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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid ▼ | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3400 | 3400 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 755 | D | 0 | 1 | 0LCE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure medications were available for one (1) of nine (9) residents reviewed for unnecessary medications. The facility failed to have available a physician's orders [REDACTED].#153. Resident identifier: #153. Facility census: 108. Findings include: a) Resident #153 Medical record review found the resident was admitted to the facility on [DATE]. The resident was admitted with the antibiotic [MEDICATION NAME], 3 grams, intravenously, every 6 hours, with the last dose to be administered on 02/15/19 at 6:00 PM. There was no diagnosis listed on the MAR for the use of the antibiotic. The resident's admitting [DIAGNOSES REDACTED]. Review of the nursing notes found the resident's admission assessment was completed at 1:30 PM on 01/17/19. Further review of the medication administration record (MAR) found the [MEDICATION NAME] was not administered on 01/17/19 or 01/18/19. The first dose of [MEDICATION NAME] was administered at 6:00 AM on 01/19/19. On 01/31/19 at 09:10 AM, the Director of Nursing said she was unaware of the above situation. She said most likely the antibiotic was ordered for the infection to his foot. She said she assumed the medication wasn't available. The DON reviewed the MAR and confirmed the antibiotic was not administered as directed by the physician. At 9:47 AM on 01/31/19, the residents nurse, Registered Nurse #76 said she guessed the medication wasn't available to administer. | 2020-09-01 |
| 3401 | 3401 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 757 | E | 0 | 1 | 0LCE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure residents were free from unnecessary medications. This was true for two (2) of nine (9) residents reviewed for the care area of unnecessary medications. Resident #72 received an incorrect dosage of Vitamin B-12. Resident #96 had incorrect indications documented for medication use. Resident identifiers: #72, #96. Facility census: 108. Findings include: a) Resident #72 Morning medication pass was observed for Resident #72 on 01/30/19 at 7:20 AM. The medication pass was performed by Licensed Practical Nurse (LPN) #4. Resident #72's Medication Administration Record [REDACTED]. The order had been typed on the MAR. The words take 2 had been underlined in pen. The words 200 mcg had also been handwritten on the MAR. LPN #4 noticed the multi-use bottle of Vitamin B-12 located in the medication cart was 1000 mcg strength per tablet. After administering the rest of the medications to Resident #72, LPN #4 went to the medication supply room to obtain 100 mcg tablets of Vitamin B-12. LPN #4 returned from the medication supply room and stated Vitamin B-12 was not available in 100 mcg strength tablets. She stated she would clarify the order with Resident #72's physician. Review of Resident #72's physician orders [REDACTED]. During an interview on 01/30/19 at 11:19 AM, the Director of Nursing was informed Resident #72's MAR gave instructions for Vitamin B-12 200 mcg to be administered although the physician's orders [REDACTED]. The Director of Nursing was informed it appeared Resident #72 received 2000 mcg of Vitamin B-12. Vitamin B-12 is not available in 100 mcg strength tablets. The Vitamin B-12 tablets located in the medication cart were 1000 mcg strength. It appeared that two (2) tablets were administered because the words take 2 had been underlined in pen and the words 200 mcg had been handwritten on the MAR. The DoN had no further information regarding the matter. b) Resid… | 2020-09-01 |
| 3402 | 3402 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 758 | D | 0 | 1 | 0LCE11 | **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 nine (9) residents reviewed for the care area of unnecessary medications was free from [MEDICAL CONDITION] medications. Resident #28 received extra doses of the antipsychotic medication, [MEDICATION NAME], in absence of a physician's orders [REDACTED]. Resident identifier: 28. Facility census: 108. Findings include: a) Resident #28 Medical record review found the resident was admitted to the facility, from the hospital, on 11/08/18. Upon admission the resident was receiving [MEDICATION NAME] 1 milligram three times a day (TID). The facility did not have a [DIAGNOSES REDACTED]. On 12/27/18, the physician discontinued the [MEDICATION NAME] 1 mg. TID and started; [MEDICATION NAME] 1 mg. twice a day (BID), for 7 days; Then [MEDICATION NAME] 1 mg. daily for another 7 days, then discontinue the medication. On 01/01/19, the old order to give [MEDICATION NAME] 1 mg. TID was copied onto the MAR. The nursing staff administered [MEDICATION NAME], 1 mg. TID on 1/1/19 instead of the physician's orders [REDACTED]. BID. On 01/29/19 at 2:59 PM, the Director of Nursing (DON) confirmed the resident did not have a physician's orders [REDACTED]. of [MEDICATION NAME] TID on 01/01/19, she said the order was only for [MEDICATION NAME] 1 mg. BID. The DON said someone copied the old order, realized they made a mistake and then discontinued the order on 01/02/19. The DON said the facility physician was discontinuing the medication because the reason the medication was started at the hospital was unclear. | 2020-09-01 |
| 3403 | 3403 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 761 | D | 0 | 1 | 0LCE11 | The facility failed to ensure medications used in the facility were labeled in accordance with currently accepted professional principles. Three (3) of three (3) of Resident #72's metered-dose inhaler medications were not labeled with the dates the inhalers were opened. Resident identifier: #72. Facility census: 108. Findings include: a) Resident #72 Morning medication pass was observed for Resident #72 on 01/30/19 at 7:20 AM. The medication pass was performed by Licensed Practical Nurse (LPN) #4. Resident #72 had orders for the following metered-dose inhaler medications: [REDACTED]. The Breo inhaler stated the inhaler should be discarded within six (6) weeks of opening. LPN #4 confirmed Resident #72's inhalers were not dated when opened. She stated facility practice was to date medication, including inhalers, with the date the medication was opened. During an interview on 01/30/19 at 11:19 AM, the Director of Nursing (DoN) was informed Resident #72's three (3) metered-dose inhaler medications were not dated to indicate when the inhalers were opened. The DoN had no additional information regarding the matter. | 2020-09-01 |
| 3404 | 3404 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 777 | D | 0 | 1 | 0LCE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to ensure radiology testing was preformed when ordered by the physician. Resident #153 was ordered an ultrasound to be performed immediately. The ultrasound was never obtained. This was true for one (1) of three (3) residents reviewed for a change in condition. Resident identifier: #153. Facility census: 108. Findings include: a) Resident #153 At approximately 12:30 PM on 01/28/19, the resident's responsible party (RP) said the residents, private parts, were very swollen. The RP said she didn't know what the facility was doing about the situation or what was causing the problem. Review of the nurses noted, dated 01/26/19 at 1:29 PM, found the resident had a, [MEDICAL CONDITION] scrotum. Review of the physician's orders [REDACTED].>STAT used as a directive to medical personnel during in an emergency situation, is from the Latin word statim, which means instantly or immediately. On 01/29/19 at 9:19 AM, Registered Nurse (RN), Risk Manager #69 said, I don't know where the results of the ultrasound are. At 11:05 AM on 01/31/19, the Registered Nurse, Minimum Data Set Coordinator, #11 confirmed the ultra sound had never been obtained. At 1:29 PM on 01/31/19, the Regional Clinical Nurse Consultant was unable to find the results of the ultrasound ordered on [DATE]. | 2020-09-01 |
| 3405 | 3405 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 791 | D | 0 | 1 | 0LCE11 | Based on observation, resident interview, medical record review, and staff interview, the facility failed to ensure that dental services were provided to a resident with dental complaints. This was true for one (1) of three (3) residents reviewed for dental care. Resident identifier: #3. Facility census: 108. Findings included: a) Resident #3 During an interview on 01/31/19 at 10:38 AM, Resident #3 stated that his teeth were infected. Resident #3 then opened his mouth to reveal that he was missing many teeth. Resident #3's remaining bottom row teeth appeared broken and discolored. Resident #3 stated that his bottom left tooth had been scratching his tongue and causing him pain. He also said that his dental problems were causing him to have difficulty with chewing food. He stated that he would like to keep his two (2) front teeth, but have the remaining teeth extracted due to his discomfort. He added that he had told staff about his dental discomfort, but the facility had not helped him obtain a dental consult. A review of Resident #3's care plan was conducted during the survey. The dental portion of the care plan revealed the following problem: Dental or oral cavity health problems related to possible carious teeth. The care plan goals associated with this problem were, Will be able to eat and drink free of pain, Will have no bleeding from gums, Will have no swelling/inflammation outcomes, and Will maintain good oral hygiene. Care plan interventions included the following: Refer to dentist/hygienist for evaluation/recommendations regarding denture realignment, new fitting, teeth extraction, repair of carious teeth, and Report changes in oral cavity, chewing ability, signs and symptoms of oral pain, etc. A review of Resident #3's Minimum Data Set (MDS) assessments was also conducted during the survey. Resident #3's annual MDS assessment with an Assessment Reference Date (ARD) of 07/14/18 had triggered the dental care portion of Section V, requiring a Care Area Assessment (CAA) to be completed by staff. The followi… | 2020-09-01 |
| 3406 | 3406 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 803 | E | 0 | 1 | 0LCE11 | b)Resident #43 During an interview on 01/28/19 at 11:30 AM, Resident #43 said his breakfast was and the portions were very small. He went on to say that he really like bacon, but only gets a half of a slice of bacon. During an interview and observation on 01/29/19 at 8:33 AM, Resident # 43 received his breakfast tray, which consisted of two (2) muffins and small scoop of scrambled eggs, no bacon which was on the menu to be served. Resident # 43 stated his food was not warm. During an interview on 01/29/19 at 2:30 PM, with Consultant Detain and Kitchen Manager # 28 they were asked about the portion sizes of bacon. The print out that was provided read that a regular diet was one (1) slice, and a large portion was two (2) slices. Consultant Detain stated that Resident #43 was to get a large portion. They were asked if they were aware that on 01/29/19 he did not get any bacon or any other meat in place of it. They did not provide any further information. The facility failed to follow the menu and/or provide an alternative to not serving a complete breakfast meal plan. Based on observation, resident interview, and staff interview, the facility failed to ensure that food was served per facility menus and in the correct portion sizes. This deficient practice had the potential to affect more than an isolated number of residents. Resident identifier: #43. Facility census: 108. Findings included: a) The Kitchen On 01/28/19 during dining observations, portion sizes appeared small. On 01/31/19 at 11:45 AM, an observation of the lunchtime tray line began in the kitchen. Cook #24 was observed placing a pair of tongs in a container of barbecue meat on the tray line. Cook #24 then began using the tongs to transfer the barbecue meat from the container to sandwich buns for service. Several observations of this tong use were completed and the serving size of the barbecue meat appeared to vary each time. Due to the use of the tongs, it was impossible to tell if each tray was receiving a full portion of the meat. On 01/31/19 at 11:50… | 2020-09-01 |
| 3407 | 3407 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 804 | E | 0 | 1 | 0LCE11 | Based on observation, resident interview, and staff interview, the facility failed to serve food at temperatures appealing to the residents. Hot foods and cold foods were not served at preferable temperatures for residents. This had the potential to affect more than an isolated number of residents. Facility census: 108. Findings include: a) Resident interviews Anonymous interviews with residents found complaints of hot foods not being hot and cold foods not being cold at the time of service. b) Food temperatures At 7:01 PM on 01/29/19, food temperatures were obtained by the dietary manager from the last tray to be served on the 300 hallway. The pureed meal temperatures are as follows: Scrambled eggs 100 degrees Hot cereal 129.7 degrees, Sausage 105.8 degrees Milk 53.6 degrees Juice 55 degrees At 8:15 AM on 1/29/19, the following temperatures were obtained from the last tray to be served on the 200 hallway: Scrambled eggs 99.6 degrees, Bacon 93.5 degrees, Milk 57.8 degrees, Coffee 134.7 degrees, Orange juice 54 degrees. The dietary manager said the milk and juice were definitely too warm. He would have preferred the scrambled eggs, sausage, and bacon to be warmer. c) Resident council meeting Anonymous interviews with the residents at 2:00 PM on 01/30/19, found complaints of cold foods being served. | 2020-09-01 |
| 3408 | 3408 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 835 | E | 0 | 1 | 0LCE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and staff interview, the facility failed to provide laboratory services to meet the needs of four of four residents who received anticoagulation therapy ([MEDICATION NAME]). The facility had no effective tracking methodology to ensure laboratory (lab) studies were obtained timely and correctly. This practice had the potential to affect all residents receiving [MEDICATION NAME] therapy placing them at serious risk for harm. Additionally, the facility failed to ensure care was provided in accordance with professional standards of care related to Peripherally Inserted Central Catheter (PICC) line care for Resident #72. Resident identifiers: #72, #101, #47, #37. Facility census: 108. Findings included: a) Resident #72 On 11/30/18, Resident #72's physician wrote an order for [REDACTED].#72's medical records demonstrated that INR testing was not performed on the following dates: 12/21/18, 12/25/18, 12/26/18, and 12/30/18. On 01/17/19, Resident #72's physician changed the order from daily INR testing to weekly PT/INR testing. Review of Resident #72's medical records demonstrated that PT/INR testing was last performed on 01/16/18. On 01/30/19 at 1:33 PM, Registered Nurse (RN) #13 confirmed INR testing had not been performed for Resident #72 on 12/21/18, 12/25/18, 12/26/18, and 12/30/18. RN #13 also confirmed Resident #72 had not had PT/INR testing since 01/16/19. He stated stat PT/INR testing would be performed. On 01/29/19, this surveyor requested the facility's Director of Nursing (DoN) to provide a copy of Resident #72's Medication Administration Record [REDACTED]. Resident #72's central line was a peripherally inserted central catheter (PICC) line inserted in his arm for intravenous antibiotics and fluid. The MAR indicated [REDACTED]. The dates 01/11/19 through 01/21/19 had either nurse initials or check marks for this order. The dates 01/21/19 through 01/24/19 and 01/26/19 through 01/28/19 containe… | 2020-09-01 |
| 3409 | 3409 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 842 | E | 0 | 1 | 0LCE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record for two (2) of 31 residents reviewed during the long-term care survey process. Resident #72's medical record was completed late, but not specified as completed late. Resident #68's medical record was illegible. Resident identifiers: #72, #68. Facility census: 108. Findings include: a) Resident #72 On 01/29/19, this surveyor requested the facility's Director of Nursing (DoN) to provide a copy of Resident #72's Medication Administration Record [REDACTED]. Resident #72's central line was a peripherally inserted central catheter (PICC) line inserted in his arm for intravenous antibiotics and fluid. The MAR indicated [REDACTED]. The dates 01/11/19 through 01/21/19 had either nurse initials or check marks for this order. The dates 01/21/19 through 01/24/19 contained no notations. The date 01/25/19 had a check mark. The dates 01/26/19 through 01/28/19 contained no notations. On 01/31/19 at 8:48 AM, Licensed Practical Nurse (LPN) #72 and #64 were interviewed regarding Resident #72's PICC line care. This surveyor noticed additional check marks had been placed on the MAR for the order, Change positive pressure cap(s) every 72 hours and as needed with each catheter change. The dates 01/21/19 through 01/24/19 and 01/26/19 through 01/28/19 now contained check marks, when they previously did not. A copy of the updated MAR indicated [REDACTED]. During an interview on 01/31/19 at 9:18 AM, the Director of Nursing and Regional Nurse Consultant were shown additional check marks had been made on Resident #72's MAR between the time the MAR indicated [REDACTED]. The Director of Nursing and Regional Nurse Consultant had no further information regarding the matter. b) Resident #68 Resident #68's Medication Administration Record [REDACTED]. A [MEDICATION NAME] is a method to check the blood glucose level by obtaining a drop of blood from the reside… | 2020-09-01 |
| 3410 | 3410 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 867 | E | 0 | 1 | 0LCE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy/procedure review, the facility's Quality Assurance and Process Improvement (QAPI) committee failed to develop, revise, and/or implement corrective plans of action for quality deficiency issues of which they had knowledge or should have had knowledge. The facility failed to ensure residents receiving the anticoagulant [MEDICATION NAME] had [MEDICATION NAME] (PT) and International Normalized Ratios (INR) completed as ordered. Four of four residents currently receiving [MEDICATION NAME] did not have PT/INR completed as ordered by the physician. Resident identifiers: #72, #101, #37, #47. Facility census: 108. Findings include: a) On 01/31/19 at 2:43 PM and interview with the facility Administrator confirmed she was the person responsible for the Quality Assurance and Process Improvement (QAPI) Committee. It was reported, all departments are included in the monthly meetings. The Administrator acknowledged they were aware of the concerns related to the machines the facility utilized to tests residents' blood for [MEDICATION NAME] (PT) and International Normalized Ratio (INR) testing. The Administrator agreed the QAPI committee should have known the blood tests were not being done as ordered. She acknowledged there was a failure to follow up after changes were implemented and new testing equipment was obtained. The QAPI policy with a revision date of 03/14/15, states under the section titled: Performance Improvement Projects (PIPs): The facility conducts Performance Improvement Projects (PIPs) to examine and improve care or services in areas that are identified as needing attention. A PIP project typically is a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information systemically to clarify issues or problems, and intervening for improvements . Section two under the Committee Audit Process states: The Quality Assurance Process Impro… | 2020-09-01 |
| 3411 | 3411 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 868 | C | 0 | 1 | 0LCE11 | Based on facility record review and staff interview, the facility failed to ensure the Quality Assurance and Process Improvement (QAPI) Committee is composed of the required committee members. The Medical Director or his designee failed to attended the QAPI Committee meetings at least quarterly. This has the potential to affect all residents. Facility census 108. Findings include: a) The facility Administrator presented the QAPI sign in sheets for the months of September, October, November, (MONTH) (YEAR) and (MONTH) 2019, on 01/31/19. The sign in sheets were dated 09/27/19 (should have been 09/27/18), 10/25/18, 11/30/18, 12/27/18, and 01/25/19. Further review of the sign in sheets revealed the Medical Director only attended the QAPI meeting once in five months, on 10/25/18. No other physician signatures were identified. On 01/31/19 at 2:43 PM and interview with the facility Administrator confirmed she was the person responsible for the Quality Assurance and Process Improvement (QAPI) Committee. The Administrator reported the QAPI meeting is held monthly and attended by all departments. The Administrator reviewed the sign in sheets and confirmed the Medical Director had only signed the QAPI attendance record on 10/25/18. Once in five months, not quarterly. | 2020-09-01 |
| 3412 | 3412 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 880 | F | 0 | 1 | 0LCE11 | Based on observation, staff interview, and policy review, the facility failed to maintain an effective Infection Prevention and Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infections. The laundry room lacked separation between the clean and soiled area to prevent cross contamination of linen and resident clothing. Staff could not determine the existence of a negative air flow from the clean area to the dirty section. Respiratory equipment was not covered and/or stored properly. Wound care supplies were stored directly on the floor. Staff contaminated medications containers during med administration and a urinary catheter bag rested directly on the floor. This practice has the potential to affect all residents. Resident identifiers: #101, #55, #66, #81, #153, #25. Facility census: 108. Findings included: a) a) Observation of the laundry room on 01/31/19 at 10:00 AM, in the presence of the Maintenance Supervisor #115, and the laundry staff, revealed the following: --No separation between the soiled and clean linen areas --No identified negative airflow from the clean to soiled areas --Multiple cracked, chipped and stained floor tiles in front of the washing machines During this observation, Maintenance Supervisor (MS) #115 acknowledged the laundry room lacked separation between the clean and soiled areas and noted the facility has been cited in the past for not having a negative airflow in the laundry room. MS #115, agreed the floor tiles were in disrepair. b) Resident #101 During an observation on 01/28/19 at 12:48 PM, a Nebulizer (tubing used for a breathing treatment that goes in the Resident's mouth) was not in a bag to after being used to prevent the potential spread of infection. On 01/28/19 at 12:50 PM, Licensed Practical Nurse (LPN) #12 was notified and she stated that she will replace the Nebulizer. c) Resident #55 During an interview on 01/28/19 at 11:44 AM, Resident # 55 states she is supposed to wear oxygen at ni… | 2020-09-01 |
