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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 201 | 201 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2017-04-19 | 246 | D | 0 | 1 | HZCX11 | Based on staff interview, resident interview and record review, the facility failed to ensure reasonable accommodations were attempted to allow Resident #2 to be able to have his preference of a shower. This was true for one (1) of three (3) residents reviewed for the care area of choices during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #2. Facility census: 39. Findings include: a) Resident #2 During an interview with the resident, at 12:04 p.m. on 04/17/17, the resident said he would like to be able to take a shower instead of a bed bath. He said he gets his bed baths two times a week but he is unable to shower because the shower chair hurts his hip. Review of the bathing schedule in the facility's point of care computer system, at 10:30 a.m. on 04/18/17, found the resident was coded as receiving, bathing, on every Tuesday and Friday during the months of (MONTH) and April, (YEAR). The point of care system noted the resident prefers a shower. At 10:30 a.m. on 04/18/17, Registered Nurse (RN) #23, the facility consultant for minimum data set (MDS) said the system does not designate a bed bath or a shower, just bathing. At 11:00 a.m. on 04/18/17, Nurse Aide (NA) #59, said she has occasionally bathed the resident. She said the resident wants a bed bath because she believed he had a fear of the shower. She thought the resident had fallen in the shower before. NA #59 said the showers/bed baths are recorded on paper before being put in the computer. The following paper information was provided by NA #59: --03/14/17, bed bath, resident says shower chair hurts him --03/17/17, the resident received a bed bath --03/21/17, bed bath, resident said he wanted to take a shower, then said he did not want one --03/31/17, resident requests bed bath complains of pain with shower. NA #59 was unable to locate all the paper documentation of the resident's bathing schedule. Review of the current care plan found staff should prove a sponge bath when a full bath or shower can not be tolerated. Review of the most … | 2020-09-01 |
| 202 | 202 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2017-04-19 | 272 | D | 0 | 1 | HZCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed an ensure two (2) of three (3) residents reviewed for the care area of dental status had an accurate comprehensive Minimum Data Set (MDS) in the care area of dental status. Resident identifiers: #22 and #18. Facility census: 39. Findings include: a) Resident #22 Observation and review of the most recent, significant change MDS with an assessment reference date (ARD) of 02/28/17, found the facility coded the resident's dental status correctly as the resident has no dentures and no natural teeth. The Care Area Assessment (CAA), which is also a part of the MDS, noted the resident's dental status would not be care planned. The information on the dental CAA asked if dental status is a problem or need. The facility responded with: Potential. The nature of the problem was noted by the facility as, [AGE] year old male admitted from another facility. Resident alert oriented to self and place. Resident has confusion. Resident has behavior issues at times where resident will refuse medications and care at times from staff. Resident ambulates with supervision. Has a history of falls due to weakness. Resident will use a WC (wheelchair) when staff puts him in one. Resident needs staff assist with care, hygiene and ADLS (activities of daily living). Resident does not always participate in activities. Resident eats in dinning room and has to be assisted to dining room from staff. Resident does feed self needs cues at times from staff. Resident is incontinent of bladder at times has had some accidents with incontinence of BM (bowel movements). Resident has not been physical with others. This information did not reference the resident's dental status. At 11:23 a.m. on 04/18/17, the administrator and social services director (SSD) were interviewed regarding the resident's dental status. Both employees were unable to provide evidence the resident's dental status was addressed on the CA[NAME] At 11:2… | 2020-09-01 |
| 203 | 203 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2017-04-19 | 278 | D | 0 | 1 | HZCX11 | Based on medical record review and staff interview, the facility failed to ensure the accuracy of a minimum data set for Resident #10 in the area of pressure ulcers. This was evident for one (1) of three residents reviewed for death, and out of sixteen (16) Stage II sampled residents. Resident identifier: #10. Facility census: 39. Findings include: a) Resident #10 The medical record was reviewed on 04/18/17. According to the medical record, this resident developed a Stage II pressure ulcer on his nose on 02/01/17. It was an in-house acquired pressure ulcer, caused by his glasses It was located on a corner of his nose near the left eye. Facility staff asked his medical power of attorney (MPOA) to have his glasses adjusted due to pressure from the nose pieces causing the wound. Facility staff applied foam padding to the nose pieces until the glasses were adjusted. On 02/13/17, facility staff notified the physician and the MPOA of the healed Stage II wound at the corner of his left eye. Review of the 30-day minimum data set (MDS) with assessment reference date (ARD) of 02/02/17, found it correctly assessed the resident as having one (1) Stage II pressure wound. It assessed correctly that the pressure wound was not present on the most recent prior assessment. Review of the 60-day MDS with ARD 03/06/17, found it correctly assessed that he had no current pressure wounds. However, the space was left blank in which to indicate the number of pressure ulcers that were noted on the prior assessment that have now completely closed. During an interview with the corporate MDS registered nurse #23 on 04/18/17 at 1:30 p.m., she said since a Stage II was identified on the 30-day MDS, then it should have been assessed on the 60-day MDS as there having been a previous Stage II wound. | 2020-09-01 |
| 204 | 204 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2017-04-19 | 280 | D | 0 | 1 | HZCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview and facility policy review, the facility failed to afford a resident the right to participate in their care planning. One (1) was not invited to participate in care plan meetings. This practice affected one (1) of two (2) residents reviewed for care planning. Resident identifier: #8. Facility census: 39. Findings include: a) Resident #8 The resident was admitted to the facility on [DATE]. The resident is her own responsible party. A review of Resident #8's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/10/17, was conducted on 04/18/17 at 9:00 a.m. Section C-Cognitive Patterns of the assessment revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) assessment. A score of 15 indicated the resident was cognitively intact at the time of the assessment. An interview with Resident #8 on 04/18/17 at 9:30 a.m., revealed the resident had not been to a care plan meeting since she was admitted to the facility. The resident stated no staff had ever discussed her care plan nor invited her to any care plan meeting. The resident stated she would love to attend a care plan meeting. A review of Resident #8's Care Plan (Target Date 06/30/17), on 04/18/17 at 9:40 a.m., revealed the following intervention: Promote participation in care planning process-Invite to team conference. Further review of the medical record, on 04/18/17 at 9:55 a.m., revealed the facility had conducted a care plan meeting for Resident #8 on 08/18/16. A progress note dated 08/21/16 stated Family did not attend plan of care meeting on 08/18/16. There was no documentation that the resident attended or was invited to the meeting. No documentation of any further care plan meetings or evidence of any invitations to the resident was found in the record. An interview with the Administrator, on 04/18/17 at 10:10 a.m., revealed she could not provide any documentation Resident #8 had… | 2020-09-01 |
| 205 | 205 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2017-04-19 | 312 | D | 0 | 1 | HZCX11 | Based on observation, record review, staff interview and resident interview, the facility failed to provide activities of daily living (ADL) care to Resident #39 who was unable to perform the care herself. Resident #39 was observed with multiple long hairs on her chin and indicated she needed the staff to remove them for her. This was true for one (1) of four (4) residents reviewed for the care area of ADL's during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #39. Facility census: 39. Findings include: a) Resident #39 An observation of Resident #39, during Stage 1 of the QIS, at 12:09 p.m. on 04/17/17, found several long hairs on her chin. A review of Resident #39's medical record, at 8:00 a.m. on 04/19/17, found the resident required extensive assistance of staff to carry out her personal hygiene ADL's. An additional observation and interview with Resident #39, at 8:45 a.m. on 04/19/17, with the Assistant Director of Nursing (ADON) and Social Service Director (SSD) present found the hair was still present on her chin. When asked if she would like to have the hair removed from her chin Resident #39 stated, Yes they are getting long and they have to remove them for me. The ADON agreed the staff needed to remove the hair from Resident #39's chin and instructed her assigned Nurse Aide to remove the hair. | 2020-09-01 |
| 206 | 206 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2017-04-19 | 505 | D | 0 | 1 | HZCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the physician was promptly notified of an abnormal laboratory value for one (1) of five (5) resident's reviewed for the care area of unnecessary medications. The physician is to be notified promptly in order for appropriate action to be taken if indicated for the resident's care. Resident identifier: #16 Facility census: 39. Findings include: a) Resident #16 On 01/09/17, the physician ordered the following laboratory values: --Lipid profile, --[MEDICAL CONDITION] profile, and --Comprehensive metabolic panel (CMP) According to the laboratory report, the results of the testing were available to the facility on [DATE]. On 01/12/17, the physician was notified of the laboratory values. The physician provided orders to discontinue the resident's [MEDICATION NAME] and obtain a BMP (Basic Metabolic Panel) in the a.m. The results of the 01/09/17, CMP noted the following abnormal values: --BUN (blood urea nitrogen) was high, 67, (Normal range is 6-35) --Creatinine was high- 2.3, (Normal range is 0.5 - 1.7) --B/C (BUN to Creatinine) ratio was high- 29.1 (Normal range was 7-18) --Sodium was high- 144, (Normal range is 136-142) --GFR ( glomerular filtration rate-measures the level of kidney function to determine your stage of kidney disease) was low - 19.83, (Normal range is greater than 60) On 01/13/17, a basic metabolic panel (BMP) was obtained as ordered. The results of the BMP are as follows: --Sodium was high- 143, (Normal range is 136 - 142) --Potassium was high - 5.6, (Normal range is 2.5 - 5.3) --BUN was high- 72, (Normal range is 6 - 35) --Creatinine was high - 1.8, (Normal range is 0.5 - 1.7) --GFR was low - 26.6, (Normal range is greater than 60) At 3:04 p.m. on 04/18/17, the Registered Nurse (RN) minimum data set (MDS) consultant was interviewed. She was unable to provide information the resident's physician was ever notified of the second laboratory values obtained on 0… | 2020-09-01 |
| 207 | 207 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2017-04-19 | 507 | D | 0 | 1 | HZCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a copy of an abnormal laboratory value was available in the medical record for physician review. This was true for one (1) of five (5) resident's reviewed fro the care area of unnecessary medications during Stage 2, of the Quality Indicator Survey (QIS). Resident identifier: #16. Facility census: 39. Findings include: a) Resident #16 Medical record review on 04/18/17, at 2:00 p.m. found the resident's physician ordered a BMP (Basic Metabolic Panel) to be completed on the morning of 01/13/17. At 3:04 p.m. on 04/18/17, the Registered Nurse (RN) minimum data set (MDS) consultant, #23 was interviewed. She was unable to provide a copy of the BMP, ordered on [DATE], by the resident's physician. A copy of the laboratory value was provided to the surveyor later in the day by RN #23. The laboratory report noted the BMP was collected on 01/13/17 at 5:16 p.m. The date received by the laboratory was 01/13/17. The date the results of BMP were provided was 04/18/17 At 8:05 a.m. on 04/19/17, the Registered Nurse , chief nursing officer, #43, was notified of the above findings. She confirmed the facility was unable to find the laboratory value from 01/13/17. The facility had to contact the laboratory to obtain the test on 04/18/17. | 2020-09-01 |
| 208 | 208 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2017-04-19 | 514 | E | 0 | 1 | HZCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident #55 Review of the medical record found the resident's physician completed a on site visit to the resident on 01/20/17. A progress note was completed for this visit by the physician. The physician noted, .The patient also presented with diabetes mellitus. It is described as impaired glucose tolerance, chronic and stable. The symptom started onset as an adult. The complaint is mild The symptom is alleviated by medication and diet. Review of the resident's Medication Administration Record [REDACTED]. At 8:31 a.m. on 04/19/17, the Registered Nurse (RN), chief nursing officer, #43, confirmed the MAR indicated [REDACTED]. She said she would call the physician in regards to the 01/20/17 visit. At 10:11 a.m. on 04/19/17, RN #43 said she had talked to the physician by telephone. The physician told RN #43, her notes were in a template and she just made a mistake in her dictation, the resident was not receiving any medications to treat diabetes mellitus. RN #43 provided a copy of a corrected physician's visit noting the following, .The patient also presented with diabetes mellitus. It is described as impaired glucose tolerance, chronic and stable. The symptom started onset as an adult. The complaint is mild. Alleviating factor diet . Based on medical record review and staff interview, the facility failed to maintain a complete and accurate medical record for two (2) of sixteen (16) Stage II sampled residents. The facility did not record monthly fasting blood sugar results for Resident #15. The facility did not ensure the accuracy of the monthly physician progress notes [REDACTED].#55's blood sugars and/or medical status related to his diabetes mellitus. Resident identifiers: #15 and #55. Facility census: 39. Findings include: a) Resident #15 The medical record was reviewed on 04/18/17. On 01/09/17, the physician discontinued the order for daily blood sugars four (4) times daily, along with the sliding scale insulin administration. The blood … | 2020-09-01 |
| 209 | 209 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2018-05-03 | 656 | D | 0 | 1 | GLW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview, the facility failed to ensure person-centered comprehensive care plan developed and implemented to meet the resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for two (2) of seventeen (17) residents reviewed. Resident #4's care plan failed to address [MEDICAL CONDITIONS] and contractures. Additionally, Resident #8's care plan failed to address the use of an anticoagulant. Resident identifiers: #4 and #8. Facility census: 37. Findings included: a) Resident #4 Review of Resident #4's medical record began on 05/01/18 at 11:15 a.m., found the resident was admitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident #4's physician progress notes [REDACTED]. Observation of Resident #4 on 04/30/18 at 11:30 a.m., found resident appeared to have contractures of upper and lower extremities. This observation was confirmed by the Occupational Therapist. Interview with the Director of Nursing (DON) on 05/02/18 at 11:15 a.m., she confirmed after review of the comprehensive care plan, the care plan did not include [MEDICAL CONDITIONS] and multiple contractures of upper and lower extremities. b) Resident #8 Resident #8 had an order for [REDACTED]. Resident #8 also had an order to Monitor for signs/symptoms of bruising/bleeding/skin alterations, every shift, due to [MEDICATION NAME] therapy. Resident #8's Medication Administration Record [REDACTED]. However, Resident #8's comprehensive care plan did not have a focus related to the medication [MEDICATION NAME]. During an interview on 05/01/18 at 1:29 PM, the Director of Nursing (DoN) agreed Resident #8's comprehensive care plan did not have a focus related to the medication [MEDICATION NAME]. | 2020-09-01 |
| 210 | 210 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2018-05-03 | 657 | D | 0 | 1 | GLW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise the comprehensive care plan for three (3) of seventeen (17) resident's comprehensive care plans reviewed. The facility failed to revise the comprehensive care plan for Resident #21 in the area of skin integrity when he developed an actual skin impairment. The facility failed to revise the comprehensive care plan for Resident #30 in the area of an overall decline and hospice involvement. The facility also failed to revise the comprehensive care plan for Resident #26 when incontinence associated [MEDICAL CONDITION] and skin tears resolved. Resident indicators: #21, #30, #26. Facility Census: 37. Findings included: a) Resident#21 Resident #21 had an order for [REDACTED].>On [DATE], the weekly Skin Observation Tool documented Resident has redden (sic) area to the area behind top of left ear d/t (due to) oxygen hose, which is being treated. No other skin tears or bruising noted. On [DATE] at 10:39 AM, Licensed Practical Nurse (LPN) #81 was observed performing care to Resident #21. The top of Resident #21's left ear was observed to be reddened. LPN #81 inserted new foam protectors on Resident #21's oxygen tubing to protect the top of his ear. LPN #81 stated the foam protectors needed to be reapplied periodically because Resident #81 removed them. She also stated Hydrogel was being applied to the reddened area on the top of Resident #21's left ear. Resident #21's comprehensive care plan contained the focus, The resident has potential for impairment to skin integrity r/t (related to) fragile skin. However, the comprehensive care plan did not contain a focus or interventions related to the reddened area on Resident #21's left ear. During an interview on [DATE] at 12:32 PM, the Director of Nursing (DoN) agreed Resident #21's comprehensive care plan did not contain a focus related to his actual skin impairment or the specific interventions being performed for the condition… | 2020-09-01 |
| 211 | 211 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2018-05-03 | 761 | D | 0 | 1 | GLW711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation amd staff interview, the facility failed to store pharmaceuticals in accordance with currently accepted standards of professional principles. The multi-dose bottle of [MEDICATION NAME] stored in the medication cart on the facility's second floor was not dated when it was opened. This was discovered during the facility task of medication adminstration and had the potential to affect all residents on the second floor who were prescribed [MEDICATION NAME]. Facility census: 37. Findings included: a) Facility task - medication pass On 05/02/18 at 7:49 AM, the morning medication pass was observed by Registered Nurse (RN) #28. During medication administration, a multi-dose bottle of [MEDICATION NAME], a laxative, was removed from a drawer in the medication cart and a dose was poured into a glass for administration to a resident. The [MEDICATION NAME] bottle had been previously opened. However, the [MEDICATION NAME] bottle was not dated when it was opened. RN #28 agreed the multi-dose bottle of [MEDICATION NAME] was not dated when it was opened. On 05/02/18 at 8:55 AM, the Director of Nursing (DoN) was notified the multi-dose bottle of [MEDICATION NAME] stored in the medication cart on the second floor was not dated when opened. The DoN stated, We'll fix it. | 2020-09-01 |
| 212 | 212 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2017-06-07 | 278 | D | 1 | 0 | 5ZTQ11 | > Based on record review and staff interview, the facility failed to ensure an accurate assessment for one (1) of six (6) residents. Resident #12's 30-day minimum data set (MDS) assessment for section M, Skin conditions revealed the dimensions of unhealed stage 3 or 4 pressure ulcers or eschar was entered incorrectly. Resident identifier: #12. Facility census: 40. Findings include: a) Resident #12 A review of the MDS, assessment reference date 03/22/17, showed the resident had one (1) stage two (2) pressure ulcer. Further review of the MDS, revealed measurements for length and width for a stage three (3) or four (4) pressure ulcer. An interview with Assistant Director of Nursing (ADON) #42 on 06/07/17 at 1:38 pm, advised she had entered the measures incorrectly in this section. She commented she would be corrected this section of the MDS. | 2020-09-01 |
