fistula to his left arm and a physicians order for no blood pressures to be obtained in the left arm. An review of Resident #56's recorded blood pressures in the electronic medical record from 04/01/19 through present found on the following the facility documented Resident #56's blood pressure was obtained in his left arm: 04/01/19 at 8:31 p.m. 04/02/19 at 1:04 p.m. 04/03/19 at 8:27 p.m. 04/04/19 at 9:30 a.m. and 1:04 p.m. 04/05/19 at 4:12 p.m. 04/06/19 at 1:18 p.m. 04/07/19 at 1:13 p.m. 04/09/19 at 6:10 a.m. 04/18/19 at 8:41 p.m. 04/19/19 at 9:12 a.m. 04/20/19 at 2:20 p.m. 04/23/19 at 1:45 p.m. 04/25/19 at 5:03 p.m. 04/26/19 at 5:36 p.m. 04/27/19 at 3:18 p.m. 04/28/19 at 3:26 p.m. 04/30/19 at 3:05 p.m. and 8:32 p.m. 05/01/19 at 8:07 p.m. 05/02/19 at 8:14 p.m. 05/04/19 at 1:16 p.m. 05/07/19 at 8:41 p.m. 05/09/19 at 8:20 p.m. 05/13/19 at 9:46 a.m. 05/14/19 at 10:11 a.m. and 8:35 p.m. 05/17/19 at 8:09 p.m. 05/19/19 at 10:30 a.m. 05/21/19 at 8:11 p.m. 05/28/19 at 5:19 p.m. 05/31/19 at 7:31 a.m. 06/02/19 at 8:53 p.m. 06/03/19 at 8:46 p.m. 06/04/19 at 8:34 p.m. 06/07/19 at 9:13 a.m. 06/08/19 at 5:50 a.m. and 9:08 a.m. 06/22/19 at 5:30 a.m. and 10:25 p.m. 06/28/19 6:01 a.m. 06/30/19 at 12:35 a.m. An interview with Resident #… | 2020-09-01 |
| 877 | 877 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 867 | E | 0 | 1 | LUON11 | Based on record review, resident interview, staff interview and policy review, the Quality Assurance and Assessment (QA&A) committee failed to identify deficient practices of which they should have been aware of. The facility failed to ensure residents were free from abuse and neglect. The facility failed to ensure allegations of abuse/neglect were reported to the proper state agencies. The facility failed to ensure the required information was sent with residents at the time of discharge/transfer. The facility failed to ensure activities of daily living (ADL) care was provided. The facility failed to ensure residents were provided restorative therapy. The facility failed to ensure residents maintained proper nutrition. The facility failed to ensure sufficient staff with appropriate skill sets were available. The facility failed to ensure sufficient dietary staff were available. This practice has the potential to effect more than an isolated number of residents. Facility census: 117. Findings include: a) Cross reference deficiency findings at F660 b) Cross reference deficiency findings at F609 c) Cross reference deficiency findings at F623 e) Cross reference deficiency findings at F677 f) Cross reference deficiency findings at F688 g) Cross reference deficiency findings at F692 h) Cross reference deficiency findings at F725 i) Cross reference deficiency findings at F802 j) Interviews On 07/01/19 at 1:01 PM, the director of nursing (DON) was interviewed regarding the above deficient practices as the administrator was not available. At 4:42 PM on 07/01/19, the DON and the registered nurse corporate consultant returned and said they could find no verification that any of the above deficient practices were discussed in QA&A meetings. | 2020-09-01 |
| 878 | 878 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 880 | E | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect a limited number of residents. this was a random opportunity for discovery. Identified Resident #94 and #6 as well as the shower room on the 200 hall and the 300 hall. Facility census 117. Findings included: a) Resident # 94 During an observation of wound care on 06/26/19 at 9:46 AM, it was noted that Nurse Aide (NA) #59 left the room and did not wash her hands even after being reminded by Registered Nurse #28 to do so. On 06/26/19 at 10:02 AM, NA #59 return to residents' room with a pillow. She and RN #28 was asked if she should have washed her hands after she removed her gloves. NA #59 stated, that she should have and just got in a hurry. They agreed this was an infections control breech. b) Resident #6 During an observation of catheter care on 07/01/19 at 9:58 AM, Nurse Aide (NA) #38, failed to use a barrier on the floor while emptying the Foley catheter bag. She also failed to wipe the tip of the drainage spout before inserting into the protective sleeve. After the care was completed NA #38 stated, that she was unaware that, she should have used a barrier and wiped the tip of the drainage spout. On 07/01/19 at 10:07 AM, Director of Nursing was informed of observations. She had no comments. c) Shower room on the 200 hall On 06/30/19 at 9:50 PM, Licensed Practical Nurse (LPN) #71 verified that in the shower room on the 200 hall had dries fecal matter on the floor and it had been walked in. She stated, that she has no idea how long that had been there, because on one received a shower today. She stated, that housekeeping left at 2:30 PM, today. On 07/01/19 at 8:45 AM, Account Manager of housekeeping was asked if the shower floor on the 200 hall was cleaned on 06/29/19 and 06/30/19. S… | 2020-09-01 |