| 8120 | 8120 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2013-10-24 | 225 | B | 1 | 0 | 0LWM11 | Based on a review of the abuse/neglect reportable allegations, the abuse/neglect reporting policy, staff interview, and review of complaint files, the facility failed to ensure seven (7) of ten (10) complaints were identified as allegations of abuse and/or neglect and reported to the appropriate outside agencies in accordance with state law. The facility investigated the complaints, but did not recognize them as allegations of abuse/neglect which required reporting to outside agencies. Resident identifiers: #59, #21, #84, #66, #37 #6, and #83. Facility census: 77. Findings include: a) Resident # 59 On 06/10/13, a complaint/concern/grievance/request form for Resident #59 stated, Daughter (name) complained that resident does not receive toileting assistance quickly enough. Stated that mom will proceed to the toilet on her own. Also complained that mother is not being offered continental breakfast. Concerned about inadequate staffing. b) Resident #21 A complaint/concern/grievance/request form for Resident #21, dated 08/06/13, stated 1.) Daughter complained that bed/mattress was noticeably dirty with dried food and also smelled of urine. 2.) Daughter also voiced concern about nursing unit being out of basic supplies like wipes, gloves, and disposable briefs. c) Resident #84 On 09/05/13, Resident #84 complained that her p.m. (night) medicines were given at 11:30 p.m., after her son had to call the facility. d) Resident #66 Resident #66 complained of not receiving baths as scheduled; being told by staff too busy. e) Resident #37 The resident's sister complained that Resident #37 is not warm enough in bed, and has told her she gets cold. The resident's sister believes this is because staff will leave Resident #37 in a thin gown instead of putting pants on her every day in bed as requested. She also believes staff does on provide Resident #37 with the use of a bedpan. The facility received the complaint on 10/02/13. f) Resident #6 Resident #6 complained that aides were not changing her at night every two (2) hours and nu… | 2016-10-01 |
| 9442 | 9442 | DAWN VIEW CENTER | 515163 | DIANE DRIVE, PO BOX 686 | FORT ASHBY | WV | 26719 | 2011-04-07 | 279 | D | 0 | 1 | 0M0411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to adequately address the needs of a [MEDICAL TREATMENT] resident in her comprehensive care plan to provide the necessary care to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being by: not including the name and contact information of the [MEDICAL TREATMENT] center; not addressing the resident's nutritional needs on days of [MEDICAL TREATMENT], and not including transportation arrangements to the [MEDICAL TREATMENT] center for one (1) of twenty-eight (28) Stage II sample residents. Resident identifier: #77. Facility census: 60. Findings include: a) Resident #77 A review of the medical record revealed Resident #77 was a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Her admission orders [REDACTED]@ [MEDICAL TREATMENT] Mondays & Thursdays @ 7am and enteral tube feeding instructions which stated: Vital 1.5 via pump @ 30ml/hr continuous X 24 hrs/day. No downtime. A later order given by the physician allowed the tube feeding to be suspended while the resident was receiving her outpatient [MEDICAL TREATMENT] treatments. A review of her comprehensive care plan, established on 11/26/10, included a Focus area stating: Resident exhibits or is at risk for complications related to [MEDICAL TREATMENT] M - TH (Monday - Thursday). The interventions did not identify the [MEDICAL TREATMENT] center or contain any emergency contact information. They also failed to identify transportation arrangements, and there were no instructions for suspending the tube feedings on the days of [MEDICAL TREATMENT]. During an interview at the south nurses' station at 3:00 p.m. on 04/06/11 with the director of nurses (DON - Employee #50) and the assistant director of nurses (ADON - Employee #36), the DON was asked to show in the medical record the name of the [MEDICAL TREATMENT] center, contact information, and … | 2015-11-01 |
| 9443 | 9443 | DAWN VIEW CENTER | 515163 | DIANE DRIVE, PO BOX 686 | FORT ASHBY | WV | 26719 | 2011-04-07 | 285 | D | 0 | 1 | 0M0411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the needs of residents with mental illness and/or mental [MEDICAL CONDITION] for specialized services were identified prior to admission, as required, for two (2) of twenty-eight (28) Stage II sample residents. Resident identifiers: #38 and #88. Facility census 60. Findings include: a) Resident #38 Medical record for Resident #38 revealed this resident was initially admitted to the facility on [DATE], but the need for a Level II evaluation of mental illness and/or mental [MEDICAL CONDITION] was not made until 03/03/11, as recorded on the PASARR Title I Mental Health Determination. b) Resident #88 Medical record for Resident #88 revealed this resident was initially admitted to the facility on [DATE], but the need for a Level II evaluation of mental illness and/or mental [MEDICAL CONDITION] was not made until 03/30/11, as recorded on the PASARR Title I Mental Health Determination. c) During an interview with the social worker at 3:30 p.m. on 04/06/11, he acknowledged these residents were admitted to the facility prior to receiving feedback on the need for Level II evaluations. | 2015-11-01 |
| 9444 | 9444 | DAWN VIEW CENTER | 515163 | DIANE DRIVE, PO BOX 686 | FORT ASHBY | WV | 26719 | 2011-04-07 | 309 | D | 0 | 1 | 0M0411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to adequately address the care and safety needs of a [MEDICAL TREATMENT] resident, by not including the name and contact information of the [MEDICAL TREATMENT] center in the medical record (or in the immediate vicinity of the nurses' station), for easy access in the event of an emergency situation, for one (1) of twenty-eight (28) Stage II sample residents. Resident identifier: #77. Facility census: 60. Findings include: a) Resident #77 A review of the medical record revealed Resident #77 was a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Her admission orders [REDACTED]@ [MEDICAL TREATMENT] Mondays & Thursdays @ 7am. A review of the medical record and care plan failed to find the [MEDICAL TREATMENT] center's contact information readily available for use by the nursing staff in the event of an emergency. During an interview at the south nurses' station at 3:00 p.m. on 04/06/11 with the director of nurses (DON - Employee #50) and the assistant director of nurses (ADON - Employee #36), the DON was asked to show in the medical record the name of the [MEDICAL TREATMENT] center, contact information, and transportation information. [MEDICAL TREATMENT] notes were on an untitled form. The physician's order did not state name of [MEDICAL TREATMENT] center, although the DON did know the name. Neither she nor the ADON could not locate this information. Neither knew contact information but said they could find it with time. They both agreed this information was not in the resident's care plan or elsewhere in the medical record and that prominently displayed contact information was needed. | 2015-11-01 |
| 9445 | 9445 | DAWN VIEW CENTER | 515163 | DIANE DRIVE, PO BOX 686 | FORT ASHBY | WV | 26719 | 2011-04-07 | 332 | D | 0 | 1 | 0M0411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure it was free of medication error rates of five percent (5.0%) or greater, affecting one (1) of eleven (11) residents observed during medication pass. Resident identifier: #90. Facility census: 60. Findings include: a) Resident #90 During a medication pass at 8:40 a.m. on 04/07/11, a licensed practical nurse (LPN - Employee #51) was observed administering medications to Resident #90. Among these were the following, all of which intended for the treatment of [REDACTED]. 1. [MEDICATION NAME] 12.5 mg PO (by mouth), 2. [MEDICATION NAME] 5 mg PO, and 3. [MEDICATION NAME] 5 mg PO. A review of the physician's orders [REDACTED]. At 8:55 a.m. on 04/07/11, Employee #51, when asked if she had checked the resident's BP prior to administering the medications, stated that she had. She looked at the resident's Medication Administration Record [REDACTED]. When informed that this was below the physician-ordered parameters for administration of these medications, Employee #51 reviewed the orders and acknowledged she had made an error by not holding these three (3) medications. The three (3) errors, out of a total observation of fifty-four (54) opportunities for error, resulted in a 5.5% medication error rate. This is above the required 5.0% error rate. During an interview with the administrator, director of nurses, and the assistant director of nurses at 1:15 p.m. on 04/07/11, they were notified of the above findings. There was no comment. | 2015-11-01 |
| 9446 | 9446 | DAWN VIEW CENTER | 515163 | DIANE DRIVE, PO BOX 686 | FORT ASHBY | WV | 26719 | 2011-04-07 | 333 | D | 0 | 1 | 0M0411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to assure one (1) of eleven (11) residents, observed during passing of medications, received three (3) antihypertensive medications in accordance with physician's orders [REDACTED]. The type of medications administered in error, and the potential for an adverse effect to the resident's health status, resulted in each of these errors being considered a significant medication error. Resident identifier: #90. Facility census: 60. Findings include: a) Resident #90 During a medication pass at 8:40 a.m. on 04/07/11, a licensed practical nurse (LPN - Employee #51) was observed administering medications to Resident #90. Among these were the following, all of which intended for the treatment of [REDACTED]. 1. [MEDICATION NAME] 12.5 mg PO (by mouth), 2. [MEDICATION NAME] 5 mg PO, and 3. [MEDICATION NAME] 5 mg PO. A review of the physician's orders [REDACTED]. At 8:55 a.m. on 04/07/11, Employee #51, when asked if she had checked the resident's BP prior to administering the medications, stated that she had. She looked at the resident's Medication Administration Record [REDACTED]. When informed that this was below the physician-ordered parameters for administration of these medications, Employee #51 reviewed the orders and acknowledged she had made an error by not holding these three (3) medications. She then rechecked the resident's BP and notified the physician, who ordered the resident's BP to be monitored. The resident, due to her post-operative status, also received pain medication ([MEDICATION NAME]) when requested and an anti-anxiety drug ([MEDICATION NAME]) when requested, both of which had the side effect of lowering blood pressure, making the need for BP monitoring very important. Because each of the medications administered by the LPN was from the category of medications with a primary action of lowering blood pressure (resulting in a high potential for an adverse eff… | 2015-11-01 |
| 87 | 87 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-12-18 | 583 | E | 1 | 0 | 0M5911 | > Based on observation and staff interview, the facility failed to protect the personal privacy of residents including personal and medical information. Documents containing personal and medical information for multiple residents were left unattended on a medication cart and in a staff bathroom. Personal identifiers including residents' names, date of births, social security numbers, phone numbers, addresses, medications, diagnoses, and other health information were accessible. This was a random observation. This practice affected eight (8) residents. Resident identifiers: #11, #12, #13, #14, #15, #16, #17, and #18. Facility census: 144. Findings include: a) Medication Cart A random observation on 12/18/17 at 9:45 a.m., on the 800 Wing, revealed Resident #11's Pre-Admission Screening form was left on a medication cart uncovered and unattended. The Pre-Admission Screening form contained the following personal information: --Resident's name --Resident's address --Resident's phone number --Resident's Social Security Number --Resident's date of birth --Resident's Medicare Number An interview with Licensed Practical Nurse (LPN) #2, on 12/18/17 at 9:50 a.m., revealed the Pre-Admission Screening form should have never been left on top of the medication cart unattended. b) Staff Bathroom A random observation on 12/18/17 at 10:10 a.m., on the 500 Wing, revealed a bin of folders in the staff bathroom. The bin containing information for Resident #12, #13, #14, #15, #16, #17, and #18 was readily accessible for anyone using the restroom. The folders within the bin contained multiple Minimum Data Set assessments, Care Plan Team Meeting Summaries, and admission records. These documents contained: --Resident's names --Resident's Social Security Numbers --Resident's date of births --Resident's diagnoses --Resident's treatment and medical information An interview with LPN #2, on 12/18/17 at 10:15 a.m., revealed the the bin of folders had been in the bathroom for a while. The LPN stated he was not sure why medical information was b… | 2020-09-01 |
| 88 | 88 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-12-18 | 689 | E | 1 | 0 | 0M5911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. Chemical substances, shaving razors, skin treatments, needles, and a knife, were unsecured and accessible to residents on the 500, 600, and 800 Wings. This practice had the potential to affect more than a limited number of residents. Facility census: 144. Findings include: a) 500 Wing A tour of the 500 Wing, on 12/18/17 at 9:50 a.m., revealed the Shower Room door was open. The room contained the following items: --Five (5) containers of Medspa Shave Cream with the warning Keep out of reach of children. --One (1) container of Medline Shampoo & Body Wash with the warning Caution-Keep out of reach of children-Avoid contact with eyes. --One (1) container of [MEDICATION NAME] Maltodextrin Powder Dressing. b) 600 Wing A tour of the 600 Wing, on 12/18/17 at 10:15 a.m., revealed the Nutrition Room was open for access by anyone. On the top shelf in the unlocked cabinet was a knife with approximately an 8 inch blade. An interview with Licensed Practical Nurse (LPN) #1, on 12/18/17 at 10:20 a.m., revealed she had no idea why the knife was in the cabinet. The LPN stated she would ensure the knife was taken away immediately. c) 800 Wing A tour of the 800 Wing, on 12/18/17 at 10:25 a.m., revealed one (1) container of [MEDICATION NAME] Solution 4%-Antiseptic/Antimicrobial Skin Cleanser was on the counter of the nurses station unattended. The container had the warning Keep out of reach of children-If swallowed get medical help or contact a Poison Control Center right away. Further touring of the 800 Wing, on 12/18/17 at 10:30 a.m., revealed the Examining Room had a key in the door and was accessible to anyone. The room contained the following items: --Seven (7) containers of Medspa Shave Cream with the warning Keep out of reach of children. --Seven (7) containers of Medline Shampoo & Body Wash with the warn… | 2020-09-01 |
| 3893 | 3893 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 154 | D | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure Resident #170 was given information in advance sufficient enough for her to make a knowledgeable health care decision in regards to a fluid restriction which her attending physician at the hospital (who was also her attending physician at the facility) had recommended upon her discharge from the hospital on [DATE]. This was true for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT]. Resident Identifier: #170. Facility Census: 178 Findings include: a) Resident #170 A review of Resident #170's medical record at 9:00 a.m. on 09/23/16, found a discharge summary completed by Resident #170's attending physician while she was at the hospital. The discharge summary completed on 08/22/16 included her attending physician recommended a fluid restriction due to her status as a [MEDICAL TREATMENT] patient and her [DIAGNOSES REDACTED]. The same physician was also her attending physician at the facility. During an interview with the corporation's Chief Medical Officer Medical Doctor (CMO-MD) #271 at 10:20 a.m. on 09/23/16, when asked why Resident #170, a [MEDICAL TREATMENT] patient, was not ordered a fluid restriction upon her return from the hospital on [DATE], he replied not every one on [MEDICAL TREATMENT] needed a fluid restriction. He indicated that people in the community very seldom ever restrict their fluid. He proceeded to state the risk and benefits related to not watching her fluid intake was explained to the resident, but she was alert and orientated and able to make her own decisions. Therefore, she had the right refuse the fluid restriction which is why she was not currently ordered a fluid restriction. CFO-MD #271 was then asked if the conversation explaining the risk and benefits related to her refusal of a physician recommended fluid restriction was documented in her medical record. He informed the surveyor that this … | 2020-04-01 |
| 3894 | 3894 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 155 | D | 0 | 1 | 0MB311 | Based on record review and staff interview, the facility failed to establish and maintain policies about a resident's right to refuse treatment. This had the potential to affect all residents currently residing at the facility. Facility Census: 178. Findings Include: a) Policy In the early afternoon of 09/23/16, the Assistant Nursing Home Administrator (ANHA) was asked to provide the facility's policy and/or procedures which were followed when a resident wished to exercise their right to refuse treatment. At 2:44 p.m. on 09/23/16, the ANHA and Nursing Home Administrator (NHA) both confirmed the facility did not have a policy in regards to the residents' right to refuse treatment. They provided the facility's advance directive policy. This policy did include the following statement, Prior to or upon admission of a resident to the facility, the Social Service Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate and advance directive. The remaining eight (8) statements contained in the policy were solely directed to written advanced directives such as medical power of attorney or a living will, and not the right to accept or refuse medical treatment. At approximately 3:00 p.m. on 09/23/16, the Admissions Coordinator #77 was asked to provide what written information was given to residents upon admission to the facility in regards to advance directives and their right to accept and/or refuse medical treatment other than an advance directive. She referred to the facility's Admission Information Packet pages 14 - 26. The information contained on these pages specifically related to the creation of and the authority of written advance directives such as a Medical Power of Attorney or Living Will. It did not include any information pertaining to the residents' right to accept or refuse medical treatment other than the creation of a written adv… | 2020-04-01 |
| 3895 | 3895 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 157 | D | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to notify Resident #170's attending physician when she experienced unrelieved pain and she refused six (6) out of eight (8) [MEDICAL TREATMENT] treatments in the month of (MONTH) (YEAR) due to pain from her [DEVICE]. This was true for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT]. Resident Identifier: #170. Facility Census: 178. Findings include: a) Resident #170 A review of Resident #170's medical record at 10:00 a.m. on 09/21/16 found the resident was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Further review of the record on 09/21/16 at 3:00 p.m., found an admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 08/29/16, identified the resident scored 15 of a possible 15 for the Brief Interview for Mental Status (BIMS) - indicating the resident was cognitively intact. Review of Resident #170's medical records found on multiple occasions Resident #170 refused [MEDICAL TREATMENT] treatments from 09/06/16 through 09/22/16. An interview with Resident #170 at 9:35 a.m. on 09/22/16, revealed she was not going to [MEDICAL TREATMENT] because of pain caused from the [DEVICE] which was placed on 09/05/16. The record contained no information to indicate Resident #170's attending physician and/or nurse practitioner were notified of her refusals of [MEDICAL TREATMENT] and/or pain. The [MEDICAL TREATMENT] center, on two (2) occasions, 08/25/16 and 09/08/16, sent recommendations to discontinue Resident #170's [MEDICATION NAME]. The facility did not address this. She continued to receive the medication and the physician had not been notified of the recommendations as of 09/22/16. In an interview on 09/22/16 at approximately 10:05 a.m., the Director of Nursing (DON) was informed of Resident #170's multiple documented occasions when the resident refused [MEDICAL TREATMENT] treatme… | 2020-04-01 |
| 3896 | 3896 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 163 | D | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure Resident #170 was afforded the right to choose her personal physician upon admission to the facility. This was true for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT]. Resident Identifier: #170. Facility Census: 178. Findings Include: a) Resident #170 A review of Resident #170's medical record at 4:00 p.m. on 09/23/16, found she had two (2) recent admissions to the facility. She was admitted on [DATE], discharged to the hospital 08/12/16 and was readmitted on [DATE]. Review of the admission orders [REDACTED]#272). Resident #170's record contained a history and physical completed by DO #272 which on 08/23/16. This History and Physical contained the following statement, Patient admitted to my services but requests to be changed to (Name of attending Medical Doctor (MD) #273 as he is her regular provider. Review of the nursing progress notes found a note dated 08/27/16 at 9:42 a.m. stating, (Name of MD #273) arrived at facility identifying patient as a long time patient of his, he requested patient be switched from (Name of DO #272) to his care in facility. Also contained in Resident #170's medical record was a form titled, Consent for Treatment and Release of Information. This form indicated that Resident #170 had designated MD #273 as her attending physician, however his name was marked out and replaced with DO #272's name. This form was signed by the resident on 08/12/16. The name of the physician was changed by the nurse completing the form and it was unknown if it was done prior to or after the resident signed the form. An interview with Resident #170 at 4:15 p.m. on 09/23/16, confirmed she was not given a choice of physician upon admission to the facility. She stated, I had one Doctor when I first got here because I did not know (Name of MD #273) came here. When I found out he came here I told them I wanted to be … | 2020-04-01 |