| 213 | 213 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2017-06-07 | 465 | F | 1 | 0 | 5ZTQ11 | > Based on policy review, observation and staff interview, the facility failed to ensure they maintained a safe environment for all residents. Observations revealed areas where oxygen was being used, had no signs or signage advising no smoking was allowed in the area. Resident # 15 was observed in the dining area, with oxygen in use. This practice had the potential to affect all residents. Resident identifier: #15. Facility census: 40. Findings include: a) Resident #15 An observation of the second floor dining room on 06/05/17 at 12:40 pm, revealed Resident #15 sitting at a table in the dining room, with oxygen in use via oxygen concentrator. Further observation in the dining room did not reveal signage advising smoking was not permitted. Observation on 06/05/17 of the facility's main entrance of the building revealed no signs or signage advising no smoking was allowed in the building. Facility policy Patient care related electrical equipment dated (MONTH) (YEAR), procedure item 7. stated. Place an 'Oxygen in Use' sign on the door frame. This was to ensure safe usage and operation of oxygen concentrators and other fixed or portable patient care related electrical equipment. According to 2012 Life Safety Code, In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. During an interview with the administrator on 06/07/17 at 2:45 pm, it was pointed out there were no signage posted on front door indicating no smoking. The administrator commented she believed that a no smoking sign does not need posted at the entrances because the entire county has not allowed smoking indoors for quite a while now. | 2020-09-01 |
| 214 | 214 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2017-06-07 | 514 | D | 1 | 0 | 5ZTQ11 | > Based on record review and staff interview, the facility failed to ensure accurate and complete medical records for two (2) of six (6) residents. Resident #4 and Resident #12 had medical records that were not complete. Resident identifiers: #4 and #12. Facility census 40. Findings include: a) Resident #4 Resident #4 experienced a fall on 02/19/17, at 1:20 p.m. After the fall, he reported left hip pain. Resident was sent to a local hospital's emergency room for evaluation and treatment on 02/19/17 at 2:09 p.m. A nursing note written at 9:14 p.m., on 02/19/17 stated, Resident returned from (name of outside hospital), no orders, no paperwork. Resident was at hospital about 2 1/2 hours. When Assistant Director of Nursing (ADON) #42 was asked on 06/06/17 at 1:00 p.m. if records from the emergency room evaluation performed on 02/19/17 had been obtained for resident's file, she contacted the outside hospital to obtain the records. The emergency room evaluation performed on 02/19/17 was faxed to the long-term care facility on 06/06/17. The print date and time indicated on the records was 06/06/17 at 3:15 p.m. Interview with ADON #42 on 06/07/17 at 10:35 a.m. revealed that it was not an unusual occurrence for a resident to be returned from evaluation at a local hospital without accompanying paperwork. However, ADON #42 commented the hospitals call the long-term facility with a report on the resident prior to transfer. b) Resident #12 Medical record review on 06/06/17 revealed Resident #12 Appointment of Health Care Surrogate was not in the medical record. On 06/07/17 at 8:15 a.m., the administrator brought a copy of the appointment of health care surrogate form. She stated the facility had to redo this form because they could not locate the original. She said it should have been in the medical record. The form was dated 06/06/17. At 11:00 a.m. on 06/07/17 Social Worker #17, stated she had contacted the family and they could not locate the original appointment of health care surrogate form. | 2020-09-01 |
| 215 | 215 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2018-02-16 | 656 | E | 1 | 0 | EN1S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, resident interview, family interview, and staff interview, the facility failed to develop comprehensive person-centered care plans for four (4) of four (4) sample residents who had an identified problem of anxiety. The care plans for Residents #49, #45, #65, and #79 did not identify specific non-pharmacological interventions for direct care staff to employ that were based on the residents' individual assessed needs. Resident identifiers: #49, #45, #65, and #79. Facility census: 102. Findings include: a) Resident #49 Review of the resident's medical record on 02/12/18 at 1:20 PM, revealed Resident #49, a [AGE] year-old female admitted to the facility in (MONTH) (YEAR), had [DIAGNOSES REDACTED]. According to her Minimum Data Set (MDS) quarterly assessment with an assessment reference date (ARD) of 01/10/18 her Brief Interview for Mental Status (BIMS) score was 15 indicating she was cognitively intact, that she continuously displayed inattention with fluctuating disorganized thinking and demonstrated behaviors 1-3 days. Her Mood score increased to 14 (indicating moderate depression). The MDS with an ARD of 10/11/17, identified a BIMS of 14 (cognitively intact), with continuous inattention and fluctuating disorganized thinking. Her Mood score was 8 indicating mild depression. No behaviors were noted in this assessment. She required assistance with all ADLS and received Antipsychotics, antidepressants, and antianxiety meds daily. The resident's care plan with a revision date of 01/21/18 identified problems of depression and anxiety. The focus for depression stated, Long history of depression related to medical condition and progression of her disease as evidenced by excessive worrying and feeling down. Resident will state, I am getting worse. The goal was, Resident will have a reduction in depressive episodes to weekly throughout next review. Interventions included (typed as written), 1. Administer medication for … | 2020-09-01 |
| 216 | 216 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2018-02-16 | 740 | D | 1 | 0 | EN1S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, resident interview, family interview, and staff interview, the facility failed to provide behavioral health care and services and/or treatment to assist Resident #49 in maintaining her highest practicable mental, and psychosocial well-being. The facility failed to provide individualized behavioral health services to assist the resident in coping with her disease process. The resident's care plan did not offer needed guidance to direct care staff to meet the resident's needs with respect to the resident's anxiety and depression. This was found for one (1) of four (4) residents reviewed for behaviors. Resident identifier: #49. Facility census: 102. Findings include: a) Resident #49 Review of the resident's medical record on 02/12/18 at 1:20 PM, revealed this [AGE] year-old resident, admitted to the facility in (MONTH) (YEAR), had [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 01/10/18 identified the resident's Brief Interview for Mental Status (BIMS) score was 15, indicating she was cognitively intact. The assessment also identified she continuously displayed inattention with fluctuating disorganized thinking and she demonstrated behaviors 1-3 days. When compared to the previous assessment, her Mood score had increased to 14 (indicating moderate depression). She required assistance with all activities of daily living (ADLs) and was occasionally incontinent of bladder and always incontinent of bowel. She received antipsychotics, antidepressants, and antianxiety medications (meds) daily. She had bed and chair alarms and had had more than 2 falls since admission. The MDS with an ARD of 10/11/17, identified a BIMS of 14 (cognitively intact), with continuous inattention and fluctuating disorganized thinking. Her Mood score was 8 indicating mild depression. No behaviors were noted in that assessment. She required assistance with all ADLs, re… | 2020-09-01 |
| 217 | 217 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2018-02-16 | 742 | D | 1 | 0 | EN1S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, resident and family interview, and staff interview, the facility failed to ensure a resident with [MEDICAL CONDITION]'s Chorea received appropriate treatment and services to assist the resident to attain the highest practicable mental and psychosocial well-being. The facility failed to utilize outside resources to assist Resident #49 in coping with her progressive disease process. The facility failed to develop a care plan to provide guidance to direct care staff regarding the resident's individual needs. No individualized plans were in place to address her mental and physical expressions of distress. Diversional meaningful activities were not based on the resident's preferences, and/or abilities. This was found for one (1) of four (4) residents reviewed for behaviors. Resident identifier #49. Facility census: 102. Findings include: a) Resident #49 Review of the medical record on 02/12/18 at 1:20 PM, revealed Resident #49 is a [AGE] year-old admitted to the facility in (MONTH) (YEAR). [DIAGNOSES REDACTED]. Resident #49 was evaluated by a psychiatrist on 04/03/17. The summary notes for the evaluation noted Resident #49's [MEDICAL CONDITION]'s disease was currently being treated with Tetrabenzene ([MEDICATION NAME]) (a medicine used to treat involuntary movements of [MEDICAL CONDITION]'s disease) to suppress her motor symptoms. It is important to be aware that this treatment might aggravate mood problems such as depression. The treatment plan stated, The patient will benefit from the continued use of [MEDICATION NAME] 50 mg (milligrams) at bedtime. A smaller dose of 25 mg can be added in the daytime to reduce irritability. Because of the concern of [NAME]D ([MEDICAL CONDITION]) symptoms and possible development of depression, the patient might benefit from adding [MEDICATION NAME] 10 mg per day, which can be increased after two weeks to 20 mg per day. The Psychotherapy section stated (typed as written): Althoug… | 2020-09-01 |
| 218 | 218 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2018-02-16 | 758 | E | 1 | 0 | EN1S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, policy review, and staff interview, the facility failed to ensure residents did not receive [MEDICAL CONDITION] drugs unless the medication was necessary to treat a specific condition. The medical records of four (4) of four (4) sampled residents reviewed for behaviors, lacked documentation of specific nonpharmacological interventions employed by staff and the residents' responses to those interventions so the effectiveness of interventions could be determined. Resident identifiers: #49, #45, #65 and #79. Facility census: 102. Findings include: a) Resident #49 Review of the resident's medical record on 02/12/18 at 1:20 PM, revealed this resident's [DIAGNOSES REDACTED]. The care plan with a revision date of 01/21/18 identified depression and anxiety as problems for the resident. One of the interventions was to, Offer non-pharmacological interventions if resident is upset such as 1:1 interaction, calling her mother, or a snack. The Medication Administration Record [REDACTED] -- [MEDICATION NAME] 20 mg at 6:00 AM for major [MEDICAL CONDITION] -- [MEDICATION NAME] 100 mg at 7:00 PM and 25 mg at 7:00 AM related to [MEDICAL CONDITION]'s disease -- [MEDICATION NAME] 1 mg 7:00 AM and 7:00 PM for anxiety -- [MEDICATION NAME] HCL 10 mg 7:00 AM, 1:00 PM, and 7:00 PM for major [MEDICAL CONDITION] The (MONTH) and (MONTH) MARs include a daily section for charting with the following information (typed as written): -- Resident receives [MEDICATION NAME] for Depression AEB yelling out questions, observe for behavior during shift. 0= not present 1 = present. If coding a 1, were non-pharmacological interventions per the CP attempted? Yes/NA --Resident receives [MEDICATION NAME] for [MEDICAL CONDITION]'s Disease AEB tearful, withdrawn, observe for behavior during shift. 0 = not present 1 = present. If coding a 1, were non-pharmacological interventions per CP attempted Yes/N[NAME] -- Resident receives [MEDICATION NAME] for Anxiet… | 2020-09-01 |
| 219 | 219 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2019-04-03 | 550 | D | 0 | 1 | P29Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure dignity during medication administration for Residents' #84 and #38. This was a random opportunity for discovery. Resident identifiers: #38 and #84. Facility census: 97. Findings included: a) Resident #38 At 11:48 AM on 04/01/19, Licensed Practical Nurse (LPN) #15, was observed obtaining the resident's blood sugar in the hallway, opposite the dining room on the Reflections unit. Record review found a physician's orders [REDACTED]. The resident's last full minimum data set (MDS), an annual, with an assessment reference date (ARD) of 11/06/18 coded the resident as having a score of 3 on the brief interview for mental status (BIMS). A score of 3 indicates the resident has severely impaired cognition. The resident would be unable to say if she preferred her blood sugar to be obtained in the hallway. On 04/01/19 at 2:13 PM, LPN #15 said she had just attended an in service about not giving medications while residents are in the dining room eating but nothing was said about obtaining blood sugars in the hallway. She was unaware she shouldn't obtain blood sugars in the hallway. On 04/02/19 at 1:02 PM, the above observation was discussed with the administrator. No further information was received before the close of the survey on 04/03/19 at 5:00 PM. b) Resident #84 At 11:44 AM on 04/01/19, Resident #84 was observed in the hallway, across from the dining room on the Reflections Unit, with LPN #15 and Resident #34. LPN #15 raised the resident's shirt and was attempting to inject insulin into the abdomen of Resident #84. The resident became combative. She was waving her hands and trying to push away the insulin. The Resident was making growling noises. LPN #15, said to the surveyor, Well I guess I will try this later. Record review found Resident #84's last full minimum data set (MDS), a significant change MDS, with a reference assessment date (ARD) of 12/11/18 coded… | 2020-09-01 |
| 220 | 220 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2019-04-03 | 558 | D | 0 | 1 | P29Y11 | Based on observation and resident/staff interviews, the facility failed to keep the call light easily accessible for Resident #21. This was a random opportunity for discovery. Facility census: 97 Findings included: a) On 04/03/119 it was observed at 8:30 a.m. the call light was down in the floor between the bed and a nightstand as it had been on the day of tour 04/01/19 . Interview with the administrator immediately after this observation revealed the resident does keep the call bell on the floor in that position, but they could get her a cow bell or some kind of bell that may work to provide her with some way of communication with staff should she need help. | 2020-09-01 |
| 221 | 221 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2019-04-03 | 656 | E | 0 | 1 | P29Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to implement the care plans of two (2) of twenty-one (21) Resident's whose care plans were reviewed. For Resident #38, the care plan was not implemented for fall prevention. Resident #48's, the care plan was not implemented for care of a [MEDICAL TREATMENT] resident. Resident identifiers: #38 and #48. Facility census: 97. Findings included: a) Resident #38 Review of the resident's current care plan found the following problem: --Resident has a history of falls. Poor balance, unsteady gait. The goal associated with the problem: --Resident will not receive any injuries from falls through next review. Interventions included: --Break away lap buddy while in wheelchair. Observation of the resident at 11:44 AM on 04/01/19, found the Resident was trying to remove her break away lap buddy. ( A lap buddy is an inflatable pillow that fits into the frame of the wheelchair and is meant to gently remind the occupant to ask for help before getting up.) She was pulling and tugging at the edges of the lap buddy. The Resident tried numerous times to stand up in her wheelchair, causing her chair alarm to engage. At one point the lap buddy released, and the resident began to stand up. A nursing assistant intervened and calmed the resident before fastening the lap buddy back into place. Review of the resident's medical record found a physician's orders [REDACTED]. At approximately 12:15 PM on 04/01/19, the breakaway lap buddy was removed from the wheelchair during meal time. The resident appeared calm. She stayed in her wheelchair, seated at the table and was not trying to stand up during her meal. At 2:26 PM on 04/01/19, the resident continued to be in the dining room area, in her wheelchair without her break away lap buddy. Licensed Practical Nurse (LPN) #15 was asked why the resident did not have her lap buddy. LPN #15 said the resident was actually better without the lap buddy. She … | 2020-09-01 |
| 222 | 222 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2019-04-03 | 657 | E | 0 | 1 | P29Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to revise the care plans for four (4) of 21 resident's reviewed when the residents treatment, preferences and needs of the resident changed in response to current interventions. Resident's #38 and #84's care plans were not revised to reflect the current activity interests. Resident #21's care plan was not revised to reflect a change in the use of the call light. Resident #17's care plan was not revised to reflect removal of a Peripherally Inserted Central Catheter (PICC) Line. Resident identifiers: #38, #84, #21, and #17. Facility census: 97. Findings included: a) Resident #38 Resident #38 resides on the Reflections Unit of the facility. To enter or exit the unit a code is required to be entered on a key pad. The unit is not a certified dementia unit but can house up to 20 residents at a time. The residents on this unit have cognitive loss. Resident #38 scored a 3 on her brief interview for mental status (BIMS). A score of 3 indicates the resident is severely cognitively impaired. Review of the resident's current plan of care found the resident was care planned for the following focus problem: --Resident has no interest in out of room activities. She at times prefers her own room, in her bed sleeping. The goal associated with the problem is: --Resident will attend 1 out of room activity per week through next review. Interventions included: --Provide in room activity supplies as needed. --Resident enjoys taking care of baby doll on occasion. --Resident has stated that in the past she enjoyed playing board games/cards with her children, doing crafts/sewing, gardening/canning, helping others, reading, shopping. --Resident has stated that she enjoys watching TV/news and weather, listening to country music/radio, playing the harmonica, singing, being outdoors weather permitting, talking to others, church, being active. Observation of the resident on 04/01/19 at 11:44 AM,… | 2020-09-01 |
| 223 | 223 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2019-04-03 | 684 | E | 0 | 1 | P29Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide care in accordance with the goals for care and professional standards of practice that will meet each resident's needs. This was in regard to medications being administered more than an hour past the time it was due and failing to provide peri care for a resident with incontinence.This was a random opportunity for discovery. Resident identifiers: #14, #62, #11 and #16. Facility census: 97. Findings included: a) Failure to administrator medications within an acceptable time frame During an observation on 04/02/19 at 11:10 AM, Registered Nurse (RN) #135 was carrying a cup of pills in the hallway. She was asked if she had more medications to pass. She said yes, it was noted that all of the residents on her computer screen was in red (indicating the medication was given late) she was asked about the medications being late. She began by saying that this is only her second day passing medication and it she must try to match the pictures of the residents in order to give the medication. So that takes a while to do and it is different than when she worked in an Intensive Care Unit (ICU). She went on to said that she does not check them off in the computer as she administrated the medication, she said, I check it off on my paper then later when I get to set down, I adjust the times given or I would be even later. She was asked if she still had any medications left to give that was supposed to be given at 9:00 AM? She said yes. Administrator was informed at 04/02/19 11:19 AM, about what this nurse was doing. She stated that it was not their practice to document after all the medications were given but as they were given. She also said that RN #135 has been working at the facility for about two (2) months. She stated that she cannot have that, and she was going to end this RN's contract and have someone else take over. She was asked for a medication audit report for t… | 2020-09-01 |
| 224 | 224 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2019-04-03 | 686 | D | 0 | 1 | P29Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, and to prevent infection in a pressure ulcer. There was a delay in treatment for [REDACTED]. This was true for One (1) of two (2) reviewed for care of pressure ulcers. Resident identifier: #6. Facility census: 97. Findings included: a) Resident #6 A review of Resident #6's medical record at 8:27 a.m. 04/02/19 found a wound culture which was collected on 10/23/18. The results of this wound culture was released to the facility on [DATE] and indicated the resident had staphylococcus in the wound. A nurse wrote on the lab result that it was noted on 10/28/18. The certified nurse practitioner (CFNP) did not sign the lab until 10/29/18 at which time she ordered [MEDICATION NAME] 500 mg every day for 10 days. Review of the Medication Administration Record [REDACTED]. An interview with the Nursing Home Administrator at 8:00 a.m. on 04/03/19 confirmed Resident #6 was not started on her antibiotic for the wound infection until 10/30/18. She stated, I don't know where the delay came from. | 2020-09-01 |
| 225 | 225 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2019-04-03 | 758 | D | 0 | 1 | P29Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #98's medication regimen was free from unnecessary [MEDICAL CONDITION] medications. She received two doses of as needed [MEDICATION NAME] prior to the facility implementing non pharmacological interventions. This was true for One (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #98. Facility census: 97. Findings include: a) Resident #98 A review of Resident #98's Medication Administration Record [REDACTED].m Further review of the medical record found no evidence the facility implemented any non pharmacological interventions prior to the administration of this medication. An interview with the Nursing Home Administrator at 11:06 a.m. on 04/03/19 confirmed there was not any non pharmacological interventions implemented prior to the administration of the as needed [MEDICATION NAME]. | 2020-09-01 |