| 1254 | 1254 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2019-07-02 | 689 | E | 1 | 0 | 06LV11 | > Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which it had control. The facility did not secure a hot steam table, chemicals, a box cutter, an oxygen tank, and shaving razors, from residents. Room identifiers: West Hall Respiratory Room, West Hall Shower Room, East Hall Shower Room, and the Transitional Care Dining Room. Facility census: 96. Findings included: a) Transitional Care Dining Room An observation of the Transitional Care Dining Room, on 7/01/19 at 9:20 AM, revealed the room had an unsecured steam table with multiple bins. No staff or residents were present at the time of the observation. The room and the area where the steam table was located is on a resident hallway and is accessible to anyone at any time. One of the steam bins was hot to touch and was observed to be filled with approximately two inches of water. The water was also hot. The water was tested to be 125 degrees Fahrenheit with both the facility's and surveyor's thermometers. The controls for the steam table were underneath the table in an unsecured cabinet. One of the steam table's controls was set on level 4 heat. The dial has an off setting along with 1 through 7, with 7 being the hottest setting. The steam table could be reached from a sitting or standing position. An immediate interview with the Administrator, on 07/01/19 at 9:30 AM, revealed that he could not explain why the steam table was heated. The Administrator immediately turned the steam table control to off. The Administrator stated I am not sure why there is water in the steam table bin. The Administrator verified the Transitional Care Dining Room is open to anyone at any time. The Administrator stated the heating controls for the steam table have never been locked. The Administrator verified anyone can turn the heat on and off for the steam table. An interview with the Dietary Aide (DA) #1, on 07/01/19 at 10:20 AM, revealed she had turned the steam table on at 9:00 AM in the Transitional Care Dinin… | 2020-09-01 |
| 1255 | 1255 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2019-07-02 | 842 | D | 1 | 0 | 06LV11 | > Based on medical record review and staff interview, the facility failed to maintain complete and accurate medical records. A resident's Medication Administration Record [REDACTED]. This practice affected one (1) of six (6) residents reviewed. Resident identifier: #6. Facility census: 96. Findings included: a) Resident #6 A review of the Resident's medical record, on 07/01/19 at 1:15 PM, revealed Medication Administration Records (MARs) with no dates as to which month the record was for. An interview with the Director of Nursing (DON), on 07/02/19 at 8:00 AM, revealed the MARS were for (MONTH) of 2019. The DON stated I have no idea why these are not dated. The DON stated she would ensure the records were dated accurately. | 2020-09-01 |
| 1256 | 1256 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2019-07-02 | 880 | E | 1 | 0 | 06LV11 | > Based on observation, medical record review, staff interview, and policy review, the facility failed to provide a safe and sanitary environment that prevented the development and transmission of communicable diseases and infections. A resident on contact precautions did not have a sign on the door advising anyone entering the room to stop and to see the nurse before doing so. This was a random observation. Resident identifier: #7. Facility census: 96. Findings included: a) Observation A random observation of the East Hallway, on 07/01/19 at 8:55 AM, revealed an isolation cart outside the door of Resident #7. There was no sign on the door advising anyone what to do before entering the room. b) Interview An interview with Licensed Practical Nurse (LPN) #2, on 07/01/19 at 8:58 AM, revealed Resident # 7 is on contact precautions. The LPN stated there should be a stop sign on the door advising anyone entering the room to see the nurse. The LPN obtained a sign from the isolation cart by the room and posted it on the door. c) Record Review A medical record review for Resident #7, on 07/01/19 at 11:00 AM, revealed the Resident had the physician order Contact Precautions dated 06/29/19. d) Policy Review A review of the facility policy IC301 Contact Precautions with a revision date 06/15/19, was conducted on 07/01/19. The policy stated Place a STOP-Please see nurse before entering the room sign on the door for residents on contact precautions. | 2020-09-01 |
| 2938 | 2938 | LOGAN CENTER | 515175 | 55 LOGAN MINGO MENTAL HEALTH CENTER ROAD | LOGAN | WV | 25601 | 2019-07-02 | 732 | C | 1 | 0 | 42VZ11 | > Based on record review and staff interview, the facility failed to post complete and accurate staffing information as required by regulation. This practice had the potential to minimally affect more than a limited number of residents. Facility census: 66. Findings included: a) Staff posting During review of the daily staff posting for 05/29/19 showed there were no registered nurses working on this day. A interview with the scheduler on 07/01/19 at 2:10 p.m. revealed there were three nurses working on 05/29/19. The posting was inaccurate for the number of registered nursing working on 05/29/19. A staff posting form dated 06/13/19 indicated three registered nurses were on duty. Interview with the scheduler on 07/01/19 at 1:57 pm revealed compared to the actual schedule there were two nurses present. The staff posting was inaccurate as to the number of registered nursing working on 07/01/19. | 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 );