| 3897 | 3897 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 241 | D | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain or enhance each resident's dignity as evidenced by staff using labels in reference to the resident's feeding ability. This affected one (1) randomly observed resident. Resident identifier: #388. Facility census: 178. Findings include: a) Resident #388 On 09/19/16 at 11:51 a.m., Resident #388 sat in a chair between his bed and the doorway. He wore a hospital gown, and a blanket covered his shoulders and upper arms. Numerous covered food items sat on an over-bed table in front of him. Nurse Aide (NA) #195 stood at the roommate's bed and opened the tray for the roommate. Another staff person entered the room to see if the resident's needed help. NA #195 relayed to the other staff person that Resident #388 was a feeder. This statement could be heard in the hallway outside the resident's room. Medical record review on 09/21/16 at 2:00 p.m. found this resident recently came to the facility. The admission minimum data set (MDS) assessment, with an assessment reference date (ARD) 09/14/16, assessed Resident #388 with severely impaired cognitive skills. Section G of the MDS assessed need for extensive staff assistance with bed mobility and transfer, dressing, eating, toilet use, personal hygiene, and total dependence for bathing. [DIAGNOSES REDACTED]. Section K of the MDS assessed feeding difficulties which included the loss of liquids or solids from his mouth when eating or drinking; holding food in his mouth or cheeks, or residual food in his mouth after meals; and coughing or choking during meals or when swallowing medications. Subsequently, he required a mechanically altered diet. During an interview with the director of nursing (DON) on 09/21/16 at 3:30 p.m., she said that referring to a resident as a feeder was not an acceptable practice at this facility. She spoke her belief that staff knew better than to do that, because this is a dignity issue. | 2020-04-01 |
| 3898 | 3898 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 250 | D | 0 | 1 | 0MB311 | Based on resident interview and staff interview, the facility failed to assist Resident #235 in maintaining or improving her ability to manage her everyday psychosocial needs. Social services failed to discuss with resident concerns arising from a visitor visiting after recommended visiting hours. This was true for one (1) of four (4) residents reviewed for choices. Resident identifier: #235. Facility Census: 178 Findings include: a) Resident #235 During a Stage 1 interview on 09/19/16 at 3:20 p.m., Resident #235 revealed a friend came to visit her late one night. The resident stated they (her friend and Resident #235) had both worked as night shift nurses for years, and at night was the only time her friend could visit. The resident said they went to the dining room and even outside during the visits, so as not to disturb any of the other residents. Resident #235 stated her friend was badly scolded on two (2) different occasions for visiting late in the night and was made to feel like a child. The night shift supervisor made her leave the first time, and her friend called the administrator to make sure it was alright to visit at night, if they did it quietly and did not disturb other residents. Her friend was told by the administrator that she could visit, but did need to be respectful of other residents. The friend came back around 1:00 a.m. to visit the next night after clarifying with the Administrator it was all right to visit. According to the resident, the night shift supervisor stopped the visit again. The resident stated, The supervisor brought a second nurse with her. The second nurse stood behind the supervisor with her arms folded across her chest while the supervisor yelled at my friend. The supervisor told my friend, you are a nurse and should know better. We have patients here that need their sleep. Resident #235 stated her friend was upset and embarrassed and demanded an incident report be filled out. When asked if an incident report had been filled out, the resident said, Yes, I think so. I don't… | 2020-04-01 |
| 3899 | 3899 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 253 | E | 0 | 1 | 0MB311 | Based on observation, random observation and staff interviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The cosmetic imperfections included peeling wallpaper, damaged chair railing, missing caulking around sinks and commodes, damaged sink tops, a light casement and cable box had pulled away from wall, missing paint, broken and stained floor tiles, and odors. Room identifiers: A1, A3, C1, C3, C5, C12, D4, D5, D7, D8, D9, E5, F11, G2, and G13. Facility census: 178. Findings include: a) Cosmetic imperfections --Room A1 - observed on 09/19/16 at 2:48 p.m., had wallpaper peeling away from the wall above resident's bed. --Room A3 - observed on 09/19/16 at 2:37 p.m. - the chair had scuffed arms. --Room C1 - observed on 09/20/16 at 9:54 a.m. - had torn wallpaper behind resident's bed. --Room C3 - observed on 09/20/16 at 9:23 a.m. - had splintered chair railing behind the resident's bed, a sink top with damaged Formica, and a cracked board above the cove base. --Room C5 - observed on 09/20/16 at 8:41 a.m. - had splintered chair railing behind the bed and the board above the cove base was splintered. --Room C12 - observed on 09/20/16 at 10:18 a.m. - had chair railing and wallpaper separated from the wall, walls had missing paint, and the entrance door had peeled paint. --Room D4 - observed on 09/20/16 at 12:44 p.m. - had broken floor tile under the sink, the light housing over the bed had pulled away from the wall and the walls had areas of paint, that did not match. --Room D5 - observed on 09/20/16 at 8:44 a.m. - had a dirty heating/cooling unit and stains around the base of the commode. --Room D7 - observed on 09/20/16 at 8:49 a.m. - had a sink with missing caulking and the front of the sink top had been poorly repaired. --Room D8 - observed on 09/20/16 at 9:07 a.m. - had a sink with missing caulking. --Room D9 - observed on 09/20/16 at 9:52 a.m. - had a closet door with scuff marks. --Room E5 - observed on 09/20/16 at 9:42 a… | 2020-04-01 |
| 3900 | 3900 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 279 | D | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop individualized and measurable goals for a resident with behaviors, who was treated with psychoactive medications. This was evident for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #225. Facility census: 178. Findings include: a) Resident #225 Medical record review on 09/21/16 at 1:30 p.m., found this [AGE] year-old resident had [DIAGNOSES REDACTED]. disorder, depression, mood disorder, [MEDICAL CONDITION], and [MEDICAL CONDITION] other than [MEDICAL CONDITION]. Daily medications included [MEDICATION NAME] (an antianxiety medication) one (1) milligram (mg) three (3) times daily; [MEDICATION NAME] (antipsychotic medication) twenty-five (25) mg daily at bedtime; and [MEDICATION NAME] (an antidepressant medication) fifteen (15) mg daily at bedtime. The most recent quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) off 07/22/16, assessed he received antipsychotic, antianxiety, and antidepressants daily. The Brief Interview for Mental Status (BIMS) assessed his score as three (3), which indicated severely impaired cognition for decision-making. Review of the care plan found a problem/focus that the resident received antipsychotic medication due to a [DIAGNOSES REDACTED]. It noted the resident exhibited mood changes for no apparent reason, and could become upset and aggressive. Also he resisted and/or refused activities of daily living care at times, hit staff, cursed and yelled. The care planned goal for this problem simply stated Resident will receive lowest dose possible with no side effects noted through next review period. The care plan contained another focus/problem area that he received antianxiety medication related to behaviors of agitation as evidenced by hitting staff, cursing and yelling, due to the [DIAGNOSES REDACTED]. Further review of the care plan found a focus/problem that… | 2020-04-01 |
| 3901 | 3901 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 280 | D | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #179's care plan was revised when her order for a fluid restriction was discontinued. This was true for one (1) of four (4) residents reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #179. Facility Census: 178. Findings Include: a) Resident #179 A review of Resident #179's medical record at 2:43 p.m. on 09/20/16, found a physician's orders [REDACTED]. A review of Resident #179's current care plan at 3:00 p.m. on 09/20/16, found a focus statement related to the resident's risk for altered nutritional and hydration status. The interventions related to this focus statement included, Provide a 1000 ml per day fluid restriction per md (medical doctor). An interview with the Director of Nursing (DON) at 2:12 p.m. on 09/21/16 confirmed the resident's care plan needed revised because she was no longer on a fluid restriction. | 2020-04-01 |
| 3902 | 3902 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 309 | H | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, and resident interview the facility failed to assess Resident #170's pain by location, quality, intensity, pattern, frequency, timing, and duration. There was no evidence the facility attempted to develop interdisciplinary nonpharmacological strategies to manage the resident ' s pain. The resident suffered actual harm by the facility's failure to ensure the most effective pain management possible for the resident. Review of Resident #170's medical records, staff interviews and resident interviews found on multiple occasions from [DATE] through [DATE] the resident had refused [MEDICAL TREATMENT] treatments. An interview with Resident #170 revealed she was not going to [MEDICAL TREATMENT] because of pain caused from the [DEVICE], which was placed on [DATE]. The record contained no information to indicate Resident #170's attending physician and/or the nurse practitioner were notified of her refusals of [MEDICAL TREATMENT] and/or pain. On [DATE] and [DATE], the [MEDICAL TREATMENT] center sent recommendations to discontinue Resident #170's [MEDICATION NAME]; however, she continued to receive this medication and the physician had not been notified of the recommendations as of [DATE]. Additionally, for Resident #170, the facility failed to correlate care between the facility and the [MEDICAL TREATMENT] center and failed to administer the Renavela as directed by the nephrologist. For Resident #225, the facility failed to provide effective pain management by failing to assess his level of pain prior to the administration of an as needed (PRN) pain medication. The facility failed to reassess the resident to determine the effectiveness of the pain medication. These issues were found for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT] and for one (1) of five (5) reviewed for the care area of unnecessary medications. Resident identifier: #170 and #225. Facility census:… | 2020-04-01 |
| 3903 | 3903 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 441 | E | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and infection control surveillance record review, the facility failed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. The infection control surveillance records did not contain needed information. One (1) randomly observed resident's Continuous Passive Motion (CPM) machine was stored directly on an unclean surface, and one randomly observed staff member did not use proper hand hygiene. These practices had the potential to affect more than an isolated number of residents. Resident identifiers: #389, #1001, and #1002. Employee identifier: #128. Facility census: 178. Findings include: a) Infection Control Program On 09/21/16 at 8:14 a.m., an interview with Infection Control Nurse (ICN) #140 who was responsible for the Station 2 side of the facility, revealed there had been a change in the infection control log form the facility used. When asked how and where she tracked the antibiotics used, ICN #140 appeared surprised, paused and said, I guess we don't have to anymore, it's not on the form. The Infection Control Nurse went on to say, We use to track antibiotic names, now just whether the resident is on IV (Intravenous) antibiotic or by mouth. Review of Station 1's infection control book on 09/21/16 at 8:48 a.m., revealed incomplete tracking on the (MONTH) (YEAR) Infection Control Log. On line #10 (Resident #1001) in the column where the organism should have been listed an antibiotic ([MEDICATION NAME]) was listed with no reference to the organism. On line #11 (Resident #1002) the column where the organism should have been listed an antibiotic ([MEDICATION NAME] and Vanc) was listed with no reference to the organism. An interview with Corporate Registered Nurse (RN) #170, on 09/22/16 at 9:21 a.m., verified it was important to know the antibiotics used and the organisms when reviewing the entire infection contr… | 2020-04-01 |
| 3904 | 3904 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 505 | D | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to promptly notify Resident #179's attending physician of the results of a basic metabolic panel (BMP) which was ordered on [DATE]. This was true for one (1) of four (4) residents reviewed for the care area of nutrition during the Quality Indicator Survey (QIS). Resident Identifier: #179. Census: 178. Findings include: a) Resident #179 A review of Resident #179's medical record at 2:43 p.m. on 09/20/16 found a physician's orders [REDACTED]. Upon further review of the record, the results of the BMP could not be located, nor was there any evidence the attending physician was ever notified of the results of the BMP. At 9:49 a.m. on 09/21/16, the results of the BMP and any information related to the notification of the attending physician were requested from the Assistant Director of Nursing (ADON) Registered Nurse (RN) #140. She stated that she would have to go to medical records and look for the information because she did not see it in the chart. An additional interview with ADON #140 at 11:02 p.m. on 09/21/16, revealed the lab result was not in the record and there was no information available to indicate the attending physician was ever notified of the lab results. She indicated the process was that the Nurse Practitioner or the Attending Physician would sign the lab and there would not be any notes or orders if they did not order any changes. She said that since she could not find the lab results she could not prove the attending physician was ever notified. These findings were reviewed with the Director of Nursing at 2:12 p.m. on 09/21/16 and as of the time of exit on 09/23/16, no additional information was provided. | 2020-04-01 |
| 3905 | 3905 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 507 | D | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain all laboratory (lab) testing results in the resident's clinical record for one (1) of four (4) residents reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey (QIS) and one (1) of three (3) residents reviewed for the care area of hospitalization during Stage 2 of the QIS. Resident #179's record did not contain the results of a Basic Metabolic Panel (BMP) which was ordered to be done on 09/12/16. Resident #151's medical record did not contain the results of a Comprehensive Metabolic Panel (CMP) and a magnesium level obtained on 09/13/16. Resident Identifiers: #151 and #179. Facility Census: 178. Findings Include: a) Resident #151 A review of Resident #151's medical record at 11:16 a.m. on 09/21/16 found a physician's orders [REDACTED]. Upon further review of the medical record, the results of the CMP and magnesium level could not be located. There was however, a nursing progress note dated 09/13/16 which indicated the lab results were reviewed by the Nurse Practitioner with new orders noted. Upon further review of the physician's orders [REDACTED]. During an interview with Assistant Director of Nursing (ADON) Registered Nurse (RN) #140 at 3:09 p.m. on 09/21/16, the results of the CMP and magnesium level were requested. She indicated that she would have to look for them. At 4:26 p.m. on 09/21/16, the Director of Nursing (DON) confirmed they could not locate the requested lab results and had to have a copy faxed to the facility after the surveyor requested them. b) Resident #179 A review of Resident #179's medical record at 2:43 p.m. on 09/20/16 found a physician's orders [REDACTED]. Upon further review of the resident's record, the results of the BMP could not be located. At 9:49 a.m. on 09/21/16 the results of the BMP were requested from the Assistant Director of Nursing ADON - RN #140. She stated that she would have to go to medical re… | 2020-04-01 |
| 7802 | 7802 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 281 | H | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review and resident interview, the facility failed to assess and treat Resident #170's pain in accordance with professional standards which has been a primary factor in her refusing to go to [MEDICAL TREATMENT]. Her refusals of [MEDICAL TREATMENT] has the potential to cause serious harm and/or death. The resident has already suffered actual harm by the facility's failure to treat her pain on multiple occasions. The resident since [DATE] has refused to go to six (6) out of eight (8) [MEDICAL TREATMENT] treatments ([DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]). Resident #170 only recieved one full treatment since the placement of the wound vac on [DATE]. She did go to [MEDICAL TREATMENT] on [DATE], but her treatment had to be stopped after seventy-nine (79) minutes because of the residents complaints of pain. The clinical diretor of the local dialyis center during and interview on [DATE] at 1:35 p.m. stated the resident was complaining of pain related to her wound vac on [DATE] and that is why her treatment had to be stopped. Review of Resident #170's medical records, staff interviews and resident interviews found on multiple occasions from [DATE] through [DATE] the resident had refused [MEDICAL TREATMENT] treatments. An interview with Resident #170 revealed she was not going to [MEDICAL TREATMENT] because of pain caused from the [DEVICE] which was placed on [DATE]. The record contained no information to indicate Resident #170's attending physician and/or nurse practitioner was notified of her refusals of [MEDICAL TREATMENT] and/or pain. The [MEDICAL TREATMENT] center on two (2) occasions [DATE] and [DATE] sent recommendations to discontinue Resident #170's [MEDICATION NAME] the facility did not address this. In fact she continued to receive this medication and the physician had not been notified of the recommendations as of [DATE]. The failures to assess and treat the residents pain which ha… | 2017-01-01 |
| 8139 | 8139 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2013-09-08 | 309 | D | 1 | 0 | 0O0I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to ensure three (3) of ten (10) sample residents were provided care and services to attain or maintain the highest level of well-being. Medications were not provided as ordered for Residents #120, #94, and #121. There were no physician's orders or reasons provided for withholding the medications. In addition, pain medication was administered to Resident #94 without an evaluation of the resident's pain and without evaluating the effectiveness of the pain medication. Resident identifiers: #120, #94, and #121. Facility Census: 116. Findings include: a) Resident #120 The medical record for this resident indicated she returned from the hospital on [DATE]. The hospital discharge record, dated 08/15/13, stated she had surgery on her hip and fractured humerus during her hospital stay. According to the discharge summary, she received sliding scale insulin at the hospital because of diabetes, her blood pressure was not under control during her hospital stay, she had diabetic gastroparesis (a condition that delays emptying of food from the stomach), and had a gastric pacemaker. The summary noted she had medications for nausea which she did not need during her hospital stay. Her hospital record stated she was receiving [MEDICAL CONDITION] ([MEDICAL CONDITION] [MEDICATION NAME] and was maintained on [MEDICATION NAME] 40 milligrams (mg) subcutaneously daily. The record noted she should continue the [MEDICATION NAME] for 35 days after her discharge from the hospital. According to the hospital discharge record, her pain was not adequately controlled at the time of discharge from the hospital. She was receiving [MEDICATION NAME] sulfate IR (immediate release) 30 mg every four (4) hours as needed and a [MEDICATION NAME] 50 (micrograms) mcg an hour. The resident also had a history of [REDACTED]. The discharge instructions stated the resident could be sent back to the Emergency De… | 2016-09-01 |
| 1375 | 1375 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 557 | D | 1 | 0 | 0O7M11 | > Based on observation, staff interview and resident interview, the facility failed to ensure all residents were treated in a dignified manner. Staff transported Resident #68 to the shower room in a shower chair and did not have him fully covered from the waist down. For Resident #91 her catheter bag was not covered and she had an undignified sign hanging in her room. Resident #94 did not have his name on the door to his room. This was true for three (3) of 114 residents currently residing in the facility. Resident identifiers: #68. #91, and #94. Facility census: 114. Findings included: a) Resident #68 An observation at 4:35 p.m. on 10/04/18 found Resident #68 being transported to the shower room in a shower chair. The resident was wearing a red shirt but was not wearing any clothing from the waist down. Nurse Aide #70 had a sheet draped over his legs but it did not fully cover the residents skin and parts of his bare body could be seen as she wheeled him down the hall to the shower room. An interview with Licensed Practical Nurse (LPN) #46 confirmed Resident #68 was not covered to ensure his privacy and dignity. When asked if she would like to be wheeled down the hall like that she replied, No I would not like that. She assisted the nurse aide in covering the resident completely. b) Resident #91 During an observation of catheter care on 10/08/18 at 10:55 AM, Nursing Aide (NA) # 51 and NA #11, revealed the indwelling Foley catheter collection bag did not have a privacy cover over it. NA# 51 said she would let the nurse know. There was a sign on the wall on this residents side of the room, that read: Bath days Tuesday and Friday *If you refuse you will not get a bath until your next scheduled day Resident #91 stated the NAs that put that there were NA#76 and NA#73. She also said NA#76 is not allowed to care for her anymore, but did not want to talk about way. On 10/08/18 at 11:30 AM, Clinical Specialist (CS) #157 acknowledged the sign and the exposed Foley collection bag. No further information was provided by CS … | 2020-09-01 |