| 226 | 226 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2019-04-03 | 761 | E | 0 | 1 | P29Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and staff interview the facility failed to label multi-use vials and/or pens of insulin (used to treat elevated level of blood sugars in people with diabetes) with the initial date it was opened and/or accessed. This failed practice was not in accordance with currently accepted professional principles. This had the potential to effect the potency and effectiveness of the medications. Resident identifiers: #24, #86, #39, and #84. This was a random opportunity for discovery during the facility task medication storage and labeling. Facility census 97. Findings included: The Facility policy titled, Medication Storage Policy and Procedure dated 06/13/16, stated the following: -Labels for multi-use vials must include: ---The date the vial was initially opened or access (needle-punctured); During an observation on 04/03/19 at 8:02 AM, Licensed Practical Nurse (LPN) verified that one (1) of five (5) insulins. This was novo log, belonging to Resident #24. It did not have a date on the practically used multi-use vial of insulin. During an observation on 04/03/19 at 8:44 AM, LPN #6 verified the one (1) of four (4) multi-use vials of insulin did not have a date on the practically used multi-use vial of insulin. This was [MEDICATION NAME]belonging to Resident #86. During an observation on 04/03/19 at 8:48 AM, LPN #27 verified that two (2) of four (4) multi-use pens of insulin did not have a date on them to indicate the initial date that it was opened. The Basaglar Kwikpen belonged to Resident #39 and the [MEDICATION NAME] pen belonging to Resident #84. During an interview on 04/03/19 at 10:04 AM, Administrator was made aware of the insulins not having dates on them. She stated that she is disappointed because she has gone over that several times. | 2020-09-01 |
| 227 | 227 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2019-04-03 | 770 | D | 0 | 1 | P29Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to obtain a physician ordered laboratory test for Resident #80. Resident #80's physician ordered a [MEDICAL CONDITION] Stimulating Hormone (TSH) test to be performed on 12/08/18 and there was not evidence this test was performed. This was true or one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #80. Facility census: 97. Findings included: a) Resident #80 A review of Resident #80's medical record at 12:28 p.m. on 04/03/19 found a lab result for a TSH that was drawn on 11/27/19. The physician reviewed this lab report on 11/28/18 and wrote the following, This is improving. Next TSH should be drawn in 10 days and fax me the results. Ten (10) days from 11/28/18 would have been 12/08/18. The medical record contained no evidence that this TSH level was obtained on or around 12/08/18. An interview with the Nursing Home Administrator at 3:02 p.m. on 04/03/19 confirmed this TSH level was never obtained. | 2020-09-01 |
| 228 | 228 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2019-04-03 | 773 | D | 0 | 1 | P29Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that Laboratory testing was only performed when ordered by a physician and that when a Laboratory Testing was performed that the ordering physician was promptly notified of the results. Resident #80 had a [MEDICAL CONDITION] Stimulating Hormone (TSH) level obtained on 11/27/18 and there was no order in the medical record for this TSH. For Resident #38 the facility failed to notify the attending of a lab result. This was true for two (2) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #80 and #38. Facility census: 97. Findings included: a) Resident #80 A review of Resident #80's medical record at 12:28 p.m. on 04/03/19 found a lab result for a TSH that was drawn on 11/27/19. Further review of the medical record found no physician order for [REDACTED].>An interview with the Nursing Home Administrator at 1:38 p.m. on 04/03/19 confirmed there was no physician order for [REDACTED]. b) Resident #38 On 02/19/19, the facility collected a specimen for a Chem 7 and HGB A1C. (A Chem 7 test can be used to evaluate kidney function, blood acid/base balance, and your levels of blood sugar, and electrolytes. The hemoglobin A1C test tells you your average level of blood sugar over the past 2 to 3 months.) Review of the resident's electronic medical record at 1:00 PM on 04/03/19, found no evidence of the results of the Chem 7 and HgbA1c obtained on 02/19/19. At 1:29 PM on 04/03/19, the Director of Nursing was asked if she could find the results of the laboratory values for the Chem 7 and the HGB A1C 1C. At 3:03 PM on 04/03/19, the DON provided a copy of the laboratory report, obtained on 02/19/19. The report indicated the laboratory results were faxed to the facility at 2:07 PM on 04/03/19. The DON said the report had been in the physician's box awaiting his signature for the past 2 months. The DON provided a copy of a nursing note, dated… | 2020-09-01 |
| 229 | 229 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2019-04-03 | 804 | D | 0 | 1 | P29Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure Resident #36's food was at a safe and appetizing temperature during the noon meal on 04/01/19. This was a random opportunity for discovery. Resident identifier: #36. Facility census: 97. Findings included: a) Resident #36 Record review found Resident #36 was admitted to the facility on [DATE]. The resident was residing on the Reflections unit. The Reflections Unit required a code to be entered on a key pad to both enter and exit the unit. The unit houses 20 residents when full. The unit is not a certified Alzheimer's/Dementia unit. Residents on this unit have cognitive loss. Observation of the noon meal on 04/01/19 found the resident received his meal at approximately 12:30 PM. The Resident was seated alone at a table beside the back wall of the dining room. At 2:20 PM on 04/01/19, the Resident was still seated at the same table continuing to eat his noon meal. He had eaten his broccoli. A BBQ sandwich, tater tots, and milk remained. At 2:20 PM on 04/01/19, the resident's Licensed Practical Nurse (LPN) #15, said the Resident likes to eat, He will eat all day long, so we just let him. The resident's current care plan was reviewed with LPN #15. An intervention on the care plan noted the resident would receive food as an intervention to distract the resident from wandering. The care plan did not include providing continuous food. At 2:31 PM on 04/01/19, the dietary manager was asked to take the temperature of the resident's meal. The temperature of the BBQ was 64 degrees, tater tots were 66 degrees. The DM obtained the temperature of his milk and said, It's at 68 degrees and continuing to rise. The DM said the temperatures were not acceptable. We could do more meals a day, we have done that before. She said she did not realize the resident liked to have food all day long. The DM checked the pantry and said there is plenty of milk in the refrigerator and snacks are available.… | 2020-09-01 |
| 230 | 230 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2019-04-03 | 842 | D | 0 | 1 | P29Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #38's medical record was complete and legible. This was found for one (1) of twenty-one (21) records reviewed. Resident identifier: #38. Facility census: 97. Findings included: a) Resident #38 Review of the consultant pharmacist reports dated 04/16/18 and 11/15/18 found the pharmacist made medication recommendations after review of the Resident's current medications. The report required the physician to write a response, sign and date the recommendations. Review of a laboratory report of a [MEDICATION NAME] acid collected on 12/19/18 found the physician had made only a mark on the laboratory report. At 1:29 PM on 04/03/19, the Director of Nursing reviewed the consulting pharmacist reports. The DON confirmed she could not read the date the physician reviewed the 04/16/18 and 11/15/19 reports. The 04/16/18 reports had only a one single mark of a pen which was did not represent a month, day or year. She believed the report for 11/15/18 was signed in (MONTH) but she could not read the date or the year. The DON could not say the reports were reviewed timely when the physician's writing was illegible. In addition, the DON unable to read the date on [MEDICATION NAME] Acid lab from 12/19/18. She said the mark on the laboratory report was the physician's signature but she did not see a date. | 2020-09-01 |
| 231 | 231 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2019-04-03 | 880 | D | 0 | 1 | P29Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, medical record review, and staff interview the facility failed to the facility failed to ensure staff used appropriate infection control practices to prevent the development and transmission of infectious and communicable disease within the facility. Facility staff failed to use proper technique during perineal care to eliminate the spread of infectious diseases for Resident #16. Oxygen tubing was found to be maintained in an unsanitary manner for Resident #30. This was a random opportunity for discovery. This practice had the potential to affect more than an isolated number of Residents. Resident Identifiers: #16, #30. Facility Census: 97. Findings included: a) Resident #16 On 04/03/19 at 1:19 PM Nurse Aide (NA) #36 and NA #141 were observed as they provided perineal care (washing genitalia and surrounding area) for Resident #16. NA #36 presented to bedside with gloves donned (to put on gloves), with one wet soapy wash cloth, one wet wash cloth without soap, one dry wash cloth, and no wash basin. NA #36 draped all wash clothes across top of left upper bed rail and positioned Resident supine (on back), unfastened Resident's brief and folded the front of brief down and tucked it under the Residents buttock. Resident's brief was visibly soiled with a bowel movement and urine. NA #36 proceeded with perineal care by separating Resident's legs that were bent at the knees and very stiff (due to contractures) and made one wipe down the front of the perineum across the labia with the soapy wash cloth. NA #141 then assisted NA #36 to turn resident to her right side and NA #36 folded soiled soapy wash cloth over one time and wiped one pass up the Resident's buttocks. NA #36 then wiped the perineal area one time from front to back bewteen the buttocks with the wash cloth that was said to be a rinse wash cloth containing only water, then wiped one time between the buttocks with the dry wash cloth. NA #36 then pulled s… | 2020-09-01 |
| 232 | 232 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2017-04-20 | 272 | D | 0 | 1 | GGWL11 | Based on record review and staff interview, the facility failed to conduct an accurate comprehensive minimum data set (MDS) assessment for one (1) of nineteen (19) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The comprehensive assessment for Resident #152 did not accurately reflect that the resident received an anticoagulant medication. Resident identifier: #152. Facility census: 104 Findings include: a) Resident #152 Medical record review, on 04/19/17 at 10:57 a.m., revealed an Medication Administration Record [REDACTED]. The comprehensive MDS assessment with the Assessment Reference Date (ARD) of 03/31/17 did not accurately indicate Resident #152 was receiving an anticoagulant. On 04/19/17 at 4:20 p.m., during an interview with the MDS Coordinator, she verified the MDS (Section N: Medications) with the ARD of 03/31/17 did not reflect Resident #152 as taking an anticoagulant. | 2020-09-01 |
| 233 | 233 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2017-04-20 | 463 | E | 0 | 1 | GGWL11 | Based on observation and staff interview, the facility failed to provide a means of communication allowing residents to call for staff assistance. Three (3) separate bathrooms were not equipped with a mechanism to allow residents to call for assistance. These bathrooms were located in the front lobby, on the rehabilitation hall and near the chapel. This practice had the potential to affect more than an isolated number of residents. Facility census: 104. Findings include: a) On 04/18/17 at 3:00 p.m., an observation was made of the bathrooms in the front lobby. These bathrooms were located near the sitting room, a gift shop, cafe and gathering room for residents. Observations revealed both male and female bathrooms were not equipped with a means of communication which would allow residents to call for staff assistance. There was no call system in the bathrooms. On 04/19/17 at 8:02 a.m., observations of the bathrooms near the chapel area also revealed these bathrooms did not have a call system for residents to use if they were in the bathroom and needed help. These bathrooms were labeled as Staff Only however, they were not locked and were located next to the facility's chapel which was for residents. A third observation, on 04/19/17 at 8:15 a.m., of a bathroom on the [NAME]lands[NAME]Rehabilitation side of the building also revealed a bathroom that did not have a call system for residents to use if they were in the bathroom and needed assistance. This bathroom was located in a hallway between the therapy gym and the hallway which housed resident rooms. On 04/19/17 at 11:30 a.m., during an interview with the administrator, she agreed the three (3) bathrooms mentioned above were not locked, and residents could have access to them. She also agreed the three (3) bathrooms did not have call systems that would allow residents to call for help if they were in the bathroom and needed assistance. The administrator said she would be able to equip these bathrooms with a call system but this would take some time. She said in o… | 2020-09-01 |
| 234 | 234 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2018-04-25 | 685 | D | 0 | 1 | CEG811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician's orders to irrigate ears after the completion of treatment to loosen ear wax. This affected one resident of one reviewed for reviewed for hearing. Resident identifier: #90. Facility census: 94. Findings included: a) Resident #90 The medical record for Resident #90 was reviewed on 04/24/18 at 9:22 [NAME]M. Resident #90 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 30-day Minimum Data Set (MDS) assessment, dated 04/12/18, indicated the resident had adequate hearing. The physician's orders were reviewed and the Medication Administration Record [REDACTED]. The physician's orders directed staff to Instill application in both ears three times a day for ear wax for five days in ear canal with [MEDICATION NAME]. Irrigate with lukewarm tap water 20 minutes after last dose. A nurse's note dated 04/18/18 at 8:59 [NAME]M. stated the resident told the nurse she knew her ears were full of wax because the nurse yesterday told her so. The nurse called the physician and discontinued a 2nd round of the [MEDICATION NAME] Solution and ordered a consult with an ear specialist regarding possible ear wax impaction. On 04/23/18 at 10:32 [NAME]M. an initial interview was conducted with Resident #90. The resident stated she had been receiving drops in her ears for wax build up and the nurse was supposed to suction her ears out after the drops were completed and didn't. The resident stated she was going to go to an ear doctor because she could not hear well out of her right ear and the nurse said it was because it was full of wax. On 04/24/18 at 9:01 [NAME]M., Resident #90 was re-interviewed and was able to hear all questions asked during the interview. The resident was asked, Can you hear okay since you still have wax in your ears? The resident stated there were no problems with hearing. On 04/24/18 at 9:36 [NAME]M. Registered Nurse (RN) #138 was interviewed. RN #38 stat… | 2020-09-01 |
| 235 | 235 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2018-04-25 | 692 | E | 0 | 1 | CEG811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three of five residents reviewed for nutrition maintained acceptable body weight. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #84, #98 and #24. Facility census: 94. Findings included: a) Resident #84 The medical record for Resident #84 was reviewed on 4/24/18 at 4:45 PM. Resident #84 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 14 day assessment dated [DATE] revealed on Section K0300 the resident had a loss of 5% or more in the last month and received a mechanically altered diet. The plan of care dated 03/26/18 was reviewed on 4/24/18 at 4:51 PM. The plan of care revealed the following: Resident was at risk for weight loss due to poor oral intake. The Admission Weight was 114 pounds on 03/28/18 and Ideal Body Weight (IBW) was 100-120 pounds. The Resident will remain within IBW range. DIET: Pureed No Added Salt, ground meat with allowance for Mechanical Soft breads, snacks, & desserts and regular fluid consistency. Meals in Assisted Dining Room. [MEDICATION NAME] Acetate 40 milligram daily for appetite stimulant. Supplement: Ensure Plus three times a day. Weight as ordered. Potential for aspiration related to dysphagia. Will have no signs or symptoms of aspiration through next evaluation. Speech therapy five days per week for 4 weeks for cognitive skill training,speech/language and swallowing. Further review of the medical record on 4/24/18 at 5:10 PM revealed the following weights recorded for Resident #84: --4/24/18 - 107 pounds (lbs) --4/17/18 - 107 lbs --4/11/18 - 107 lbs --4/10/18 - 107 lbs --4/01/18 - 113 lbs --3/29/18 - 113 lbs --3/28/18 - 114 lbs A nutritional progress note dated 3/28/18 revealed the resident's weight upon admission was 114 pounds and the resident was 62 inches tall. The note further indicated the resident's current average oral … | 2020-09-01 |
| 236 | 236 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2018-04-25 | 758 | D | 0 | 1 | CEG811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to conduct gradual dose reductions for [MEDICAL CONDITION] drugs in an effort to discontinue those drugs for one of six residents reviewed for Unnecessary Medications. Specifically, the facility failed to attempt a gradual dose reduction for Resident #100's anti-psychotic medication. [MEDICATION NAME], with no evidence of justification for the medication. Resident identifier: #100. Facility census: 94. Findings included: a) Resident #100 The behavior management policy, last revised on 05/30/17, was provided by the interim director of nursing (DON) on 04/25/18 at 9:48 AM. The policy read in pertinent part: --It is the policy of this facility to enhance the quality of life for each resident by assuring the optimal level of functioning with the least restrictive yet safe environment. A [MEDICAL CONDITION] drug is any drug that affects brain activities . These drugs include drugs in the following categories: anti-psychotic . Initiate and maintain a behavior monitoring record . Attempt to manage the behavior through non-pharmacological interventions . Notify the legally responsible party if medical intervention is needed and complete informed consent for psycho-active medication consent and have signed . Maintain clinical documentation to record behavior exhibited and response to interventions and observation of continued behaviors . If medication is necessary, monitor for side effects and the resident's response to the medication and any unusual drowsiness . New physician orders [REDACTED]. Medications will be monitored by the consultant pharmacist, DON or his/her designee and dose reduction attempted at least every three to six months as ordered by physician. Resident #100 admitted to the facility on [DATE], with a current [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessments and care plans were reviewed on 04/24/18 at 9:26 AM. According to the 04/3/18 MDS assessment, … | 2020-09-01 |
| 237 | 237 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2018-06-12 | 755 | D | 1 | 0 | LZL711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and review of the facility's guidance tool for insulin storage, the facility failed to discard two (2) vials of insulin after having been opened for use for greater than twenty-eight (28) days. Another insulin vial was not inscribed with the date of initial opening, which rendered it so that it could not be determined as to what date to dispose of that vial. This was evident for one (1) of five (5) medication carts, and affected Residents #17 and #57. Facility census: 94. Findings include: a) Resident #17 Observation of the Mountain Village medication cart was completed on 06/11/18 at 2:05 p.m. while accompanied by licensed nurse Employee #133 (E#133). The medication cart contained an opened and partially used vial of [MEDICATION NAME] for Resident #17 which was marked as having been initially opened on 05/05/18. E#133 showed a copy of the insulin storage recommendations that is kept on the medication cart in a three (3) ring binder. This guidance tool for the storage of medications stated that [MEDICATION NAME] may be used for twenty-eight (28) days after having been initially opened, and may be stored in a refrigerator or at room temperature from thirty-six (36) degrees Fahrenheit (F) to eighty-six (86) degrees F. b) Resident 57 Observation of the Mountain Village medication cart was completed on 06/11/18 at 2:05 p.m. while accompanied by licensed nurse Employee #133 (E#133). The medication cart contained an opened and partially used vial of Humalog insulin for Resident #57 which was marked as having been initially opened on 05/10/18. The medication cart contained an opened and partially used vial of [MEDICATION NAME] for Resident #57 which was delivered to the floor on 05/03/18. There was no date inscribed to indicate when this vial of insulin had been initially opened for use. E#133 showed a copy of the insulin storage recommendations that is kept on the medication cart in a three (3) ring binder. … | 2020-09-01 |
| 238 | 238 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2018-06-12 | 761 | E | 1 | 0 | LZL711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview and review of the facility's guidance tool for insulin storage, the facility failed to discard two (2) vials of insulin after having been opened for use for greater than twenty-eight (28) days. Another insulin vial was not inscribed with the date of initial opening, which rendered it so that it could not be determined as to what date to dispose of that vial. This was evident for one (1) of five (5) medication carts, and affected Residents #17 and #57. Facility census: 94. Findings included: a) Resident #17 Observation of the Mountain Village medication cart was completed on 06/11/18 at 2:05 p.m. while accompanied by licensed nurse Employee #133 (E#133). The medication cart contained an opened and partially used vial of [MEDICATION NAME] for Resident #17 which was marked as having been initially opened on 05/05/18. E#133 showed a copy of the insulin storage recommendations that is kept on the medication cart in a three (3) ring binder. This guidance tool for the storage of medications stated that [MEDICATION NAME] may be used for twenty-eight (28) days after having been initially opened, and may be stored in a refrigerator or at room temperature from thirty-six (36) degrees Fahrenheit (F) to eighty-six (86) degrees F. b) Resident 57 Observation of the Mountain Village medication cart was completed on 06/11/18 at 2:05 p.m. while accompanied by licensed nurse Employee #133 (E#133). The medication cart contained an opened and partially used vial of Humalog insulin for Resident #57 which was marked as having been initially opened on 05/10/18. The medication cart contained an opened and partially used vial of [MEDICATION NAME] for Resident #57 which was delivered to the floor on 05/03/18. There was no date inscribed to indicate when this vial of insulin had been initially opened for use. E#133 showed a copy of the insulin storage recommendations that is kept on the medication cart in a three (3) ring binder. … | 2020-09-01 |
| 239 | 239 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2019-10-08 | 609 | D | 1 | 0 | RZPJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon staff interview, observation and record review, the facility failed to ensure that an allegation of neglect was reported to the state survey agency and the state protective services agency. A resident's responsible party made a complaint that after she requested he be put to bed, her family member was left unattended in his wheelchair for two hours in his room, resulting in a fall. This was found for one (1) of seven (7) residents reviewed. Resident identifier: #54. Facility census: 103. Findings included: a) Resident #54 Record review revealed a complaint documented on 09/03/19 from a family member to Social Worker #132. The description of the concern was (typed as written): MPOA (Medical Power of Attorney) concerned that she left resident at 7:30 (PM) with his call light on to lay down and he fell at 9:30 (PM) from his wheelchair. (The incident report for the fall also documented he was found on the floor in front of his wheelchair.) Niece had requested he be transferred to bed or wheelchair to prevent fall. (Social Worker #132 explained on 10/8/19 at 2:35 PM she meant to write recliner but wrote wheelchair in error.) She feels he is not being repositioned or moved out of wheelchair and gets tired. The niece remarked she .would like resident to not be left in wheelchair unattended. Move to recliner or bed. Social Worker #132 stated on 10/8/19 at 2:35 PM she had educated Nursing Staff to not leave resident #54 in his wheelchair unattended previously on 8/20/19, and this had been added to his care plan. A care plan note written by Social Worker #132 on 8/20/19 stated in part (typed as written): Resident's niece attended meeting. Resident lacks capacity and is a full code. His niece is his POA and MPO[NAME] He has a [DIAGNOSES REDACTED]. He takes [MEDICATION NAME] and [MEDICATION NAME]. Niece would like him to be out of his wheelchair and in his bed or recliner more during the day. The investigation of the complaint was done by Ad… | 2020-09-01 |
| 240 | 240 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2019-10-08 | 689 | D | 1 | 0 | RZPJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon staff interview, observation, and record review, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents. A resident was observed without ordered leg rests and chair alarms. This was found for one (1) of seven (7) residents reviewed. Resident identifier: #54. Facility census: 103. Findings included: a) Resident #54 Record review found a complaint documented on 9/3/19 from his family member to Social Worker #132. The concern was (typed as written): MPOA (Medical Power of Attorney) concerned that she left resident at 7:30 (PM) with his call light on to lay down and he fell at 9:30 (PM) from his wheelchair. (The incident report for the fall also documented he was found on the floor in front of his wheelchair.) Niece had requested he be transferred to bed or wheelchair to prevent fall. (Social Worker #132 explained on 10/8/19 at 2:35 PM she meant to write recliner but wrote wheelchair in error.) She feels he is not being repositioned or moved out of wheelchair and gets tired. The niece remarked she .would like resident to not be left in wheelchair unattended. Move to recliner or bed. Social Worker #132 stated on 10/8/19 at 2:35 PM she had educated Nursing Staff to not leave resident #54 in his wheelchair unattended previously on 8/20/19, and this had been added to his care plan. A care plan note written by Social Worker #132 on 8/20/19 stated in part (typed as written): Resident's niece attended meeting. Resident lacks capacity and is a full code. His niece is his POA and MPO[NAME] He has a [DIAGNOSES REDACTED]. He takes [MEDICATION NAME] and [MEDICATION NAME]. Niece would like him to be out of his wheelchair and in his bed or recliner more during the day. Review of resident #54's current physician's orders [REDACTED]. Resident #54 was observed at least four times each day during the investigation. On 10/8/19 at 10:50 AM, resident #54 was observed in his wheelchair ju… | 2020-09-01 |
| 241 | 241 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2020-02-13 | 558 | D | 0 | 1 | G76I11 | Based on observation and interview, the facility failed to ensure a call light and bed controller was accessible and within reach for two (2) residents. This was a random opportunity for discovery. Resident identifiers: #26 and #313. Facility census: 62. Findings included: a) Resident #26 On 02/10/20 at 3:02 PM, Resident #26's call light and bed controller were not in reach. The call light and bed controller were located at the head of the bed, behind the headboard on the left side of the headboard. Resident #26 was lying across the middle of the bed. Resident #26's feet were on the floor, body angled across the bed, and her head lying near the wall. Resident #26 had a nutritional shake in her hand and was yelling, I can't get up, I can't drink my milk. On 02/10/20 at 3:04 PM, Employee #[AGE], Nursing Assistant (NA), entered the room when asked by the surveyor. On 02/10/20 at 3:06 PM, Employee #6, NA, entered Resident #26's room to assist NA #[AGE]. On 02/10/20 at 3:09 PM, Employee #6, Nursing Assistant, placed the call light and bed controller after the surveyor asked where the call light and bed controller were located. On 02/12/20 at 3:13 PM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 0[DATE]20. b) Resident #313 On 02/11/20 at 8:53 AM, Resident #313's bed controller was observed to be located behind the headboard, on the right side of the bed. Resident #313, who has capacity to make medical decisions, was asked if he could adjust his bed. Resident #313 stated that the did not know where the controller was located. On 02/11/20 at 9:01 AM, Employee #96, Clinical Quality Consultant, placed the bed controller in reach of Resident #313. On 02/12/20 at 3:13 PM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 0[DATE]20. | 2020-09-01 |
| 242 | 242 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2020-02-13 | 583 | D | 0 | 1 | G76I11 | Based on observation and staff interview, the facility failed to ensure resident privacy. This was a random opportunity for discovery. This failed practice had the potential to affect a limited number of residents. Resident identifier: #26. Facility census: 62. Findings included: a) Resident #26 During the initial tour of the facility on 02/10/20 at 11:18 AM, Resident #26's window blinds handle, used to opening and closing the blinds, was observed to be off of the blinds and lying in the windowsill. On 02/10/20 at 11:22 AM, Employee #51, Maintenance Assistant, entered the room. Employee #51 examined the window blinds and attempted to place the handle back on the window blinds. Employee #51 stated that the window blinds were broken. Employee #51 stated that she would have someone repair the window blinds that day. Employee #51 was asked if the blinds could be pulled to allow the resident privacy since Resident #26's bed was against the wall as well as located on the side of the room with the window. Employee #51 stated that the blinds could not be closed. On 02/10/20 at 3:02 PM, the window blind was still broken and the handle to the window blind was still lying in the windowsill. Employee #[AGE], Nursing Assistant (NA), was asked to enter the room since Resident #26 was calling for help. On 02/10/20 at 3:06 PM, Employee #6, NA, entered the room to assist NA #[AGE] with providing care for Resident #26. On 02/10/20 at 3:09 PM, after Resident #26 was transferred to her wheelchair, the surveyor asked NA #6 and NA#[AGE] what do they do when providing personal care to Resident #26 since the window blinds do not close. NA #6 and NA #[AGE] stated that Resident #26 takes herself to the bathroom. When NA #6 and #[AGE] were asked how do staff members ensure privacy when assisting Resident #26 with changing clothes, assisting with bathing, or any other aspect of care, NA #6 and NA #[AGE] did not provide an answer. On 02/11/20 at 9:04 AM, the window blinds for Resident #26 were still broken, with the handle lying in the windo… | 2020-09-01 |
| 243 | 243 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2020-02-13 | 684 | D | 0 | 1 | G76I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. This was a random opportunity for discovery. Resident identifier: #26. Facility census: 62. Findings included: a) Resident #26 During the initial tour of the facility on 02/10/20 at 11:18 AM, a fall mat was observed to be propped up against the exterior wall of Resident #26's room. The fall mat was located between the exterior wall and the tv cabinet. On 02/10/20 at 11:22 AM, Employee #52, Maintenance Assistant, observed the fall mat leaning against wall. On 02/10/20 at 3:02 PM, Resident #26 was lying across the middle of the bed. Resident #26's feet were on the floor, body angled across the bed, and her head lying near the wall. The fall mat was laying on the floor beside of Resident #26's bed. Employee #[AGE], Nursing Assistant (NA) entered Resident #26's room on 02/10/20 at 3:04 PM and NA #6 entered Resident #26's room at 3:06 PM. Both NA #6 and NA #[AGE] noted that the fall mat was located beside Resident #26's bed. A review of Resident #26's physician orders [REDACTED].#26 did not have an order for [REDACTED]. On 02/11/20 at 9:06 AM, the Director of Nursing (DON) entered Resident #26's room with the surveyor. The DON noted that the fall mat was against the exterior wall, between the wall and the tv cabinet. In an interview with the DON on 02/11/20 at 2:10 PM, the DON stated Resident #26 did not have an order for [REDACTED]. The findings were discussed with the Administrator and the DON on 02/12/2020 at 3:13 PM. No further information was provided prior to the end of the survey on 0[DATE]20. | 2020-09-01 |
| 244 | 244 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2020-02-13 | 812 | E | 0 | 1 | G76I11 | Based on observations and interviews with facility staff, the facility failed to maintain kitchen appliances in a sanitary manner. Equipment was found to be in need of cleaning. This practice has the potential to affect more than a limited number of residents who receive food served from this central location. Facility census: 62. Findings included: a) During the initial tour of the dietary department on 02/10/20 prior to lunch revealed the dietary staff had not followed proper sanitary techniques. The tour was performed with the Assistant Food Service Director, Employee #26, The following issues were noted at the time: 1. A reach-in freezer did not contain an internal thermometer which would allow the staff to determine if the unit was keeping the correct temperature. This is to ensure the food items are maintained in safe temperatures levels for consumption. 2 The milk cooler located near the serving line was found to have many spills in the bottom of the unit and to be in need of cleaning. 3. Drip pans under the range top had a large accumulation of food debris and in need of cleaning. 4. Oven doors had a greasy buildup both on the inside and outside the unit that needed cleaned. The handles of the doors were found to need cleaning as they were greasy and sticky to the touch. 5. The toaster was noted to have a large accumulation of crumbs and debris This was after the unit had been used for breakfast and had not been cleaned as yet. | 2020-09-01 |
| 245 | 245 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2020-02-13 | 867 | D | 0 | 1 | G76I11 | Based on record review and staff interview, the facility failed to ensure the Quality Assessment and Assurance (QA&A) committee corrected quality deficiencies it had or should have had knowledge of. This practice has the potential to effect all residents currently residing in the facility. Facility census: 62. Findings included: a) Cross reference deficiency cited at F 8[AGE] During an interview on 0[DATE] at 8:44 AM with the Administrator, the findings related to Quality Assurance were discussed with the Administrator. The Administrator stated that they are currently reviewing the action steps related to the deficient practice. The Administrator discussed future ways that they would track and trend with regard to the pneumococcal vaccinations. No further information was provided prior to the end of the survey on 0[DATE]20. | 2020-09-01 |
| 246 | 246 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2020-02-13 | 880 | E | 0 | 1 | G76I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record 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 diseases and infections. This was a random opportunity for discovery. Resident identifiers: #62 and #25. Facility census: 62. Findings included: a) Resident #62 On 02/11/20 at 11:34 AM, surveyor entered Resident's room with Registered Nurse (RN) #32 to observe wound care. Upon entering the room, observation was made of contracted hospice nurse assistant (HNA) providing incontinence care to the Resident #62. The HNA tossed the soiled wash clothes and towels smeared with dark brown substance that appeared to be stool over her shoulder onto the floor on top of a pile of existing dirty linens. The soiled linens were noted not to be in a bag or have any barrier between them and the floor. The dirty pile of linens created by the HNA was approximate two (2) feet into the doorway of the resident's room, and surveyor had to step over the dirty linens in order to enter room. RN# 32 was asked if she agreed with the procedure the HNA used for handling and disposing of the soiled linens, and RN#32 stated, No way, I saw that, they should have been placed in bag and not just tossed in the floor. At 11:49 AM on 02/11/20, surveyor informed Infection Control Nurse RN# 66 of surveyor's observation that occurred for Resident #62. RN #66 stated, Oh no, that's not our staff but they still should know better. During an interview at 12:35 PM on 2/11/20, the Director of Nursing (DON) stated, I have a call out the hospice agency the nursing assistant works for and will address her performance issues with the way she handled the soiled linens, and will be providing education all staff. b) Resident #25 During the initial tour of the facility on 02/10/20 at 11:19 AM, Resident #25's oxygen tubi… | 2020-09-01 |
| 247 | 247 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2020-02-13 | 883 | D | 0 | 1 | G76I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop, maintain and follow policies and procedures for immunization of residents against pneumococcal disease in accordance with national standards of practice for two (2) of five (5) residents reviewed for the provision of immunizations. Resident identifiers: #62, #20. Facility census: 62. Findings included: a) Resident #62 Record review indicated Resident #62, [AGE] years of age, was administered 13-valent pneumococcal conjugate vaccine (PCV13) vaccine on 08/17/16. No documentation was found to indicate the resident either received the 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23) or did not receive the vaccine due to medical contraindications, previous vaccination, or refusal. During an interview on 02/12/20 at 10:05 AM, Infection Control Nurse (ICN) #66 verified there was no evidence to indicate the facility made an attempt to determine if the Resident had been offered or administered the PPSV23 vaccine. ICN #66 stated the facility had no process or procedure in place for monitoring the provision of both vaccines (PPSV23 and PCV13 vaccines) and said, I didn't know there were two vaccines and they both had to be given. Review of the facility's Pneumococcal Vaccine (Series) policy implemented on 11/27/17, stated the type of pneumococcal vaccine will be offered to Residents in accordance with current CDC guidelines and recommendations. The policy further stated: Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. b) Resident #20 Record review indicated Resident #20, [AGE] years of age, was administered 13-valent pneumococcal conjugate vaccine (PCV13) vaccine on 08/17/16. No documentation was found to indicate the resident either received the 23-va… | 2020-09-01 |
| 248 | 248 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2019-02-27 | 552 | D | 0 | 1 | DBDN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview the facility failed to ensure Resident #50 was afforded the opportunity to be informed of, and participate in, his treatment while a resident at the facility. This was true for one (1) of two (1) residents reviewed for the care area of Language and communication during the long-term care survey process. Resident identifier: #50. Facility census: 65. Findings included: a) Resident #50 A review of Resident #50's medical record, at 8:27 a.m. on 02/26/19, found Resident #50 had two (2) admissions to the facility since 05/01/18. Resident #50 was admitted to the facility on [DATE] and was discharged to home on 08/06/18. He was then readmitted to the facility on [DATE] and is currently still residing in the facility at the time of this review. Further review of the record found two (2) physician's determination of capacity forms. The first form was completed by Resident #50's attending physician on 05/18/18 and was the capacity form in effect from 05/18/18 until his discharge home on 08/06/18. Review of this form found Resident #50's attending physician indicated Resident #50 lacked capacity to make medical decisions. The reason given for this decision by the attending physician read as follows, Significant barrier to communication d/t (due to) thick accent/limited English use. The second capacity statement was completed by Resident #50's attending physician on 01/04/19 and was the current capacity statement in effect at the time of this review it indicated Resident #50 lacked capacity to make medical decisions due to inability to process information, delusions, hallucinations, and dementia secondary to Parkinson disease. Further review of Resident #50's medical record found Resident #50 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated he was cognitively intact. The medical record contained no indication he had a [DIAGNOSES REDACTED]. A review of a physician's pr… | 2020-09-01 |
| 249 | 249 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2019-02-27 | 561 | D | 0 | 1 | DBDN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview and family interview, the facility failed to ensure one (2) of two (2) residents reviewed for the care area of choices, had the opportunity to participate in their usual daily routine for dining. Resident #6 was not offered a choice to get up in chair and attend lunch in the atrium. Resident #47 did not get the choice to sleep in and have breakfast served at her preferred time. Resident identifiers: #6, #47. Facility census: 65. Findings included: a) Resident #6 On 02/25/19 at 12:30 PM Resident was observed setting in bed eating lunch. Resident's Medical Power of Attorney (MPOA) was present at bedside and stated that Resident was usually up in chair by now and eats her lunch in the dining hall. MPOA said she had just questioned Nurse Aide (NA) #12 as to why Resident was not up in a chair or eating in dining hall. NA #12 informed MPOA that she did not have enough help to get Resident up with lift. During an interview with Resident #6, on 02/25/19 at 12:35 PM, Resident #6 expressed her personal preference was to be up in chair after breakfast and to go to the atrium to eat her lunch. Resident stated it took two (2) people to get her up, and this morning they were too busy to get her up. At 11:08 AM on 02/26/19 during an interview NA #12 stated, When I have hall 26-30, I never have help, restorative was supposed to help but they usually don't. Yesterday I couldn't find anybody to help me get her (Resident #6) up and it takes two people for the lift. She is usually up in chair by 10:00 and goes to dining hall for lunch. When I work that hallway (Rooms 26-30) I am usually by myself. NA #12 verified that being up chair by mid-morning prior to lunch was the Resident's personal preference and part of her usual daily routine. During an interview, on 02/27/19 at 8:26 AM, Director of Nursing (DON) stated that NA #6, who was assigned to care for Resident #6 was assigned with a resto… | 2020-09-01 |