| 1376 | 1376 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 558 | D | 1 | 0 | 0O7M11 | > Based on observation and staff interview, the facility failed to ensure Resident #67's call light was within reach at all times so she would be able call for assistance when needed. This was a random opportunity for discovery. Resident identifier: #67. Facility census: 114. Findings included: a) Resident #67 At 1:45 p.m. on 10/02/18 Resident #67 was overheard yelling loudly for help. When the surveyor entered the room the resident indicated she was wet and needed help getting cleaned up. Observation found the resident to be wet from her waist to her knees with urine. Further observation found Resident #67's call light was not within her reach. In fact the call light was not easily found. The surveyor had to go to the wall and find the call light cord and follow the cord to locate the call light. The call light was found balled up under Resident #67's bed. Licensed Practical Nurse (LPN) # 130 entered the residents room and indicated she would take care of her. When asked if Resident #67 was able to use her call light LPN #130 indicated she was able to use the call light. She also confirmed Resident #67's call light was not within her reach. She stated, Sometimes she will throw it across the room. LPN #130 agreed it was not likely that she placed it under the foot of her bed. No further information was provided prior to the survey exit conference. | 2020-09-01 |
| 1377 | 1377 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 569 | D | 1 | 0 | 0O7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to convey, within 30 days of a resident's death at the facility, a final accounting of personal funds to the individual or probate jurisdiction administering the individual's estate as provided by State law. This was found for one (1) of seven (7) discharged resident's reviewed during the complaint survey. Resident identifier: #123. Facility census: 114. Findings included: a) Resident #123 Review of Resident #123's account with Employee 73, the business office manager, at 8:05 AM on [DATE], found Resident #123 was admitted to the facility on [DATE]. The resident expired at the facility on [DATE]. The resident had a remaining balance of $13.84 in her personal account. Employee #73 closed the account on [DATE] and asked for a refund from the corporate office. The resident had no family members to settle her estate. Employee #73 said the money would be sent to the State's Treasury, unclaimed property. [NAME] #73 explained, a check is written by the corporate office and sent to the facility. Once the facility receives the check, the check is then mailed to the jurisdiction administering the resident's estate. E#73 provided information the posting date of the check was [DATE]. At 9:30 AM on [DATE], [NAME] #73 said the corporate office had not mailed a check to the facility and the money had not been released to unclaimed properties. No further information was provided prior to the survey exit conference. | 2020-09-01 |
| 1378 | 1378 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 580 | D | 1 | 0 | 0O7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to notify Resident #32's family/responsible party when a change in condition (elevated temperature) occurred. This had a potential to affect an isolated number of residents. Resident identifier: #32. Facility census:114. Findings included: a) Resident #32 Review of Resident #32's medical record found a progress note written by Employee #123, Licensed Practical Nurse (LPN), on 10/01/18 at 1:02 pm read: A change in condition has been noted. The symptoms include: Fever on 10/01/18 in the am. Vital: blood pressure (B/P) 114/76 .Pulse- 136 .Respirations- 20 .temperature- 103 degrees rectally .Oxygen level (SPO2)- 96% with at 2 (two) liters via nasal cannula. Primary physician notified at 1:00 p.m. on 10/01/18. Orders obtained includes complete blood count (CBC), chest x-ray (CXR), urinalysis (UA) and a culture and sensitivity (C&S) of urine and [MEDICATION NAME] (antibiotic) one (1) gram intramuscular (IM) for seven (7) days. Review of the physician orders [REDACTED]. Additionally, a physician's orders [REDACTED]. No indication the family was notified of these changes in Resident #32's condition. Further review of the progress notes found a note written by Employee #40, LPN, on 10/01/18 at 10:45 pm, which read: Vital signs obtained from resident. B/P- 152/94, heart rate (pulse) 167 and temperature 104.5 degrees, SPO2- 87%, this nurse took blankets off resident, checked to make sure oxygen was on and working. Administered Tylenol at 10:38 pm as ordered. Applied cool rags to resident and rechecked vitals at 10:34 pm. B/P 139/78, temperature103.7, SPO2 99% and heart rate- 118. Lungs sound clear. Heart rate rapid with periods of slowing down and then rapid again. Now, I notified the physician on call. Received orders to send resident to be evaluated in the emergency room due to resident being a full code and unable to maintain vital signs. Checked vital signs at 10:45 PM, B/P- 1… | 2020-09-01 |
| 1379 | 1379 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 583 | D | 1 | 0 | 0O7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to ensure personal privacy during medication administration. Resident #39 was administered a subcutaneous (SQ) injection ([MEDICATION NAME]) in the abdomen without shutting the door and/or closing the privacy curtain. Additionally, Resident #94 had a patch ([MEDICATION NAME]) applied to his upper right arm in the middle of the hallway. Resident identifiers: #39 and #94. Facility Census: 114. Findings included: a) Resident #39 Observation of medication administration on 10/03/18 at 8:00 am, found Employee #54, licensed practical nurse (LPN) administering a SQ injection ([MEDICATION NAME]) in Resident #39's abdomen. Employee #54, did not close the resident's door or the privacy curtain to provide the resident's personal privacy. Interview with LPN #54, immediately following the injection, confirmed she should have provided privacy during the administration of the injection. Review of the facility's policy on administration of injections, explain procedure and provide privacy . b) Resident #94 Observation of medication administration on 10/03/18 at 8:30 am, found Employee #128, LPN administering a topical patch (Nitrderm) patch to Resident #94's upper right arm while in the middle of the hallway. LPN #128, did not provide the resident's personal privacy. Interview with LPN #128, immediately following the application of the topical patch she confirmed she should have provided privacy during the application of the topical patch ([MEDICATION NAME]). Review of the facility's policy on administration of topical medication/patches, explain procedure and provide privacy . No further information was provided prior to the survey exit conference. | 2020-09-01 |
| 1380 | 1380 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 584 | F | 1 | 0 | 0O7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, resident interview, and staff interview, the facility failed to ensure residents' environment was clean, comfortable and homelike. Mice feces was found in numerous resident rooms on the floor, in dresser drawers, wardrobes, and in a resident's personal chair. Door facings and doors were marred, scraped, rusted and had missing paint. The walls in resident rooms were soiled. Toilets did not flush. A toilet was leaking around the floor in a room. Filters in the heating and air conditioning units were covered with lint and debris. The floors were dirty in resident rooms with a heavy buildup of debris and dirt in the corners of the rooms. Baseboards were loose or missing from the walls. A door on a nightstand was broken. The veneer finish had been peeled away from the top of a night stand. Resident care equipment was soiled and unclean: bedside tables, floor mats, and oxygen concentrators. The furniture in the common areas was torn and dirty. Activity supplies were molded. Window blinds were dirty. Privacy curtains in several resident rooms were soiled and loose from the tracks. The carpet in the hallways was stained and unclean. The window seals in the dining room were covered with lint, food stains and other debris. Dining room chairs were dirty, worn and had holes in the fabric. Bugs were present in the globes of light fixtures. Spider webs were in the corners of resident rooms. These observations were random opportunities for discovery during the survey. Facility census: 114. Findings include: a) North/Short Hall A tour of the facility with Employee #58 a Registered Nurse, Minimum Data Set Coordinator. (E #58 was chosen by the administrator to accompany this surveyor on tour.) The tour of the North/Short Hall began at 12:00 noon and ended at 1:15 PM on 10/02/18. The following issues were identified: 1. Resident rooms room [ROOM NUMBER] - The baseboard was missing at the bathroom door. The wall along where the baseboard… | 2020-09-01 |
| 1381 | 1381 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 600 | D | 1 | 0 | 0O7M11 | > Based on observation and staff interview, the facility failed to ensure Resident #67 was free from verbal abuse. Nurse Aide # 76 was overheard speaking to Resident #67 in a loud tone and saying comments to the resident which were verbally abusive in nature while providing care to Resident #67. This was a random opportunity for discovery, Resident identifier: #67. Facility census: 104. Findings included: a) Resident #67 During an initial tour of the building on 10/02/18 at approximately 10:15 a.m. Resident #67 was overheard yelling loudly from her room. While standing outside of Resident #67's door the surveyor overheard someone saying the following comments to the resident in a very loud voice: --You need to stop act liking a two (2) year old. --Stop yelling and screaming if you want something you have to say please. --(First name of Resident) you got to quit yelling stop acting like this. --How are we supposed to talk to you when you are yelling and screaming and squalling like that. --(First name of Resident #67) Please stop this. When the nurse aides opened the door to exit the room there were two (2) nurse aides observed in the room. NA # 29 who exited the room first with the soiled items and NA #76 who remained in the room for a few minutes and continued to fix Resident #67's hair. When NA #76 exited the room she was interviewed. The statements which were overheard were read to the N[NAME] NA #76 was asked who said those things. She stated, That was me. I said those things to the resident. She continued, I am really sorry about this. I try to treat her like an adult but it is hard when she is screaming at you. It gets really frustrating. She stated, I try to remind her that she is not a child and does not need to throw temper tantrums like that. At 10:30 a.m. the above findings were reported to the Nursing Home Administrator (NHA). He stated that he would speak with NA #76 to see what was going on. No further information was provided prior to the survey exit conference | 2020-09-01 |
| 1382 | 1382 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 607 | D | 1 | 0 | 0O7M11 | > Based on observation, policy review and staff interview, the facility failed to ensure they implemented the facility's abuse policy related to reporting all allegations of abuse to appropriate state agencies within the appropriate time frames. Nurse Aide # 76 was overheard speaking to Resident #67 in a loud tone and saying comments to the resident which were verbally abusive in nature while providing care to Resident #67. This information was reported to the Nursing Home Administrator (NHA), but the allegations were not reported in the appropriate timeframe's as per the facility's Abuse Prohibition Policy. This was a random opportunity for discovery. Resident identifier: #67. Facility census: 114. Findings included: a) Resident #67 During an initial tour of the building on 10/02/18 at approximately 10:15 a.m. Resident #67 was overheard yelling loudly from her room. While standing outside of Resident #67's door the surveyor overheard someone saying the following comments to the resident in a very loud voice: --You need to stop act liking a two (2) year old. --Stop yelling and screaming if you want something you have to say please. --(First name of Resident) you got to quit yelling stop acting like this. --How are we supposed to talk to you when you are yelling and screaming and squalling like that. --(First name of Resident #67) Please stop this. When the nurse aides opened the door to exit the room there were two (2) nurse aides observed in the room. NA # 29 who exited the room first with the soiled items and NA #76 who remained in the room for a few minutes and continued to fix Resident #67's hair. When NA #76 exited the room she was interviewed. The statements which were overheard were read to the N[NAME] She was asked who had said those things. She stated, That was me. I said those things to the resident. She continued, I am really sorry about this. I try to treat her like an adult but it is hard when she is screaming at you. It gets really frustrating. She stated, I try to remind her that she is not a child… | 2020-09-01 |
| 1383 | 1383 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 609 | D | 1 | 0 | 0O7M11 | > Based on observation and staff interview, the facility failed to ensure they identified and reported all allegations of abuse to appropriate state agencies within the appropriate time frames. Nurse Aide # 76 was overheard speaking to Resident #67 in a loud tone and saying comments to the resident which were verbally abusive in nature while providing care to Resident #67. This information was reported to the Nursing Home Administrator (NHA), but the allegations were not reported in the appropriate frames. This was a random opportunity for discovery. Resident identifier: #67. Facility census: 114. Findings included: a) Resident #67 During an initial tour of the building on 10/02/18 at approximately 10:15 a.m. Resident #67 was overheard yelling loudly from her room. While standing outside of Resident #67's door the surveyor overheard someone saying the following comments to the resident in a very loud voice, --You need to stop act liking a two (2) year old. --Stop yelling and screaming if you want something you have to say please. --(First name of Resident) you got to quit yelling stop acting like this. --How are we supposed to talk to you when you are yelling and screaming and squalling like that. --(First name of Resident #67) Please stop this. When the nurse aides opened the door to exit the room there were two (2) nurse aides observed in the room. NA # 29 who exited the room first with the soiled items and NA #76 who remained in the room for a few minutes and continued to fix Resident #67's hair. When NA #76 exited the room she was interviewed. The statements which were overheard were read to the N[NAME] She was asked who had said those things. She stated, That was me. I said those things to the resident. She continued, I am really sorry about this. I try to treat her like an adult but it is hard when she is screaming at you. It gets really frustrating. She stated, I try to remind her that she is not a child and does not need to throw temper tantrums like that. At 10:30 a.m. the above findings were reported to… | 2020-09-01 |
| 1384 | 1384 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 622 | D | 1 | 0 | 0O7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to ensure Resident #106's condition at the time of transfer was documented in the medical records and appropriately communicated to the receiving health care institution. This was a random opportunity for discovery. Resident identifier: #106. Facility census: 114. Findings included: a) Resident #106 Review of Resident #106's medical records revealed the following notes: 07/15/18 at 1:49 AM --Change in Condition Follow-up Note: --This is a follow-up note from the change in condition-medical that occurred on 07/15/18 --Status of condition: no change --DATA: resident laying in bed resting at this time --ACTION: continue meds and tx's (treatments) as ordered --RESPONSE: no complaints noted 07/15/18 at 6:26 AM --General Note: --Sent resident to ER (emergency room ) for tx (treatment) and evaluation d/t (due to) decreased loc (level of consciousness). 07/15/18 at 6:27 AM --Transfer Note: --(Resident's name) had an unplanned transfer. Contact person notified of transfer. A Nursing Home to Hospital Transfer Form dated 7/25/18 at 6:27 AM stated, Altered Mental Status. Vital signs were documented as the following: blood pressure 99/65, heart rate 125, respiratory rate 20, and temperature 100.9. Resident 106's medical record did not contain documentation regarding the change in medical condition to which the note written on 07/15/18 at 1:49 AM referred. Also, no additional information was given in the notes or on the transfer form regarding Resident 106's decreased level of consciousness and altered mental status. During an interview on 10/03/18 at 2:45 PM, Unit Manager (UM) #5 stated she had no further information regarding Resident #106's transfer to the hospital on [DATE] due to decreased level of consciousness and altered mental status. UM #5 provided no additional information throughout the conclusion of the investigation. During an interview on 10/08/18 at 1:00 PM, the Clini… | 2020-09-01 |
| 1385 | 1385 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 656 | E | 1 | 0 | 0O7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and observation the facility failed to implement and/or develop the comprehensive care plan for six (6) facility residents. These were all random opportunities for discovery. For Resident #41, #67, and #22 the facility failed to implement their risk for injury from falls care plan. Also, for Resident #67 the facility failed to implement her behavior management care plan. For Resident #61 the facility failed to implement her care plan regarding her sliding scale insulin. Resident identifiers: #41, #67, #22 and #61, . Facility census: 114. Findings included: a) Resident #41 An observation of Resident #41's room at 8:30 a.m. on 10/04/18 with the Nursing Home Administrator (NHA), found an over the bed table and a chair sitting on her bedside fall mat. The NHA agreed the items should not be sitting on the mat. Resident #41 was resting in bed at the time of the observation. An additional interview with the NHA at 10:15 a.m. on 10/04/18 confirmed the items had been moved. He stated, They had the items sitting there when they fed her breakfast. He agreed when they were done feeding Resident #41 the items should have been moved from the mat. A review of Resident #41's care plan at 10:45 a.m. on 10/04/18 found the following focus statement related to falls: --Resident is at risk for falls: cognitive loss , lack of safety awareness, and impaired mobility. This focus statement was initiated on 11/20/17 with no revision since then. The goals associated with this focus statement read as follows: --Resident will have no falls with major injury through next review. This goal was initiated on 11/20/2017 with the most recent revision being on 04/16/18 and a target date of 10/31/18. The interventions associated with this goal include but are not limited to the following: --Bed to wall left side open. This intervention was initiated on 01//05/18. --Fall mat to left side of bed. This intervention was initiated on 07/03/18… | 2020-09-01 |
| 1386 | 1386 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 677 | E | 1 | 0 | 0O7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, resident and staff interview, the facility failed to ensure residents who are unable to carry out activities of daily living receives the necessary services to maintain good grooming and bathing (showers). For Residents #51, #67, #53, #5, and #83, the facility failed to provide showers and/or baths as each resident requested or needed to maintain good grooming. This was random oppurtunies for discovery. Resident identifiers: #51, #67, #53, #5, #83 and #37. Facility census: 114. Findings included: a) Resident #51 Review of Resident #51's medical records, found the resident required extensive assistance with bathing, grooming and personal hygiene due to weakness from sttaus post exploratory surgery with the removal of old mesh/small bowel obstruction, left above the knee amputation and right [MEDICAL CONDITION]. Additionally, the resident perfers to be given showers. Review of the master shower schedule indicates Resident #51 is to receives showers on Tuesdays and Fridays and the resident agreed to this schedule. From (MONTH) 04, (YEAR) thru (MONTH) 2, (YEAR), Resident #51 should have received showers on (MONTH) 4, 7, 11, 21, 25, 28 and (MONTH) 1,2018. Further review of the Activities of Daily Living (ADL) documentation found no documentation of showers except on 09/28/18, documented the resident refused and on (MONTH) 1, (YEAR) a shower was given. Interview with Employee #5, registered nurse (RN) south unit manager (SUM) on 10/04/18, found after review of the medical records together, the resident did not receive her showers as scheduled and furthermore no documentation of any bed baths or refusaul of showers could be found. No further information provided. b) Resident #67 A review of Resident #67's medical record at 3:00 p.m. on 10/04/18 found Resident #67 received zero (0) shower or tub baths from 09/05/18 through 10/04/18. Also during this time frame Resident #67 only received three (3) bed or sponge baths. The res… | 2020-09-01 |
| 1387 | 1387 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 684 | K | 1 | 0 | 0O7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observations, resident interview, and staff interview, the facility failed to ensure six (6) of twelve (12) residents who were ordered sliding scale insulin received the necessary care and services to maintain their highest practicable physical well-being. For Resident #5, the facility failed to notify the attending physician when the resident's blood sugar was greater than 400 on multiple occasions as directed by the physician's order. Also, Resident #5 was given the incorrect amount of sliding scale insulin based on her blood sugar readings. Furthermore, there was no evidence Resident #5's scheduled insulin was administered as ordered on multiple days with no documented reason why the medication was not given. For Resident #102 the facility failed to notify the physician when Resident #102's blood sugar was greater than 400 on one (1) occasion in (MONTH) of (YEAR). Furthermore, the Medication Administration Record (MAR) had multiple blank spaces in (MONTH) (YEAR) and (MONTH) (YEAR) indicating Resident #102 did not receive his insulin on those dates and at those times. Resident #93 received the wrong dose of sliding scale insulin on five (5) separate occasions since her admission on 09/20/18. Additionally, her MAR was blank indicating she did not get her scheduled insulin on three (3) occasions and on one (1) occasion the MAR was blank indicating she did not get Sliding Scale Insulin Coverage. For Resident #61, the facility failed to notify the physician when Resident #61's blood sugars were greater than 400 on multiple occasions. Also, Resident #61 received the incorrect dosage of sliding scale insulin based on the blood sugar readings. For Resident #12, the facility failed to administer her sliding scale insulin in accordance with the physician's orders on four (4) occasions. For Resident #18, the facility failed to administer his sliding scale insulin in accordance with the physician's orders on multiple occasion… | 2020-09-01 |