| 250 | 250 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2019-02-27 | 576 | C | 0 | 1 | DBDN11 | Based on resident interview and staff interview, the facility failed to ensure residents had the right to receive mail on Saturdays when delivery was available through the postal service. This had the potential to affect all residents residing at the facility. Facility census: 65. Findings included: a) Resident council meeting At 2:15 PM on 02/26/19, residents attending the council meeting were asked the question, is mail delivered unopened and on Saturdays? The residents agreed their mail was unopened, but they didn't know if mail was delivered on Saturdays. The activity director (AD) #10 attended the meeting. The AD said the facility did not get mail on Saturdays. She did not know if the mail could be delivered. On 02/27/19 at 3:46 PM, the administrator said the mail hadn't been delivered on Saturdays. The administrator contacted the postal carrier who can deliver mail on Saturdays and mail delivery has been arranged. | 2020-09-01 |
| 251 | 251 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2019-02-27 | 622 | D | 0 | 1 | DBDN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure documentation regarding the specific reason for the transfer on the Notice of Discharge or Transfer was provided to the guardian and ombudsman for one (1) of one (1) residents reviewed for the care area of hospitalization . Additionally, the physician did not document the reason for the resident's transfer. Resident identifier: #70. Facility census: 65. Findings included: a) Resident #70 Review of Resident #70's medical records revealed an emergency transfer to the hospital on [DATE] at 2:15 AM. The reason for the transfer according to the medical records was, Resident physically struck roommate, causing unsafe environment. A Notice of Transfer of Discharge was completed on 12/31/18. The Notice of Transfer or Discharge stated, Due to the reason indicated below a discharge or transfer from this center will be necessary. - The transfer or discharge is appropriate because your health has improved sufficiently that you no longer need the services provided by this center. - The transfer or discharge is necessary for your welfare and your needs cannot be met in this center. - The safety of other individuals in this center is endangered. - The health of other individuals in this center is endangered. Each of the discharge or transfer reasons had a box before the item that could be checked as appropriate. None of the reasons for discharge or transfer had been checked. The Notice of Transfer or Discharge stated Resident #70's guardian was verbally notified on 12/31/18. The time of notice was not given. A facsimile communication report showed the Notice of Transfer or Discharge was sent to the ombudsman on 01/18/19. No physician documentation regarding the reasons for Resident #70's transfer was in the medical records. The resident was ultimately not permitted to return to the facility. During an interview, on 02/27/19 at 12:21 PM, the Director of Nursing (DoN) agreed the reason … | 2020-09-01 |
| 252 | 252 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2019-02-27 | 626 | D | 0 | 1 | DBDN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure physician documentation regarding the reason the resident was not permitted to return to the facility for one (1) of one (1) residents reviewed for the care area of hospitalization . Additionally, the facility failed to provide written notice to the resident's guardian and to the ombudsman specifically stating the resident would not be permitted to return to the facility. Resident identifier: #70. Facility census: 65. Findings included: a) Resident #70 Review of Resident #70's medical records revealed an emergency transfer to the hospital on [DATE] at 2:15 AM. The reason for the transfer according to the medical records was, Resident physically struck roommate, causing unsafe environment. A nursing note written at 12/31/2018 at 12:45 PM stated, This nurse called facility medical director, (physician name) regarding resident's status in facility pending return from hospital. (Physician name) expressed to this nurse that he did not feel comfortable accepting him back because he felt that the resident has had an increase in combative behavior and feels that we have to take into consideration our other resident's well-being. He feels that this resident may be a danger to other resident's going forward. It is also his belief that he requires more care than we are able to provide. At this time, we are unable to meet his needs and he will not accept him back in facility as a resident. A nursing note, written on 12/31/2018 at 1:20 PM stated, (Guardian name), guardian notified by this nurse that (physician name) has decided to not accept this resident back into this facility as he feels that this resident requires more care than we can provide. (Resident's name's) ongoing increase in behaviors towards staff and other resident's places the safety of our resident's at risk. It was explained that we had to take into account the safety of all residents at this time and in doing so, … | 2020-09-01 |
| 253 | 253 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2019-02-27 | 641 | D | 0 | 1 | DBDN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observation, the facility failed to ensure the accurate completion of the Minimum Data Set (MDS) for Resident #69 in the area of prognosis, for Resident #23 in the area of dental and prognosis, and Resident #68 in the area of discharge/return to the community. This was true for three (3) of 16 MDSs reviewed during the long term care survey. Resident Identifiers: #69, #23, and #68. Facility Census: 65. Findings included: a) Resident #69 A review of Resident #69's medical record, on 02/26/18 at 10:32 AM, found Resident #69 was admitted to hospice services on 09/25/18. A review of a signficant change MDS with an Assessment Reference Date (ARD) of 09/29/18 found Section J1400 Prognosis was marked to indicate Resident #69 did not have a condition or chronic disease that would result in a life expectancy of less than 6 months. This was not accurate considering Resident #69 was admitted to hospice services on 09/25/18. An interview with the MDS Coordinator Registered Nurse (RN) #66, at 3:00 PM on 02/27/19, confirmed this section was coded incorrectly. She stated, Since she was a hospice resident this should have ben marked yes not no. b) Resident #23 1. Dental Observations of Resident #23, on 02/25/19 at 1:58 PM, found Resident #23 was edentulous. She was observed sitting in her Geri- Chair in her with her mouth open. Her entire mouth could be observed and there were no teeth in her mouth. A review of Resident #23's medical record, at 1:12 PM on 02/26/19, found on 08/27/18 Resident #23 was assessed as having no natural teeth. Review of a Signficant Change MDS with an Assessment reference date (ARD) 09/18/18 found Section L Oral/Dental Status L Dental was marked Z. None of the above were present. This indicated Resident #23 had no dental problems. This was inaccurate and should have been marked B. No natural teeth or tooth Fragments (edentulous) . An interview with the MDS Coordinator Registered Nurse (RN) … | 2020-09-01 |
| 254 | 254 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2019-02-27 | 656 | D | 0 | 1 | DBDN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to implement a care plan for one (1) of sixteen (16) residents whose care plans were reviewed. Resident #47's care plan regarding her morning meal preference time was not implemented. Resident identifier: #47. Facility census: 65. Findings included: a) Resident #47 During an interview with the resident's responsible party (RP), at approximately 3:15 PM on 02/25/19, the RP said the resident always liked to sleep in and have breakfast around 10:00 AM when she was home. The RP felt staff woke the resident up too early which made her combative. The RP said, Staff don't listen to me when I try to tell them to give her breakfast at 10:00 and don't wake her up so early. Staff want to get her up at 5:00 AM so she can eat at 7:00 AM. Review of the nursing notes found the following entry: 2/15/2019 08:21 Care Plan Note Note : Annual Care conference held on 2/13/19. No Nursing concerns noted. Nursing reports that Medication review by pharmacy was completed in (MONTH) 2019 with no medication recommendations. No Activity concerns noted, Resident continues to participate well and remains very social. Discussed information provided by Director of Dietary, (name of dietary manager); Resident is currently on a mechanical soft diet eating an average of 76-100% of meals with her weight remaining stable. Reviewed CNA (certified nursing assistant) Reports: Resident does not like to get up in the mornings and can be quite grumpy at times and at times refusing her breakfast tray, but once up she is pleasant. Resident's POA (power of attorney) states that all you can do is encourage her to get up and eat breakfast say that she can lay back down when finished if she wants. She also states that Resident prefers to not get up until around 10am. Social Worker reviewed advance directives, preferences for care. No issues or concerns noted. Care Plan reviewed. Review of the Resident's current car… | 2020-09-01 |
| 255 | 255 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2019-02-27 | 684 | D | 0 | 1 | DBDN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to administer medication in accordance with physician orders. This was a random opportunity for discovery. The facility did not obtain the resident's pulse or systolic blood pressure before administering the beta-blocker, [MEDICATION NAME]. Resident identifier: #47. Facility census: 65. Findings included: a) Resident #47 Medical record review found a physician's orders [REDACTED]. Systolic is the first number of the resident's blood pressure. Systolic blood pressure, measures the pressure in your blood vessels when your heart beats. The order was effective on 12/29/18. [MEDICATION NAME] is a beta-blocker. Beta-blockers affect the heart and circulation. [MEDICATION NAME] is used to treat heart failure and hypertension. Review of the resident's medication administration (MAR) for (MONTH) (YEAR), (MONTH) 2019, and (MONTH) 2019, found the medication was given daily; however, there was no evidence staff obtained the resident's pulse or blood pressure before administering the medication. On 02/26/19 at 9:05 AM, the director of nursing (DoN) verified staff would not know if the resident's medication should be held if pulse and systolic blood pressure were not obtained before administration. The DoN said staff should record the pulse on the MAR. The DoN was unable to provide verification the physician's orders [REDACTED]. | 2020-09-01 |
| 256 | 256 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2019-02-27 | 745 | D | 0 | 1 | DBDN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #50 was provided medically-related social services to enable him to attain and/or maintain his highest practicable physical, mental and psychosocial well-being. This was true for one (1) of two (2) residents reviewed for the care area of communication during the long-term care survey. Resident identifier: #50. Facility census: 65. Findings included: a) Resident #50 A review of Resident #50's medical record at 8:27 a.m. on 02/26/19 found Resident #50 had two (2) admissions to the facility since 05/01/18. Resident #50 was admitted to the facility on [DATE] and was discharged to home on 08/06/18. He was then readmitted to the facility on [DATE] and is currently still residing in the facility at the time of this review. Further review of the record found two (2) physician's determination of capacity forms. The first form was completed by Resident #50's attending physician on 05/18/18 and was the capacity form in effect from 05/18/18 until his discharge home on 08/06/18. Review of this form found Resident #50's attending physician indicated Resident #50 lacked capacity to make medical decisions. The reason given for this decision by the attending physician read as follows, Significant barrier to communication d/t (due to) thick accent/limited English use. The second capacity statement was completed by Resident #50's attending physician on 01/04/19 and was the current capacity statement in effect at the time of this review it indicated Resident #50 lacked capacity to make medical decisions due to inability to process information, delusions, hallucinations, and dementia secondary to Parkinson disease. Further review of Resident #50's medical record found Resident #50 had a Brief Interview of Mental Status (BIMS) score of 15 which indicates he is cognitively intact. The medical record contained no indication he had a [DIAGNOSES REDACTED]. In fact, a review of a physicia… | 2020-09-01 |
| 257 | 257 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2019-02-27 | 757 | D | 0 | 1 | DBDN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #62's drug regimen was free from unnecessary medications. Resident #62 received three (3) excessive doses of an antibiotic. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during the long term care survey process. Resident identifier: 62. Facility census: 65. Findings included: a) Resident #62 A review of Resident #62's medical record, at 9:21 AM on 02/27/19, found a physician's orders [REDACTED]. This order had a start date of 02/04/19. A review of Resident #62's Medication Administration Record [REDACTED]. Resident #62 was only prescribed 20 doses by her attending physician. An interview with the Director of Nursing (DoN), at 11:16 a.m. 02/27/19, confirmed Resident #62 received three (3) extra doses of Cipro. She stated, It looks like they took the first three (3) doses from the Emergency box and then gave the 20 doses that were ordered from the pharmacy also. | 2020-09-01 |
| 258 | 258 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2019-02-27 | 842 | D | 0 | 1 | DBDN11 | Based on record review, observation, and staff interview the facility failed to ensure Resident #23's medical record was complete and accurate. Resident #23 had multiple dental assessments contained in her record that were not accurately completed. This was true for one (1) of 16 sampled residents. Resident identifier: 23. Facility census: 65. Findings included: a) Resident #23 An observation of Resident #23, at 1:58 PM, on 02/27/19 found she edentulous. She was observed sitting in her Geri Chair. Her mouth was opened and could be easily observed. This observation revealed Resident #23 had no teeth. A review of Resident #23's medical record, at 1:12 PM on 02/26/19, found the following dental assessments which were inaccurately completed: 12/18/18 Indicated Resident #23 had no dental problems. 04/01/18 Indicated Resident #23 had no dental problems. 04/26/18 Indicated Resident #23 had no dental problems. 09/23/16 Indicated Resident #23 had no dental problems. An interview with the Director of Nursing on 02/26/19 at 01:50 PM confirmed Resident #23 was edentulous and the above mentioned assessments should have been marked to indicate this, but they were not. | 2020-09-01 |
| 259 | 259 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2018-03-14 | 565 | E | 0 | 1 | YXUB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, record review and staff interview, the facility failed to respond to a group grievance concerning the water pitches in a timely manner. This failed practice had the potential to affect more than an isolated number. Facility census: 56. Finding included: a) Resident council meeting On 11/21/17 the resident council filed a Concern/Grievance Form concerning the water pitchers not returned to them in a timely manner. The investigation completed on 11/27/18 stated, Audit was done to see if all residents had water pitchers. We noted during audit that there was a shortage of water pitchers. This was taken care of immediately. Extra water pitchers were ordered by dietary department. The date of the complaint resolution as left blank. During an interview on 03/12/18 at 10:49 AM, Resident # 28 said, We don't have anyway to keep ice and water in the rooms, we used to. It stopped when a new company took over and they stopped using the plastic pitchers and now are using these old Styrofoam cups. They don't hold much or keep the water very cold long, plus it is hard to hold. She demonstrated that she can not hold the cup very easy. She said she and others have request to get the pitchers back sometime ago but they did not get them back. On 03/13/18 at 01:30 PM, DON said about two weeks ago they started using Styrofoam cups, but have already ordered new pitchers to replace the others because they kept disappearing. She said the Food Service Manager had ordered some new ones. She was shown the resident council meeting minutes, which was in (MONTH) 21, (YEAR) concerning a complaint about not having any pitchers, she said they had not been worried about because they were worried about getting ready for the surveyors. During an interview on 03/13/18 at 01:45 PM, Food Service Manager #20 said about a month ago nursing asked if they could change from the pitchers to throw cups. No order order has been made because he was unaware of th… | 2020-09-01 |
| 260 | 260 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2018-03-14 | 641 | D | 0 | 1 | YXUB11 | **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 four (4) resident's reviewed for the care area of nutrition had an accurate and complete minimum data set (MDS). This failed practice had the potential to affect a limited number of residents. Resident identifier: #40. Facility census: 56. Findings included: a) Resident #40 Record review on 03/13/18 at 11:00 AM, found the resident was admitted to the facility on [DATE]. The residents first weight was recorded as 271.3 pounds on 10/06/17. A significant change in status MDS with an assessment reference date (ARD) of 02/01/18, noted the resident's current weight was 221 pounds. The MDS coded the resident as having no weight loss, (5% or more in the last month or loss of 10% or more in last 6 months.) An interview with the dietary manager (DM) #20, at 12:14 PM on 03/13/18, confirmed the resident had an actual weight loss of 18.54 % as calculated by dietary manager at the time of the MDS with an ARD of 02/01/18. The DM verified the MDS was coded incorrectly. | 2020-09-01 |
| 261 | 261 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2018-03-14 | 656 | D | 0 | 1 | YXUB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for the care area of nutrition had a measurable care plan to address fluid intake. In addition, one (1) of three (3) residents reviewed for pressure ulcers failed to have interventions in place, as directed by the care plan, to promote healing of existing pressure ulcers and/or prevent the development of new pressure ulcers. Resident identifiers: #40 and #26. Facility census: 56. Findings included: a) Resident #40 Review of the resident's current care plan, dated 01/03/18, found the following focus/problem: --Risk of altered nutrition/hydration status related to inadequate intake of food and fluids. A goal associated with the problem was: --Resident will remain free of sign/symptoms of dehydration such as sunken eyes, decreased urine output, dry mucous membranes, daily through next review. A second care plan focus/problem, dated 03/12/18: --Resident has a urinary tract infection. The goal associated with the problem: --Resident's urinary tract infection will resolve with no complication. Interventions included: --Encourage fluids as tolerated. A comprehensive nutritional assessment, completed by the registered dietician on 01/26/18, noted the resident required 2070 milliliters of fluid a day. At 2:45 PM on 03/14/18, the director of nursing (DON) verified the facility did not keep any records to determine how much fluids any residents may or may not have consumed during the day. The facility only records the percent of food consumed by residents in a day. She was unable to verify how the facility determined the resident had an inadequate intake of fluids as specified on the care plan or how the facility would monitor daily fluid intake to ensure the resident consumed the required milliliters of daily fluid. The resident also had a urinary tract infection and the DON confirmed the facility could not v… | 2020-09-01 |
| 262 | 262 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2018-03-14 | 657 | D | 0 | 1 | YXUB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the comprehensive care plan was revised in the area of nutrition for one (1) of four (4) residents reviewed for the care area of nutrition. This failed practice had the potential to affect a limited number of residents. Resident identifier: #5. Facility census: 56. Findings included: a) Resident #5 Resident #5 had an order written [REDACTED]. This order was discontinued on 10/25/17 because the resident preferred a different nutritional supplement. Review of Resident #5's comprehensive care plan on 03/13/18 revealed the focus of Risk of altered nutrition/hydration status related to inadequate intake of food and fluids contained the intervention of 2-cal, 60 ml, twice a day. During an interview on 03/13/18 at 1:07 PM, the Director of Nursing (DON) was informed Resident #5's comprehensive care plan continued to include the intervention of 2-cal, 60 ml, twice a day even though this nutritional supplement had been discontinued 10/15/17. The DoN had no further information regarding this matter. | 2020-09-01 |
| 263 | 263 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2018-03-14 | 684 | D | 0 | 1 | YXUB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to follow physician orders [REDACTED]. This failed practice had the potential to affect a limited number of residents. Resident identifier: #5. Facility census: 56. Findings included: a) Resident #5 Resident #5 had an order written [REDACTED]. Medication side effects were ordered to be monitored. Review of Resident #5's Medication Administration Record [REDACTED]= SE and 2 = No SE. However, side effects had not been monitored. Resident #5 was also prescribed another medication, [MEDICATION NAME], for depression and appetite stimulation. The resident was also to be monitored for side effects of [MEDICATION NAME]. The MAR indicated [REDACTED]. However, the MAR indicated [REDACTED]. During an interview on 03/13/18 at 1:07 PM, the Director of Nursing (DoN) was informed physician's orders [REDACTED].#5 for side effects of [MEDICATION NAME] was not followed in March, (YEAR). The DoN had no further information regarding this matter. | 2020-09-01 |