| 1388 | 1388 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 689 | E | 1 | 0 | 0O7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview and Material Safety Data Sheet (MSDS), the facility failed to ensure each resident's environment was free from accident hazards as possible. For Residents #41, #67, #22 and #9 all had items (chairs, tables and concentrators on the fall matts while the resident was in bed. Treatment cart on the North hallway was left unlocked and unattended. For Resident #95 Clorox spray was underneath the sink and unattended. All incidents were random opportunities of discovery. Had the potential to affect more than an isolated number of residents residing in the facility. Resident identifiers: #41, #67, #22, #9, #95, and north hallway treatment cart. Facility census: 114. Findings included: a) Resident # 95 On 10/02/18 at 10:00 AM, a tour of residents rooms revealed that under the sink was a bottle of spray Clorox. This has the potential to cause harm for any Resident that could come in contact with this product. Safety Data Sheet classification stated, This Product is considered hazardous . During a tour on 10/02/18 at 12:00 PM, with Administrator this was pointed out to him. He said it was probably the family put it there, he removed it from the room and stated it should not have been there. b) Resident #41 An observation of Resident #41's room at 8:30 a.m. on 10/04/18 with the Nursing Home Administrator (NHA), found an over the bed table and a chair sitting on her bedside fall mat. The NHA agreed the items should not be sitting on the mat. Resident #41 was resting in bed at the time of the observation. An additional interview with the NHA at 10:15 a.m. on 10/04/18 confirmed the items had been moved. He stated, They had the items sitting there when they fed her breakfast. He agreed when they were done feeding Resident #41 the items should have been moved from the mat. c) Resident #67 An observation of Resident #67's room at approximately 8:30 a.m. on 10/04/18 with the NHA found Resident #67 wheelchair to be sitting o… | 2020-09-01 |
| 1389 | 1389 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 690 | D | 1 | 0 | 0O7M11 | > Based on observation and staff interview, the facility failed to meet the professional standards for indwelling Foley catheter care, This has the potential to cause tissue injury and/or accidental removal. This was a random opportunity for discovery. Resident identifier: #91. Facility census 114. a) Resident #91 During an observation of catheter care on 10/08/18 at 10:55 AM, Nursing Aide (NA) # 51 and NA #11, it was revealed the indwelling Foley catheter was not secured or anchored to the resident's leg. NA# 51 said she would let the nurse know. On 10/08/18 at 11:30 AM, Clinical Specialist #157 was made aware of the Foley Catheter not having a secure anchored devise in place. She said she would let the nurse know. No further information was provided. | 2020-09-01 |
| 1390 | 1390 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 697 | E | 1 | 0 | 0O7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to ensure pain management was provided consistent with professional standards of practice, the comprehensive person centered care plan, and the resident's goals and preferences. This was true for two (2) random oppurtunity of discovery (Residents #34 and 51). Resident identifier: #34. Facility census: 114. The findings included: a) Resident #34 Resident #34 was admitted to the facility on [DATE] with a past medical history that included [MEDICAL CONDITION] and chronic generalized pain Review of the (MONTH) (YEAR) physician's orders [REDACTED]. (MONTH) 7, (YEAR) through (MONTH) physician's orders [REDACTED]. On (MONTH) 20, (YEAR) forward, there was an order that read [MEDICATION NAME] 5/325 mg 1 tablet every 6 hours as needed for pain greater than six(6) and Tylenol extra strength (ES) 500 mg every 6 hours for pain rating of 1-5. Review of the (MONTH) through (MONTH) (YEAR) Medication Administration Record [REDACTED] --July MAR indicated [REDACTED]. --August MAR indicated [REDACTED]. --September MAR indicated [REDACTED]. --October MAR indicated [REDACTED]. Further review of the clinical record revealed that the resident's pain varied from 0 out of 10 to 10 out of 10 with 10 out of 10 being the most severe pain. R#34 received medication for all levels of identified pain. Review of nurses pain flow sheets, MARs and electronic progress notes failed to consistently record, descriptors of/for pain and the effectiveness after pain medication given. Nor did the facility provide non-pharmacological interventions prior to the administration of pain medication. It also did not yield any descriptors such as the quality, duration and aggravating factors. On 10/08/18 at approximately 9:50 AM, the facility's pain management program and Resident #34's pain assessments, care plans, progress notes and Medication Administration Records for (MONTH) through (MONTH) (YEAR) were reviewed with… | 2020-09-01 |
| 1391 | 1391 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 726 | E | 1 | 0 | 0O7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, policy review, resident interview, and staff interview, the facility failed to ensure licensed nursing staff had the appropriate competencies and skill sets to administer medications per physician's orders, accurately assess residents, and obtain laboratory testing and weights as ordered. This practice had the potential to affect more than an isolated number of residents resident at the facility. Facility census: 114. Findings included: a) During the course of the survey it was found that the facility failed to ensure six (6) of twelve (12) residents who were ordered sliding scale insulin received the necessary care and services to maintain their highest practicable physical well-being. For Resident #5, the facility failed to notify the attending physician when the resident's blood sugar was greater than 400 on multiple occasions as directed by the physician's order. Also, Resident #5 was given the incorrect amount of sliding scale insulin based on her blood sugar readings. Furthermore, there was no evidence Resident #5's scheduled insulin was administered as ordered on multiple days with no documented reason why the medication was not given. For Resident #102 the facility failed to notify the physician when Resident #102's blood sugar was greater than 400 on one (1) occasion in (MONTH) of (YEAR). Furthermore, the Medication Administration Record (MAR) had multiple blank spaces in (MONTH) (YEAR) and (MONTH) (YEAR) indicating Resident #102 did not receive his insulin on those dates and at those times. Resident #93 received the wrong dose of sliding scale insulin on five (5) separate occasions since her admission on 09/20/18. Additionally, her MAR was blank indicating she did not get her scheduled insulin on three (3) occasions and on one (1) occasion the MAR was blank indicating she did not get Sliding Scale Insulin Coverage. For Resident #61, the facility failed to notify the physician when Resident #61'… | 2020-09-01 |
| 1392 | 1392 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 756 | E | 1 | 0 | 0O7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure that the pharmacist identified and reported irregularities in Resident #5, #102, and #61's drug regimen in regards to irregularities in the administration of Sliding Scale Insulin. Irregularities included blank space in the Medication Administration Record (MAR), the wrong dosage of sliding scale insulin administered based on the residents blood sugar, and finally there were multiple occasions when the residents blood sugars were above 400 and the physician was not notified. This was a random opportunity for discovery. Resident identifiers: #5, #102, and #61. Facility census: 114. Findings included: a) Resident #5 A review of Resident #5's medical record beginning at 9:00 a.m. on 10/04/18 found the record contained the following physician orders [REDACTED].>--Humalog Solution Inject per sliding scale: if 150 - 200 = 2 units: 201- 250 = 4 units: 251- 300 = 6 units: 301- 350 = 8 units; 351- 400 = 10 units notify physician if less than 60 or greater than 400. Subcutaneously four times a day related to Type 2 diabetes mellitus (DM) without complications. This was ordered on [DATE] and was discontinued on 08/17/18. --[MEDICATION NAME] Solution Inject per sliding scale: if 150 - 200 = 2 units: 201- 250 = 4 units: 251- 300 = 6 units: 301- 350 = 8 units; 351- 400 = 10 units notify physician if less than 60 or greater than 400. Subcutaneously four times a day related to Type 2 diabetes mellitus (DM) without complications. This was ordered on [DATE] and was an active order at the time of this review. --[MEDICATION NAME] Solution Inject 15 units subcutaneously one time a day related to Type 2 DM without complications. This was ordered on [DATE] and was discontinued on 08/20/18. --[MEDICATION NAME] Solution Inject 20 units subcutaneously one time a day related to Type 2 DM without complications. This was ordered on [DATE] and discontinued on 08/22/18. -- [MEDICATION NAME] Solutio… | 2020-09-01 |
| 1393 | 1393 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 760 | E | 1 | 0 | 0O7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, medication error reports, family and resident interviewed staff interview, the facility failed to ensure each resident was free from significant medication errors. This practice had the potential to affect all residents residing in the facility. Resident identifiers: #130, #129, #127, #113, #36 and #63. Facility census: 114. Findings included: a) Allegations made in Complaint # and # , allegations made that residents did not receive their medications as ordered. Additionally, during the complaint survey conducted from 10/02/18 through 10/08/18, several anonymous interviews indicated the residents did not receive the medications as ordered and at times the medications were just omitted. b) Resident #130 Review of the event summary report indicates on 07/03/18, Resident #130, was admitted to the facility with instructions from the discharge summary to administer [MEDICATION NAME] ([MEDICATION NAME]) 400 milligrams (mg) by mouth three times a day for treatment of [REDACTED].#123, agency Licensed Practical Nurse (LPN), transcribed the order for [MEDICATION NAME] to the Medication Administration Record [REDACTED]. The error was discovered on 07/31/18 with reconciliation of orders for (MONTH) (YEAR). This error resulted in fifty-six (56) omitted doses. c) Resident #129 Review of the event summary report indicates on 07/05/18, Resident #129, had a consultation with a Nephrologist for treatment of [REDACTED]. Recommendations were to increase [MEDICATION NAME] 30 mg by mouth to two (2) tablets (60) mg daily. [MEDICATION NAME] decreases levels of [MEDICAL CONDITION] hormone (PTH), calcium, and phosphorous in the body. Employee #54, LPN, initialed the consultation report the recommendations had been approved and completed. The error was discovered on 07/17/18. This error resulted in thirteen (13) doses not given at the new dosage. On 07/18/18, Resident #129's physician followed up due to the resident had two (2) recent … | 2020-09-01 |
| 1394 | 1394 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 804 | E | 1 | 0 | 0O7M11 | > Based on resident interview, staff interview and observation, the facility failed to ensure food was served at an appetizing temperature. This practice had the potential to affect more than an isolated number of residents at the facility. Facility census: 114. Findings included: a) Resident interviews Anonymous residents had complained of cold food temperatures during the initial tour of the facility on 10/02/18. b) Food temperatures on the North/Short Hall At 8:25 AM on 10/04/18, the food temperatures of the last tray served from the cart were obtained by the Dietary Manager, Employee #108 The scrambled eggs were 109 degrees Oatmeal 120 degrees. Milk poured from a pitcher was 44 degrees. orange Juice was 42 degrees. The temperature of a cinnamon roll was not obtained. E #108 said she would expect the temperature of hot foods to be no less than 135 degrees at the time of service to the residents. [NAME] #108 said the cold temperatures should be no more than 50 degrees at the time of service. At 2:00 PM on 10/05/18, numerous anonymous residents at the counsel meeting complained about food temperatures. Several residents said the hot foods are usually not even at room temperature. | 2020-09-01 |
| 1395 | 1395 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 812 | F | 1 | 0 | 0O7M11 | > Based on observation and staff interview, the facility failed to ensure food was stored and prepared in a safe, clean, and sanitary environment in accordance with professional standards for food service safety. Kitchen equipment was visable soiled, sticky to touch, and rusted. Air vents in the ceiling were covered with black dust, cob webbs and debris. The walls in the kitchen were splattered with debris. The floors in the kitchen and dish room were heavily soiled and dirty. Food in the refrigerator was not labeled and dated to determine when to discard. Food in the pantry was stored on the floor. Mice and insect monitors in the kitchen contained dead and alive roaches and other insects. These practices had the potential to affect all residents residing at the facility. Facility census: 114. Findings included: a) Tour of the kitchen with the dietary manager At 11:30 AM on 10/02/18, a tour of the kitchen area was conducted with the dietary manager, Employee #108. The following was found and confirmed with [NAME] #108: The wall behind the 3 well sink was stained with splashes of debris. The plastic PVC drain pipe under the 3 sinks was littered with dried food, lint and other debris. The legs of the sink were rusted and covered with dried food particles and other debris. The legs of a step stool were rusted and dirty. The legs of the stainless-steel preparation table were covered with dried debris. A blue metal storage cart had wheels and legs cover with lint and other dried debris. The stainless-steel mixer stand was soiled. Two mouse traps, under the 3 sink, stainless-steel stand had dead roaches and other insects trapped inside. The garbage can at the hand washing sink in the kitchen was soiled. The garbage can in the dining room hand sink had the lid missing. The dish rack, used to store the dome lids for keeping food warm, was soiled. Three (3) stainless-steel serving carts, used by the kitchen to serve beverages, were heavily soiled. Lint and other debris were also in the rolling wheels of all 3 carts. The c… | 2020-09-01 |
| 1396 | 1396 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 842 | E | 1 | 0 | 0O7M11 | > Based on observation, staff interview, and record review the facility failed to ensure the medical record was complete and accurate for two (2) residents. For Resident #93 the facility failed to document in her medical the steps taken by nursing after a hypoglycemic incident. For resident #32 the facility failed to ensure that her medical record did not contain records of other residents. These were random opportunities for discovery. Resident identifiers: #93 and #32. Facility census: 114. Findings included: a) Resident #93 A review of Resident #93's medical record at 12:00 p.m. on 10/04/18 found on the Medication Administration Record [REDACTED]. There was not indication the physician was notified and the residents blood sugar was rechecked in 10 to 15 minutes as directed by the protocol. An interview with Registered Nurse (RN) #5 at 4:39 p.m. on 10/04/18 confirmed there was not documentation in the record regarding this incident. Licensed Practical Nurse (LPN) #46 who was sitting near by during the interview with RN #5 stated, That was me. I did not write a note about what I did. LPN #46 then showed the surveyor a report sheet she completes during every shift. She stated I have it wrote here that I called the physician and when I went back to check her sugar she stated, I feel fine I don't want you to do that. LPN #46 stated, I forgot to write a note but I did it. b) Resident #32 Review of Resident #32's medical records found three (3) forms not belonging to Resident #32 in her medical records. These forms were: --Daily Shift Check List- no names on the form. --A witness statement of an incident regarding Resident #76's incident. --A lab result belonging to Resident #76 This confirmed by Employee #64, medical records (MR) clerk on 10/03/18 at 2:26 p.m. No further information provided. | 2020-09-01 |
| 1397 | 1397 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 867 | F | 1 | 0 | 0O7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility's Quality Assessment and Assurance (QA&A) committee failed to implement an appropriate plan of action to correct the mice infestation at the facility. In addition, the facility environment was not homelike. Resident areas and the kitchen were not sanitary and clean. This practice had the potential to affect all residents at the facility. Facility census: 114. Findings include: a) Administrator interview At 4:12 PM on 10/04/18, the administrator said the facility had discussed the problem with mice in the (MONTH) and (MONTH) QA&A meetings. The facility had contacted the exterminator, set traps and tried to determine how the mice were entering the facility. No further information was provided. b) Findings related to the mice infestation The following information, regarding the mice population was discovered during the survey: Observation of the exit door on North/Short Hallway with maintenance Employee #1, at 11:00 AM on 10/02/18, found the door did not seal when closed. A crack of at least 1 inch was present when the door closed. [NAME] #1 said the door needed to be sealed. Observation of Resident rooms #32 and #31 with [NAME] #1, at 11:05 AM on 10/02/18, found medicine cups with a green substance in the resident's word robes and drawers. [NAME] #1 identified the substance as Irish Spring soap. E#1 said the soap was placed by a housekeeper who heard soap would keep mice away. On 10/02/18, mice feces were found in Resident rooms #61, #47, #3, #8, #9, #16, #18, #19, #31, #30, #29, and #28. (Rooms #30, #29, #31 and #28 were on the North/Short Hallway where the opening was found in the exit door.) c) Resident rooms 1. North/Short Hall A tour of the facility was conducted with Employee #58 a Registered Nurse, Minimum Data Set Coordinator. (E #58 was chosen by the administrator to accompany this surveyor on tour.) The tour of the North/Short Hall began at 12:00 noon and ended at 1:15 PM on 10/… | 2020-09-01 |
| 1398 | 1398 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 880 | F | 1 | 0 | 0O7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, policy review and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. In the laundry room the staff failed to wear Personal Protection Equipment (PPE) and not laundering and sorting laundry properly. Personal items commingling in Rooms #57,36,38.40,42,46,48,50,56,58,62,and 64. Failure to use a barrier during medication pass for [MEDICATION NAME] (used to prevent blood clots) injection. This had the potential to effect all residents. The facility census was 114. Findings included: a) Laundry During a tour of the laundry room on 10/03/18 at 8:00 AM, the door was ajar, the room was wall to wall with hampers and plastic bags of soiled laundry. It was noted there was 13 hampers, seven (7) large bags of soiled laundry. On 10/03/18 at 8:10 AM, an interview with Housekeeping Supervisor (HS) # 94, was asked why is there so much soiled laundry in this room? She said that her staff does not come in until 9:00 AM. She was asked to demonstrate how she would sort the laundry and load the washing machine. She put gloves on and tried to empty the washing machine the machine was packed so tight she struggled to pull any of it out. The countenance of the washing machine was: -sheets -under pads (pads user to prevent the bed sheet from becoming soiled) -colored personal resident clothing -green and gold colored table cloths and napkins -towels and wash clothes One of the table clothes came out of the washing machine still folded. She was asked if it was common practice to fill the washing machine that full and to wash the sheets, chucks and towels with the table clothes, napkins and dark colored resident clothing. She said yes she was told that the machine only works if the washer is filled full. She did agree that the table clot… | 2020-09-01 |
| 1399 | 1399 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 908 | D | 1 | 0 | 0O7M11 | > Based on observation and staff interview, the facility failed to ensure resident equipment was in safe operating condition. Resident #108's intravenous (IV) pole was broken. The headboard and footboard of Resident #15's bed was loose from the frame. These observations were a random opportunity for discovery. Facility census: 114. Findings included: a) Resident #108 At 11:00 AM on 10/02/18, two employees, Employee #1 a maintenance worker and Licensed Practical Nurse (LPN) #128 confirmed the residents IV pole was broken. An IV pole is a medical device designed as a slender aluminum portable pole with an adjustable height and a wheeled base for stability. There are hooks on the pole top that provides a secure place to hang bags of medicine/fluid. The fitting on the IV pole, that allowed the pole to be adjusted for height was missing. The pole was in two pieces and the top piece was leaning forward. The top of the pole was not secured to the bottom pole which extended into the wheeled base. The IV tubing, leading to Resident #108's arm, was attached to a bag of normal saline solution, hooked to the top part of the pole. The pole was leaning forward with the IV tubing dangling. E #1 said he would get another IV pole for the resident. b) Resident #15 An initial tour with Registered Nurse (RN) #61 beginning at 12:17 p.m. and concluding at 1:42 p.m. on 10/02/18 found Resident #15's bed had a loose head board and foot board. Both the head and foot board were easily shaken when touched slightly. RN #61 stated that they should not be that loose and they needed to be tightened up. | 2020-09-01 |
| 1400 | 1400 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 925 | F | 1 | 0 | 0O7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, review of the pest control program and staff interview, the facility failed to eradicate and contain common household pests e.g. mice and roaches for which they were aware of. This practice had the potential to affect all residents at the facility. Facility census: 114. Findings included: a) Resident rooms 1. North/Short Hall A tour of the facility was conducted with Employee #58 a Registered Nurse, Minimum Data Set Coordinator. (E #58 was chosen by the administrator to accompany this surveyor on tour.) The tour of the North/Short Hall began at 12:00 noon and ended at 1:15 PM on 10/02/18. room [ROOM NUMBER] --Mice feces were found inside of the wardrobe drawers. --Mice feces were found behind bed-[NAME] room [ROOM NUMBER] --Mice feces were on the residents personal chair beside Bed-B. --Mice feces was present behind both bed-A and bed-B. --Mice feces were found in the drawers of both sides of the wardrobe. room [ROOM NUMBER] --Mice feces were found in both residents drawers in the wardrobe. In the drawer of bed-B was what appeared to be the beginnings of a mouse nest in a pink house slipper. --Torn pieces of paper, the chewed ends of a Q-tip, hair and other debris were rolled up into a ball inside the house slipper. room [ROOM NUMBER] --A large amount of mice feces were present under the hand sink. room [ROOM NUMBER] --Mice feces were found behind the night stand at bed-B. -room [ROOM NUMBER]: Mice feces inside and on Resident's shoes. -room [ROOM NUMBER]: Mice feces inside of the nightstand, on the top and bottom shelf. 2. North Long Hall An initial tour with Registered Nurse (RN) #61 beginning at 12:17 p.m. concluding at 1:42 p.m. on 10/02/18 found the following rooms on the long north hall which had mouse feces in the room: -- room [ROOM NUMBER] - Mice feces were found in the wardrobe. -- room [ROOM NUMBER] - Mice feces were found in the wardrobe. -- room [ROOM NUMBER] - Mice feces were found in the wardrobe and in … | 2020-09-01 |