| 264 | 264 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2018-03-14 | 686 | D | 0 | 1 | YXUB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review and staff interview, the facility failed to provide care and services to promote the healing of existing pressure ulcers and prevent development of additional pressure ulcers for one (1) of three (3) residents reviewed for the care area of pressure ulcers. Resident #26 did not have pressure relieving devices in place as directed by the care plan. Resident identifier: #26. Facility census: 56. Findings include: a) Resident #26 Review of the care plan, dated 02/12/18, found the current problem/focus: --Resident has or was admitted with pressure injuries to left inner foot, right gluteal fold, unstageable to right outer foot, and blanchable reddened area to right lateral foot, Deep tissue pressure injury to left inner heel. Potential for further pressure injury related to diabetes mellitus, [MEDICAL CONDITION] with bilateral leg contractures, recurrent hip dislocation, chronic pain, [MEDICAL CONDITION] requiring transfusion, hypertension, [MEDICAL CONDITION], dry skin and scalp, [MEDICAL CONDITION] and muscle wasting. Including the following pressure ulcers: --Stage 4 pressure ulcer to the right (middle) outer foot --Stage 2 pressure ulcer to the left buttock --Resolved Stage 2 pressure ulcer to the left elbow --Unstageable pressure ulcer to the right outer foot (distal, below little toe) The goal associated with the focus/problem: --Resident will have no further pressure ulcer formation noted through next review period. Interventions included: --May use knee/ankle abductor cushion between knees to help prevent further skin breakdown, --Resident will have elbows heels floated as allowed by the resident while in bed. Observation of the resident with the director of nursing (DON) at 1:57 PM on 03/13/18, found the resident did not have the abductors on and did not have elbows/heels floated as directed by the care plan. When asked why he did not have the abductors on the resident said, I had th… | 2020-09-01 |
| 265 | 265 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2018-03-14 | 692 | D | 0 | 1 | YXUB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, observation, and staff interview, the facility failed to recognize, evaluate, and address the nutritional needs of one (1) of four (4) residents reviewed for the care area of nutrition. In addition, the facility failed to to ensure proper hydration was provided to one resident during a random opportunity for discovery. Resident identifiers: #40 and #30. Facility census: 56. Findings included: a) Resident #40 During an interview with the resident on 03/12/18 at 10:12 AM, she said, I get mashed potatoes for every meal, I don't know why they can't fortify something else-like some macaroni and cheese for a change. The resident said she was losing weight because she can not eat and the food is not good. Record review found the resident was admitted to the facility on [DATE]. The resident's weight was recorded as 271.3 pounds on 10/06/17. The last weight recorded was 219 pounds on 03/12/18. A 19.28% weight loss since admission. Review of the resident's current care plan, dated 01/03/18, found the following focus/problem: Risk of altered nutrition/hydration status related to inadequate intake of food and fluids. A goal associated with the problem was: --Resident will remain free of sign/symptoms of dehydration such as sunken eyes, decreased urine output, dry mucous membranes, daily through next review. Interventions included: --Dietary to provide fortified foods one item per tray, initiated on 01/24/18, --Honor food preferences, --Dietary to provide 8 ounces of whole milk with meals, yogurt at 2pm and 1/2 sandwich hs (at night time) Two comprehensive nutritional assessments were completed by the registered dietician (RD) since the resident's admission. On on 10/07/17 and 01/29/18. On 10/07/17, the nutrition summary noted: --New admission. [AGE] year old female .BMI (body mass index) indicates obesity; no interventions warranted due to diagnosis. Will allow resident time to adjust to facility, encourage po … | 2020-09-01 |
| 266 | 266 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2018-03-14 | 757 | D | 0 | 1 | YXUB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure Resident #62's medication regimen was free from unnecessary medication. Resident #62 was administered an antihypertensive ([MEDICATION NAME]) medication outside of the physician prescribed parameters. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #62. Facility census: 56. Findings included: a) Resident #62 Review of Resident #62's medical records found a physician order [REDACTED]. Review of Resident #62's Medication Administration Record [REDACTED] --11/26/17- blood pressure was 118/68. --11/27/17- blood pressure was 118/78. --12/05/17- blood pressure was 118/70. --12/11/17- blood pressure was 118/74. --12/13/17- blood pressure was 118/68. Interview with the Director of Nursing (DON) on 03/13/18 at 11:30 AM found after review of the MARs for (MONTH) and (MONTH) (YEAR). Resident was administered [MEDICATION NAME] when the medication should have been held as directed by the physician prescribed parameters. | 2020-09-01 |
| 267 | 267 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2018-03-14 | 758 | D | 0 | 1 | YXUB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure [MEDICAL CONDITION] medications prescribed on an as needed basis or PRN were limited to a 14 day order, nor did the facility address non-pharmacological interventions prior to the administration of as needed, PRN [MEDICAL CONDITION] medications for one (1) of five (5) residents reviewed for unnecessary medications. This failed practice had the potential to affect more than a limited number of residents. Resident identifier: #61. Facility census: 56. Findings include: a) Resident #61 Record review for Resident #61 found physician order [REDACTED].>--[MEDICATION NAME], give 0.25 mg (milligrams) by mouth every 12 hours as needed for anxiety. Order date 11/02/17 and start date 11/03/17. Review of the MAR indicated [REDACTED] --11/03/17 at 8:13 a.m. --11/05/17 at 10:30 p.m. --11/06/17 at 7:30 p.m. --11/07/17 at 7:49 p.m. --11/08/17 at 8:15 p.m. --11/12/17 at 7:59 p.m. Interview with the Director of Nursing (DON) on 03/15/18 at 11:45 AM confirmed non-pharmacological interventions were not implemented prior to the administration of PRN [MEDICAL CONDITION] medications. Facility failed to attempt non pharmalogical interventions prior to the administration of an anti anxiety medication. ([MEDICATION NAME]) Resident #61 | 2020-09-01 |
| 268 | 268 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2018-03-14 | 803 | E | 0 | 1 | YXUB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review and staff interview, the facility failed to make a reasonable effort to assure menus were prepared to meet resident's choices for one (1) of four (4) residents reviewed for the care area of nutrition. Resident #40 received mashed potatoes every day for 49 days in a row. In addition, the facility failed to consider a menu/diet appropriate for a resident after having Laparoscopic gastric band surgery. Resident identifier: #40. Facility census: 56. Findings included: a) Resident #40 During an interview with the resident on 03/12/18 at 10:12 AM., she said, I get mashed potatoes for every meal, I don't know why they can't fortify something else-like some macaroni and cheese for a change. The resident said she was losing weight because she can not eat and the food is not good. Record review found the resident was admitted to the facility on [DATE]. The resident's weight was recorded as 271.3 pounds on 10/06/17. The last weight recorded was 219 pounds on 03/12/18. A 19.28% weight loss since admission. Review of the resident's current care plan, dated 01/03/18, found the following focus/problem: --Risk of altered nutrition/hydration status related to inadequate intake of food and fluids. A goal associated with the problem was: --Resident will remain free of sign/symptoms of dehydration such as sunken eyes, decreased urine output, dry mucous membranes, daily through next review. Interventions included: --Dietary to provide fortified foods one item per tray, initiated on 01/24/18, --Honor food preferences, --Dietary to provide 8 ounces of whole milk with meals, yogurt at 2pm and 1/2 sandwich hs (at night time) Two comprehensive nutritional assessments were completed by the registered dietician (RD) since the resident's admission. On on 10/07/17 and 01/29/18. On 10/07/17, the nutrition summary noted: --New admission. [AGE] year old female .BMI (body mass index) indicates obesity; no interventions w… | 2020-09-01 |
| 269 | 269 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2018-03-14 | 804 | E | 0 | 1 | YXUB11 | Facility failed to provide palatable, attractive and appetizing and proper temperature of food with complaints from 12 anonymous residents. This failed practice had the potential to affect more than a limited number of residents. Facility census: 56. Finding included: a) Anonymous resident statements, from resident council and resident interviews Statements from random residents during resident interviews and resident council meeting. --The bread is always dry like it's been frozen. --Food is cold and mashed potatoes everyday sometimes twice a day --Too many potatoes --The food is either over cooked or under cooked, potatoes every day, the bread is always dried out. --Sometimes I don't even know what the food is. --Today the chicken and dumplings were cold. --They run out of things a lot, the orange juice don't even taste like juice, the vegetables are either over cooked or under cooked. We have told them in resident council, several of us we don't like that old black gravy on everything. --We have a lot of chicken with fancy names, but it ain't good. Sundays pork chop was so tough you can't cut it. --I eat in my room and the food is cold even though it is in a warmer. --I couldn't eat my lunch dried up lima beans and old chicken again. We all agree that we don't like that old brown goo stuff on our food. My meat needs to be cooked good and done. The chicken and dumplings only had 1 piece of meat in it the size of my finger the rest was dough. b) Temperature check on test tray, On 03/13/18 at 11:28 AM, trays arrived on the floor for the Short hall. Many staff members arrive to dispatch trays. They were asked to get a temperature on the last tray to be served on this food cart. Food Service Manager #20 arrived on the floor with thermometer on 03/13/18 at 11:39 AM, to check temperatures of a test tray. Roast beef 108 degrees Fahrenheit. Food Service Manager #20 agreed the temperature of the roast beef was not high enough to meet safe and palatable standards. c) Interviews with Food Service Manager (FSM) and Adminis… | 2020-09-01 |
| 270 | 270 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2018-03-14 | 842 | D | 0 | 1 | YXUB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, facility failed to ensure each resident's medical records was complete and accurate. Resident #62 had an inaccurate lab value, International normalized ratio (INR) documented on the resident's anticoagulant ([MEDICATION NAME]) flow record. For Resident #29, the resident's weekly wound/pressure ulcer flow sheets were blank and/or inaccurate. Resident identifiers: #62 and #29. Facility census: 56. Findings included: a) Resident #62 Review of Resident #62's medical records found a [MEDICATION NAME] (anticoagulant) Flow sheet in which read: INR 15.1, normal range is 2.0 to 3.0. Interview with the Director of Nursing (DON) on 0n 03/13/18 at 11:30 AM, confirmed the lab was documented in error. This error was confirmed by Resident #62's physician at 3:47 PM on 03/13/18. b) Resident #29 Resident #29 had pressure ulcers on the right upper/inner posterior thigh and the left outer ankle. Resident #29's right thigh pressure ulcer had been present since (YEAR). Despite the presence of pressure ulcers, Resident #29's Weekly Licensed Nurse Skin Evaluations indicated No for the question Any existing ulcers (previously identified)? for the following dates: --03/02/18 --02/16/18 --01/26/18 --01/19/18 A Weekly Wound Evaluation for Resident #29 on 01/05/18 indicated a left ankle wound was identified on 01/05/18. Weekly Wound Evaluations on 01/12/18, 01/19/18, and 01/26/18 also indicated Resident #29's left ankle wound was identified on 01/05/18. However, Weekly Wound Evaluations on 01/29/18, 02/05/18, and 02/12/18 indicated Resident #29's left ankle wound was identified on 01/05/16. A Weekly Wound Evaluation on 02/14/18 indicated Resident #29's left ankle wound was identified on 01/05/18. Weekly Wound Evaluations on 02/23/18 and 03/09/18 indicated Resident #29's left ankle wound was identified on 01/05/16. Additionally, during review of Resident #29's medical records, Weekly Wound Evaluations for Resident # 29'… | 2020-09-01 |
| 271 | 271 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2019-11-06 | 609 | D | 1 | 0 | L1WQ11 | > Based on policy review, record review, and staff interview, the facility failed to report allegations of abuse and neglect within the required timeframe. This deficient practice was found for three (3) of four (4) residents reviewed for the care area of abuse. Resident identifiers: #65, #26, #40. Facility census: 65. Findings included: a) Policy Review A review of the facility's abuse policy titled, Abuse, Neglect and Exploitation, implemented on 11/27/17 and last revised on 02/01/19 abuse and neglect are to be reported to the required agencies within specified time frames. b) Resident #65 Per a review of the facility's abuse and neglect logs during the survey, Resident #65 was noted to have an incidence of abuse and/or neglect in (MONTH) 2019. Resident #65's abuse/neglect investigation with an incident date of 08/29/19 was reviewed on 11/05/19 at 12:16 PM. According to the investigation, the incident occurred between 11:00 AM and 4:00 PM on 08/29/19. Per the fax sheets attached to the investigation, the incident was reported to Adult Protective Services (APS), the Nurse Aide Registry, and the Office of Health Facility Licensure and Certification (OHFLAC) on 08/30/19 at 4:25 PM, more than 24 hours after the incident occurred. The Ombudsman was faxed on 08/30/19 at 4:26 PM, more than 24 hours after the incident occurred. c) Resident #26 Per a review of the facility's abuse and neglect logs during the survey, Resident #26 was noted to have had two (2) incidences of abuse and/or neglect in (MONTH) 2019. Resident #26's abuse/neglect investigation with an incident date of 09/10/19 was reviewed on 11/05/19 at 10:50 AM. According to the investigation, the incident occurred on 09/10/19 at 9:00 AM. Per the fax sheets attached to the investigation, the incident was reported to APS on 09/11/19 at 5:21 PM, more than 24 hours after the incident occurred. OHFLAC was notified on 09/11/19 at 5:22 PM, more than 24 hours after the incident occurred. The Ombudsman was notified on 09/11/19 at 5:27 PM, more than 24 hours after the … | 2020-09-01 |
| 272 | 272 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2020-01-15 | 583 | E | 0 | 1 | URBH11 | Based on observation and staff interview, the facility failed to ensure resident's personal and health information was kept confidential. Information regarding resident's names, medications, physicians, and how many and what size bowel movements, were visible to the public on the medication cart on the C wing hallway. This had the potential to affect more than a limited number of residents. Resident Identifiers #39, #10, #15, #23, #34, #44, #151, #45, #25, #18, #13, #17, #5, #50, #22, #48, and #1. Facility census 51. Findings included: a) C wing hallway medication cart A random observation on 01/14/20 at 7:51 AM, revealed a bowel management report was lying face up on top of the medication cart in the hallway on the C wing. The information was visible to anyone walking down the hallway. No nursing staff were present to obscure anyone from reading the information on the report. The bowel management report contained the following confidential information: Resident #39 Resident's name, medical record number, room number, physician's name, how many bowel movements the resident had and the size of the resident's bowel movement. Comments on the report indicated the resident received a laxative, which is a medication that loosen stools and increase bowel movements. Resident #10 Resident's name, medical record number, room number, physician's name, how many bowel movements the resident had and the size of the resident's bowel movement. Resident #15 Resident's name, medical record number, room number, physician's name and the size of the resident's bowel movements. Comments on the report indicated the Resident received PJ (Prune Juice). Prune juice can alleviate constipation. Resident #23 Resident's name, medical record number, room number, physician's name, how many bowel movements the resident had and the size of the resident's bowel movement. Resident #34 Resident's name, medical record number, their room number, physician's name, how many bowel movements the resident had and the size of the resident's bowel movements.… | 2020-09-01 |
| 273 | 273 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2020-01-15 | 584 | D | 0 | 1 | URBH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide a safe, sanitary, and homelike environment. This was a random opportunity for discovery. Resident identifier: #11, #38, and #41. Facility census: 51. Findings include: a) room [ROOM NUMBER] / 104 bathroom During the initial tour on 01/13/20 02:42 PM, a commode riser in the bathroom, shared by resident's in rooms [ROOM NUMBERS], was observed to be rusted as well as missing paint. On [DATE] at 2:47 PM, the commode riser was in the bathroom, placed over the toilet. The bathroom is shared by residents in both room [ROOM NUMBER] and room [ROOM NUMBER]. The commode riser appeared to have a rust-colored substance on the front brace, running the length of the brace bar. Also, the back two (2) legs had a rust-colored substance beginning about 1/4 down the front as well as sides of the commode riser. The adjustable holes, used for adjusting the height of the commode, had a rust-colored substance on them as well as rust-colored debris inside the adjustment holes. The arms of the commode riser had rust on the arm braces, extending to the back braces of the commode. In addition, the commode riser had nine (9) separate quarter-sized areas of a brown, dried substance, beginning one inch below the commode seat and extending in a scattered pattern. On [DATE] at 2:51 PM, Employee #178, Licensed Practical Nurse (LPN), observed the commode riser and confirmed the commode riser was rusted and had dried fecal matter present. On [DATE] at 2:52 PM, Employee #200, Registered Nurse (RN), entered the resident bathroom and stated the bedside commode was rusted and would be removed immediately and replaced. RN #200 put on medical exam gloves before removing the bedside commode from the resident's room. At 5:00 PM on [DATE], Director of Nursing stated the bedside commode had been replaced. | 2020-09-01 |
| 274 | 274 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2020-01-15 | 600 | G | 0 | 1 | URBH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident was free from neglect. This failed practice caused actual physical harm to Resident #46. This resident sustained [REDACTED]. This practice affected one (1) of three (3) residents reviewed for falls. This failed practice caused actual harm to Resident #46 when she was transferred without the assistance of two staff members (in violation of her care plan) and sustained a fall that resulted in a fractured femur. Resident identifier: #46. Facility census 51. Findings included: a) Resident #46 Review of the Admission, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 0[DATE], revealed the functional status in Section G, concerning transfers, assessed Resident #46 as--total dependence --with two plus person physical assistance when moving from a seated to standing position. The Resident had a Brief Interview for Mental Status (BI[CONDITION]) score of 15, which means the Resident had no cognitive impairment at the time of assessment. Review of the care plan initiated on 06/22/19, revealed the following Problem: Resident is at risk for falls due to impaired mobility, [MEDICAL CONDITION] ([CONDITION]) effects and history of falls. Approach: Transfer with maximum assistance of two (2) staff. Guard extremities with transfers and positioning. Review of the Resident's Kardex Report, revealed Resident #46 was marked as two (2) assist with transfers with an effective date of 06/22/19. A Kardex is a medical information system used by nurses and nursing assistants to communicate important information regarding a resident's care. A progress note, dated 07/22/19 at 9:40 AM, revealed Licensed Practical Nurse (LPN) #36 was called to Resident's room. Resident #46 and Nursing Assistant (NA) #202 were on the floor, Resident complained of right knee pain and area was malformed. Physician notified and order received for x-ray. The x-ray report completed on 07/22/19 at … | 2020-09-01 |
| 275 | 275 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2020-01-15 | 609 | D | 0 | 1 | URBH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure an allegation of neglect was reported immediately, but not later than two hours after a resident had received a serious injury. Resident #46 sustained an acute [MEDICAL CONDITION], which was caused by neglect of the facility staff. The facility did not report this serious injury to the State Survey Agency or Adult Protective Services. Resident identifier: #46 Facility census: 51. Findings included: a) Resident #46 Review of the Admission, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 0[DATE], revealed the functional status in Section G, concerning transfers, assessed Resident #46 as--total dependence --with two plus person physical assistance when moving from a seated to standing position. The Resident had a Brief Interview for Mental Status (BI[CONDITION]) score of 15, which means the Resident had no cognitive impairment at the time of assessment. Review of the care plan initiated on 06/22/19, revealed the following Problem: Resident is at risk for falls due to impaired mobility, [MEDICAL CONDITION] ([CONDITION]) effects and history of falls. Approach: Transfer with maximum assistance of two (2) staff. Guard extremities with transfers and positioning. Review of the Resident's Kardex Report, revealed Resident #46 was marked as two (2) assist with transfers with an effective date of 06/22/19. A Kardex is a medical information system used by nurses and nursing assistants to communicate important information regarding a resident's care. A progress note, dated 07/22/19 at 9:40 AM, revealed Licensed Practical Nurse (LPN) #36 was called to Resident's room. Resident #46 and Nursing Assistant (NA) #202 were on the floor, Resident complained of right knee pain and area was malformed. Physician notified and order received for x-ray. The x-ray report completed on 07/22/19 at 12:27 PM, for Resident #46 found: Significant fracture deformity with comminution of the… | 2020-09-01 |
| 276 | 276 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2020-01-15 | 656 | E | 0 | 1 | URBH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to implement the individual plans of care for three (3) of eighteen (18) sampled residents. The facility failed to implement a care plan for Resident #1 with regard to diet orders. The facility failed to implement a care plan for Residents # 15 and #42 in the area of falls. Resident identifiers: 1, 15, and 42. Facility census: 51. Findings include: a) Resident #1 Record review found a diet order, dated [DATE], Regular Special Instructions: BITE SIZE MEATS 5 SMALL MEALS/DAY **2 HANDLED CUP AT ALL TIMES. On 01/14/20 at 11:38 AM, Resident #1's tray was delivered to her room. The following items were on Resident #1's tray for the noon meal: full serving of meat, full serving of mashed potatoes, roll, slice of pie, bowl of tomato soup, orange jello in a plastic cup, vanilla pudding in a plastic cup, a bowl of applesauce, and a bowl of sliced beets. Employee #161, a Nursing Assistant (NA) was placing the items and setting up Resident #1's tray. NA #161 was asked if the amount of food on Resident #1's tray was what normally comes for her for the noon meal? NA #161 stated the number of items on Resident #1's tray was the normal amount that is placed on her tray. On 01/14/20 at 11:59 AM, during an interview with Employee #201, Dietary Manager(DM). DM #201 was asked what should be on a tray for a resident who is ordered small meals? DM #201 stated for small meals, the resident should be served half (1/2 ) the serving of meat and potatoes called for by the recipe. The resident should not have pudding or jello on their tray. The pudding and / or jello or a supplement would be served to the resident around 2:00 PM. On 01/14/20 at 12:02 PM, DM #201 accompanied the surveyor to view Resident #1's lunch tray. DM #201 stated, Resident #1's family had voiced that they wanted her to have extra pudding and jello on her tray. DM #201 stated there was no order of clarification to the exi… | 2020-09-01 |
| 277 | 277 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2020-01-15 | 689 | G | 0 | 1 | URBH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure the resident's environment remains as free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents. Resident #46 sustained serious injury during an improper transfer. The fall mat for Resident #15 was not applied properly at bedside. This was true for two (2) of three (3) residents reviewed for the care area of accidents. This failed practice caused actual harm to Resident #46 when she was transferred without the assistance of two staff members (in violation of her care plan) and sustained a fall that resulted in a fractured femur. Resident identifiers: #46 and #15. Facility census: 51. Findings included: a) Resident #46 Review of the Admission, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 0[DATE], revealed the functional status in Section G, concerning transfers, assessed Resident #46 as--total dependence --with two plus person physical assistance when moving from a seated to standing position. The Resident had a Brief Interview for Mental Status (BI[CONDITION]) score of 15, which means the Resident had no cognitive impairment at the time of assessment. Review of the care plan initiated on 06/22/19, revealed the following Problem: Resident is at risk for falls due to impaired mobility, [MEDICAL CONDITION] ([CONDITION]) effects and history of falls. Approach: Transfer with maximum assistance of two (2) staff. Guard extremities with transfers and positioning. Review of the Resident's Kardex Report, revealed Resident #46 was marked as two (2) assist with transfers with an effective date of 06/22/19. A Kardex is a medical information system used by nurses and nursing assistants to communicate important information regarding a resident's care. A progress note, dated 07/22/19 at 9:40 AM, revealed Licensed Practical Nurse (LPN) #36 was called to Resident's room. Resident #46 … | 2020-09-01 |
| 278 | 278 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2020-01-15 | 692 | D | 0 | 1 | URBH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to provide a diet as ordered by a physician. This was a random opportunity for discovery. Resident identifiers: 1. Facility census: 51. Findings include: a) Resident #1 Record review found a diet order, dated [DATE]: Regular Special Instructions: BITE SIZE MEATS 5 SMALL MEALS/DAY **2 HANDLED CUP AT ALL TIMES. On 01/14/20 at 11:38 AM, Resident #1's tray had been delivered to her room. The following items were on Resident #1's tray for the noon meal: full serving of meat, full serving of mashed potatoes, roll, slice of pie, bowl of tomato soup, orange jello in a plastic cup, vanilla pudding in a plastic cup, a bowl of applesauce, and a bowl of sliced beets. Employee #161, Nurse Aid (NA), was placing the items and setting up Resident #1's tray. NA #161 was asked if the amount of food on Resident #1's tray was what normally comes for her for the lunch and dinner meal? NA #161 stated the number of items on Resident #1's tray was the normal amount that is placed on her tray. On 01/14/20 at 11:59 AM, during an interview with Employee #201, Dietary Manager(DM), DM #201 was asked what should be on a tray for a resident who is ordered small meals? DM #201 stated for small meals, the resident should be served half (1/2 ) the serving of meat and potatoes that the recipe calls for. The resident should not have pudding or jello on their tray. The pudding and / or jello or a supplement would be served to the resident around 2:00 PM. On 01/14/20 at 12:02 PM, DM #201 accompanied the surveyor to view Resident #1's lunch tray. DM #201 stated the Resident's family had voiced that they wanted her to have extra pudding and jello on her tray. DM #201 stated there was no order of clarification to the existing diet order of small meals, 5 times a day for Resident #1. DM #201 observed Resident #1's lunch tray and confirmed the amount of food on the resident's tray was not consistent with th… | 2020-09-01 |
| 279 | 279 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2020-01-15 | 842 | D | 0 | 1 | URBH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for Resident #42 for a Pharmacy Regimen Review for [MEDICATION NAME]. This was true for one (1) of five (5) residents reviewed for unnecessary medications. This had the potential to affect more than a limited number of residents. Resident identifier: #42. Facility census 51. Findings included: a) Resident #42 During a medical record review on 01/14/20, it was discovered that a Pharmacy Regimen Review for [MEDICATION NAME] had been presented for a gradual dose reduction on 0[DATE] for Resident #42. The Physician disagreed with the recommendation on 0[DATE]. Further investigation provided no evidence Resident #42 had ever taken [MEDICATION NAME]. In an interview with the Director of Nursing (DON) on 01/14/20 at 2:36 PM, the DON reported Resident #42 had never been on [MEDICATION NAME]. She also called the hospital pharmacy and they had no record indicating Resident #42 ever received [MEDICATION NAME]. | 2020-09-01 |
| 280 | 280 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2020-01-15 | 880 | D | 0 | 1 | URBH11 | Based on observation, record review, policy review, and staff interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment with regard to respiratory services. This was a random opportunity for discovery. Resident Identifiers: #1 and #34. Facility census 51. Findings include: a) Resident #1 During the initial tour on 01/13/20 at 12:57 PM, Resident 1's Bilevel Positive Airway Pressure (bi-pap) mask was observed lying on the bedside table, not in a bag. There was not a bag for storage present in the Resident's room. On 01/13/20 at 12:59 PM, Employee #54, Nursing Assistant (NA), entered the resident's room. When asked how bi-pap masks were stored, NA #54 stated that they were supposed to be in a bag. NA #54 confirmed a storage bag was not in the Resident's room. NA #54 stated she would inform the nurse and left to get the resident a bag. On 01/14/20 at 3:27 PM, the findings were discussed with the Administrator. No further information was provided prior to the end of the survey on [DATE] at 5:00 PM. b) Resident #34 During the initial tour on 01/13/20 at 11:09 AM, Resident #34's nebulizer mask was observed lying on the table, bedside the resident's recliner. There was not a bag present in the resident's room. Resident #34's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/03/19, noted the resident had a score 15 on the Brief Interview for Mental Status. A BI[CONDITION] score of 15 is the highest score obtainable and indicates that the resident is cognitively intact. Resident #34 stated that she never has a bag and that she would like one, since sometimes the staff drop the mask on the floor. On 01/13/20 at 11:26 AM Employee #149, Nursing Assistant (NA), was asked to enter Resident #34's room. NA #149 was asked how nebulizer hand units and masks were supposed to be stored when not in use. NA #149 stated, they were supposed to be in a bag. NA #149 noted that there was no bag in Resident #34's room and went to … | 2020-09-01 |
| 281 | 281 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2017-12-07 | 656 | D | 0 | 1 | WMI211 | Based on record review and staff interviews, the facility failed to ensure care plans included measurable goals. This was found for one (1) of seventeen (17) residents in the final resident sample. Resident identifier: #30. Facility census: 45. Findings include: a) Resident #30 Review of the resident's care plan found the following goals were not written in measureable terms that would allow for achievement toward the goal to be evaluated: -- Resident will have stable mood & behaviors or be redirected daily. What mood and behaviors were to be addressed and how one would determine whether they decreased was not identified. -- Resident will have ADL (activities of daily living) needs met daily. There was no methodology by which this could be determined. -- Pressure injuries will show healing as evidence by decrease in area through the next evaluation. No location of the injuries or measurements were included to render this goal measurable. -- Optimal breathing pattern will be maintained, O2 (oxygen) via NC (nasal cannula) per orders. What would be considered optimal for this resident was not identified in order enable evaluation of achievement toward the goal. At lunch time on 12/07/17, these findings were brought to the attention of the Director of Nursing, and with the Care Plan Nurse prior to exit on 12/07/17. | 2020-09-01 |
| 282 | 282 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2017-12-07 | 756 | D | 0 | 1 | WMI211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the pharmacist failed to identify a medication irregularity for Resident #30. The resident received [MEDICATION NAME] and [MEDICATION NAME] for behavioral disturbances, but had not exhibited any behaviors after experiencing a major decline in both her functional abilities and behaviors. Resident identifier: #30. Facility Census: 45. Findings include: a) Resident #30 Observations at lunch time on 12/04/17 noted this resident in the dining room. The resident moved very little and did not vocalize to any extent. Several staff tried to feed the resident, and even obtained ice cream, but she refused to eat more than a few bites of her meal. Medical record review on 12/04/17 at 1:51 p.m. found Resident #30 was admitted from the community on 09/08/17 and discharged [DATE] to a psychiatric hospital. She reentered the facility from an acute care facility on 10/06/17. Her discharge to the psychiatric facility Minimum Data Set (MDS) assessment for 09/15/17, identified she only needed supervision for her activities of daily living (walking, eating, etc.) except for requiring extensive assistance for toileting. According to her Admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/11/17, her [DIAGNOSES REDACTED]. This assessment identified the resident did not walk and required total care for most activities of daily living. No behaviors were assessed during the look back period for this assessment. On 12/06/17 at 11:18 a.m., medical record review found the resident was receiving [MEDICATION NAME] delayed release 250 mg at 8:00 a.m. and 8:00 p.m. for dementia with behavioral disturbances. The resident was also on Donepezil ([MEDICATION NAME]) 10 mg at 20:00 (8:00 p.m.) for unspecified dementia with behavioral disturbances Since her return and major decline, she had not had behaviors, yet remained on [MEDICATION NAME] and [MEDICATION NAME]. From 11/23/17 through 8:00 a.m. on 1… | 2020-09-01 |
| 283 | 283 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2017-12-07 | 758 | D | 0 | 1 | WMI211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and staff interviews, the facility did not ensure Resident #30's drug regimen was free of unnecessary medications. The resident had a significant decline in her functional and behavioral status, yet she continued to receive [MEDICATION NAME] and [MEDICATION NAME] for dementia with behavioral disturbances. Resident identifier: #30. Facility Census: 45. Findings include: a) Resident #30 Observations at lunch time on 12/04/17 noted this resident in the dining room. The resident moved very little and did not vocalize to any extent. Several staff tried to feed the resident, and even obtained ice cream, but she refused to eat more than a few bites of her meal. Medical record review on 12/04/17 at 1:51 p.m. found Resident #30 was admitted from the community on 09/08/17 and discharged [DATE] to a psychiatric hospital. She reentered the facility from an acute care facility on 10/06/17. Her discharge to the psychiatric facility Minimum Data Set (MDS) assessment for 09/15/17, identified she only needed supervision for her activities of daily living (walking, eating, etc.) except for requiring extensive assistance for toileting. According to her Admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/11/17, her [DIAGNOSES REDACTED]. This assessment identified the resident did not walk and required total care for most activities of daily living. No behaviors were assessed during the look back period for this assessment. On 12/06/17 at 11:18 a.m., medical record review found the resident was receiving [MEDICATION NAME] delayed release 250 mg at 8:00 a.m. and 8:00 p.m. for dementia with behavioral disturbances. The resident was also on Donepezil ([MEDICATION NAME]) 10 mg at 20:00 (8:00 p.m.) for unspecified dementia with behavioral disturbances Since her return and major decline, she had not had behaviors, yet remained on [MEDICATION NAME] and [MEDICATION NAME]. From 11/23/17 t… | 2020-09-01 |
| 284 | 284 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 550 | D | 0 | 1 | SPY211 | Based on observation and staff interview, the facility failed to preserve one (1) resident's dignity during a mealtime. Private medical information was discussed with this resident in the presence of other residents dining at the same table. This was found during a random opportunity for observation. Resident identifier: #252. Facility census: 52. Findings included: On 12/03/18 at 12:07 PM, facility Urologist #179 was observed speaking to Resident #252 about confidential medical information while she was eating lunch. Two (2) other residents were dining at the table with Resident #252. Urologist #179 asked Resident #252 about potentially placing a catheter because she can't pee. At 12:12 PM, Urologist #179 was interviewed about the observations. He said that most of the residents in the facility know each other and that a lot of them have catheters. He added, What (Resident #252) said to me didn't make sense anyway. He said the alternative would have been to interrupt Resident #252's lunch and take her to her room to have the conversation in private instead. He said he thought talking to her in front of others while she was eating lunch was a preferable method to communicate the information. He then said, You're right, and added that maybe it should have been a private conversation. On 12/06/18 at 8:39 AM the facility's Director of Nursing (DoN) was informed of the issue. No further information was provided prior to the end of the survey. | 2020-09-01 |
| 285 | 285 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 565 | E | 0 | 1 | SPY211 | Based on resident interview, policy and procedure review and staff interview, the facility failed to ensure resident grievances/concerns were reconciled in a timely manner for two (2) of 18 residents reviewed during the Resident Council meeting. Resident identifiers: #20. Facility census: 52. Findings included: a) Resolution of Grievances/Concerns A review of the policy and procedure dated 03/01/02 Handling of Complaints/Grievances to the Extended Care Facility (ECF) found All complaints must be reported to the hospital CEO (Chief Executive Officer) or licensed nursing home administrator within 24 hours of the initial report. In the section titled Resident Council Meetings stated that any suggestions or concerns that residents may have are assigned to the appropriate person and shall be followed up in the next meeting. In addition for those residents with suggestions/concerns who wish to remain anonymous or for those residents who are unable to complete a form, the ECF Director of Nursing shall complete the form and submit it along with the meeting ' s minutes to the CEO or COO (Chief Operations Officer) with 24 hours of the meeting. In the Time Guidelines, B. The administrator or designee shall conduct (or direct) an investigation and initiate any corrective action within five (5) working days of receipt. A review of the Resident Council minutes during the survey found that grievances/concerns were reported to the Administrator and Supervisor and resolution was completed by the next monthly meeting or were marked ongoing. The minutes from the 07/09 and 08/06/18 meetings found a concern regarding Restorative nursing being pulled to the nursing units. Not until the 09/10/18 was the issues resolved. No evidence was provided by the facility that the residents received a response to this concern for two (2) months. In an interview with the Nursing Home Administrator (NHA) on 12/04/18 at 2:37 PM, when asked who was the facility Grievance Officer, the NHA stated there was no designated Grievance Officer. The NHA did no… | 2020-09-01 |
| 286 | 286 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 577 | E | 0 | 1 | SPY211 | Based on observation, staff interview and policy review, the facility failed to post survey results that were readily available, visible, and accessible to residents and visitors. This had the potential to affect more than a limited number of residents. Facility census: 52. Findings included: a) Survey Results During resident council meeting on 12/03/18 at 2:45 PM resident council president (Resident #101) stated he was unaware survey results were available for residents to review and did not know where the survey results were located. Observation on 12/03/18 at 3:20PM revealed a red sign at the lobby of the entrance that stated: This facility is certified by Medicare/Medicaid and is regularly surveyed by the WV Office of Health Facility Licensure Certification. Written survey results are available in the West Solarium. During an interview on 12/03/18 at 03:22, the Director of Nursing (DoN) #99 stated she does not know where the survey results are posted at and suggested asking the Administrator (NHA) for help finding them. At 03:24 on 12/03/18 during an interview, survey results were located by NHA and were found to be located on a wall identified by the Administer as the West Wing of building. Survey results were kept inside a binder and stored inside a single pocket wall file holder that was mounted adjacent to nursing station. The sign above stated: Federal Regulations require that inspection survey results and plan of corrections are available for public review. Please contact the ECF supervisor to see such documentation. | 2020-09-01 |
| 287 | 287 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 584 | D | 0 | 1 | SPY211 | Based on observation, and staff interview, the facility failed to ensure that two (2) of 18 sampled residents' rooms and equipment were in good repair. Resident Identifiers: Resident #16 and Resident #1. Facilty census: 51. Findings included: Observations made 12/03/18, at 12:11 PM, revealed both side rails on Resident #16's bed were scraped and rough and areas on the resident's door and walls were scraped. Observations made 12/03/18, at 3:01 PM, revealed scraped walls behind Resident #1's bed and holes in the wall outside the bathroom. An interview with the Maintenance Supervisor, on 12/06/18, at 11:55 AM, confined the areas needing repair in the rooms occupied by Resident #16 and Resident #1. The Maintenance Supervisor stated the areas would be repaired. | 2020-09-01 |