| 2536 | 2536 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 156 | E | 0 | 1 | 0QX311 | Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility census: 88 Findings include: a) On 07/31/17 at 10:45 a.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform a resident on how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. During an interview with the Nursing Home Administrator on 07/31/17 at 11:50 a.m., agreed the information was not posted prominently to inform residents on how to apply for and use Medicare and Medicaid benefits. | 2020-09-01 |
| 2537 | 2537 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 166 | D | 0 | 1 | 0QX311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, resident interview and staff interview, the facility failed to make prompt efforts to resolve grievances. Resident #26 was concerned he was not receiving Passive Range of Motion (PROM) services from Nursing. This concern was not resolved for sixteen (16) days. This was found for one (1) of ninety-seven (97) grievances reviewed. Resident identifier: #26. Facility census: 88. Findings include: a) Resident #26 is [AGE] years of age. He was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was determined by a physician to possess the capacity to make informed medical decisions. Review of his record began on 8/7/17 at 11:47 a.m. b) Review of complaints/grievances for (YEAR) to date on 8/7/17 at 11:47 a.m. found a complaint filed by resident #26 on 6/21/17. His concern was expressed to a Physical Therapist and he said he only received range of motion services (ROM) once. The complaint form documented the Therapist gave the concern to the administrator, the social services director, the director of nursing, and the nurse supervisor. There was a note dated 6/26/17 that the administrator told him We are working on his ROM program and will update him soon. There was a memorandum from the Director of Nursing dated 7/6/17 that she had spoken with resident #26 on 7/5/17. She also spoke with Nursing Assistants and his nurse. She wrote All parties were receptive to the plan moving forward. The administrator had a note that said she spoke with resident #26 on 7/26/17 and he said he began receiving his range of motion on 7/6/17. c) Review of therapy notes found he was receiving therapy from 5/5/17 to 6/1/17. He was discharged on [DATE] after he met short term goals. He was discharged to a passive range of motion program with nursing staff (PROM) to prevent any decline in function after discharge. Nursing documentation provided showed he first started receiving the PROM on 7/6/17. d) Resident #26 was interviewed on 8/7/… | 2020-09-01 |
| 2538 | 2538 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 225 | H | 0 | 1 | 0QX311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy and procedure review, accident/incident reports review, resident interviews and staff interviews, the facility failed to ensure incidents of verbal abuse, physical abuse and sexual harassment were identified, thoroughly investigated and reported to the appropriate State agencies. The facility's failure to identify and investigate allegations of verbal abuse, physical abuse, psychological abuse, and sexual harassment also resulted in a failure to ensure alleged victims were protected from further abuse, resulting in actual harm. These finding affected more than a limited number of residents residing in the facility. Resident identifiers: #127, #13, #96, #136, and #45. Alleged perpetrator: #86. Facility census: 88. Findings include: The following information was discovered in a review of Resident #86's nursing progress notes of occurrences of behaviors toward other residents. a) Resident #13 Review of the resident's medical record on 08/02/17 at 1:35 p.m. revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) performed on 06/05/17 revealed a score of 11 meaning Moderately impaired cognition. Review of the grievances/concern forms on 08/02/17 at 8:00 a.m. found grievance/concern forms dated: -- 06/15/17 (typed as written): (Name of Resident #13) stated that when he is going by room [ROOM NUMBER] (room of Resident #86 and near the dining room), that the man in the cowboy hat yells things at me. He (Resident #86) said, Get the f---- out of the hallway! (Name of Resident #13) said that he shouldn't have to listen to that or worry about it. -- 06/16/17 (typed as written): MSW (Masters of Social Work) and CED (Administrator) met with resident (Resident #86) to discuss another resident's (Resident #13) concern that he (Resident #86) had been cursing and yelling at him (Resident #13) in the hallway. Informed resident (Resident #86) that this behavio… | 2020-09-01 |
| 2539 | 2539 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 226 | H | 0 | 1 | 0QX311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of accident/incident reports, facility policy and procedure review, review of immediate and five (5) day reporting information, and staff interview, the facility failed to implement its written policies and procedures for the prohibition and prevention of allegations of verbal and physical abuse and/or neglect. The facility failed to identify and/or recognize allegations resident to resident behavior as verbal abuse, physical abuse, or sexual harassment. In addition, the facility failed to complete documentation of incidents, have evidence of investigations and/or thorough investigations, and failed to report allegations to the appropriate State agencies of occurrences involving alleged resident to resident abuse. Resident #86, had documented behaviors in the nursing progress notes of yelling, screaming, cursing, and physical aggression toward other residents including an allegation of possible sexual harassment. Residents (#127, #13, and #96) were subjected to repeated verbal and/or physical abuse and Resident #136 experienced possible sexual harassment. These types of behaviors caused actual and potential psychosocial harm, mental anguish and/or emotional harm to residents, using the terms and verbiage afraid, uncomfortable, verbal abuse and physical assault causing them to be fearful in the facility and afraid to come out of their rooms. Additionally, the facility failed to report and investigate an allegation of verbal abuse of a resident (#45) by staff. These finding affected more than a limited number of residents residing in the facility. Resident identifiers: #127, #13, #96, #136, and #45. Alleged perpetrator: #86. Facility census: 88. Findings include: The following information was discovered in a review of Resident #86's nursing progress notes of occurrences of behaviors toward other residents. a) Resident #13 b) Resident #13 Review of the resident's medical record on 08/02/17 at 1:35 p.m. reve… | 2020-09-01 |
| 2540 | 2540 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 253 | E | 0 | 1 | 0QX311 | Based on observations and staff interview, the facility failed to provide services to ensure rooms were in good repair. Four (4) of twenty-nine (29) rooms observed during Stage 1 of the Quality Indicator Survey were found to have cosmetic imperfections such as cracks in floor tiles, stained caulking around commode base and a damaged sink countertop. Room identifiers: #207, #238, #332 and #333. Facility census: 88 Findings include: a) Stage 1 observations on 07/31/17 revealed the following cosmetic imperfections: --Room #207, #332 and #333 had multiple cracks in the floor tiles. --Room #238 had stained caulking around the commode base and the underneath the sink countertop had splintered edges. b) Tour with Maintenance Director On 08/03/17 at 8:48 a.m., the Maintenance Director toured the identified rooms and confirmed the areas needed to be repaired. | 2020-09-01 |
| 2541 | 2541 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 278 | D | 0 | 1 | 0QX311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to accurately complete a quarterly Minimum Data Set (MDS) for Resident #49 in the area of life expectancy and hospice services. This was true for one (1) of one (1) MDS reviewed for hospice services during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #49. Facility census: 88. Findings include: a) Resident #49 During a medical record review for Resident #49 on 08/08/17 at 2:34 p.m., revealed a quarterly MDS with an assessment reference date (ARD) of 06/20/17 did not indicate a life expectancy prognosis or hospice services being received by Resident #49. Further review of the current physician's orders [REDACTED]. An interview with Employee #36 Clinical Reimbursement Coordinator on 08/03/2017 10:09 a.m., verified the quarterly MDS with the ARD of 06/20/17 did not include a life expectancy prognosis or Hospice services being received by Resident #49. | 2020-09-01 |
| 2542 | 2542 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 279 | D | 0 | 1 | 0QX311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop individualized care plans based on a resident's current health condition/status that includes measurable objectives and timetables to meet a resident's medical, nursing and psychosocial needs. This was identified for three (3) of twenty-eight (28) Stage 2 sampled residents, whose care plans were reviewed during the Quality Indicator Survey (QIS), for the care areas of behaviors, advanced directives, and pressure ulcers. Resident identifiers: #92, #49, and #88. Facility census: 88. Findings include: a) Resident #92 On 08/02/17 at 8:00 a.m., a medical chart review revealed Resident #92 was admitted to the facility in (MONTH) (YEAR). [DIAGNOSES REDACTED]. The progress notes identify suicidal idealization on 03/02/17 and the resident was referred for psychiatric treatment. Resident #92 was sent out for psychiatric evaluations on 04/21/17 and 04/23/17 following episodes of physical aggression towards residents and staff. The progress notes identify further episodes of verbal and physical aggression on 05/24/17, 07/19/17 and 07/23/17. The significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/24/17, notes Resident #92 has been exhibiting physical behaviors toward others for 4-6 days. These behaviors are coded as significantly intruding on the privacy or activity of others and disrupting the care or living environment. The care plan revised 05/23/17, lacks individualized goals and interventions. The focus for verbal outbursts directed towards others list the following two (2) interventions: -- Monitor for conditions that may contribute to verbal behaviors, including: metabolic causes (e.g., [MEDICAL CONDITION], diabetes, [MEDICAL CONDITION] disorder, liver disease, [MEDICAL CONDITION], electrolyte imbalance) respiratory problems,[MEDICAL CONDITION], delusions, hallucinations, psychiatric disorder(s), poor nutrition, hearing … | 2020-09-01 |
| 2543 | 2543 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 280 | D | 0 | 1 | 0QX311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the care plan for one (1) of twenty-eight (28) sample residents whose care plan was reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #86's care plan was not revised to reflect updated and/or alternative interventions in the area of behaviors. Resident identifier: #86. Facility census: 88. Findings include: a) Resident #86 Review of the medical record on 08/02/17 at 1:35 p.m. revealed Resident #86 was originally admitted on [DATE] and the most recent re-admission on 04/08/17 following a hospitalization . His [DIAGNOSES REDACTED]. He has been determined by his attending physician to have capacity to make his own medical decisions. Assessed to have a brief interview for mental status (BIMS) score of 15 showing him to be cognitively intact. His current medications include, [MEDICATION NAME] 10 milligrams (mg) by mouth (po) for major [MEDICAL CONDITION]. The nursing progress notes from 05/11/17 to 07/23/17 contained documentation of incidents involving Resident #86 yelling, cursing, throwing clothing protector at other residents and verbally threatening other residents. The most recent incident occurring on 07/23/17 involving Resident #86 .cursing at another resident while in dining room waiting for lunch to be served and was asked to leave the dining room . Resident returned to his room and cursing at staff and residents . Also contained in the nursing progress notes were documentation of verbal and physical aggression toward staff from 10/13/16 to 07/23/17. This included screaming, yelling, cursing, pulling staff hair and hitting of staff providing or attempting to provide care. A significant change minimum data set (MDS) with an assessment reference date (ARD) of 07/05/17 revealed a decline in behaviors for Section E0200; item B. Verbal behaviors symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) coded … | 2020-09-01 |
| 2544 | 2544 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 282 | D | 0 | 1 | 0QX311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement the care plan for three (3) of twenty-eight (28) residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey. Residents behaviors were not documented on the behavior monitoring flow sheets, as directed in the care plan. Resident identifiers: #6, #24, #122. Facility census: 88. Findings include: a) Resident #6 On 08/02/17 at 9:00 a.m., review of the medical record revealed Resident #6 was admitted to the facility in (YEAR). Her [DIAGNOSES REDACTED]. The out patient psychiatric visit dated 02/24/17, states: patient admitted to worsening depression, expressed passive death wishes - will recommend to keep patient closely monitored for safety. The psychiatric consult note dated 07/21/17 states under the findings: .[MEDICAL CONDITION] disorder persistent somatic delusions, anxiety secondary to persecutory delusions, mood -depressed . The Quarterly Minimum Data set (MDS) with an Assessment Reference Date (ARD) of 07/16/17 notes Resident #6 has a Brief Interview for Mental Status (BIMS) of 12 indicating moderate impairment and a Patient Health Questionnaire (PHQ) of 09 indicating mild depression. She has delusions and hallucinations and rejected care 1-3 days. [DIAGNOSES REDACTED]. The care plan with a revision date of 07/26/17, identifies Resident #6's impaired cognition, anxiety, depression, and [MEDICAL CONDITION] disorder. Under the focus Resident is at risk for complications related to the use of antipsychotic, antidepressant the interventions include Complete behavior monitoring flow sheet. The Behavioral Monitoring and Interventions records are blank from 02/01/17 through 07/31/17 except for one documentation on the evening of 05/09/17. The Behavioral Monitoring and Interventions records are silent in regards to the resident's behaviors related to her [DIAGNOSES REDACTED]. During an interview with the Clinical Records Coordinator (CRC) #36,… | 2020-09-01 |
| 2545 | 2545 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 309 | D | 0 | 1 | 0QX311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, resident interview, and staff interview, the facility failed provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Resident #26 did not receive Passive Range of Motion (PROM) services from Nursing after his discharge from Therapy as recommended by the Physical Therapist for sixteen (16) days. This was found for one (1) of twenty-eight (28) residents reviewed. Resident identifier: #26. Facility census: 88. Findings include: a) Resident #26 is [AGE] years of age. He was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was determined by a physician to possess the capacity to make informed medical decisions. Review of his record began on 8/7/17 at 11:47 a.m. b) Review of complaints/grievances for (YEAR) to date on 8/7/17 at 11:47 a.m. found a complaint filed by resident #26 on 6/21/17. His concern was expressed to a Physical Therapist and he said he only received range of motion services (ROM) once. The complaint form documented the Therapist gave the concern to the administrator, the social services director, the director of nursing, and the nurse supervisor. There was a note dated 6/26/17 that the administrator told him We are working on his ROM program and will update him soon. There was a memorandum from the Director of Nursing dated 7/6/17 that she had spoken with resident #26 on 7/5/17. She also spoke with Nursing Assistants and his nurse. She wrote All parties were receptive to the plan moving forward. The administrator had a note that said she spoke with resident #26 on 7/26/17 and he said he began receiving his range of motion on 7/6/17. c) Review of therapy notes found he was receiving therapy from 5/5/17 to 6/1/17. He was discharged on [DATE] after he met short term goals. He was discharged to a passive range of motion program with nursing staf… | 2020-09-01 |
| 2546 | 2546 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 314 | D | 0 | 1 | 0QX311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of information from the National Pressure Ulcer Advisory Panel (NPUAP), review of information from Wound Ostomy and Continence Nurse Society and staff interview, the facility failed to ensure Resident #88 who entered the nursing home with a deep tissue injury (DTI) to her coccyx received care and services to promote healing of existing pressure areas and to prevent the development of new, or worsening of existing pressure sores, unless unavoidable. The facility failed to implement any preventative and/or wound healing interventions until initiated on 05/02/17, although her readmission from the hospital was 03/04/17 which at that time was identified as an intact purple area on coccyx. The facility's failure to provide needed care and services to Resident #88 resulted in actual harm to the resident due to requiring 21 weeks for healing of the DTI. This practice was found for one (1) of three (3) sample residents reviewed for the care area of pressure ulcers during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #88. Facility Census: 88. Findings include: a) Resident #88 Review of the medical record on 08/01/17 at 12:27 p.m. revealed Resident #88 was originally admitted on [DATE] with most recent readmission on 03/04/17 following a hospitalization . Her [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) with an assessment reference date (ARD) A deep tissue injury (DTI) on her coccyx was identified to be present on admission (POA) on 03/04/17. The resident was assessed to have a Braden scale score of 14 being at moderate risk for pressure ulcer (PU) on 03/11/17. The care plan revealed no individualized measurable goals or established interventions to meet the immediate needs of the resident at the time of admission for the identified coccyx DTI. The care plan did display a Focus initiated on 05/30/17 (typed as written): Resident has actual skin breakdown as evidenced by DTI to coccyx and … | 2020-09-01 |
| 2547 | 2547 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 319 | H | 0 | 1 | 0QX311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility behavior policy review, abuse prohibition policy review, resident interview, and staff interview, the facility failed to ensure that a resident who displays behaviors and/or is diagnosed with [REDACTED]. This was found for residents with ongoing and/or worsening behaviors within the past twelve (12) months without evidence of routine or initial psychiatric treatment and/or services. Residents #86, #92, and #24 had documented behaviors in the nursing progress notes of yelling, screaming, cursing, and of physical aggression toward other residents and staff. These types of behaviors caused psychosocial and/or emotional harm to other residents, who used the terms and verbiage verbal abuse and physical assault causing them to be fearful in the facility and afraid to come out of their rooms. This practice was found for three (3) of three (3) Stage 2 sample residents reviewed for the care area of behaviors during the QIS survey. Resident identifiers: #86, #92, and #24. Resident identifiers for recipients of resident behaviors: #127, #13, and #96. Facility census: 88. Findings include: a) Resident #86 Medical record review on 08/02/17 at 1:35 p.m. revealed Resident #86 was originally admitted on [DATE] and the most recent re-admission was on 04/08/17 following a hospitalization . His [DIAGNOSES REDACTED]. He was determined by his attending physician to have the capacity to make his own medical decisions and assessed to have a Brief Interview for Mental Status (BIMS) score of 15 showing him to be cognitively intact. His current medications included [MEDICATION NAME] 10 milligrams (mg) by mouth (po) for major [MEDICAL CONDITION]. The nursing progress notes from 05/11/17 to 07/23/17 contained documentation of incidents involving Resident #86 yelling, cursing, throwing clothing protectors at other residents, and verbally threatening other residents. In addition, Resident #86 displayed verbal and physical aggressio… | 2020-09-01 |
| 2548 | 2548 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 323 | E | 0 | 1 | 0QX311 | Based on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Observations during Stage 1 of the Quality Indicator Survey (QIS) found four (4) commodes with loose side rails. This had the potential to affect more than an isolated number of residents. Room identifiers: #330, #331, #334 and #336. Facility census: 88. Findings include: a) Observations of resident bathrooms On 07/31/17 observations of resident bathrooms during Stage 1 revealed commodes in Rooms #330, #331, #334 and #336 had loose commode side rails allowing unsafe transferring for any residents using these commodes. During an observation with the Maintenance Director on 08/03/17 at 8:48 a.m., verified the side rails for commodes in the bathrooms of Rooms #330, #331, #334 and #336 were loose and needed to be tightened for resident's safety. | 2020-09-01 |