| 288 | 288 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 585 | E | 0 | 1 | SPY211 | Based on resident interviews, review of policy, staff interview, and observation, the facility failed to provide residents with information on how to file a grievance. This had the potential to affect more that a limited number of residents. Facility census: 52. Findings included: a) Grievances During Residence Council Meeting on 12/03/18 at 2:41 PM, Resident Council President #101 stated that he just learned of the grievance form 2 months ago. The remainder of Residence Council members present stated they did not know how to file a grievance or where to obtain form. Review of the facility's policy with effective date of 03/01/02 titled Handling of Complaints/Grievances to the Extended Care Facility: stated: ECF Suggestion/Concern forms shall be available in solariums and from the Social Worker. All completed ECF Suggestion/Concern Forms and accompanying documentation shall be permanently stored in the Administration file. On 12/04/18 at 2:23 PM observation of A wing Solarium revealed no grievance forms posted or available in the A solarium as stated in the grievance policy. On 12/04/18 at 2:26 PM observation revealed a B/C wing solarium revealed a faded teal colored 8x10 sign hanging above eye level on wall in B/C wing solarium that stated: ECF suggestion/concern Form/Medicare concern form/SMH Customer Complaint Form/Medicare & Medicaid Information. Below the sign was a wall mounted chart holder that contained a thin blue paper binder containing blank forms titled: Summersville Memorial Hospital ECF Suggestion/Concern Form. Positioned directly below the forms was a soiled linen cart blocking access to the forms. During an interview on 12/04/18 at 3:06 PM Administrator (NHA) #72 clarified that the grievance forms were only available in the B/C wing solarium. | 2020-09-01 |
| 289 | 289 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 600 | D | 0 | 1 | SPY211 | Based on observation, and staff interview the facility failed to ensure the residents were free from abuse, including but not limited to verbal and physical abuse. Resident identifier: #28. Facility census: 52. Findings included: a) Resident # 28 During an observation on 12/03/18 at 11:35 AM, Residents were in dining room trays had just arrived. Physical Therapist Assistant (PTA) #180 was seen by Surveyor take the doll in a blanket from Resident #28 without asking or explaining what she was doing. She then pulled Resident # 28 forward by placing her hand on the back of the resident's head. The resident yelled for her to let go of her head. That is when PTA #180 put her face very close to the face of the resident and said, you are not being very lady like in a loud and harsh tone. She then very roughly placed this resident in a wheelchair. Licensed Practical Nurse (LPN) # 96 was trying to tell the resident what they were doing but was not allowed the time to do so by PTA #180. LPN# 96 realized this resident was not in her wheelchair and PTA # 180 appeared to be frustrated by huffing and throwing up her arms. The correct wheel chair was collected by LPN# 96. Again Resident #28 was not told what they were going to do. PTA #180 got behind the resident placing both hands on her upper back and pushed her forward she directed LPN #96 to place the gait belt behind her. This action of pushing her forward appeared to scare the resident as evidenced by her facial expression and she yelled loudly, stop you are hurting me. PTA #180 did not stop her actions towards Resident #28. It looked as though PTA #180 was pushing her out of her wheelchair. PTA #180 roughly pulled the resident into her wheelchair. When she was removing the belt now in front of the resident she once again put her face inches from the resident's face and repeated, You are not very lady like in a loud tone of voice. On 12/05/18 at 3:20 PM, DoN revealed LPN#96 told her on that day that PTA #180 was rude to the resident right in front of the surveyor and not t… | 2020-09-01 |
| 290 | 290 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 655 | D | 0 | 1 | SPY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to fully develop a baseline care plan to address pertinent care needs upon admission. This affected one (1) of 18 residents reviewed for care plans. Resident identifier: #252. Facility census: 52. Findings included: a) Baseline Care Plan Resident #252 was admitted to the facility on [DATE]. On 12/04/18 at 09:20 AM, review of Resident #252's base line care plan (titled Admission Care Plan) revealed only to have resident name written at top, no admitted , no resident identifiers, and no initiation dates for goals or plan of care and no progress dates. On 12/05/18 at 8:40 AM review of the facility's policy titled Care Planning Process with review and revise date of 11/08/18, stated an initial care plan addressing the specific needs of the resident will be developed by the IDT team within 48 hours after admission. During an interview on 12/05/18 at 8:48 Director of Nursing (DoN) #99 agreed care plan was incomplete with no date or time of implementation, no date of admission. DoN #99 also stated that the missing information on the care plan made the care plan unacceptable to use. | 2020-09-01 |
| 291 | 291 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 684 | F | 0 | 1 | SPY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy and procedure review, the facility failed to administer medications within acceptable time frames for 7 of 8 sampled residents. Resident Identifiers : Residents #16, # 8, #22, #35, #25, #2, and #18. Findings included: a) Resident #16 1. A review of the Medication Administration Policy, effective date 02/20/18, page 7, verified per standard protocol, medications can be administered one (1) hour before or one (1) hour after scheduled time. 2. An interview with Resident #16, on 12/03/18, at 12:11 PM, revealed the resident suffered from painful arthritis but did not always receive pain medication in a timely fashion because staff are usually late with the medication. 3. Review of the medical record showed Resident #16 to have a physician's orders [REDACTED]. A review of the Medication Administration Record, [REDACTED]. The medication was administered late 23 times in (MONTH) (YEAR) and was late with administration four times during the month of (MONTH) (YEAR). Examples of the late administration were as follows: --[MEDICATION NAME] was given late on 11/14/18 through 11/18/18, 11/20/18, 11/22/18, 11/23/18, 11/27/18, 11/27/18, 11/29/18,11/30/18, 12/01/18, 12/2/18, and 12/03/18. Further review of the MAR indicated [REDACTED]. The medication was given late on 11/13/18, 11/16/18, 11/22/18 and 11/28/18. A review of (MONTH) MARs showed the dose of [MEDICATION NAME] was late 7 of the 10 documented administered doses. Doses were administered late on 09/02/18, 09/05/18, 09/11/18, 09/14/18, 09/17/18, 09/20/18, and 09/23/18. The 20:00 dose was administered as late as 22:16 on 9/23/18 and 22:17 on 09/05/18. 4. An interview with the Director of Nursing on 12/05/18, at 10:19 AM, revealed medications are to be given within the hour of the time ordered. She further stated I understand these pain meds are being given late and the resident is experiencing pain. b) Resident #8 1. A review of the medical record for R… | 2020-09-01 |
| 292 | 292 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 697 | D | 0 | 1 | SPY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and resident interview, the facility failed to provide pain management in accordance with physician's orders for one of 18 sampled residents who experienced pain. Resident identifier: #16. Facility census: 52. Findings included: a) Resident #16 1. A review of the Medication Administration Policy, effective date 02/20/18, page 7, verified per standard protocol, medications can be administered one (1) hour before or one (1) hour after scheduled time. 2. An interview with Resident #16, on 12/03/18, at 12:11 PM, revealed the resident suffered from painful arthritis but did not always receive pain medication in a timely fashion, stating staff are usually late with the medication. 3. Review of the medical record showed Resident #16 to have a physician's orders for a [MEDICATION NAME] every 12 hours, [MEDICATION NAME] 25 mcg/hr once a day every third day. 4. A review of the Medication Administration Record, [REDACTED]. The medication was administered late 23 times in (MONTH) (YEAR) and was late with administration four times during the month of (MONTH) (YEAR). Examples of the late administration were as follows: --[MEDICATION NAME] was given late on 11/14/18 through 11/18/18, 11/20/18, 11/22/18, 11/23/18, 11/27/18, 11/27/18, 11/29/18,11/30/18, 12/01/18, 12/2/18, and 12/03/18. 5. Further review of the MAR indicated [REDACTED]. The medication was given late on 11/13/18, 11/16/18, 11/22/18 and 11/28/18. 6. A review of (MONTH) MARs showed the dose of [MEDICATION NAME] was late 7 of the 10 documented administered doses. Doses were administered late on 09/02/18, 09/05/18, 09/11/18, 09/14/18, 09/17/18, 09/20/18, and 09/23/18. The 20:00 dose was administered as late as 22:16 on 9/23/18 and 22:17 on 09/05/18. 7. An interview with the Director of Nursing, on 12/05/18, at 10:19 AM, revealed medications are to be given within the hour of the time ordered. She further stated I understand these pain meds are being given lat… | 2020-09-01 |
| 293 | 293 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 804 | D | 0 | 1 | SPY211 | Based on observation, staff interview, resident interview, and record review, the facility failed to provide food and drink that was safe and at an appetizing temperature. Residents reported being served cold food that was not palatable. This had the potential to affect more than a limited number of residents. Resident identifier: #16. Facility census: 52. Findings included: a) Resident #16 During an interview on 12/03/18 at 2:12 PM Resident #16 stated the food was still being served cold, that she liked her soup hot and it was never warm enough for her eat. Resident council minutes dated 10/01/18 revealed Resident #16 voiced a concern of cold food when delivered with corrective action as trays would be passed in a more timely manner and facility do a test tray. Resident council minutes dated 11/05/18 also revealed that Resident #16 complained the food was not hot when served. b) Test Tray On 12/05/18 at 11:39 AM observation for test tray started when staff started passing trays in B/C wing solarium. At 11:46 AM trays split between carts for meal tray hall pass. At 11:51 AM just prior to being served, notified staff that the last tray left on meal cart will be tested . Test tray temperatures obtained by Dietary Manager (DM) #170 at 11:55 AM consisting of: --Ground spaghetti with meat temperature 125 degrees Fahrenheit (F). --Spinach 1/2 cup temperature of 118 degrees (F). --Ground citrus cup temperature 48 degrees (F) --Chocolate milk temperature 51 degrees (F) --Grape juice temperature 51 degrees (F) --Gelatein (nutritional supplement) temperature 48 degrees (F) --Garden Salad temperature 60 degrees (F) c) Dietary Manager Interview During an interview on 12/05/18 at 2:30 PM Dietary Manger (DM) #170 stated she was aware that some of the residents have complained about cold food, and they have tried staggering out the meal times and tray line processing to allow meal trays to be delivered more timely while hot. | 2020-09-01 |
| 294 | 294 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 812 | E | 0 | 1 | SPY211 | Based on observation, staff interview, and policy review, the facility failed to ensure that resident food was stored appropriately in unit refrigerators and that a unit microwave was kept clean. This had the potential to affect more than a limited number of residents. Facility census: 52. Findings included: On 12/03/18 at 11:24 AM, a tour of the facility's main kitchen, waste disposal areas, and unit kitchens began with Certified Dietary Manager (CDM) #170. At 11:46 AM, the microwave in the A wing unit kitchen was found to be dirty. Multiple droplets of a pink substance were present on the bottom of the inside of the microwave. CDM #170 acknowledged that the microwave was dirty. At 11:50 AM, a pie with one (1) piece missing was found in the B wing refrigerator. It was marked with a date of 11/28/18. A sticker on the refrigerator stated that resident food should be discarded after three (3) days. CDM #170 confirmed that the pie should have been removed after three (3) days. Also at 11:50 AM, a plastic reusable container with food in it was found in a plastic shopping bag in the B wing refrigerator. The container was not labeled with any dates or identifying information. CDM #170 said she was concerned about this and removed it from the refrigerator, along with the pie. She said she would discard both items. At 2:51 PM, the facility's policy for food brought into the facility for residents was obtained and reviewed. The policy, titled Patient Food from Non-Hospital Sources was most recently reviewed on 05/19/18 by CDM #170. The policy stated, Any food brought in from the outside shall be labeled with patient's name, date and room number, and held in a unit refrigerator specifically designated for patient food, for 24- hours only. A document titled Safe Food Handling Tips was provided with the policy and stated, All cooked or prepared foods stored in pantry or refrigeration will be checked daily by the diet clerk from Nutrition Services, and will be tossed if not properly labeled. On 12/06/18 at 8:39 AM the facilit… | 2020-09-01 |
| 295 | 295 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 880 | D | 0 | 1 | SPY211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The nurse failed to use a protective barrier when she placed the two inhalers on the resident's side table and failed to provide isolation precautions by not posting signs alerting the public of an infection control risk for residents in isolation. These were random Resident opportunities for discovery. Identified Residents #14 and #16. Facility census was 52. Findings included: a) Resident #14 On 12/04/18 at 7:45 AM, Licensed Practical Nurse (LPN) #78 failed to place a barrier on Resident's #14 bedside table before laying to inhalers on the table. LPN#78 said she realized what she did as soon as she did it and that is why she wiped the inhalers off with an alcohol pad. On12/04/18 at 12:38 PM, Director of Nursing (DoN) was informed of observation and said that LPN#78 had already told her about it. b.) Resident #16 Observations during the tour, on 12/03/18, at 12:00 PM, , revealed no precautionary measures alerting staff and visitors to obtain more information about care provided to Resident #16 before entering the room. b.) A review of the medical record for Resident #16, showed the resident was being isolated in Contact Isolation for an infection as of 11/25/18, c.) An interview with LPN #137, on 12/03/18, at 01:51, revealed Resident #16 was being isolated for [MEDICAL CONDITION] but verified there was no sign on the door to alert staff and visitors that extra precautions would be required when entering the room. LPN #137, further stated, a sign that stated STOP should have been on the resident's door. d.) An interview with the infection control nurse, on 12/03/18, at 2:10 PM, verified the isolation policy required a sign on the door but stated it must have… | 2020-09-01 |
| 296 | 296 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2018-12-07 | 947 | E | 0 | 1 | SPY211 | Based on inservice record review and staff interviews, the facility failed to ensure Nurse Aides (NA's) received the required twelve (12) hours of annual inservice training. This practice was true for three (3) of employee inservice records reviewed. Employee identifiers: #145, #65, #155. Facility census: 52. Findings include: On 12/05/18 02:36 PM a review of inservice records found three (3) of five (5) inservice records for NA's #145 (hire date 05/02/16), #65 (08/04/08), #155 (hire dated (05/10/17) had no evidence of the required 12 hours of inservices. An interview with Registered Nurse (RN #173), stated that the previous nursing educator had retired and produced a copy of the nursing schedule with a hand written Infection Control, Handwashing and PPE's (personal protected equipment) at the top of the schedule. Red check marks were beside staff names who attended the inservice. RN #173 was unable to confirm the length of time of the inservices. RN #173 stated that she would try to contact the retired inservice educator to obtain the length of the inservices. An additional interview on 12/06/18 at 8:12 AM, RN #155 confirmed there was no evidence of the number of hours of inservice education provide for the facility NA's. | 2020-09-01 |
| 297 | 297 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2017-03-08 | 167 | C | 0 | 1 | UN5811 | Based on observations and staff interview, the facility failed to have a notice posted as to the location of the most-recent survey results during a random observation. This has the potential to affect all residents and visitors. Facility census 81. Findings include: a) Observation On 03/05/17 during an initial tour of the facility, the recent State survey results were observed in the main dining room in a box on the wall. A notice as to the location of the survey results was not observed during the survey week (03/05/17- 03/08/17). b) Interview During an interview with the Administrator, on 03/08/17 at 10:30 a.m., the Administratorwas asked where the notice was located to inform a visitor where the survey results would be located. The Administrator said we do not have a notice. She was not aware a posting was required to inform visitors of where to find the facility's survey results. | 2020-09-01 |
| 298 | 298 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2017-03-08 | 241 | D | 0 | 1 | UN5811 | Based on observation and staff interview, the facility failed to ensure Resident #7 was provided with a dignified dining experience during the breakfast meal on 03/06/17. This was a random opportunity for discovery. Resident identifier: #7. Facility census: 81. Findings include: a) Resident #7 During an observation at 9:02 a.m. on 03/06/17, Nurse Aide (NA) #65 was observed feeding Resident #7. NA #65 was standing at the residents bedside instead of being seated where she could be at eye level with Resident #7. An interview with NA #65, at 9:06 a.m. on 03/06/17, confirmed she was standing instead of sitting down while feeding Resident #7. She stated she should have been sitting, but there was no chair in the residents room to sit on so she had to stand. She stated, You can look in all these rooms there are no chairs in any of them. | 2020-09-01 |
| 299 | 299 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2017-03-08 | 246 | D | 0 | 1 | UN5811 | Based on observation, resident interview, and staff interview, the facility failed to provide reasonable accommodations of individual needs for one (1) of thirty-five (35) residents during a random opportunity for discovery during Stage I and Stage II of the Quality Indicator Survey (QIS). A resident's call light was not within reach. Resident identifier: #78. Facility census: 81. Findings include: a) Resident #78 During Stage 1 of the Quality Indicator Survey (QIS), on 03/05/17 at 2:54 p.m., an observation revealed Resident #78's call light was not within his reach while he was lying in bed. During Stage 2 of the QIS, an observation and interview with Specialist Maintenance 2 (SM2) #19, on 03/08/17 at 8:32 a.m., found Resident #78's call light on the floor, and not within the resident's reach. SM2 #19 verified the placement of the call light was out of reach of the resident, and the resident would not be able to use the call light. During Stage 2 of the QIS, on 03/08/17 at 9:05 a.m., the resident was lying in his bed and he was observed by the assistant director of nursing (ADON) #45. The resident's call light was lying on the floor. Resident #78 was asked by this surveyor whether he used his call light and Resident #78 stated, Yes, I use my call light. The ADON picked the resident's call light off the floor and attached his call light within the resident's reach. The resident was asked by this surveyor to ring his call light. The resident reached down and pushed the button and the light turned red on the wall. The ADON agreed the resident's call light was not in reach and therefore the resident was unable to use his call light for assistance if wanted to. | 2020-09-01 |
| 300 | 300 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2017-03-08 | 253 | E | 0 | 1 | UN5811 | Based on observations and staff interview, the facility failed to provide maintenance and housekeeping services necessary to maintain a comfortable and sanitary interior for six (6) of thirty-five (35) resident rooms observed during Stage 1 of the Quality Indicator Survey (QIS). The entrance doors to the resident's rooms had deep gouges, in which the wood was exposed with no finish on the door. The wall in one room was cracked. The floor tile was cracked, and there was a discolored substance on the caulking which was around the sink and the air conditioner. A bathroom had been missing paint on the door facing going into the bathroom, and tape and white mark was on the bathroom doors. A gray raised toilet seat has an area of rust color where a resident's legs would touch. This had the potential to affect more than an isolated number of residents. Resident room identifier: 101,102,103,106,115, and 118. Facility census 81. Findings include: a) Cosmetic imperfection --Room 101 observed, on 03/05/17 at 12:03 p.m., found cracked floor tiles on the side of the air conditioner unit. There was deep gouges in the woood below the door handle on the side of the entry door. The wood was exposed with no finish on the door. --Room 102 observed, on 03/05/17 at 2:52 p.m., found deep gouges in the wood of the door leading into the room on the outside edges, and there was chunks of wood missing off the door. --Room 103 observed, on 03/05/17 at 12:33 p.m., found cracked floor tile under the sink and dark spaces showing between the tiles. The hand sink had a large amount of black markings on the caulking. --Room 105 observed, on 03/05/17 at 12:28 p.m., found a crack in the wall above the air conditioner with a brown color substance on the white caulking. --Room 115 observed, on 03/05/17 at 12:05 p.m., found deep gouges on the entry door to the resident's room and missing paint in the door facing of the bathroom door. --Room 118 observed, on 03/05/17 at 12:41 p.m., found tape marks and white marks on the insdie of the inside of the ba… | 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 );