| 2549 | 2549 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 371 | E | 0 | 1 | 0QX311 | Based on observation, staff interview and policy review, the facility failed to serve food in a safe and sanitary manner. Observation of a total of four (4) employees failing to perform hand hygiene during meal service. This occurred in two separate main dining room areas located on B hall (Magnolia main dining room and across the hallway Vintage dining room for residents who need assistance with their meals). This practice has the potential to affect more than an isolated number of residents. Employee identifiers: #14, #33, #72 and #79. Facility census: 88. Findings include: a) During a dining observation of the lunch meal with random residents in the Magnolia dining room on 07/31/17 at 12:05 p.m., Employee #33 and Employee #72 distributed meals to various residents through out the lunch meal without performing hand hygiene or sanitizing hands between residents or at any time during the meal service. Immediately following the observation Employee #72 stated, I did sanitize my hands maybe a couple of times but not between each resident like I am supposed to. She did not reply upon inquiry of where the hand sanitizer dispenser is located. Vintage dining room observation on 07/31/17 at 12:20 p.m. revealed Employee #14 and #79 distributed meals to various residents through out the lunch meal without performing hand hygiene or sanitizing hands between residents or at any time during the meal service. Employee #14 reported immediately following this observation, No I did not wash or sanitize my hands between residents and it is the policy to always either wash or sanitize between residents. I do it when I am on the floor working but guess I forgot to do it in here. On 07/31/17 at 12:40 p.m. spoke with the Administrator regarding the previous observations. He stated, That is the fault of the facility by not having any hand sanitizer dispensers located in either dining room. I will have them installed immediately. | 2020-09-01 |
| 2550 | 2550 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 425 | E | 0 | 1 | 0QX311 | Based on review of controlled substance medication sheets, pharmacy reports, staff interview, and policy review, the consulting Pharmacist failed to identify the facility controlled substance records were incomplete and lacked information to show complete reconciliation by on-coming and off-going nurses. This was found for two (2) of four (4) narcotic books/shift to shift logs reviewed during medication storage. This practice has the potential to affect more than an isolated number of residents. Facility census: 88. Findings include: a) On 08/03/17 at 8:10 a.m. review of the two (2) controlled substance inventory logs (one (1) for A hall for rooms beginning with 220 + and one (1) B hall for rooms beginning with 320+) dated 10/05/16 through 08/03/17 found there were thirty-four (34) blank signature spaces for reconciliation of the controlled medication counts at the change of shifts identified. After reviewing the two (2) shift change controlled substance inventory logs dated 10/05/16 through 08/03/17 at 8:33 a.m. on 08/03/17 the Director of Nursing (DON) stated, No there are not supposed to be any blanks. The expectation is the on-coming and off-going shift nurses are to sign to ensure the narcotic count is correct. As you can see this has not been occurring according to facility policy. I do not routinely check the shift logs for narcotics and it should have been done. The consultant Pharmacist is supposed to look at those monthly, but it doesn't look like she has looked at them either. A review of the facility's policy, NSG300 Controlled Drugs: Management of with a reviosion date of 05/01/16, on 08/03/17 at 9:03 a.m. revealed on page 1, Titled Ongoing Inventory: A complete count of all Schedule II-IV controlled drugs is required at the change of shifts per state regulation or at any time in which narcotic keys are surrendered from one licensed nursing staff to another. The count must be performed by two licensed nurses . On 08/03/17 at 9:52 a.m. review of the monthly Quality Improvement: Consultant Pharmacist S… | 2020-09-01 |
| 2551 | 2551 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 428 | D | 0 | 1 | 0QX311 | Based on medical record review, staff interview, and policy review the licensed pharmacist failed to conduct monthly drug regimen reviews on all residents residing in the facility. This was found for two (2) of six (6) Stage 2 sampled residents reviewed for unnecessary medications. Resident identifiers: #92 and #88. Facility census: 88. Findings include: a) Resident #92 On 08/02/17 at 8:00 a.m., a review of the medical record revealed Resident #92's monthly Medication Regimen Review (MRR) form was initialed and dated by the pharmacist for a review conducted on 05/08/17. However, the MRR form did not show if there were or were not any drug irregularities and/or recommendations for this date. The consultant pharmacy report summary generated by Corporate Consultant #128 for the month of (MONTH) (YEAR) states at the top: The following residents were reviewed and based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my professional judgement that at such time, the residents' medication regimens contained no new irregularities (as defined in SOM Appendix PP 483.60(c)). Resident #92 is not listed on the form and there is no information indicating a MRR was conducted for Resident #92 during the month of (MONTH) (YEAR). LPN #19 confirmed the MRR form was incomplete during an interview on 08/01/17 at 5:00 p.m. On 08/02/17 at 1:00 p.m., the Corporate Consultant #128 acknowledged Resident #92 was not listed on the consultant pharmacist's summary report she had generated on 08/02/17 at 11:42 a.m. Thus indicating the pharmacist had not conducted a monthly MRR on Resident #92. b) Resident #88 Review of the medical record on 08/01/17 at 3:00 p.m. revealed Resident #88's monthly Medication Regimen Review (MRR) form was initialed and dated by the pharmacist for a review conducted on 06/03/17. The MRR form did not show if there were or were not any drug irregularities and/or recommendations for this date. The consultant pharmacy report summary generated… | 2020-09-01 |
| 2552 | 2552 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 431 | E | 0 | 1 | 0QX311 | Based on review of controlled medication sheets, pharmacy reports, staff interview, and policy review, the facility failed to ensure controlled substance records were complete and contained information to show complete reconciliation by on-coming and off-going nurses. This was found for two (2) of four (4) narcotic books reviewed during medication storage. This practice has the potential to affect more than an isolated number of residents. Facility census: 88. Findings include: a) On 08/03/17 at 8:10 a.m. review of the two (2) controlled substance inventory logs (one (1) for A hall for rooms beginning with 220 + and one (1) B hall for rooms beginning with 320+) dated 10/05/16 through 08/03/17 found there were thirty-four (34) blank signature spaces for reconciliation of the controlled medication counts at the change of shifts identified. On 08/03/17 at 8:15 a.m. Licensed Practical Nurse (LPN) #40 explained the procedure/process for shift to shift reconciliation. She commented, every on-coming and off-going nurse are to count the narcotics and then each nurse is to sign the shift reconciliation sheets. After reviewing the two (2) shift change controlled substance inventory logs dated 10/05/16 through 08/03/17 at 8:33 a.m. on 08/03/17 the Director of Nursing (DON) stated, No there are not supposed to be any blanks. The expectation is the on-coming and off-going shift nurses are to sign to ensure the narcotic count is correct. As you can see this has not been occurring according to facility policy. I do not routinely check the shift logs for narcotics and it should have been done. The consultant Pharmacist is supposed to look at those monthly, but it doesn't look like she has looked at them either. A review of the facility's policy, NSG300 Controlled Drugs: Management of on 08/03/17 at 9:03 a.m. revealed on page 1, Titled Ongoing Inventory: A complete count of all Schedule II-IV controlled drugs is required at the change of shifts per state regulation or at any time in which narcotic keys are surrendered from one li… | 2020-09-01 |
| 2553 | 2553 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 441 | E | 0 | 1 | 0QX311 | Based on observation and staff interview, the facility failed to maintain an effective Infection Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. The nurse failed to maintain aseptic technique during wound care, creating a potential for cross contamination and infection during the procedure. This practice was found for one (1) of two (2) wound care observations observed for pressure ulcer dressings during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #21. Facility census: 88. Findings include: a) During an observation on 08/02/17 at 9:15 a.m., Licensed Practical Nurse (LPN) #10 provided wound care. The LPN obtained supplies from the treatment cart, cleaned the bedside table and set up her supplies. She then proceeded to wash her hands and donned gloves. LPN #10 assisted Resident #21 onto her left side with the help of a nursing assistant. LPN #10 untaped the feces soiled brief and allowed it to lay open and flat with a visibly soiled area in the dressing field. The LPN removed the old dressing, and preceded to the sink to remove her gloves, wash her hands and apply clean gloves. LPN #10 preceded to clean the wound bed with her left hand with no attempt to cover the soiled brief or remove it. LPN #10's left hand touched the soiled brief twice during wound cleaning. At this point the surveyor asked the nurse if she thought she was maintaining aseptic technique with a soiled brief that she has touched twice during wound care. LPN #10 folded the brief over, and preceded to wash her hands a apply clean gloves before continuing the procedure. LPN #10 was interviewed immediately after this observation. She confirmed she had made no attempts to remove or cover up the soiled brief prior to performing wound care and agreed this was a break in aseptic technique. | 2020-09-01 |
| 2554 | 2554 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 490 | F | 0 | 1 | 0QX311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, policy review and staff interview, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Facility systems in place failed to adequately address prevention, recognition, reporting, and investigation of allegations of abuse and neglect. Facility systems in place failed to ensure consistent reconciliation of narcotics counts and failed to recognize and identify when the counts were not being completed by Nurses. This had the potential to affect all residents. Facility census: 88. Findings include: a) Abuse/neglect issues cited represent system failures. The following information was discovered in a review of Resident #86's nursing progress notes of occurrences of behaviors toward other residents. 1. Resident #13 Review of the medical record on 08/02/17 at 1:35 p.m. revealed Resident #13 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) performed on 06/05/17 revealed a score of 11 meaning Moderately impaired cognition. Review of the grievances/concern forms on 08/02/17 at 8:00 a.m. found a grievance/concern forms dated: --06/15/17 (typed as written): (Name of Resident #13) stated that when he is going by room [ROOM NUMBER] (room of Resident #86 and near the dining room), that the man in the cowboy hat yells things at me. He (Resident #86) said, Get the f---- out of the hallway! (Name of resident #13) said that he shouldn't have to listen to that or worry about it. ---06/16/17 (typed as written): MSW (Master of Social Work) and CED (Administrator) met with resident (Resident #86) to discuss another resident's (Resident #13) concern that he (Resident #86) had been cursing and yelling at him (Resident #13) in the hallway. Informed resident (Resident #86) that this behavior is inappropriate and cannot c… | 2020-09-01 |
| 2555 | 2555 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 514 | E | 0 | 1 | 0QX311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to maintain complete, accurately documented, and readily accessible medical records. Behavior documentation sheets were not completed, and Consultant Pharmacist monthly drug regimen review forms were not filled out completely or were not done at all. This was found for seven (7) of twenty-eight (28) records reviewed. Resident identifiers: #87, #92, #6, #24, #88, #122, #86. Facility census: 88. Findings include: a) Resident #87 triggered for investigation of possible unnecessary medications in her regimen due to stage one record review coding she was receiving an antidepressant, [MEDICATION NAME], an anticoagulant, [MEDICATION NAME], and insulin, [MEDICATION NAME] flex pen and [MEDICATION NAME]. Resident #87 is [AGE] years of age. She was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Drug regimen reviews were found monthly. No review was done for (MONTH) because resident #87 was not in the building. The spaces to mark either No irregularities or See report for any noted irregularities and/or recommendations. were all blank for (YEAR). A request was made to LPN #19 and RN #112 to provide evidence of any reports, irregularities or recommendations. They were able to provide sections of the consultant pharmacist's monthly reports that showed she reviewed resident #87 each month and that she found no irregularities. During an interview on 8/3/17 at 11:00 a.m., when the documentation was provided, they confirmed the drug regimen reviews conducted by the consultant pharmacist for (YEAR) were not fully completed. The investigation did not find sufficient evidence to substantiate deficient practice by the facility for the medication regimen of resident #87, but the consultant pharmacist did not fully complete the monthly drug regimen review forms causing the medical record to be incomplete and not readily accessible. f) Resident #122 A review of the medical record for Res… | 2020-09-01 |
| 2556 | 2556 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 520 | F | 0 | 1 | 0QX311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interviews, record reviews, facility policy and procedure reviews, abuse and neglect reports, resident grievance/concern reports, incident/accident reports, the facility's quality and assurance (QA&A) committee failed to develop, revise and/or implement corrective plans of actions of which it was aware of or should have been aware of under the previous administration of Nursing Home Administrator (NHA) . The present NHA #111 started employment at the facility on 07/31/17 and the systemic breakdown was already in place. This systemic breakdown and failure to implement and maintain action plans outlined in the annual Quality Indicator Survey (QIS) for identifying, reporting, investigating and taking appropriate action regarding allegations of abuse and neglect, reconciliation of controlled substances, maintaining an effective infection control program, monthly pharmacy medication reviews, and incomplete medical records. On 08/089/17 at 10:30 a.m., the NHA #111 agreed changes would need to be implemented and education completed for identifying, reporting, investigating and taking appropriate action regarding allegations of abuse and neglect, reconciliation of controlled substances, maintaining an effective infection control program, monthly pharmacy medication regimen reviews and incomplete medical records. He commented he had taken over the facility as NHA on 07/31/17 and was not aware of all of the system failures at present but was working on getting the matters resolved which were brought to his attention during the survey a) Abuse/neglect issues cited represent system failures. The following information was discovered in a review of Resident #86's nursing progress notes of occurrences of behaviors toward other residents. 1. Resident #13 Review of the medical record on 08/02/17 at 1:35 p.m. revealed Resident #13 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A Brief Intervie… | 2020-09-01 |
| 7990 | 7990 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2013-11-11 | 201 | D | 1 | 0 | 0RE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, staff interview, family interview, and interview with outside behavioral health professionals, the facility failed to ensure a resident was involuntarily discharged on ly when her needs could not be met at the facility. There was no evidence of any attempts to assess, monitor, and manage her admitting [DIAGNOSES REDACTED]. This was found for one (1) of twelve (12) residents whose records were reviewed. Resident identifier: #91. Facility census: 90. Findings include: a) Resident #91 1) This [AGE] year old resident was admitted to the facility on [DATE]. She was discharged on [DATE]. Her [DIAGNOSES REDACTED]. Review of the resident's medical record, beginning on 11/04/13 at 11:00 a.m., found she was assessed as having severe cognitive impairment. Her Brief Interview for Mental Status (BIMS) score as assessed on 08/12/13 was 06 indicating severe cognitive impairment. Review of the Pre-admission Screening form, required by the West Virginia Department of Health and Human Resources (WVDHHR), found Resident #91 was residing at a local geriatric behavioral health unit at the time of the initial referral. The [DIAGNOSES REDACTED]. The physician from the behavioral health unit signed attesting she required nursing home care and would not be able to return home or be discharged . A Level II, or Mental Illness/Mental [MEDICAL CONDITION] Screen, needed to be done to ensure that nursing home placement was appropriate. The required screen was completed on 07/28/13, with a recommendation of nursing facility services with no specialized services needed. The social services history/admission assessment completed 08/06/13, under the Behavior: (check all that apply.) section had checkmarks indicating Physical behavior symptoms directed towards others. (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually.), and Verbal behavioral symptoms directed toward others. (e.g., threatening others, screaming at others, c… | 2016-11-01 |
| 7991 | 7991 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2013-11-11 | 203 | D | 1 | 0 | 0RE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Clevenger, Tom Based upon record review and the inability of the facility to provide evidence, the facility failed to notify the family of one (1) of twelve (12) residents reviewed a written discharge notice and a notice of the right to appeal the discharge. There was no notice which included the reason for discharge, the effective date of discharge, a statement that the resident has the right to appeal the action to the State, and the name, and the address and telephone number of the State long term care ombudsman. Resident identifier: #91 Facility census: 90. Findings include: a) Resident #91 This [AGE] years old resident was admitted to the facility on [DATE], and involuntarily discharged on [DATE]. The record review was begun on 11/4/13 at 11:00 a.m. Medical record review found no evidence the responsible party was provided a written discharge notice which included the reason for discharge, the effective date of discharge, a statement that the resident has the right to appeal the action to the State, and the name, and the address and telephone number of the State long term care ombudsman. A request was made on the morning of 11/07/13 for documentation of any written discharge notice and/or notice of right to appeal the discharge of Resident #91 from the facility. No documents were provided by the time of exit on 11/11/13. A discharge summary was found signed by the physician on 10/15/13. It listed the discharge date as 08/14/13. The sections of the form Brief History:, Pertinent Physical and Laboratory Findings:, Condition on discharge:, discharged to:, and Follow-Up and discharge Medication Instruction: were blank. | 2016-11-01 |
| 7992 | 7992 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2013-11-11 | 225 | D | 1 | 0 | 0RE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse were reported immediately in accordance with State law through established procedures (including to the State survey and certification agency) and failed to submit the required five-day follow up report to the agencies. This was found for two (2) of twelve (12) residents whose records were reviewed. Resident identifiers: #91 and #38. Facility census: 90. Findings include: a) Resident #91 The record of Resident #91 was reviewed on 11/04/13 at 11:00 a.m. There was an abuse/neglect report allegation found that was sent to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Regional Ombudsman on 08/14/13. It documented the date of the incident as 8/12/13 and the time as 7:45 p.m. The allegation was reported 08/14/13 at 4:43 p.m., after Resident #16 was found to have suffered a [MEDICAL CONDITION]. The description of the incident was (typed as written): (#91), resident, picked up and tossed another resident, (#16) in the hallway. He landed on (right) hip. Both residents are on Solana unit and do not have capacity. There was no evidence of the required five-day follow-up form in the record to document the disposition of the allegation as required by State law. Following discussion with the facility administrator, Employee #48 on 11/07/13 at 10:47 a.m., the five-day follow-up was faxed to the appropriate agencies. b) Resident #38 The record of Resident #38 was reviewed on 11/11/13 at 9:00 a.m. Resident #38 was involved in an altercation on the Alzheimer's unit on 09/20/13 at 2:45 p.m. The incident report stated she was seen pulling another resident, Resident #86, across the hallway. Resident #86 suffered multiple scratches to her face and neck, and was sent to the emergency room for treatment. The resident-to-resident altercation with injury requiring med… | 2016-11-01 |
| 7993 | 7993 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2013-11-11 | 323 | G | 1 | 0 | 0RE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review, staff interview, family interview, and interview with outside behavioral health professionals, the facility failed to ensure five (5) of twelve (12)residents reviewed received adequate supervision and/or assistive devices to prevent avoidable accidents. Residents #91, #16, #38, and #85 did not receive supervision to prevent resident-to-resident altercations. The altercation involving Resident #91 resulted in actual harm to Resident #16, and the altercation involving Resident #38 resulted in actual harm to Resident #86. In addition, Resident #57 did not receive supervision or assistive devices to prevent accidents involving himself. Resident identifiers: #91, #16, #38, #85, and #57. Facility census: 90. Findings include: a) Resident #91 Review of this resident's medical record, on 11/04/13 at 11:00 a.m., found this [AGE] year old resident was admitted to the facility on [DATE]. Review of the Pre-admission Screening form found the resident was residing at a local geriatric behavioral health unit at the time of the initial referral. The [DIAGNOSES REDACTED]. The facility's social services history/admission assessment was completed on 08/06/13. Under the Behavior: (check all that apply.) section were checkmarks indicating Physical behavior symptoms directed towards others. (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually.), and Verbal behavioral symptoms directed toward others. (e.g., threatening others, screaming at others, cursing at others.) Under the section Impact on others - Did any of the identified symptoms: was checked Put others at significant risk for physical injury. Under the section Discharge plan review checkmarks were made that indicated discharge to the community was not feasible, and that long-term placement was anticipated. There was no evidence the information regarding behavior issues, which was available to the facility, was ever included in a care plan fo… | 2016-11-01 |
| 7994 | 7994 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2013-11-11 | 353 | G | 1 | 0 | 0RE211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review, staff interview, and family interview, the facility fails to deploy sufficient nursing staff across all shifts to provide nursing and related services to minimize resident-to-resident altercations and/or accidents for five (5) of twelve (12) residents reviewed. There was not adequate monitoring and intervention by staff to consistently prevent or minimize the risk of injury to residents. Residents #91, #16, #38, and #85 did not receive supervision to prevent resident-to-resident altercations. The altercation involving Resident #91 resulted in actual harm to Resident #16, and the altercation involving Resident #38 resulted in actual harm to Resident #86. In addition, staff were not deployed to monitor Resident #57 to assist in the prevention of falls and/or injury. Resident identifiers: #91, #16, #38, #85, and #57. Facility census: 90. Findings include: a) Resident #91 This resident's medical record, reviewed on 11/04/13 at 11:00 a.m., found this [AGE] year old resident was admitted to the facility on [DATE]. Review of the Pre-admission Screening form found the resident was residing at a local geriatric behavioral health unit at the time of the initial referral. The [DIAGNOSES REDACTED]. The facility's social services history/admission assessment was completed on 08/06/13. Under the Behavior: (check all that apply.) section were checkmarks indicating Physical behavior symptoms directed towards others. (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually.), and Verbal behavioral symptoms directed toward others. (e.g., threatening others, screaming at others, cursing at others.) Under the section Impact on others - Did any of the identified symptoms: was checked Put others at significant risk for physical injury. Under the section Discharge plan review checkmarks were made that indicated discharge to the community was not feasible, and that long-term placement was anticipated. The… | 2016-11-01 |
| 7995 | 7995 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2013-11-11 | 514 | E | 1 | 0 | 0RE212 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure accurate documentation for seven (7) of thirteen (13) residents who required bed and/or chair alarms for safety precautions. These residents had no directives on the Treatment Administration Records (TAR) to check the functionality of the alarms. Instead, the TAR directed that alarms were to be used, or nurses may utilizealarms. This had the potential to endanger those seven (7) residents by not ensuring clear directives to nursing staff to check and document the functionality of the alarm equipment. Resident identifiers: #55, #18, #35, #85, #62, #26, and #32. Facility census: 87. Findings include: a) Resident #55 An incident and accident report was reviewed on 01/08/14 at 12:00 p.m. This review revealed that on 01/04/14 at 7:45 a.m., Resident #55 was found on the floor by staff. The resident had removed her alarm prior to the fall. The report did not indicate whether it was alarming at or before the time of the fall. Another incident report, dated 01/04/14 at 9:00 a.m., revealed she was again discovered by staff lying on the floor beside her bed. According to the incident report, the alarm did not sound. Staff replaced the alarm at that time. The treatment administration record (TAR) was reviewed on on 01/08/14 at 1:00 p.m It directed that staff may utilize sensor pad alarm to bed at al limes, to alert staff to resident's attempts to transfer unassisted, to minimize falls risk. The start date for this intervention was 12/24/13. Nurses initialed the TAR at 10:00 a.m. and 10:00 p.m. daily from 01/01/14 through 01/08/14. An interview was conducted with licensed nurse Employee #44 at 1:30 p.m. on 01/08/14. She first checked the TAR, then said there is no order on the TAR for staff to check the functionality of the bed alarm. She said there was someone assigned to check the functionality via daily audits. On 01/08/14 at 1:45 p.m., the administrator was asked how sta… | 2016-11-01 |
| 9887 | 9887 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-01-08 | 514 | E | 1 | 0 | 0RE212 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure accurate documentation for seven (7) of thirteen (13) residents who required bed and/or chair alarms for safety precautions. These residents had no directives on the Treatment Administration Records (TAR) to check the functionality of the alarms. Instead, the TAR directed that alarms were to be used, or nurses "may utilize"alarms. This had the potential to endanger those seven (7) residents by not ensuring clear directives to nursing staff to check and document the functionality of the alarm equipment. Resident identifiers: #55, #18, #35, #85, #62, #26, and #32. Facility census: 87. Findings include: a) Resident #55 An incident and accident report was reviewed on 01/08/14 at 12:00 p.m. This review revealed that on 01/04/14 at 7:45 a.m., Resident #55 was found on the floor by staff. The resident had removed her alarm prior to the fall. The report did not indicate whether it was alarming at or before the time of the fall. Another incident report, dated 01/04/14 at 9:00 a.m., revealed she was again discovered by staff lying on the floor beside her bed. According to the incident report, the alarm did not sound. Staff replaced the alarm at that time. The treatment administration record (TAR) was reviewed on on 01/08/14 at 1:00 p.m.. It directed that staff "may utilize sensor pad alarm to bed at al limes, to alert staff to resident's attempts to transfer unassisted, to minimize falls risk". The start date for this intervention was 12/24/13. Nurses initialed the TAR at 10:00 a.m. and 10:00 p.m. daily from 01/01/14 through 01/08/14. An interview was conducted with licensed nurse Employee #44 at 1:30 p.m. on 01/08/14. She first checked the TAR, then said there is no order on the TAR for staff to check the functionality of the bed alarm. She said there was someone assigned to check the functionality via daily audits. On 01/08/14 at 1:45 p.m., the administrator was asked… | 2015-08-01 |
| 10065 | 10065 | WYOMING NURSING AND REHABILITATION CENTER, LLC | 515164 | P.O. BOX 149 | NEW RICHMOND | WV | 24867 | 2009-10-23 | 502 | D | 0 | 1 | 0RO511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure that three (3) of thirteen (13) sampled residents received ordered laboratory testing in a timely manner. Resident identifiers: #26, #23, and #12. Facility census: 59. Findings include: a) Resident #26 Review of the medical record found a late entry nursing note at 1:00 p.m. on 10/15/09. The nurse documented that staff reported the resident had a loose stool with blood present. An order was obtained, at 1:45 p.m., to collect stool for [MEDICAL CONDITIONS] a stool culture and test for ova and parasites. Further review found a nursing note, dated on 10/16/09 at 4:30 a.m., which documented the stool specimen was obtained for testing related to [MEDICAL CONDITION] and parasite infestation. A thorough review found no evidence the facility had obtained the laboratory report. A registered nurse (Employee #84) was notified that the resident had this test ordered and the laboratory report could not be located Employee #84 and the director of nursing (DON, Employee #82), when interviewed about the missing laboratory results at 12:15 p.m. on 10/21/09, relayed the stool culture had been stored in a cabinet (for five (5) days) and had not been sent to the laboratory as ordered. Further interview elicited that the resident had been experiencing liquid stools on a daily basis from 10/1/09 through 10/21/09. The staff members obtained a stat stool culture, which was negative for [MEDICAL CONDITION], but had no results for possible parasitic involvement. b) Resident #23 Review of the medical record found a nursing note written on 10/17/09 at (unable to decipher handwritten time) to obtain a [MEDICAL CONDITION] stool culture due to two (2) reported bowel movements containing mucus, orange color, and odor. Further review found that the facility did not obtain the ordered stool sample until at 6:00 a.m. on 10/20/09. An interview with Employee #82, on 10/22/09 at 4:10 p.m., elicited … | 2015-07-01 |
| 10066 | 10066 | WYOMING NURSING AND REHABILITATION CENTER, LLC | 515164 | P.O. BOX 149 | NEW RICHMOND | WV | 24867 | 2009-10-23 | 371 | F | 0 | 1 | 0RO511 | Based on observation and staff interview, the facility failed to assure beverage glasses and bowls were free from moisture (wet nesting) and failed to assure garbage was properly secured during food service. These deficient practices had the potential to affect all resident receiving on oral diet. Facility census: 59. Findings include: a) Random observations of the dietary department, on 10/20/09 at 5:30 p.m., found racks containing bowls and beverage glasses stored in the dishwasher room. An inspection of the glasses and bowls noted drops of water present on the inside of randomly selected glasses and bowls. The dietary manager agreed that moisture was present and the glasses and bowls had not been properly air dried. b) On 10/19/09 at approximately 5:30 p.m., observation during meal service in the kitchen revealed an open trash can in the dishroom that did not have a lid on it. The dietary manager indicated the lid was probably left off by an employee who was preparing coffee. However, she agreed the employee needed to put the lid on the can after she it was used to discard trash. . | 2015-07-01 |
| 10067 | 10067 | WYOMING NURSING AND REHABILITATION CENTER, LLC | 515164 | P.O. BOX 149 | NEW RICHMOND | WV | 24867 | 2009-10-23 | 279 | D | 0 | 1 | 0RO511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop comprehensive care plans which contained measurable objectives, timetables, and relevant services to be provided to achieve the highest practicable physical, mental, and psychosocial well-being for two (2) of thirteen (13) residents currently residing in the facility. Resident identifiers: #5 and #36. Facility census: 59. Findings include: a) Resident #5 1. Review of the current care plan (with a resolution date of 11/20/09) found the facility identified the resident as demonstrating decreased cognitive ability related to dementia and confusion. The resident was refusing most invitations to group activity with some activity in room. The objectives (goals) developed by the facility were for the resident to participate in one-on-one activities two (2) times a seek and continue to do individual activities in the room. A review of the services to be provided in order to achieve the above goal included: "Do not correct resident try to redirect;" "Invite resident to go out of room for short periods of time just for a stroll;" and "When husband is visiting invite and encourage them to come and sing for peers and staff." None of the services to be provided were consistent with the goal of participating in one-on-one or in- room activities. 2. Further review of the care plan found the facility had identified the resident was at risk for falls. The objective was for the resident to have no falls requiring hospitalization through the next review. The services provided to obtain the stated objective included: "Administer Ambilify (sic) 20 mg po (by mouth) daily" and "Administer [MEDICATION NAME] 60 mg po daily". The care plan nurse could not state how the administration of antipsychotic and antidepressant drugs would assist the resident in not experiencing falls, during an interview on the afternoon of 10/21/09. b) Resident #36 1. The record review for Resident #36, conduc… | 2015-07-01 |
| 10068 | 10068 | WYOMING NURSING AND REHABILITATION CENTER, LLC | 515164 | P.O. BOX 149 | NEW RICHMOND | WV | 24867 | 2009-10-23 | 281 | D | 0 | 1 | 0RO511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of standing orders, facility staff interview, and review of West Virginia Nursing Code and Legislative Rules, Including Criteria for Determining Scope of Practice of Licensed Practical Nurses and Guidelines for Determining Acts That May Be Delegated or Assigned by Licensed Nurses (2009 Edition), the facility failed to assure licensed nurses acted within their respective scopes of practice while delivering care to two (2) of thirteen (13) sampled residents. Licensed practical nurses (LPNs) failed to notify the registered professional nurse (RN) or physician when Resident #26 had a change in condition, failed to act under the direction of the physician when ordering and administering medications for Resident #26, and failed to accurately document when Resident #23 refused medications. Resident identifiers: #26 and #23. Facility census: 59. Findings include: a) Resident #26 1. Review of the medical record found a nursing transfer / discharge summary with nursing notes written by a licensed practical nurse (LPN) on the night shift of 10/08/09. The LPN documented that the resident was nauseated and vomited a small amount at 3:30 a.m. At 4:30 a.m., the resident vomited a moderate amount. At 5:30 a.m., the resident vomited a large amount, his respirations were 30, and his oxygen saturation was 84%. Review of the facility's standing orders found the following: "IX. Acute Shortness of breath ...2. Check oxygen saturation via pulse oximeter PRN (as needed). If O2 (oxygen) SAT (saturation) less than 90, call physician." The nursing note written at 6:30 a.m. found the resident's oxygen saturation was only 87% with the use of oxygen. The documentation contained no evidence the LPN collected data related to the resident's breath sounds, bowel sounds, skin color, etc., nor was there evidence to reflect the LPN attempted to contact the physician or the RN for direction in providing care. The nursing transfer / discharge… | 2015-07-01 |
| 10069 | 10069 | WYOMING NURSING AND REHABILITATION CENTER, LLC | 515164 | P.O. BOX 149 | NEW RICHMOND | WV | 24867 | 2009-10-23 | 309 | D | 0 | 1 | 0RO511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure two (2) of thirteen (13) sampled residents received the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the plan of care. Facility nurses continued to administer laxatives to Resident #26 in the presence of multiple liquid stools. Additionally, the facility failed to assure Resident #57 received ordered antibiotics for treatment of [REDACTED]. Resident identifiers: #26 and #57. Facility census: 59. Findings include: a) Resident #26 Review of the medical record found a late entry nursing note on 10/15/09 at 1:00 p.m., documenting that staff reported the resident had a loose stool with blood present. The LPN wrote an order for [REDACTED].) Review of the Medication Administration Record [REDACTED]. Further review found licensed nurses administered both laxatives on 10/16/09, 10/17/09, 10/18/09, 10/19/09, and 10/20/09, and administered the [MEDICATION NAME] 8.6 mg/50 mg on the morning of 10/21/09. The facility utilizes a computer system to track resident bowel movements. The director of nursing (DON, Employee #82) accessed the information concerning Resident #26's bowel movements during an interview conducted at 12:15 p.m. on 10/21/09. Upon reviewing the electronic records, Employee #82 relayed the resident had large-to-extra-large liquid stools at the following times: 10/16/09 at 2:47 p.m., 10/17/09 at 2:50 p.m. and 9:50 p.m., 10/18/09 at 5:04 a.m., 10/19/09 at 2:14 a.m., 10/20/09 at 9:41 p.m., and 10/21/09 at 6:44 a.m. Following the above interview, the facility obtained an order to discontinue all the resident's laxatives due to loose stools. The nursing staff continued to administer laxatives to Resident #26 in the presence of liquid stools for a period of six (6) days. b) Resident #57 Review of the medical record found Resident #57 was prescribed the antibiotic [MEDICATION NAME] 875 mg every twelv… | 2015-07-01 |
| 10070 | 10070 | WYOMING NURSING AND REHABILITATION CENTER, LLC | 515164 | P.O. BOX 149 | NEW RICHMOND | WV | 24867 | 2009-10-23 | 364 | E | 0 | 1 | 0RO511 | Based on random observation, testing of food temperatures, and staff interview, the facility failed to assure each resident received food at the proper temperature for palatability. This deficient practice had the potential to affect more than an isolated number of residents receiving an oral diet. Facility census: 59. Findings include: a) During the evening meal service on the resident hallway on 10/20/09 at 5:50 p.m., random observations noted that undistributed resident trays were sitting on racks on an open cart. After the last resident on the hall was served their tray and began to eat, the dietary manager was asked to assist in obtaining food temperatures on the remaining tray. She obtained a thermometer and determined that the beans were 108.1 degrees Fahrenheit (F) and the hot dog chili was 109.9 degrees F. She agreed that both food items should have been at least 120 degrees at the point of service. . | 2015-07-01 |
| 10071 | 10071 | WYOMING NURSING AND REHABILITATION CENTER, LLC | 515164 | P.O. BOX 149 | NEW RICHMOND | WV | 24867 | 2009-10-23 | 328 | D | 0 | 1 | 0RO511 | Based on observation, policy review, and staff interview, the facility failed to assure a licensed nurse appropriately positioned one (1) of two (2) residents receiving medications via gastrostomy tube to avoid choking and potential aspiration. Resident identifier: #2. Facility census: 59. Findings include: a) Resident #2 During observation of the medication administration pass on 10/21/09 at 7:40 a.m., the nurse (Employee #13) was noted to prepare Resident #2's medications for administration via her gastrostomy tube. Observation found that, while the head of the resident's bed was raised approximately 30 degrees, the resident had slid down the bed until her chest and stomach were lying in a flat position. Employee #13 prepared the resident's medications individually. She checked for proper placement of the gastrostomy tube prior to flushing the tube with approximately 30 cc of water. The nurse then placed diluted medication into the tube followed by a 5 cc to 30 cc flush, administered another medication followed by a flush, administered another medication followed by a flush. After this, the resident began to make gurgling sounds. The nurse then administered a 350 cc flush, and the resident started to gurgle and cough. The nurse surveyor pointed out to Employee #13 that the resident's chest and stomach were flat in the bed and suggested the resident be pulled up in the bed, so she was in an elevated position. The resident continued to gurgle and cough until the nurse obtained assistance in pulling her up in the bed. The director of nursing (DON) was informed of the above observation. She provided the facility's policy, which stated the resident was to be assisted to a semi or high-Fowler's position (30 degrees to 45 degrees) if tolerated (policy titled Administering Medications through a Gastrostomy Tube, revised July 1, 2006). The DON agreed the resident should not have been administered medications when she was lying flat in the bed. . | 2015-07-01 |
| 10072 | 10072 | WYOMING NURSING AND REHABILITATION CENTER, LLC | 515164 | P.O. BOX 149 | NEW RICHMOND | WV | 24867 | 2009-10-23 | 441 | D | 0 | 1 | 0RO511 | Based on observation and review of facility policy, the facility failed to ensure licensed nursing staff sanitized or washed their hands prior to instilling medications via gastrostomy tubes for two (2) of two (2) randomly observed residents. Resident identifiers: #2 and #42. Facility census: 59. Findings include: a) Resident #2 During the medication administration pass on 10/21/09 at 7:40 a.m., observations found the nurse (Employee #13) preparing Resident #2's medications for administration via her gastrostomy tube. She was noted to touch her keys, the medication cart, the medication administration book, and the sink faucet handle prior to donning gloves without first washing or sanitizing her hands. b) Resident #42 During the medication administration pass on 10/21/09 at 8:20 a.m., the nurse (Employee #6) was observed to prepare Resident #2's medications for administration via her gastrostomy tube. She was noted to touch the medication cart, the medication administration book, and the sink faucet handle prior to donning gloves without first washing or sanitizing her hands. c) Review of the facility's policy related to "Administering Medications through a Gastrostomy Tube" (revised July 1, 2006), under the section entitled "Infection Control Protocol and Safety", found the following language: "1. Wash your hands thoroughly with soap and water at the following intervals: a. before the procedure;...". . | 2015-07-01 |
| 2870 | 2870 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2019-11-06 | 550 | D | 0 | 1 | 0RSH11 | Based on observation, staff interview, and resident interview, the facility failed to provide a dignified dining experience. This was a random opportunity for discovery. Resident identifiers: #70. Facility census: 95. Findings included: a) Resident #70 During dining observation on 11/04/19 at 12:19 PM, Resident #70, asked, what was in the two (2) bowls, which both had a pudding consistency. Resident # 70 was eating a regular tray, of lima beans, mashed potatoes, and a roll. On 11/04/19 at 12:25 PM, Nurse Aide #44 was asked, what was in the bowls, she said it was puree roll and puree pears. She stated that she does not know why Resident #70 was given puree food, because she eats a regular diet. She removed the bowls and returned with a fruit cup. Resident #70 stated, just the appearance of the puree in the bowls made her lose her appetite. Nurse Aide #44 apologized. | 2020-09-01 |
| 2871 | 2871 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2019-11-06 | 583 | D | 0 | 1 | 0RSH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure visual privacy for one (1) of one (1) residents receiving injections during the facility task of medication administration. Resident identifier: #43. Facility census: 95. Findings included: a) Resident #43 On 11/05/19 at 9:40 AM, medication administration to Resident #43 was observed. The medication administration was performed by Licensed Practical Nurse (LPN) #106. Resident #43 was ordered insulin, [MEDICATION NAME] FlexTouch Solution Pen-Injector, 35 units subcutaneously, one (1) time a day. Resident #43 was sitting on her bed and was facing the door when LPN #106 administered the insulin injection into her left upper arm. Resident #43's door was open during the insulin injection. Resident #43's roommate was sitting on her bed, facing Resident #43, when the insulin injection was given. Following the insulin injection, LPN #106 was informed she did not draw back the bedside curtain to ensure Resident #43 had visual privacy during the medication injection. LPN #106 agreed the curtain should have been drawn to ensure privacy. No further information was provided through the completion of the survey. | 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 );